Patrick A. DeValeria

Complement Inhibition With Soluble Complement Receptor Type 1 in Cardiopulmonary Bypass

Although complement activation during cardiopulmonary bypass (CPB) is well documented, its pathogenic role in postperfusion organ injury is unproven. In this study, soluble human complement receptor type 1 (sCR1), a potent inhibitor of complement activation, was used to determine the contribution of complement activation to pulmonary injury in a porcine model of CPB. In vitro experiments demonstrated that sCR1 inhibits both classic and alternative complement pathways in the pig. Seven control piglets and 6 piglets treated with sCR1 (12 mg/kg intravenously) underwent 2 hours of hypothermic (28 degrees C) CPB followed by 2 hours of observation. In control piglets, total hemolytic complement activity and functional activities of C3 and C5 declined to 61.3%, 67.8%, and 61.4% of prebypass values, respectively, after 2 hours of CPB. Plasma from animals treated with sCR1 had virtually no hemolytic activity (total hemolytic complement activity < 5% of baseline), demonstrating effective complement inhibition. Similar degrees of neutropenia developed in the two groups during CPB, and there was no difference in post-CPB lung tissue myeloperoxidase level. Two hours after CPB, pulmonary vascular resistance increased 338% in control piglets but only 147% in piglets pretreated with sCR1 (p < 0.05); the alveolar-arterial gradient was not significantly different between controls (331 +/- 52 mm Hg) and piglets receiving sCR1 (290 +/- 85 mm Hg). Histologic examination revealed similar degrees of pulmonary edema in both groups. These data constitute direct evidence that complement activation plays a pathogenic role in lung injury after CPB.(ABSTRACT TRUNCATED AT 250 WORDS)

Low-dose oral amiodarone prophylaxis reduces atrial fibrillation after pulmonary resection.

BACKGROUND Atrial fibrillation after pulmonary resection increases morbidity and costs. To evaluate the efficacy of low-dose oral amiodarone (LDOA) as prophylaxis for atrial fibrillation after pulmonary resection, we reviewed all patients 60 years or older having pulmonary resections by thoracotomy in a 30-month period. METHODS We identified 31 patients who received prophylactic LDOA (200 mg by mouth every 8 hours) while hospitalized and 52 patients who received no prophylactic treatment. The groups were comparable for sex, age, comorbidities, and surgical procedure. RESULTS Twenty of 83 patients (24%) had postoperative atrial fibrillation: 17 of 52 patients (33%) without prophylaxis and 3 of 31 (9.7%) with prophylaxis (odds ratio, 0.221; 95% confidence interval, 0.059 to 0.829; p = 0.0253). The median total hospital charge was

Nontraditional Surgical Approaches for Implantation of Pacemaker and Cardioverter Defibrillator Systems in Patients With Limited Venous Access

30,800 (range,

Successive circulatory support stages: a triple bridge to recovery from fulminant myocarditis.

20,400-

Parallel Application of Extracorporeal Membrane Oxygenation and the CardioWest Total Artificial Heart as a Bridge to Transplant

96,900) for 50 patients without prophylaxis and

Coccidioidal pericarditis: Implications of surgical treatment in the elderly

26,700 (range,

Anterolateral papillary muscle rupture: An unusual complication of septic coronary embolism

11,000-

Transcatheter, valve-in-valve transapical aortic and mitral valve implantation, in a high risk patient with aortic and mitral prosthetic valve stenoses

55,900) for 31 patients with prophylaxis (p = not significant). Patients receiving LDOA had lower accumulated charges per day of hospital stay (p = 0.0011). CONCLUSIONS LDOA prophylaxis significantly reduces the incidence of atrial fibrillation after pulmonary resection. Its use in this population may be cost-effective. Results of this pilot study provide a rationale for a prospective randomized trial.

Simultaneous Heart and Kidney Transplantation After Bridging With The CardioWest Total Artificial Heart

BACKGROUND Indications for placement of implantable cardioverter-defibrillators (ICD) and pacemakers have expanded, and traditional transvenous implantation may not be feasible in patients with aberrant anatomy or venous obstruction. In these settings, successful lead placement has required innovative surgical approaches. A case series of successful placement of these systems in challenging patients is presented. METHODS A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed. RESULTS Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died. CONCLUSIONS Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.

An unusual presentation of left ventricular assist device thrombus

Fulminant myocarditis with rapid onset of symptoms and hemodynamic compromise is a rare indication for mechanical support. Because of the potentially reversible nature of this illness, advanced mechanical circulatory support is warranted to achieve recovery or as a bridge to transplantation. Circulatory device options currently available allow for a phased implementation of support modalities in a manner that reduces costs and patient risk. We present a patient with fulminant myocarditis where extracorporeal membrane oxygenation (ECMO) support escalated to short-term Levitronix CentriMag (Levitronix, Waltham, MA) biventricular assist devices (BiVADs). These in turn were exchanged, without major surgery, to long-term paracorporeal VADs (Thoratec, Pleasanton, CA). After rehabilitation and nearly total recovery, the patient was weaned from mechanical circulatory support after 104 cumulative days.