T. D. T. Tjan

Initial Clinical Experience With the HeartWare Left Ventricular Assist System: A Single-Center Report

BACKGROUND The HeartWare ventricular assist device (HVAD) system (HeartWare International Inc, Framingham, MA) is a new centrifugal continuous-flow ventricular assist device. The aim of the present study is to review our institutional experience with this novel device. METHODS We reviewed the files of 50 patients (39 men, 11 women) with a mean age of 50.6 ± 11.8 years (range, 19 to 70 years) who underwent HVAD implantation between July 2009 and November 2011. Two patients underwent HeartWare BIVAD implantation. The underlying heart diseases were end-stage ischemic heart disease (n = 12), acute myocardial infarction (n = 9), dilated cardiomyopathy (n = 27) and acute myocarditis (n = 2). Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles were level 1 (n = 11), 2 (n = 5), 3 (n = 10), and 4 (n = 24). RESULTS After a cumulative support duration of 11,086 days, Kaplan-Meier analysis revealed a survival of 82.0%, 77.9%, 75.5%, at 1, 12, and 24 months, respectively. Causes of early death were right heart failure (n = 4), multiorgan failure (n = 2), septic shock (n = 2), and major neurologic complications (n = 4). One late death occurred due to a right heart failure. Comparison between patients operated on in cardiogenic shock (INTERMACS 1 and 2) and patients who underwent elective HVAD implantation (INTERMACS 3 and 4) revealed a survival of 61.5% and 44.1% for the INTERMACS 1 and 2 group and 90.3% and 87.1% for the INTERMACS 3 and 4 group at 1 and 12 months, respectively (odds ratio, 4.67; p = 0.003). One patient was weaned from the system after 2 years. Eleven patients (22%) were successfully bridged to transplantation. Mean time to transplantation was 209 days (range, 72 to 427 days). Posttransplant survival at the 1-year follow-up was 90.9% (11 patients). CONCLUSIONS Our experience with HVAD shows satisfying results with an excellent posttransplantation survival. Moreover, the stratified survival based on the level of preoperative stability shows better outcomes in patients undergoing elective HVAD implantation.

Myocardial ischaemia in patients with impaired left ventricular function undergoing coronary artery bypass grafting — milrinone versus nifedipine

Background and objective: Myocardial ischaemia and infarction are major complications immediately after coronary artery bypass grafting. They may be due to incomplete surgical revascularization, perioperative anaesthetic management or vasospasm of arterial grafts, e.g. the internal mammary artery. Infusions of nifedipine or milrinone have been advocated to prevent spasm of the mammary artery. The study compared the incidence of myocardial ischaemia after continuous infusion of either nifedipine (0.2 μg kg−1 min−1) or milrinone (0.375 μg kg−1 min−1) in patients with compromised left ventricular function scheduled for elective coronary artery bypass graft. Methods: After Institutional Review Board approval, this double-blinded randomized clinical study enrolled 30 adult patients with compromised left ventricular function (ejection fraction <0.4) scheduled for elective coronary artery bypass grafting after written informed consent had been obtained. Ischaemia was detected by Holter electrocardiographic monitoring. The incidence of myocardial cell death was monitored by serial determinations of the creatine kinase-MB (CK-MB) and troponin-I. Results: New ST elevation ⩾0.2 mV or new ST depression ⩽0.1 mV occurred in five of 15 patients in the milrinone group (33.3%) and in 13 of 15 patients (86.6%) in the nifedipine group (P < 0.05). There were increases in CK-MB and troponin-I in both groups. Twenty-four hours postoperatively, CK-MB (P = 0.003) and troponin-I (P = 0.001) were significantly higher in the nifedipine group. Conclusions: Perioperative continuous infusion of milrinone, compared with nifedipine, results in a significantly lower incidence of myocardial ischaemia and myocardial cell damage after elective coronary artery bypass grafting.

Ischemic preconditioning by unstable angina reduces the release of CK-MB following CABG and stimulates left ventricular HSP-72 protein expression.

Abstract  Background and Aim: Whether the CK‐MB reducing effect of ischemic preconditioning (IP) by unstable angina within 24 to 48 hours before CABG is achieved by early or by delayed preconditioning of left ventricular myocardium in humans is unknown. We investigated whether IP is associated with phosphorylation of p38 MAPK (characteristic for early preconditioning) or with increased protein expression of HSP‐72 (characteristic for delayed preconditioning) at the time of CABG in patients. Methods: Nineteen patients were grouped according to the occurrence of ischemic episodes within 48 hours before CABG. The patients without angina were assigned to the control group (CON, n = 10) whereas patients who had experienced angina within 48 hours before CABG were assigned to the preconditioned group (IP, n = 9). The effect of IP on the CABG induced maximal release of creatine kinase (CK) and CK‐MB was examined. Left ventricular biopsy specimens taken immediately before cross clamping from ischemic (ISCH) and from reference (REF) areas were processed to analyze p38 MAPK phosphorylation and HSP‐72‐protein expression. Results: While IP significantly reduced CK‐MB (18.7 ± 1.3 vs. 13.8 ± 1.5 U/L, mean ± SEM, p < 0.05), it only tended to reduce CK (292.7 ± 32.8 vs. 274.1±31.1 U/L, p = NS, mean ± SEM). CK‐MB release for any given cross‐clamp time was significantly reduced by IP (regression lines: CON, y= 0.4x+ 2, r= 0.8; IP, y= 0.1x+ 10, r= 0.2; p < 0.01, ANCOVA). There was no effect of IP on left ventricular p38 MAPK phosphorylation. IP increased left ventricular HSP‐72‐protein expression in ischemic areas when compared to reference areas (1.78 ± 0.35 vs. 2.58 ± 0.65, REF vs. ISCH, PhosphorImager units ×106, mean ± SEM, p < 0.05, ANCOVA). Conclusions: Thus, in the human left ventricular myocardium there is a second window of protection lasting for at least 48 hours, while at that time the early phase of preconditioning has already gone.

Creation of a self-made total artificial heart using combined components of available ventricular assist devices.

We describe the case of a 39-year-old woman who received a self-made total artificial heart built of components from the Thoratec and ExCor Berlin Heart systems. The patient had a severe aortic/myocardial infection following replacement of the ascending aorta with a Shelhigh conduit due to type A aortic dissection. The surgical technique is described in detail in this article. This technique is feasible if a total artificial heart is not available and implantation of a biventricular assist device is not possible.

Postoperative Complications and Long-Term Results after Primary Cardiac Sarcoma Resection

Background Primary malignant cardiac tumors rarely occur in clinical care. Little is known about the impact of a parameter on postoperative survival. Methods From May 1991 to May 2014, a total of 24 patients underwent surgical treatment of a primary cardiac sarcoma in our center. We analyzed our clinical database retrospectively for information on patient characteristics and treatment data. The follow‐up could be completed to 91.7%. Results Angiosarcoma and non‐otherwise‐specified sarcoma were the most common tumor entities. R0 resection was achieved in most cases. Postoperative mortality within the first 30 days was 20.8% (n = 5). In four of these five cases, postoperative low‐output cardiac failure was the leading cause of death. The cumulative survival rate was 77.3% after 30 days, 68.2% after 3 months, 50.0% after 6 months, 45.0% after 12 months, and 18.0% after 24 months. The mean survival time in the whole group was 47.0 months. A low tumor differentiation was associated with low mean survival, but this was not statistically significant. Mean survival of sarcoma was higher after R0 resection. There was no significant rate of survival difference regarding the adjuvant therapy concept. Conclusion Extended surgery alone or in combination with chemo‐ and/or radiotherapy may be successful in certain cases and may offer a satisfactory quality of life. The establishment of a multicenter heart tumor register in Germany is necessary to increase the number of cases in studies, get more remarkable study results, and standardize the diagnosis and therapy.

Switch from assist device to total artificial heart to improve cardiac output.

Left ventricular assist devices (LVADs) offer the opportunity to substantially improve the clinical condition and to interrupt the hospitalization of patients suffering from end-stage heart failure awaiting heart transplantation.We report a case of a 30-year-old patient (body surface area 2.49 m2) suffering from idiopathic dilative cardiomyopathy who was primarily given an LVAD with a free floating impeller pump and was finally switched to a total artificial heart due to the demand for a higher cardiac output.

Does body surface potential mapping (bspm) predict functional recovery in chronic ischemic myocardium after revascularization

Irreversibly dysfunctional myocardium is electrically characterized by decreased amplitudes and prolonged duration of local electrograms. We investigated whether ECGs from body surface correlate with epicardial electrograms. A 120-channel body surface potential mapping (BSPM) was performed in 24 patients before CABG. During CABG epicardial mapping was performed. For all BSPM leads the Q-amplitude and QR-duration were measured and correlated to epicardial electrogram characteristics. Q-wave-amplitude neighboring the area over the left scapula correlated well with epicardial amplitudes in scarred LAD. QR-duration caudal to V5,V6 correlated well with epicardial signal duration in scarred CxA, Q-amplitude in paramedian epigastric region correlated with epicardial amplitudes in scarred RCA. Epicardial electrogram characteristics can be estimated from body surface in patients with chronic ischemia

Surgery of the inferior vena cava for tumor-related obstruction

Kidney tumors and pheochromocytomas of the adrenal gland may extend into the inferior vena cava (IVC) or even the right atrium. In these cases, curative surgery frequently requires partial resection of the IVC. From 1992 to 1995, 8 patients (6 kidney tumors, 2 pheochromocytomas of the adrenal gland) underwent tumor surgery with concomitant IVC resection. Four patients had tumor growth into the right atrium. Surgery was carried out during hypothermic circulatory arrest (n=4) using veno-venous bypass from the IVC to the jugular vein (n=2), or by simply clamping the IVC (n=2). In 6 patients the IVC was reconstructed using a PTFE prosthesis (n=2) or patch (n=4), in 2 patients the IVC was closed by a running suture only. All patients were discharged home 10–23 days after surgery (mean 13 days). During the follow-up (mean 23 months), 6 patients were in good clinical condition and without evidence of tumor recurrence up to 44 months after surgery and 2 patients died of metastases (16 and 17 months). Refinements of surgical techniques combined with a multidisciplinary approach involving vascular surgeons, cardiac surgeons, and urologists allow successful treatment of advanced tumor stages with IVC involvement, formerly considered a contraindication for surgery. The aggressive surgical approach is warranted not only for relief of symptoms, and acceptable survival rates can be achieved; even cure of the disease is possible.

Herztumor als Manifestation eines Li-Fraumeni-Syndroms

ZusammenfassungDas Li-Fraumeni-Syndrom ist eine autosomal dominant vererbte Erkrankung, die durch das Auftreten multipler Tumoren bei jungen Patienten charakterisiert ist. Erstmals wurde die Erkrankung 1969 von Frederick P. Li und Joseph F. Fraumeni beschrieben. Ursächlich ist meist eine Mutation im p53 Gen auf Chromosom 17.Wir berichten über eine 46 Jahre alte Patientin, die sich im Februar 2008 mit einem großen Herztumor in unserer Klinik vorstellte. Computertomographisch fand sich ein Tumor, der den rechtsventrikulären Ausflusstrakt obstruierte und die Pulmonalarterie befallen hatte. Intraoperativ reichte der Tumor bis an die Bifurkation der Pulmonalarterie heran und infiltrierte das Perikard. Zur vollständigen Entfernung des Tumors wurde die A. pulmonalis reseziert und der rechtsventrikuläre Ausflusstrakt mit einer Prothese rekonstruiert.Angesichts der Vorgeschichte der Patientin leiteten wir eine genetische Untersuchung ein, die das Vorliegen eines Li-Fraumeni-Syndroms bestätigte. Histologisch fand sich ein gering differenziertes, pleomorphes Sarkom. Neun Monate nach der Operation hat sich die Patientin vollständig erholt, bisher ohne Anhalt für ein Rezidiv des Herztumors.AbstractLi-Fraumeni syndrome is a disease with autosominal dominant heredity, characterized by the appearance of multiple tumors in young patients, first described in 1969 by Frederick P. Li and Joseph F Fraumeni. The cause for the disease is generally a mutation in the p53 gene on chromosome 17.We report a 46-year-old female patient. In February 2008 she presented at our clinic with a cardiac tumor. CT imaging showed a tumor obstructing the right ventricular outflow tract (RVOT) and infiltrated the pulmonary artery.Intraoperatively, the tumor reached the bifurcation of the pulmonary artery with infiltration of the pericardium. To remove the tumor, the pulmonary artery had to be resected. The RVOT was reconstructed with a Contegra© graft.Due to the medical history we performed a genetic analysis, which confirmed Li-Fraumeni syndrome. Histology showed a low differentiated pleomorphic sarcoma. After 9 months of follow-up the patient has fully recovered with no tumor recurrence of the heart.

Psychological care of heart-transplanted children and their families.

Heart transplantation is not a unique event, neither from the medical point of view nor from the standpoint of psychosocial care. It is a process which begins during the evaluation for transplantation and continues up to re-integration of the patient into everyday life. It is obvious that during the entire time both the child suffering from heart disease and the family of the affected child have to deal with heavy emotional stresses and adjustments. For this reason transplantation centers are obliged by law to provide psychological care.