Themistokles Chamogeorgakis

Outcomes of axillary artery side graft cannulation for extracorporeal membrane oxygenation

OBJECTIVEnTo determine the safety, efficacy, and frequency of side graft axillary artery cannulation for extracorporeal membrane oxygenation support and compare it with other cannulation techniques.nnnMETHODSnFrom January 2001 to October 2011, 308 adult patients were supported with extracorporeal membrane oxygenation at a single center. In 81 patients (26.3%), the extracorporeal membrane oxygenation circuit was composed of an arterial inflow by a side graft sewn to the axillary artery. Of the 308 patients, 166 (53.9%) underwent femoral arterial cannulation and 61 (19.8%) underwent ascending aortic cannulation The pertinent variables and postprocedural events were retrospectively analyzed in this cohort of patients.nnnRESULTSnThe most common complication in the axillary artery group was hyperperfusion syndrome of the ipsilateral upper extremity (n = 20, 24.7%), followed by bleeding from the arterial outflow graft (n = 14, 17.3%). Lower extremity ischemia and fasciotomy were more frequent after femoral arterial cannulation (n = 27, 16%, and n = 18, 10.8%, respectively). The predictors for a poor in-hospital outcome for the entire group of patients were age and postoperative cerebral vascular accident. The cannulation method was not a predictor of in-hospital outcomes.nnnCONCLUSIONSnExtracorporeal membrane oxygenation support with side graft axillary artery technique was more frequently associated with hyperperfusion syndrome than other cannulation sites. Lower extremity ischemia and compartment syndrome was more common after femoral arterial cannulation.

Combined Heart and Liver Transplantation: The Cleveland Clinic Experience

BACKGROUNDnCombined heart-liver transplantation (CHLT) has been utilized as a life-saving procedure in those with end-stage cardiac and hepatic pathology. Techniques and outcomes of this procedure are varied. We sought to review the Cleveland Clinic experience with CHLT.nnnMETHODSnThis study is a retrospective chart review of patients who received simultaneous heart and liver transplantation between January 2006 and December 2012.nnnRESULTSnFive patients received CHLT. The mean age was 49 (± 20) years. All cardiac pathology was nonischemic cardiomyopathy, with a mean ejection fraction of 0.36 (± 0.13). Three of the 5 were on preoperative inotropic support, 1 of which required placement of a total artificial heart for support pretransplant. Liver pathology was amyloid in 1 patient and hepatitis C in the remaining 4. Mean Model for End-Stage Liver Disease score was 17 (± 5), and mean Childs-Pugh score was 8 (± 1). Survival, now at a mean of 38 (± 20) months remains 100%, with no cardiac or hepatic graft dysfunction or episodes of rejection. One hospital readmission was required for gastroenteritis at 15 months posttransplant.nnnCONCLUSIONSnThese results suggest that excellent outcomes can be achieved in this extremely sick cohort of patients, and add to the growing literature of perioperative management of CHLT recipients.

Impact of nutritional state on lung transplant outcomes

BACKGROUNDnWhen high-risk lung transplant candidates are evaluated, nutritional state is often neglected. We evaluated the prevalence of markers reflecting pre-transplant malnutrition and their association with post-operative complications and death.nnnMETHODSnFrom January 2005 to July 2010, 453 patients underwent primary lung transplantation at our institution. Pre-operative nutrition-related variables, including body mass index and weight/height ratio, reflecting cachexia, and albumin, total protein, immunoglobulins, and absolute lymphocyte count were considered in identifying risk factors for time-related major post-operative complications (renal failure requiring dialysis, respiratory failure requiring tracheostomy), pulmonary or bloodstream infections, and death.nnnRESULTSnForty-eight patients had BMI <18.5 kg/m(2), 41 had a weight/height ratio ≤ 0.3, 102 had albumin <3.5 g/dl, 110 had total protein <6 g/dl, and 112 had an absolute lymphocyte count <1,000/μl, indicative of a malnourished state. At 6 months, 30% had experienced pulmonary infection, with lower total serum protein concentration an important risk (p = 0.02). One-year actuarial mortality was 15%; risk factors included lower serum albumin (p = 0.004), particularly when <3 g/dl. In contrast, variables reflecting nutritional state were not statistically significantly correlated with dialysis, respiratory failure requiring tracheostomy, or bloodstream infections.nnnCONCLUSIONnAlthough malnutrition is uncommon in lung transplant patients, those at extremes of low serum albumin and total protein have worse survival and increased risk of post-operative infection. Strategies to improve nutrition of these high-risk candidates awaiting lung transplantation should be developed.

Outcomes associated with surgical management of infections related to the HeartMate II left ventricular assist device: Implications for destination therapy patients.

outcomes among patient groups in which the results are sub-optimal. We believe that immunosuppression protocols, as currently practiced, are sub-optimal for young adults and should be changed. Among young adults, it may be argued that the increased rates of rejection death can be attributed to non-compliance and/or transition from pediatric to adult care. Although there likely exist subgroups within this demographic range that are at higher risk for these reasons, the magnitude of the observed effect is not likely explained solely on the basis of compliance. The outcomes data suggest that studies addressing optimal levels of immunosuppression in this group should be implemented immediately.

Omental flap transposition with intra-abdominal relocation for LVAD pump-pocket infection

be associated with wound morbidity in young patients with end-stage congenital cardiac failure, due to the need for hosting the device in unconventional abdominal positions. The findings from this case suggest that the use of continuous-flow LVADs, such as the HeartMate II, which presents dramatic miniaturization with totally intrathoracic insertion, is feasible in patients with isolated dextrocardia without incurring additional wound morbidity. Furthermore, stable and satisfactory performance of the assist device in addition to significant clinical improvement may be expected well after device insertion.

Fate of retained right ventricular assist device outflow grafts after right ventricular recovery.

(BNP-32) in severe human heart failure. Proc Natl Acad Sci USA 2005;102:17442-7. 5. Arabia FA, Copeland JG, Smith RG, et al. International experience with the CardioWest total artificial heart as a bridge to heart transplantation. Eur J Cardiothorac Surg 1997;11(suppl): S5-10. 6. Copeland JG, Smith RG, Arabia FA, et al. Total artificial heart bridge to transplantation: a 9-year experience with 62 patients. J Heart Lung Transplant 2004;23:823-31. 7. El-Banayosy A, Arusoglu L, Morshuis M, et al. CardioWest total artificial heart: Bad Oeynhausen experience. Ann Thorac Surg 2005;80:548-52.

Ambulatory Extracorporeal Membrane Oxygenation with Subclavian Venoarterial Cannulation to Increase Mobility and Recovery in a Patient Awaiting Cardiac Transplantation

Venoarterial extracorporeal membrane oxygenation (ECMO) can provide temporary cardiopulmonary support for patients in hemodynamic extremis or refractory heart failure until more durable therapies—such as cardiac transplantation or a left ventricular assist device—can be safely implemented. Conventional ECMO cannulation strategies commonly employ the femoral artery and vein, constraining the patients to the supine position for the duration of ECMO support. We have recently adopted a modified cannulation approach to promote patient mobility, rehabilitation, and faster recovery and to mitigate complications associated with femoral arterial cannulation, such as limb ischemia and compartment syndrome. This technique involves cannulation of the subclavian artery and vein. The current case report details our recent experience with this approach in a critically ill patient awaiting cardiac transplantation.

Using extracorporeal membrane oxygenation support preoperatively and postoperatively as a successful bridge to recovery in a patient with a large infarct-induced ventricular septal defect

Rupture of the ventricular septum during acute myocardial infarction usually occurs within the first week. The event is usually followed by low cardiac output, heart failure, and multiorgan failure. Despite the many advances in the nonoperative treatment of heart failure and cardiogenic shock, including the intra-aortic balloon pump and a multitude of new inotropic agents and vasodilators, these do not supplant the need for operative intervention in these critically ill patients. This article describes the successful use of extracorporeal membrane oxygenation support as a bridge to recovery postoperatively in a patient with a large infarct-produced ventricular septal defect.

Heart transplantation in the Ehlers-Danlos syndrome.

We describe a woman with Ehlers-Danlos syndrome and aortic aneurysm who experienced a myocardial infarction due to spontaneous left circumflex coronary artery dissection 3 weeks postpartum. She developed end-stage heart failure and subsequently underwent a successful orthotopic heart transplantation. To our knowledge, this is the first report of a heart transplant performed in an individual with Ehlers-Danlos syndrome.

Fat in the ventricular septum.

Described herein is a 68-year-old man who underwent cardiac transplantation for severe chronic heart failure resulting from ischemic cardiomyopathy. Examination of the excised heart showed not only extensive left ventricular scarring but also a huge collection of adipose tissue in the subepicardial region and surprisingly also in the ventricular septum. The finding of fat in the ventricular septum is extremely rare and prompted this report.