Victor Pretorius

Pulmonary Endarterectomy: Recent Changes in a Single Institution's Experience of More Than 2,700 Patients

BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a known sequela of acute pulmonary embolic disease and yet remains underdiagnosed. Although nonsurgical options for patients with CTEPH have become increasingly available, including pulmonary artery hypertensive medical therapy, surgical endarterectomy provides the most appropriate intervention as a potential cure for this debilitating disorder. This article summarizes the most recent outcomes of pulmonary endarterectomy at a single institution over the past 12 years, with emphasis on the surgical approach to segmental-level chronic thromboembolic disease. METHODS More than 2,700 pulmonary endarterectomy operations have been performed at the University of California, San Diego Medical Center. Because of recent changes in the patient population and in surgical results, 1,500 patients with symptomatic chronic thromboembolic disease who underwent pulmonary endarterectomy between March 1999 and December 2010 were analyzed. The outcomes for the more recent 500 patients, compared with the previous 1,000 were studied. RESULTS In-hospital mortality for the cohort of 1,000 patients (group 1) was 5.2% compared with 2.2% for the last 500 operations (group 2) (p < 0.01). There was no mortality in the last 260 consecutive patients undergoing isolated pulmonary endarterectomy. More patients presented with segmental type III disease in the more recent 500 patients (21.4% versus 13.1%; p < 0.001). Between the 2 patient groups, there was a comparable decline in pulmonary vascular resistance (PVR) (group 1: 861.2 ± 446.2 to 94.8 ± 204.2 dynes/sec/cm(-5); group 2: 719.0 ± 383.2 to 253.4 ± 148.6 dynes/sec/cm(-5)) and mean pulmonary artery (PA) pressures (group 1: 46.1 ± 11.4 to 28.7 ± 10.1 mm Hg; group 2: 45.5 ± 11.6 to 26.0 ± 8.4 mm Hg) after endarterectomy. CONCLUSIONS Despite a patient population with more distal disease, results continue to improve. Pulmonary endarterectomy for patients with CTEPH results in significant pulmonary hemodynamic improvement, with favorable outcomes achievable even in patients with distal segmental-level chronic thromboembolic disease.

Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction

AIMS After extraction of an infected cardiac implantable electronic device (CIED) in a pacemaker-dependent patient, a temporary pacemaker wire may be required for long periods during antibiotic treatment. Loss of capture and under sensing are commonly observed over time with temporary pacemaker wires, and patient mobility is restricted. The use of an externalized permanent active-fixation pacemaker lead connected to a permanent pacemaker generator for temporary pacing may be beneficial because of improved lead stability, and greater patient mobility and comfort. The aim of this study was to investigate the efficacy and safety of a temporary permanent pacemaker (TPPM) system in patients undergoing transvenous lead extraction due to CIED infection. METHODS AND RESULTS Of 47 patients who underwent lead extraction due to CIED infection over a 2-year period at our centre, 23 were pacemaker dependent and underwent TPPM implantation. A permanent pacemaker lead was implanted in the right ventricle via the internal jugular vein and connected to a TPPM generator, which was secured externally at the base of the neck. The TPPM was used for a mean of 19.4 ± 11.9 days (median 18 days, range 3-45 days), without loss of capture or sensing failure in any patient. Twelve of 23 patients were discharged home or to a nursing facility with the TPPM until completion of antibiotic treatment and re-implantation of a new permanent pacemaker. CONCLUSION External TPPMs are safe and effective in patients requiring long-term pacing after infected CIED removal.

Device Infections Management and Indications for Lead Extraction

An 83-year-old woman is referred for lead extraction as a result of pacemaker pocket infection. She has a history of atrial fibrillation and complete heart block after an AV node ablation. A left-sided pacemaker was placed in 2007. One month before admission, she developed urosepsis, followed by an infection of the pacemaker pocket. Blood cultures revealed methicillin-sensitive Staphylococcus aureus . She was admitted to an outside institution where the device was removed, but the leads were left in place after a failed attempt to remove the leads with traction alone. A new single-chamber pacemaker was placed on the right side. On presentation to our institution, the patient appeared quite ill. Physical examination documented congestive heart failure and evidence of pocket infection at sites on both the right and left sides of the chest. Serum chemistry was significant for worsening renal function. A chest x-ray demonstrated a large right pleural effusion. The patient was taken to the hybrid operating room for further management. A transesophageal echocardiogram performed under general anesthesia showed a large pericardial effusion compromising ventricular filling, and a pericardial drain was placed. A temporary pacing wire was placed in the right ventricular apex via a femoral approach. The recently implanted right-sided pacemaker system could then be removed with traction under fluoroscopic guidance. The 2 left-sided leads were extracted with locking stylets and a laser sheath. Both wounds were extensively debrided, and bilateral wound vacuums were placed. An active fixation pacemaker lead was then placed via a right internal jugular approach and connected to a previously used, resterilized pacemaker to provide temporary/permanent right ventricular pacing. Finally, a right-sided chest tube was placed. The patient remained hospitalized for 2 weeks for management of her infected pacemaker sites and sepsis, with her initial care in the intensive care unit and with collaboration …

Case 13--2014: Management of pulmonary hemorrhage after pulmonary endarterectomy with venovenous extracorporeal membrane oxygenation without systemic anticoagulation.

From the *University of California, San Diego, Thornton Hospital, †University of Chicago, Chicago, IL, ‡University of Pittsburgh, Pittsburgh, PA; and §Duke University Medical Center, Durham, NC. Address reprint requests to Brett Cronin, MD, Dept. of Anesthesiology, University of California, San Diego, Thornton Hospital, 9300 Campus Point Drive #7770, La Jolla, CA 92037. E-mail: bcronin@ ucsd.edu

CASE 1--2015: left ventricular assist device insertion in a patient with heparin-induced thrombocytopenia and renal failure.

From the *University of California, San Diego, Sulpizio Cardiovascular Center, LaJolla, CA, †Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany; and ‡Department of Anesthesiology, Queen Fabiola Children’s University Hospital, Brussels, Belgium. Address reprint requests to Sonia Nhieu, MD, University of California, San Diego, Department of Anesthesiology, Thornton Hospital, 9300 Campus Point Drive #7770, LaJolla, CA 92023-7770. E-mail: snhieu@ucsd.edu Cardiac Anesthesia Fellow. UNFRACTIONATED HEPARIN (UFH) is the most widely used intravenous drug in the United States with as many as 60% of hospitalized patients receiving this agent. The incidence of heparin-induced thrombocytopenia (HIT) is approximately 2% of patients who receive UFH. HIT syndrome type II (HIT-II) is an immune-mediated reaction in which serum antibodies against heparin-platelet factor 4 (HPF4) complexes are produced in patients who receive heparin therapy. The reaction typically develops 5 to 10 days after exposure and leads to a decrease in platelet count of 50% or more and a paradoxical hypercoagulable state. No ideal method of anticoagulation exists for patients with HIT. In non-surgical patients requiring anticoagulation and medical management of HIT, approved therapies in the United States are limited to argatroban and lepirudin. Recommendations for anticoagulation for patients with HIT requiring cardiac surgery include delaying surgery until HIT antibodies are negative, administering platelet inhibitors in addition to heparin, or using an alternative anticoagulation strategy. Unfortunately, many patients, especially those requiring cardiac surgery, cannot delay the operation, and an alternative to heparin for intraoperative anticoagulation must be used. The use of cardiopulmonary bypass (CPB) further complicates the situation because of the higher levels of anticoagulation required. Use of bivalirudin for anticoagulation in patients with HIT undergoing cardiac surgery has increased and, in a few small studies, has demonstrated a similar safety and efficacy profile compared to UFH. Bivalirudin is a synthetic, direct thrombin inhibitor made up of twenty amino acids and is approved for patients undergoing percutaneous coronary intervention. Its elimination is predominantly dependent on thrombin active site-mediated proteolytic cleavage, resulting in a short half-life of 25 minutes. Approximately 20% of the drug is excreted unchanged by the kidney, leading to a doubling of the half-life in patients with severe renal impairment. The drug’s safety profile appears unchanged, even with respect to hemorrhagic complications, in patients with moderate impairment of renal function. However, in dialysis-dependent patients, the half-life increases markedly to approximately 3 to 5 hours. While the

A Case Series of Biventricular Circulatory Support Using Two Ventricular Assist Devices: A Novel Operative Approach

Increased use of continuous-flow left ventricular assist devices (LVADs) to treat advanced heart failure has heightened concern for right ventricular failure after LVAD implantation, which is associated with increased morbidity and mortality. Biventricular support is required in up to 30% of LVAD recipients. Currently, no durable long-term right ventricular assist device (RVAD) has been approved other than the Syncardia (Tucson, AZ) total artificial heart. A recent publication reported the placement of continuous flow LVAD in the heavily trabeculated right ventricle; however, this orientation may jeopardize both assist device and right ventricle function. We describe three cases of right-sided mechanical circulatory support with durable RVAD implanted in the right atrium, allowing long-term support with fewer anatomic limitations as compared with right ventricular cannulation.

Multidisciplinary Approach to Transvenous Lead Extraction: A Single Center’s Experience

OBJECTIVE To evaluate the success and complication rates of a single centers multidisciplinary approach to transvenous lead extraction. SETTING One university hospital. PARTICIPANTS One hundred ninety-five patients scheduled for transvenous lead extraction. INTERVENTIONS A multidisciplinary approach to transvenous lead extraction involving cardiac surgery, electrophysiology, perfusion, and cardiac anesthesiology. MEASUREMENTS AND MAIN RESULTS A case series of 351 lead extractions performed in 195 patients over a 42-month period. Indications, success rates, and complication rates were tracked and retrospectively evaluated and reported. Indications for lead extraction included 53.3% because of lead malfunction, 36.9% because of infection, with the remaining 9.7% from other categories such as venous stenosis. The lead extraction rate was 99.7%, with complete removal in 97.7%. The overall major complication rate was 3.08%. After an initial 1-year period of performing lead extractions, the overall major complication rate reduced to 1.23%. CONCLUSIONS Transvenous lead extraction generally is a safe procedure, but not without complications. A multidisciplinary approach involving cardiac surgery, electrophysiology, and cardiac anesthesiology allows for successful management and the ability to rapidly manage major complications.

Prevalence of coronary artery–pulmonary artery collaterals in patients with chronic thromboembolic pulmonary hypertension

This study sought to determine the prevalence of coronary artery–pulmonary artery collaterals in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to correlate their presence with the degree of clot burden. CTEPH is a treatable cause of severe pulmonary hypertension and right heart failure. Bronchopulmonary collateral vessels have been used as a supplementary diagnostic and prognostic tool for this disease. Coronary artery–pulmonary artery collaterals in this population have not been described. The coronary angiograms of 300 consecutive patients with CTEPH evaluated for pulmonary thromboendarterectomy (PTE) between January 1, 2007, and May 1, 2014, were examined. Of these patients, 259 (50% male; mean age, 58.3 ± 10.6 years) had cineangiographic images deemed adequate to definitively assess for the presence of coronary artery–pulmonary artery collaterals and were included in the final analyses. Pulmonary angiogram reports were reviewed for extent of pulmonary artery obstruction. The coronary angiograms of 259 age- and sex-matched control patients were also examined. Among 259 CTEPH patients with definitive imaging, 34 coronary artery–pulmonary artery collaterals were found in 28 patients (10.8%), versus 1 coronary artery–pulmonary artery collateral among control subjects (0.4%; P < 0.001). Compared with CTEPH patients without collaterals, patients with collaterals had a significantly higher prevalence of total occlusion of their right or left main pulmonary artery (P < 0.001) or lobar arteries (P < 0.001). In conclusion, the prevalence of coronary artery–pulmonary artery collaterals in CTEPH patients undergoing coronary angiography for possible PTE is approximately 11%. These vessels are associated with more severe pulmonary artery occlusion.

Pocket infections of cardiac implantable electronic devices treated by negative pressure wound therapy.

AIMS Managing an infection of the pocket of a cardiac implantable electronic device (CIED) is frequently challenging. The wound is often treated with a drain or wet-to-dry dressings that allow healing by secondary intention. Such treatment can prolong the hospital stay and can frequently result in a disfiguring scar. Negative pressure wound therapy (NPWT) has been frequently used to promote the healing of chronic or infected surgical wounds. Here we describe the first series of 28 patients in which NPWT was successfully used to treat CIED pocket infections. METHODS AND RESULTS After removal of the CIED and debridement of the pocket, a negative pressure of 125 mmHg continuously applied to the wound through an occlusive dressing. Negative pressure wound therapy was continued for a median of 5 days (range 2-15 days) and drained an average of 260 mL sero-sanguineous fluid (range 35-970 mL). At the conclusion of NPWT, delayed primary closure of the pocket was performed with 1-0 prolene mattress sutures. The median length of stay after CIED extraction was 11.0 days (range 2-43 days). Virtually all infected pockets healed without complications and without evidence of recurrent infection over a median follow-up of 49 days (range 10-752 days). One patient developed a recurrent infection when NPWT was discontinued prematurely and a new device was implanted at the infected site. CONCLUSION We conclude that NPWT is a safe and effective means to promote healing of infected pockets with a low incidence of recurrent infection and a satisfactory cosmetic result.

Lead Extractions: Indications, Procedural Aspects, and Outcomes

As a result of more cardiac implantable electronic devices being placed, a trend toward increasing device infections, and concerns regarding lead malfunction, there is an increased need for lead extraction skills and comprehensive lead management programs. This review discusses the current indications for lead extractions as well as the training requirements and tools and technology needed to create the foundation for a successful lead management program.