Benefit of extracorporeal membrane oxygenation in myocardial infarction-induced cardiogenic shock.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is frequently used for emergency support in patients with profound cardiogenic shock (CS) of all etiologies. However, no controlled study investigating ECMO in myocardial infarction (AMI)-induced CS is available. METHODS: Retrospective analysis of patients experiencing AMI induced CS; ECMO therapy vs. non ECMO therapy. A total of 476 patients with AMI-induced CS were investigated. One hundred twenty-seven patients (26.7%) received emergency veno-arterial ECMO support, 349 patients did not receive ECMO support. Patients were propensity score matched based on relevant clinical and laboratory factors and revealed 127 matched pairs. RESULTS: Mean age of patients was 65.0±12.3 years and mean Syntax score was 25.9±7.3 in the full unmatched patient population. Survival at 1, 3 and 5 years after CS was 45.6%, 43.5%, and 41.3% in the ECMO group and 17.4%, 15.8%, and 14.9% in the full unmatched control group (log-rank: P<0.001). After propensity score matching, 1-, 3-, and 5-year survival was 14.4%, 13.5%, and 11.2% in the matched control group (P<0.001). Cox regression analysis identified ECMO support (HR: 2.57; 95% CI: 1.89-3.50; P<0.001) and completeness of revascularization (HR: 1.89; 95% CI: 1.74-2.34, P=0.003) to be independent predictors for long term survival. CONCLUSIONS: Extracorporeal life support by ECMO significantly increased survival in patients with AMI-induced CS. ECMO insertion increased survival probability 2.57-fold and should be considered as first line treatment in patients with profound AMI-induced CS.

Minimally invasive redo-aortic valve replacement.

Bioprosthetic aortic valves have been used with increasing frequency over the past two decades, often in relatively young patients who may eventually require aortic valve re-operations due to degeneration of the bioprosthesis. Growing experience with minimally invasive aortic valve replacement has prompted surgeons to use minimally invasive approaches also with redo operations for replacement of the aortic valve.  This tutorial describes the operative steps for a minimally invasive redo replacement of the aortic valve through an upper ministernotomy. We demonstrate the surgical access, initiation of cardiopulmonary bypass, venting, and cardioplegia strategies. Special situations, such as how to approach patent coronary grafts, the small aortic annulus, and the use of sutureless or rapid deployment valves are demonstrated and discussed. The tutorial shows that minimally invasive redo aortic valve replacement is a safe, effective, and reproducible procedure.

Ventricular assist devices in patients with chemotherapy-induced cardiomyopathy: new modalities.

INTRODUCTION: Cardiotoxicity is a fatal complication of chemotherapeutic agents in which the implantation of a mechanical circulatory support system (MCS) can be a life-saving modality. The aim of this article is to analyse this available therapeutic option for patients with cardiotoxicity induced by treatment of malignancy in the light of current literature. We analysed our recent experience with MCS implantations in patients who have advanced heart failure associated with chemotherapy-induced cardiotoxicity. Methods In the hospital registries of 386 adult cardiomyopathy patients who were supported with a long-term impantable MCS in our institution between January 2008 and June 2012, were retrospectively evaluated. In 11 of these patients (mean age ?SD years; overall %; female/male (n); 42 +/- 14, 2.8%, 4/7) MCS was implemented due to chemotherapeutic drug-induced cardiomyopathy (CDIC). Pre-operative and post-operative data of CDIC patients were analysed. RESULTS: In this cohort of CDIC patients, mean duration of circulatory support was 413 ?445 days. One of the patients was successfully bridged to heart transplantation (HTx) after exclusion of possible contraindications. In one patient, left ventricular assist device (LVAD) was successfully explanted after myocardial recovery. In the late post-operative period, five patients expired due to multi-organ failure and gastrointestinal haemorrhage. The remaining 4 patients are still under follow-up on LVAD-support. One of these patients was listed for high-urgency HTx because of device-related infection. CONCLUSION: Cardiotoxicity leading to advanced heart failure is a serious complication of chemotherapeutic agents with a high risk of mortality. In our series LVAD therapy seems to be a beneficial and safe option. LVAD therapy is an acceptable option in chemotherapy-induced, advanced cardiomyopathy.

The biomarker plasma galectin-3 in advanced heart failure and survival with mechanical circulatory support devices.

BACKGROUND: During screening of heart transplantation (HTx) candidates supported by ventricular assist devices (VADs) for plasma biomarkers we found that galectin-3 (Gal-3) was increased pre-operatively in patients who later died during VAD support. Therefore, we analyzed the predictive value of plasma Gal-3 in the context of other potential clinical risk factors for death on device (DOD) in a cohort of 175 VAD patients. METHODS: We analyzed numerous clinical factors and plasma Gal-3 levels of 175 VAD patients before device implantation. Eighty VAD patients were successfully bridged to HTx (BTT, 45.7%), 80 (45.7%) died on VAD, 2 recovered on device (BTR, 1.1%) and 13 (7.4%) were still on device. Uni- and multivariate analyses were performed to assess the importance of Gal-3 with respect to other clinical factors. Myocardial gene expression of Gal-3 was investigated in apex samples by RT-PCR (n = 30) and Western blotting (n = 45). RESULTS: Plasma Gal-3 levels were higher in VAD patients than in controls (16.6 ± 9.3 vs 9.5 ± 3.9 ng/ml, p < 0.0001). Cox regression showed several clinical factors and type of VAD as independent outcome predictors, but Gal-3 was not among them. Using the regression equation we grouped patients according to their factor constellation for prediction of survival on VAD. We propose a calculation method for VAD survival prediction. Gal-3 mRNA and protein were detectable in failing myocardium, but did not correlate with its plasma concentration. CONCLUSIONS: Galectin-3 levels are associated with severe heart failure but do not provide sufficient discrimination for prediction of outcomes after VAD implantation. Importantly, we were unable to confirm myocardial tissue as a primary source for the observed plasma elevations of Gal-3.

Successful lung volume reduction surgery brings patients into better condition for later lung transplantation.

OBJECTIVES: Lung volume reduction surgery (LVRS) is accepted as a potential alternative therapy to lung transplantation (LTX) for selected patients. However, the possible impact of LVRS on a subsequent LTX has not been clearly elucidated so far. We therefore analyzed the course of 27 patients who underwent LVRS followed by LTX in our institution. METHODS: Twenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2 years) out of 119 patients who underwent LVRS between 1994 and 1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after LVRS. Based on the postoperative course of FeV1 after LVRS (best value within the first 6 months postoperatively compared with the preoperative value) patients were divided into two groups: Group A (n=11) without any improvement (FeV1 <20% increase), and Group B (n=16) with FeV1 increase > or = 20% after successful LVRS which declined to preoperative values after 8-42 months. Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients were analyzed according to the course of their functional improvement and of their body mass index (BMI) after LVRS and to survival after LTX, respectively. Values are given as the mean+/-SEM and significance was calculated by the chi(2)-test whereas continuous values were estimated by Student's t-test. RESULTS: Patients in Group A without improvement in FeV1 after LVRS had no increase in BMI as well and this resulted in a high perioperative mortality of 27.3% after LTX. On the contrary, patients in Group B, who had a clear increase of FeV1 after LVRS, experienced a significant increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement in BMI remained stable despite a later deterioration of FeV1 prior to LTX. After LTX, these patients had a significantly lower perioperative mortality of 6.3% as compared to Group A (P=0.03). CONCLUSIONS: Successful LVRS delays the need for transplantation, improves nutritional status and brings patients into a better pretransplant condition, which results in decreased perioperative mortality at LTX. Patients after failed LVRS, however, should be considered as poor candidates for later transplantation.