Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support.

BACKGROUND: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

Emergent valve replacement after circular mapping catheter entrapment in mitral valve apparatus.

We present the case of a 47-year-old male patient with a history of symptomatic paroxysmal atrial fibrillation who failed guideline-directed medical treatment and cardioversion. Electrical mapping was attempted and complicated with catheter entrapping in the mitral valve (MV) apparatus, and multiple attempts for retrieval were unsuccessful and caused severe valvular dysfunction. Emergent valve replacement was required secondary to the extensive disruption of the valvular apparatus and posterior annulus. Mapping catheter entrapment in the valvular apparatus is an uncommon complication, but when it occurs, there is a high risk of injury to the MV apparatus during retrieval. To avoid extensive MV damage, operators should use minimal force during standard manoeuvres to extract the catheter. If gentle retrieval manoeuvres fail, surgical exploration and open retrieval may prevent MV damage. Early surgical consultation and exploration could result in open catheter retrieval or MV repair versus MV replacement.

Axillary Access TAVR: Entrapment of a Transcatheter Aortic Valve in the Innominate Artery With Aortic Dissection.

Non-femoral transcatheter aortic valve replacement (TAVR) is indicated when peripheral vascular disease is diagnosed. We describe the "double-stick" technique via the axillary artery. During the procedure, the pigtail coiled around the TAVR system. While retracting the TAVR sheath, the seam along system split dislodging the valve from the balloon. The valve was entrapped in the innominate artery, and an aortic dissection required surgery. With the double-stick technique, friction and resistance between the pigtail and delivery system must be avoided. Pre-procedural planning and early identification is paramount. Smaller and more seamless delivery systems may reduce risk for dissection and entrapment.

Left Ventricular Rupture After Impella® Placement During High-Risk Percutaneous Coronary Intervention.

Ventricular perforation is a rare complication during a high-risk percutaneous coronary intervention (PCI) when supported by Impella® (Abiomed). However, instrumentation of the left ventricle several days after transmural infarct potentially increases susceptibility for perforation. While a patient is on Impella support, physicians should review ventriculograms carefully to detect perforation and should consider the presence of a decompressed ventricle, the absence of normal systolic pressure and the movement of contrast from the ventricle into the aorta bypassing the left ventricular ejection. Immediate removal of the Impella if a perforation occurs must be avoided. Retrieving the device would risk a catastrophic bleed, while alternative repair techniques are available. Here, we describe a patient with a left ventricle perforation that occurred during a high-risk PCI supported by an Impella device. ANNOTATED SUMMARY: The repair of a left ventricle perforation during high-risk PCI in a patient who had an unrecognized left ventricular perforation is described. Physicians are encouraged to carefully review ventriculograms to identify the subtle changes that can indicate a perforation. Further, immediate removal of the temporary LVAD should be avoided to minimize the risk of catastrophic bleeds.

Total Artificial Heart Salvage of a Heterotopic Heart Transplant Patient.

Rescuing heterotopic heart transplantation (HHT) patients remains a challenge in the field. When a 41-year-old patient was transferred to our service, we chose a novel approach that is reported herein. The HHT had been performed over 20 years ago, and in 2016, because of complications, the patient was listed for transplant with a 1A status. For the first time, the SynCardia 50cc total artificial heart (TAH) (SynCardia Systems, LLC, Tucson, AZ) was used in an HHT patient. Investigators attained approval to use the SynCardia 50cc investigational device, as this was an emergent case with few options. The donor heart from the HHT was left in place, alongside the TAH. By leaving the donor heart from the HHT, the need for long and tedious extensive dissection around the right lung was eliminated; thereby reducing the potential risk of lung parenchymal injury, massive bleeding, and complex air leaks. The procedure was successful, and the patient underwent a successful orthotopic heart transplantation six months after being placed on TAH.

Left Ventricular Assist Device Outflow Graft Obstruction: A Case Series.

Dysfunction of different components within continuous-flow (CF) left ventricular assist device (LVAD) systems may cause adverse cardiovascular and end-organ sequelae. Outflow graft obstruction is a recognized type of LVAD component dysfunction. Ten patients were admitted and treated for LVAD outflow graft obstruction. Two of these patients subsequently developed recurrent outflow graft obstruction requiring reintervention; however, each reoccurrence was at a different site than the original obstruction. Thus, a total of 12 cases of obstruction were analyzed. The most common reasons for hospital admission were low flow LVAD alarms or decompensated heart failure. Presentation with outflow graft obstruction occurred an average of 3.0 years after LVAD implantation. Patients underwent echocardiographic evaluation at the time of admission. Left ventricular assist device component dysfunction was suspected based on echocardiographic findings, and follow-up contrast studies were used to establish the specific diagnosis of outflow graft stenosis. The majority of stenotic lesions (10/12) were treated percutaneously with balloon angioplasty and stenting with balloon-expandable endovascular prostheses. Postintervention, all patients had significant improvement in LVAD flow rates.

Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era.

IMPORTANCE: Recent trials of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for multivessel disease were not designed to detect a difference in mortality and therefore were underpowered for this outcome. Consequently, the comparative effects of these 2 revascularization methods on long-term mortality are still unclear. In the absence of solid evidence for mortality difference, PCI is oftentimes preferred over CABG in these patients, given its less invasive nature. OBJECTIVES: To determine the comparative effects of CABG vs PCI on long-term mortality and morbidity by performing a meta-analysis of all randomized clinical trials of the current era that compared the 2 treatment techniques in patients with multivessel disease. DATA SOURCES: A systematic literature search was conducted for all randomized clinical trials directly comparing CABG with PCI. STUDY SELECTION: To reflect current practice, we included randomized trials with 1 or more arterial grafts used in at least 90%, and 1 or more stents used in at least 70% of the cases that reported outcomes in patients with multivessel disease. DATA EXTRACTION: Numbers of events at the longest possible follow-up and sample sizes were extracted. DATA SYNTHESIS: A total of 6 randomized trials enrolling a total of 6055 patients were included, with a weighted average follow-up of 4.1 years. There was a significant reduction in total mortality with CABG compared with PCI (I2 = 0%; risk ratio [RR], 0.73 [95% CI, 0.62-0.86]) (P < .001). There were also significant reductions in myocardial infarction (I2 = 8.02%; RR, 0.58 [95% CI, 0.48-0.72]) (P < .001) and repeat revascularization (I2 = 75.6%; RR, 0.29 [95% CI, 0.21-0.41]) (P < .001) with CABG. There was a trend toward excess strokes with CABG (I2 = 24.9%; RR, 1.36 [95% CI, 0.99-1.86]), but this was not statistically significant (P = .06). For reduction in total mortality, there was no heterogeneity between trials that were limited to and not limited to patients with diabetes or whether stents were drug eluting or not. Owing to lack of individual patient-level data, additional subgroup analyses could not be performed. CONCLUSIONS AND RELEVANCE: In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality and myocardial infarctions and to reductions in repeat revascularizations, regardless of whether patients are diabetic or not. These findings have implications for management of such patients.