First pediatric transatlantic air ambulance transportation on a Berlin Heart EXCOR left ventricular assist device as a bridge to transplantation.

INTRODUCTION: Mechanical circulatory devices are indicated in patients with refractory cardiac failure as a bridge to recovery or to transplantation. Whenever required, transportation while on mechanical support is a challenge and still limited by technical restrictions or distance. CASE REPORT: We report the first pediatric case of transatlantic air transportation on a Berlin Heart EXCOR ventricular assist device (Berlin Heart, Berlin, Germany) of a 13-yr-old American female who presented in cardiogenic shock with severe systolic dysfunction while vacationing in France. Rapid hemodynamic deterioration occurred despite maximal medical treatment, and she was supported initially with extracorporeal membrane oxygenation converted to a Berlin Heart EXCOR left ventricular assist device. Long-distance air transportation of the patient was accomplished 3 wks after implantation from Marseille, France, to Denver, Colorado. No adverse hemodynamic effects were encountered during the 13.5-hr flight (8770 km). The patient did not recover sufficient cardiac function and underwent successful orthotopic heart transplantation 3 months after the initial event. CONCLUSIONS: Our experience suggests that long-distance air transportation of pediatric patients using the Berlin Heart EXCOR mobile unit as a bridge to recovery or transplantation is feasible and appears safe.

Laparoscopic total esophagogastric dissociation.

The total esophagogastric dissociation (Bianchi's procedure) is used to control the severe gastroesophageal reflux in patients after failure of the fundoplication techniques. The laparoscopic approach can be usefully performed in patients with impaired respiratory function. We report here 2 patients in whom the total esophagogastric dissociation has been entirely performed by laparoscopy. The laparoscopic examination of the proximal esojejunal anastomosis is made feasible using an intestinal clamp placed to avoid the esophageal retraction up into the posterior mediastinum. The principal complication after this surgery is the risk of internal hernia.

Absence of rapid deployment extracorporeal membrane oxygenation (ECMO) team does not preclude resuscitation ecmo in pediatric cardiac patients with good results.

We evaluated the results of using extracorporeal membrane oxygenation (ECMO) as resuscitation for cardiac patients undergoing cardiopulmonary resuscitation (CPR) in our setting where neither perfusionists nor surgeons are always on site, and no circuit may be ready. Between 2003 and 2006, we used ECMO for all cardiac patients who underwent cardiac arrest in the pediatric intensive care unit (PICU) or Cath Laboratory. We reviewed retrospectively 14 consecutive files (15 episodes). Mean CPR time before ECMO institution was 44 minutes (10-110 minutes). The surgeons, perfusionist, and scrub nurse, not on site for three of these patients, had to be called in simultaneously with institution of CPR. Two died on ECMO, the third one was successfully transplanted after 5 days. Globally, 10 patients could be weaned (66%). Eight patients (57%) survived to hospital discharge, seven without obvious neurological damage. One patient was bridged to a left ventricular assist device (LVAD) and was eventually successfully transplanted. He had an ischemic brain lesion with good recuperation and no sequel. We obtained good results with resuscitation ECMO in our setting where a permanently on-site rapid deployment ECMO team is not present at all times.

Current outcome of elective open repair for infrarenal abdominal aortic aneurysm.

The outcome of conventional elective open repair for infrarenal abdominal aortic aneurysm (AAA) has improved mainly as a result of screening to detect coronary artery disease, the main risk factor for morbidity and mortality. Our group's policy is to perform routine coronary angiography in patients scheduled to undergo elective AAA repair. The purpose of this study was to evaluate morbidity and mortality in our department using this work-up strategy. From January 1990 to December 2000 we performed elective open repair on 632 patients, including 580 men (92%) and 52 women (8%). Preoperative coronary angiography performed in 607 cases (96%) revealed significant coronary disease in 53% of patients and led to the decision to propose prior myocardial revascularization in 12.5% of cases. Mortality and morbidity in the first 30 days after AAA repair were 1.4% and 15%, respectively. Analysis with the Cox model showed that the only risk factor for mortality was chronic renal insufficiency. Our data support routine use of coronary angiography prior to AAA repair. Screening and, if necessary, treatment of coronary artery disease that is commonly associated with AAA enhances the outcome of open AAA repair.