Cardiogenic shock: collaboration between cardiac surgery and cardiology subspecialties to bridge to recovery.

Acute cardiogenic shock is a lethal condition that results in death from myocardial failure, arrhythmia, or combinations of both. Aggressive medical, surgical, and interventional maneuvers have helped reduce the mortality. For the most advanced cases, ventricular assist devices have been used for persistent shock states. The purpose of this report is to describe the collaboration between cardiac surgery and cardiology subspecialty in an effort to promote native heart recovery in a complex case of cardiogenic shock requiring coronary artery bypass surgery, percutaneous coronary intervention, ventricular ablative therapy, and mechanical cardiac support.

Incorporation of an in-line filter for ultrafiltration or hemodialysis to the Abiomed BVS5000 ventricular assist device.

Multiple organ system dysfunction is an associated finding in patients requiring acute ventricular assist device (VAD) support. In the setting of acute renal failure, percutaneous catheters are placed for hemodialysis and/or ultrafiltration. Incorporation of an ultrafiltration or hemodialysis system in the Abiomed BVS5000 VAD circuit is a simple maneuver that eliminates the need for an additional catheter, thereby reducing the vascular and infectious complications associated with these catheters. We recommend splicing connectors into the outflow tubing of the right VAD circuit for attachment to an ultrafiltration or hemodialysis unit. This technique is a safe, simple, and reliable method by which to perform intermittent or continuous ultrafiltration or hemodialysis.

The Thoratec Implantable Ventricular Assist Device (IVAD): initial clinical experience.

BACKGROUND: The Thoratec Implantable Ventricular Assist Device (IVAD) is the only FDA-approved intracorporeal biventricular cardiac assist device. It is a titanium-coated version of its predecessor, the Paracorporeal Ventricular Assist Device (PVAD). The blood pump is compatible with the portable TLC-II driver, making home discharge feasible. METHODS: Nine consecutive patients were implanted with the IVAD from June 2005 through March 2006. The indications for support were acute heart failure in 6 cases and chronic heart failure in 3 cases. All patients were managed with maximal medical therapies including intravenous inotropic drugs prior to implant. RESULTS: All patients survived the surgical implant. Six patients were considered successful: 3 patients discharged to home and subsequently received transplantation, 2 are awaiting transplantation (1 at home and 1 in-house), and 1 patient was successfully explanted. Three patients expired postoperatively because of multiple organ system failure (2 patients) and pulmonary hemorrhage (1 patient). There were no device malfunctions. There was 1 localized driveline site infection and 1 thromboembolic event with partial visual loss. CONCLUSIONS: The IVAD is a unique device capable of providing uni- or bi-ventricular support for either acute or chronic heart failure conditions. Its versatility permits bridge to transplant or recovery options. Home discharge is feasible.

Cognitive dysfunction in advanced heart failure and prospective cardiac assist device patients.

BACKGROUND: Extended periods of hypoperfusion in an advanced heart failure (HF) places patients at high risk for neurobehavioral compromise, which has not been studied systematically. It is also not clear how intravenous inotropic therapy and mechanical cardiac assist devices (MCAD) affect cognitive function. METHODS: This prospective cross-sectional cognitive preliminary study evaluated 252 potential heart transplant candidates assessing functions in memory, motor, and processing speed. Patients were divided into three HF groups based on severity of disease: group 1 outpatients (n = 113), group 2 in-patients requiring inotropic infusion (n = 83), and group 3 inpatients likely requiring MCAD support (n = 56). Aggregate z-scores for memory, motor, and processing speed and independent samples t tests assessed intergroup differences on 13 cognitive measures. RESULTS: A broad pattern of cognitive impairment was observed within the advanced HF group; fewer deficits were found in group 1 outpatients and more severe deficits in group 3 MCAD subjects. A difference in motor functions was observed as the earliest abnormality, with group 3 showing significant changes compared with group 1. The most dramatic changes were seen in domain mental processing speed along with specific verbal and visual memory functions, which were slower in group 3 compared with groups 1 and 2. CONCLUSIONS: Cognitive deficits are common in advanced HF and worsen with increasing severity of HF. Appropriately designed and randomized studies will be needed to demonstrate if earlier MCAD implantation is warranted to arrest cognitive dysfunction and better postimplantation adaptation.

Initial experience with the Abiomed AB5000 ventricular assist device system.

PURPOSE: We describe our initial experience with the Abiomed AB5000 ventricular assist device (VAD). DESCRIPTION: The Abiomed AB5000 VAD is a system recently approved by the Food and Drug Administration that consists of a fully automatic, vacuum-assisted console and a paracorporeal, pneumatically driven blood pump. The VAD is designed for short or intermediate term use. The console is designed to support the BVS5000 or AB5000 blood pumps. The cannulas and implantation are similar to the BVS5000 system. EVALUATION: Four cases are described in which two AB5000 systems were placed de novo and two were transitioned from previously placed BVS5000 units. Hemolysis was observed in 2 cases. The AB5000 VAD flows were generally 4.0 to 4.5 L/min, approximately 0.5 L/min less than the BVS5000. Echocardiography demonstrated high-velocity jets from the inflow cannula in the 2 hemolysis cases. One patient died of multiorgan system failure while on support, 2 were successfully weaned from support and transferred to long-term care facilities, and 1 was weaned from support and successfully discharged to home. CONCLUSIONS: The AB5000 VAD is a versatile paracorporeal pneumatic VAD that can be placed de novo or transitioned from a previously placed BVS5000 unit without the need for additional surgery. Lower outputs, high-velocity jets, and hemolysis were observed in 2 of 4 cases. Modifications in cannulas design and placement as well as console reconfigurations may be necessary to optimize performance.

Transmyocardial laser revascularization as sole reoperative therapy following late anginal recurrence: case report.

A case of recurrent angina 3 years following sole therapy transmyocardial laser revascularization (TMR) is described. Repeat sole therapy TMR with the Holmium:YAG system was performed and resulted in complete and immediate angina relief. Repeat TMR should be considered in patients with angina recurrence who underwent primary TMR.

Selective use of amiodarone and early cardioversion for postoperative atrial fibrillation.

BACKGROUND: Postoperative atrial fibrillation (AF) occurs in 20%-40% of patients undergoing open-heart surgery. Numerous pharmacological and electrical therapies have been used as a prophylaxis to prevent this dysrhythmia. The purpose of this study was to examine the selective use of amiodarone and early cardioversion (CVN) postoperatively to restore normal sinus rhythm (NSR). METHODS: A retrospective nonrandomized review of patients who received amiodarone and early electrical CVN (study group) for postoperative AF after coronary artery bypass grafting (CABG) were compared with patients who received nonamiodarone therapies (control group). The study group received 150 mg of amiodarone bolus intravenously and thereafter received an infusion of 1 g over a 24-hour period. If NSR was established within 24 hours, then the intravenous (IV) infusion was continued for another 24 hours with concomitant oral amiodarone overlap. If NSR was not established within 24 hours, then external electrical CVN was performed. After 48 hours, the IV infusion was discontinued and the oral regimen maintained through discharge. Control group patients received either combination digoxin and procainamide or diltiazem. Postoperative beta-blocker administration was instituted in all patients. RESULTS: Six-hundred forty consecutive CABG patients were examined between July 1995 and June 2003. Postoperative AF developed in 160 of these patients (25%). One-hundred patients constituted the study group and 60 patients represented the control group. Restoration of NSR within 24 and 48 hours occurred in 79 (79%) and 90 patients (90%) for the study group, respectively, compared with 38 (64%) and 44 patients (73%) for the control group, respectively. The presence of NSR at discharge was achieved in 98 study patients (98%) and 50 control patients (83%). The length of stay (LOS) for the study and control patients was 7.4 and 9.1 days, respectively. There was no mortality in either group. CONCLUSIONS: Amiodarone and early CVN was more effective than nonamiodarone therapies with regard to restoring NSR for patients in whom AF developed after elective CABG. A trend toward a decrease in LOS was observed in the study group, but was not statistically significant. The overall LOS using amiodarone therapy with early CVN was similar to postoperative AF for patients in whom the condition did not develop.

Complications following placement or extraction of endovascular pacemaker and defibrillator leads--cardiothoracic surgical intervention: case reports.

Complications related to the insertion or removal of permanent pacemakers and implantable cardiac defibrillators are rare events. However, when adverse events occur, their severity may be life threatening. Rapid recognition of a problem followed by prompt consultation with a cardiothoracic surgeon is necessary to stabilize potentially catastrophic events. The immediate availability of surgical instruments as well as a formalized algorithm for management is necessary to control hemorrhagic situations. Four case reports illustrate these points.

Psychosocial and sexual concerns of patients with implantable left ventricular assist devices: a pilot study.

OBJECTIVE: We sought to determine the psychosocial and sexual concerns of patients discharged from the hospital with implantable left ventricular assist devices. METHODS: Bridge-to-transplant patients with the Heartmate left ventricular assist device received a psychosocial and sexual survey at 1 month after discharge from the hospital. The survey consisted of 3 parts, with 5 questions in each category. The patients were asked to complete the survey by circling the responses and to provide more detailed answers when necessary. RESULTS: There were 8 male patients who completed the questionnaire. Psychologically, all patients expressed a positive mood and found support from family or religious sources. The majority described a change in attitude and behavior. Socially, all patients described a change in lifestyle, as well as a change in the reaction of family and friends. No patient went back to work or had the desire to return to work until after transplantation. The minority of patients admitted to smoking or drinking. Sexually, the majority had the desire or participated in sexual activities. The majority of patients either used or were interested in using sexual stimulants. There were no mechanical problems with the left ventricular assist devices. CONCLUSIONS: Psychosocial and sexual conditions are altered in patients with heart failure who are discharged with implantable left ventricular assist devices. At 1 month's time interval, there is an improvement in mood, an adjustment in lifestyle, and a positive shift in relations with family and friends. There is sexual desire, with interest in sexual-enhancing medication. The most common concern is related to the pump, such as the durability of the device or damage to the components.

Outpatient management of long-term assist devices.

Current VAD technology has enabled patients to be safely discharged from hospital, awaiting transplantation in the setting of their home. The results of recent studies have proven that patients on LVADs as destination therapy fare better than their medical counterparts and enjoy a higher quality of life. The lessons learned thus far in the outpatient management of LVADs has convinced the medical and non-medical communities that this form of therapy is more than feasible in addressing the epidemic of heart failure. Newer devices are on the horizon. It is inevitable that more patients will be visible in the streets and workplace as the modifications in size and application become more user friendly. It will be our responsibility, as the guardians of this technology, to use it wisely and provide the support that is necessary for this special population of people.

The AbioCor totally implantable replacement heart.

An artificial heart with adequate circulatory support and an acceptable quality of life remains one of the holy grails of heart failure medicine and surgery. The totally implantable AbioCor is powered electrically via an external power source and has no skin-piercing cables. To date, seven critically ill patients with end-stage heart failure have been implanted with it. Four patients survived beyond 2 months, and two patients were discharged from the hospital. Both enjoyed improved quality of life with frequent social excursions; another patient is about to be discharged. While three patients died, early trials suggest that this device holds promise.

Ventricular assist device support for management of sustained ventricular arrhythmias.

We describe herein the cases of 2 patients who had ventricular arrhythmias. In one, a short-term biventricular assist device, the ABIOMED BVS 5000, was placed because the patient had sustained ventricular tachycardia and could not be weaned from cardiopulmonary bypass. Excellent hemodynamic support was maintained for several days while the antiarrhythmic therapy was maximized. Sinus rhythm was restored, and the patient was successfully weaned from the ventricular assist device. However, the substrate for the arrhythmia persisted, and a recurrence, 1 week later, resulted in the patient's death. In the 2nd patient, the use of an implantable left ventricular assist device was successful in temporarily alleviating the ventricular tachycardia associated with ischemic cardiomyopathy. However, after 2 days of device assistance, the patient experienced a recurrence of the tachycardia, which degenerated into ventricular fibrillation with a marked deterioration in the patient's hemodynamics. The arrhythmia persisted despite multiple attempts at external cardioversion, and internal cardioversion and placement of an automatic implantable cardioverter-defibrillator were necessary. This treatment, along with repeated boluses of amiodarone, led to successful suppression of the arrhythmias, and the patient eventually underwent transplantation. The mechanical hemodynamic support of the circulation by ventricular assist devices was effective in supporting these 2 patients who had sustained ventricular arrhythmias.