Non-Cardiac Symptoms of Moderate to Severe Hypokalemia in a Patient with a Syncardia™ Total Artificial Heart.

The Syncardia™ total artificial heart (TAH) is an option for patients as a bridge to transplant in those who are not candidates for left ventricular assist devices (LVAD) due to right ventricular failure. Postoperative course is highly dependent on volume status and aggressive diuresis is often necessary. One complication from aggressive diuresis is hypokalemia; however, in these patients we tolerate a lower potassium level because cardiac arrhythmias are not a concern.  However, in two separate instances non-cardiac symptoms related to severe hypokalemia occurred. These symptoms included nystagmus in one patient and agitation, tremors, and having an "out-of-body" experience in the other patient. Both these patients had resolution of symptoms with potassium replacement.

Percutaneous Endoscopic Gastrostomy Tube in a Syncardia™ Total Artificial Heart.

As a bridge to transplant, the Syncardia™ total artificial heart (TAH) is an option for patients who are not candidates for left ventricular assist devices (LVAD) due to right ventricular failure. The need for nutritional support in these patients is essential for a favorable outcome. Low body mass indexes and albumin levels have been associated with increased morbidity and mortality in cardiac surgery patients [Alverdy 2003]. It is not uncommon for postoperative patients to have difficulty in consuming enough calories after surgery, which is further complicated by a hypermetabolic demand due to surgical stress. Enteral nutrition has typically been favored for gut mucosal integrity and bacterial flora [Alverdy 2003] [Engleman 1999]. We describe the need for prolonged enteral nutritional support in a TAH patient that was accomplished with a percutaneous endoscopic gastrostomy (PEG) tube.

Pump Thrombosis following HeartMate II Left Ventricular Assist Device Implantation in a Patient with Aspirin and Plavix Resistance.

Despite advances in pump technology, thromboembolic events and pump thrombosis are potentially life-threatening complications in patients with continuous flow ventricular assist devices. Here we describe a patient with pump thrombosis following LVAD HeartMate II implantation presenting with Aspirin and Plavix resistance and signs of acute hemolysis as manifested by high LDH, changing pump power, pulse index and reduced pump flows.

Bloodless lung transplantation in Jehovah's Witnesses: impact on perioperative parameters and outcome compared with a matched control group.

BACKGROUND: Jehovah's Witnesses (JW) refuse to receive blood products due to their religious beliefs. Bloodless transplantation programs have made the successful transplantation of solid organs like heart, liver, kidney, and pancreas in JW feasible. In this study we present the third and fourth case of a successful bloodless lung transplantation and analyze perioperative parameters and outcome with a strictly selected matched control group (CG). METHODS: Two JW patients suffering from idiopathic pulmonary fibrosis had single lung transplantation in the transfusion-free program. Ten of 113 patients (8.8%) undergoing lung transplantation fulfilled the matching criteria and served as CG. Perioperative parameters including blood loss and transfusions were collected from the charts. Regarding outcome parameters arterial blood gas, lung function testing, length of stay, and survival were analyzed. RESULTS: Concerning perioperative parameters no significant differences could be found between both groups except for the creatinine level, which was significantly lower in the JW group on postoperative day 0 (P = .037), and the hemoglobin and hematocrit levels, which were significantly higher in the JW group on postoperative day 3 (P = .032 and P = .041, respectively). The analysis of the outcome parameters revealed significantly higher postoperative lung functional testing values forced expiratory volume after 1 second (FEV1) and forced vital capacity (FVC) in the JW group compared with the CG (P = .037 and P = .036, respectively). CONCLUSION: Bloodless lung transplantation is feasible in carefully selected JW recipients. Comparing JW to CG, no statistically significant difference in the perioperative course and a trend towards a favorable postoperative lung function outcome were detected.

Acute and chronic thoracic aortic disease: surgical considerations.

Acute thoracic aortic aneurysm is one of the most life-threatening vascular disorders recognized to date. The majority of these aortic ruptures rapidly end in mortality, with 50% of patients suffering death before reaching the hospital. Thus, acute management through surgical intervention is often indicated, especially in cases of ascending aortic rupture. Physical examination is critical in making the diagnosis, as clinical signs and symptoms often vary depending on the location of the dissection. Clinicians should have a low threshold for including thoracic aortic dissection in their differential diagnosis, especially when a patient presents with acute onset chest or back pain. In this report, we discuss the different categories of aortic dissections and the current treatment modalities for each. These include endovascular aortic repair, which has become a viable treatment modality in certain cases of type B dissection. Offering a less invasive approach, the technique known as thoracic endovascular repair currently affords a treatment option to a patient population who would have otherwise been deemed non-surgical candidates. Hybrid thoracic endovascular aortic repair has also become a pertinent surgical technique, and successful outcomes have been demonstrated when it is employed to repair ascending aortic aneurysms. We also describe our Acute Aortic Treatment Center, a rapid multicentric triage system for the management of acute aortic pathologies, which has resulted in significant improvements in patient outcomes.

[Quality management in cardiac surgery in the USA]. / Qualitätssicherung in der Herzchirurgie in den USA.

Quality control and performance improvement in the US health care system are based on several pillars: external review is performed by either government agencies, insurance companies, or public media. In cardiac surgery the STS database forms the backbone of most of these reviews. Internal review is based on providing outcome data, establishing benchmarks for performance, and root-cause analysis of adverse events. Peer review is used to analyze major issues in providing care. Transparency of the process and of outcome numbers generated is key for the success of measurements to improve performance. Finally, education of all health care providers in the hospital is needed to provide quality care and good outcomes. Maintaining proficiency of physicians and hospital personal in pathways and procedures requires constant educational efforts and clear pathways and guidelines. Growing resources have to be dedicated to quality management. As outcome data become essential in obtaining insurance contracts and government certification the investing into a comprehensive quality assurance program will pay off.

Surgical considerations on the use of the percutaneous ventricular assist device TandemHeart in critical aortic valve stenosis.

Decompensated aortic valve stenosis is a life-threatening condition. Aortic valve replacement in patients with cardiogenic shock due to critical aortic stenosis is a high-risk procedure and is associated with increased operative mortality. We describe the clinical course of a patient who was transferred to our institution in cardiogenic shock and with multiple organ failure, due to decompensated aortic valve stenosis. The patient received the percutaneous left ventricular assist device TandemHeart which has been developed for short-term cardiac support. After hemodynamic improvement the patient underwent successful aortic valve replacement. The device was left in place until the patient had recovered from surgery. The excellent outcome suggests that a perioperative mechanical support might greatly improve the safety of aortic valve replacement in the presence of cardiogenic shock.

[Diabetes and heart transplantation]. / Diabetes und Herztransplantation.

Diabetes is frequently encountered in patients presenting with end-stage heart failure to be listed for transplantation. While diabetes used to be a contra-indication for heart transplantation, careful preoperative evaluation and individualized postoperative medication lead to long-term outcome after heart transplantation equal to non-diabetic patients. About 1/3 of transplanted patients develop a post-transplant diabetes. Several risk factors have been identified leading to this condition. Mostly, post-transplant diabetes is of temporary nature. Several studies have shown no impact of diabetes on the incidence of rejection, malignancies, and transplant vasculopathy. However, glucose intolerance must be taken into consideration when planing immunosuppressive therapy since different medications have distinct impact on glucose metabolism after transplant. A multidisciplinary team allows for closely monitoring and treating patients with diabetes after heart transplant.

Effect of acute brain death on release of atrium and B-type natriuretic peptides in an animal model.

INTRODUCTION: Atrium and B-type natriuretic peptides (ANP and BNP) and big endothelin (ET)-1 are markers for severity of heart failure and may be used in the quality assessment of donor hearts. Elevated cardiac troponins predict early graft failure after heart transplantation. This study evaluated the effects of acute brain death (BD) on the release of ANP, BNP, big ET-1, and cardiac troponins in an animal model. MATERIALS AND METHODS: Pigs were randomized into a BD group (n=5) and a control group (n=5). In the first group, acute BD was induced, and anesthesia was stopped. In the control animals, a sham operation was performed, and anesthesia was continued. Parameters were measured at baseline and for 13 hours postoperatively. RESULTS: After acute BD, there were significant hemodynamic changes. In the control group, the BNP level was higher than in the BD group and decreased over time (P =0.016). There was no significant change in BNP release in the BD group up to 13 hours (P =0.1). ANP release remained stable over time in the control group (P =0.35) but decreased in the BD group (P =0.043). The big ET-1 levels were not different between groups. Cardiac troponin I was elevated in the BD group 5 hours after BD (P< 0.05) but remained under 1.5 mg/L throughout the study. CONCLUSION: Acute BD did not lead to an increase of BNP and ANP levels. Moreover, intact brain function seems to augment the release of natriuretic peptides from the myocardium. Further clinical evaluation of prognostic values of natriuretic peptides for the assessment of donor hearts is necessary. Cardiac troponins are a useful additional tool in the evaluation of donor hearts.

Autologous plasma and platelet sequestration at the beginning of cardiopulmonary bypass: a pilot investigation in five patients undergoing extended vascular surgery in deep hypothermia.

Platelet dysfunction and loss of procoagulants and platelets leads to impaired hemostasis after cardiopulmonary bypass (CPB). Preoperative platelet sequestration delays surgery, and the large volume shifts, necessary to harvest therapeutically effective components, may be associated with hemodynamic instability. We performed platelet and plasma sequestration after the initiation of CPB during the cooling period in patients undergoing surgery in deep hypothermic cardiac arrest. Five patients who underwent major vascular surgery in deep hypothermia were enrolled in this pilot study. Platelet and plasma sequestration was performed during cooling with the CATS cell saver using the plasma sequestration set. Before processing, 2 x 1,000 ml of blood were concentrated by means of hemofiltration to reduce dilution effects of CPB. The autologous platelet concentrates were rotated at 24 degrees C, and the plasma was stored at room temperature. The harvested plasma and platelets were re-transfused during modified ultrafiltration after CPB. Platelet count, 20 mmol/L ADP stimulated platelet aggregation, and fibrinogen levels were measured preoperatively in the harvested material and in patient blood before and after transfusion. A heparinase thromboelastogram (TEG) was performed preoperatively before and after re-transfusion. There was a significant increase in the ADP stimulated platelet aggregation, platelet count, fibrinogen level, and maximum amplitude of the TEG after re-transfusion of the harvested material. No patient needed transfusion of fresh frozen plasma or random donor platelet concentrates. No patient needed re-exploration due to hemorrhage. The data presented provide evidence that autologous plasma and platelet sequestration during CPB initiation is effective. The harvested material reveals a high platelet count and fibrinogen level and preserves functional integrity.

Ventricular assist device in severe heart failure: effects on cytokines, complement and body weight.

AIMS: Inflammatory and immune activation and body wasting are important features of end-stage chronic heart failure. It is not known whether restoration of cardiac output by assist device implantation can improve these abnormalities. METHODS: We studied 48 patients (39 males; age 45+/-2 years) with NYHA class IV heart failure. All patients underwent ventricular assist device implantation for end-stage heart failure as a bridge to cardiac transplantation. Plasma levels of tumour necrosis factor alpha, and its receptors, interleukin-6, elastase, activated complement, and soluble CD14 receptors were measured at the time of operation and in survivors at 1 week (n=46), 40 days (n=35) and 90 days (n=26). Follow-up was for a minimum of 1 year. RESULTS: One-year survival was 35% (95% CI: 22-49%). Body mass index was the only predictor of survival (body mass index >25 (n=16); survival 63 (39-86) %; body mass index <25 (n=32); survival 22 (7.5-36) %: P=0.003). Tumour necrosis factor alpha fell from 9.66+/-1.33 pg x ml(-1) to 4.2+/-1.0 at 1 week (P=0.008), but returned to pre-operative levels at 90 days. Interleukin-6, activated complement and elastase fell progressively to 40 days, but were rising at 90 days. There was no change in tumour necrosis factor receptor. There was a gradual rise in CD14 (3.99+/-0.15 microg x ml(-1) at baseline, 5.02+/-0.39 at 90 days, P=0.006). After surgery, body weight fell from 80+/-2 to 73+/-2 kg by 1 month (P<0.001) and to 72+/-2 kg at 90 days. CONCLUSIONS: Ventricular assist device implantation results in a short-term fall in tumour necrosis factor alpha and interleukin-6, but no change in CD14 or tumour necrosis factor receptor, suggesting that the pathophysiological process resulting in inflammation was not altered by left ventricular assist device implantation. Low body mass index is related to poor outcome after assist device implantation, and no weight gain.

Decreased plasma concentration of brain natriuretic peptide as a potential indicator of cardiac recovery in patients supported by mechanical circulatory assist systems.

OBJECTIVES: We sought to investigate the relationship between the plasma concentration of brain natriuretic peptide (BNP), echocardiographic findings and the clinical outcome of patients supported with ventricular assist devices (VADs) to determine the role of BNP as a predictor for cardiac recovery. BACKGROUND: Ventricular unloading in patients with end-stage heart failure supported by VADs may lead to myocardial recovery. The BNP is produced in the myocardium in response to chronic volume overload, but the effects on it of ventricular unloading by VADs are largely unknown. METHODS: Twenty-one patients diagnosed with nonischemic cardiomyopathy and supported by VADs were evaluated for echocardiographic data and blood chemistry including BNP. They were divided into patients who died while on mechanical support (group I; n = 9), patients who were transplanted (group II; n = 8) and patients who were successfully weaned off the system and did not require transplantation (group III; n = 4). RESULTS: Brain natriuretic peptide plasma concentrations decreased significantly after initiation of mechanical circulatory support (p = 0.017). Furthermore, the changes in BNP plasma concentrations showed a faster decrease to normal levels within the first week after implantation of the VAD in patients who were weaned off the system (group III) compared to patients in group I and group II. CONCLUSIONS: This study shows that ventricular unloading with VADs decreases BNP plasma concentrations in patients who suffer from end-stage heart failure. Furthermore, we hypothesize that an early decrease of BNP plasma concentration may be indicative of recovery of ventricular function during mechanical circulatory support.

Postoperative course of S-100B protein and neuron-specific enolase in patients after implantation of continuous and pulsatile flow LVADs.

BACKGROUND: In the early post-operative period after implantation of a continuous flow left ventricular assist device (LVAD) a non-pulsatile flow occurs. We compared the post-operative time-courses of protein S-100B (S100B) and neuron-specific enolase (NSE) as biochemical markers of brain injury in patients after implantation of a continuous flow LVAD and patients receiving a pulsatile flow LVAD. METHODS: Since 1998 the continuous flow DeBakey VAD has been implanted in 8 patients at our institution. For comparison purposes, a group of 7 consecutive patients in whom a pulsatile Novacor N100 LVAD was implanted were investigated. In both groups cardiopulmonary bypass (CPB) with cardiotomy suction was used. S100B and NSE were measured in serum pre-operatively, 4 hours after CPB, and on days 1, 3, 7, and 14 after implantation of the LVAD. A neurologic examination was performed pre-operatively and post-operatively on days 3 and 14. RESULTS: No differences were found between groups in pre-operative characteristics. The analysis of variance with repeated measurements for S-100B and NSE showed significant time effects (p = 0.004, p = 0.009, respectively) but no group effects (p = 0.06, p = 0.26, respectively) and no interaction between groups and time (p = 0.12, p = 0.48, respectively). The pre-operative serum level of S100B was significantly higher (p = 0.03) in the DeBakey VAD group. The pre-operative serum level of NSE was similar in the 2 groups (p = 0.7). In both groups there was a significant increase of S100B and NSE immediately after surgery (S100B: p = 0.006, p = 0.019; NSE: p = 0.01, p = 0.001). The values returned to pre-operative levels in the DeBakey VAD group on day 1 after implantation and in the Novacor group for S100B on day 3 and NSE on day 1. Post-operatively the mean values of S100B and NSE in the DeBakey VAD group compared with the Novacor group were significantly elevated only on day 3 (p = 0.005, p = 0.023).No neurologic complications were noted in patients with a continuous flow LVAD, whereas in the pulsatile LVAD group 2 patients presented neurologic abnormalities during the study period. CONCLUSIONS: The similar course of biochemical markers of brain damage in both groups may indicate that the non-pulsatile flow in the early post-operative period does not lead to increased brain injury or permeability of the brain blood barrier.Elevated levels of S100B and NSE in the post-operative period can be used as diagnostic markers of brain injury in patients after implantation of both types of LVAD.

Predictors of survival 1 hour after implantation of an intra-aortic balloon pump in cardiac surgery.

From July 1996 to March 2000, 391 patients with intraoperative cardiac low-output syndrome who underwent surgery with heart-lung bypass and had an intra-aortic balloon pump (IABP) implanted were analyzed in a prospective study. Of these 391 patients, 153 (39%) were operated on in an emergency situation, and 238 (61%) patients had elective surgeries. The perioperative mortality was 34% (133 patients). Clinical parameters were analyzed 1 hour after IABP support began. Statistical multivariate analysis showed that patients with an adrenaline requirement higher than 0.5 microg/kg/min, a left atrial pressure higher than 15 mmHg, output of less than 100 mL/hour, and mixed venous saturation (SvQ2) of less than 60% had poor outcomes. Using this data, we developed an IABP score to predict survival early after IABP implantation in cardiac surgery. We conclude that the success or failure of perioperative IABP support can be predicted early after implantation of the balloon pump. In patients with low-output syndrome despite IABP support, implantation of a ventricular assist system should be considered.

Outpatients on biventricular assist devices.

As waiting times for transplants have lengthened, long-term mechanical circulatory support (MCS) has become more common in patients who present with severe cardiogenic shock leading to multiorgan failure. With these patients, we used the biventricular assist device (BVAD, Berlin Heart). In this report, we will describe our 4 years of experience with 11 patients on a BVAD who were discharged home while awaiting transplantation. The 11 patients underwent BVAD implantation from 1997 to 2000. These were 2 women and 9 men. The mean support time was 382 days (range: 156 - 567). The indication for BVAD was cardiomyopathy--six dilated, one restrictive and four ischemic. These patients were monitored for infections, thromboembolic events, bleeding complications, and psychological effects during the time they spent at home. Our experience shows that all of the patients could leave hospital following sufficient training for dressings and anticoagulation after recovering completely from secondary organ dysfunction. The mean time period the patients spent at home was 48 days (range: 3 - 182) days. Seven patients (63 %) had to be readmitted to the hospital--due to transitory ischemic attacks in two cases, hemorrhoidal bleeding in one and wound infections in four cases. One patient died of a traumatic accident during sexual activity. The use of a BVAD is feasible for outpatient use as a bridge to transplantation. It ensures the survival of the patient, enables recovery from multiorgan failure and offers an acceptable quality of life.

Procalcitonin, a donor-specific predictor of early graft failure-related mortality after heart transplantation.

BACKGROUND: To date, donor-specific markers to predict outcome after heart transplantation (HTx) are unknown. Increased procalcitonin (PCT) levels have been found in infectious inflammation with systemic reactions and/or poor organ perfusion but have not been studied in heart donors. We evaluated PCT as a predictor of early graft failure-related mortality after HTx. METHODS AND RESULTS: PCT and C-reactive protein (CRP) serum concentrations were measured in samples collected immediately before pericardium opening from 81 consecutive brain-dead multiple-organ donors. Donors for high-urgency-status recipients (n=2) were excluded from analysis. The remaining donors were retrospectively divided into 2 groups: donors for recipients who died within 30 days after HTx, after an early graft failure (group II, n=8), and all other donors (group I, n=71). No differences in donor and recipient demographic characteristics were found between groups. Areas under the receiver operating characteristic curves for graft failure-related mortality were 0.71 for PCT and 0.64 for CRP. A PCT value >2 ng/mL as a predictor of graft failure-related mortality had a specificity of 95.8% and sensitivity of 50.0%. The odds ratio for graft failure-related mortality for recipients of hearts from donors with PCT levels >2 ng/mL was 22.7 (unadjusted, 95% CI 3.7 to 137.8, P=0.0007) and 43.8 (after adjustment for prespecified potential confounders, 95% CI 1.4 to 1361.0, P=0.031). CONCLUSIONS: A PCT level >2 ng/mL in a cardiac donor at the time of explantation appears to predict early graft failure-related mortality.

Revascularization of the occluded right coronary artery during left ventricular assist device implantation.

A 62-year-old man with end-stage ischemic cardiomyopathy and left ventricular function of 20% was evaluated for heart transplantation. Cardiac catheterization revealed proximal occlusion of the dominant right coronary artery (RCA) with collateral blood flow and significant stenosis in the distal part, but no significant re-occlusions of the stented left coronary artery and no significant stenosis of the left circumflex artery. When the patient became catecholamine dependent, Novacor left ventricular assist device (LVAD) implantation, as a bridge to transplantation, was considered and the patient operated upon. To avoid ischemic right heart failure after LVAD implantation, a concomitant re-vascularization of the distal RCA was performed. The post-operative course was uneventful. Five weeks later, a control angiogram showed the patent bypass graft. The distal stenosis of the RCA was treated successfully with dilation and stent implantation. The patient is presently in stable condition on LVAD and awaits transplantation as an outpatient.

Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure.

BACKGROUND: Cardiac troponin I and T (cTnI and cTnT) are sensitive and specific markers of myocardial damage. We evaluated them for the selection of heart donors and as predictors of early graft failure after heart transplantation. METHODS: cTnI, cTnT, myoglobin, and creatine kinase (CK) levels and its isoenzyme MB (CKMB) activity and mass were measured in serum samples immediately before opening the pericardium from 126 consecutive brain-dead multi-organ donors over 10 years of age inspected by our harvesting team. Donors with serum creatinine >2.0 mg/dL (n=6) were excluded from the analysis. Donors for high-urgency status recipients (n=2) were also excluded. The remaining donors were retrospectively divided into three groups: group I (n=68), grafts with good function; group II (n=11), grafts with impaired function; and group III (n=39), grafts not accepted for transplantation. RESULTS: No differences in donor and recipient characteristics were found among the groups. The mean values of cTnI (0.36+/-0.88 microg/L, 4.45+/-3.28 microg/L, and 3.02+/-7.88 micog/L, respectively) and cTnT (0.016+/-0.029 microg/L, 0.134+/-0.114 microg/L, and 0.123+/-0.245 microg/L, respectively) were lower in group I when compared with groups II or III (cTnI: P<0.0001, P=0.018; cTnT: P<0.0001, P=0.012). The cTnI value was higher in group II compared with group III (P=0.023). The cTnT values were similar in groups II and III. A cTnI value >1.6 microg/L as a predictor of early graft failure had a specificity of 94%, and a cTnT value of >0.1 microg/L had a specificity of 99%. The odds ratio for the development of acute graft failure after heart transplantation was 42.7 for donors with cTnI >1.6 microg/L and 56.9 for donors with cTnT >0.1 microg/L. No differences of myoglobin, CKMB activity, or CKMB/CK ratio were found among the groups. CONCLUSIONS: Significantly higher cTnI and cTnT values were found in peripheral blood at the time of explantation in donors of hearts with subsequently impaired graft function and in not accepted donors. cTnI and cTnT are useful as additional parameters for heart donor selection.