Infective endocarditis in patients after percutaneous pulmonary valve implantation with the stent-mounted bovine jugular vein valve: Clinical experience and evaluation of the modified Duke criteria.

AIMS: Percutaneous pulmonary valve implantation (PPVI) has proven good hemodynamic results. As infective endocarditis (IE) remains a potential complication with limited available clinical data, we reviewed our patient records to improve future strategies of IE prevention, diagnosis and treatment. METHODS: Medical records of all patients diagnosed with Melody® valve IE according to the modified Duke criteria were retrospectively analyzed in three Belgian tertiary centers. RESULTS: 23 IE episodes in 22 out of 240 patients were identified (incidence 2.4% / patient year) with a clear male predominance (86%). Median age at IE was 17.9 years (range 8.2-45.9 years) and median time from PPVI to IE was 2.4 years (range 0.7-8 years). Streptococcal species caused 10 infections (43%), followed by Staphylococcus aureus (n = 5, 22%). In 13/23 IE episodes a possible entry-point was identified (57%). IE was classified as definite in 15 (65%) and as possible in 8 (35%) cases due to limitations of imaging. Echocardiography visualized vegetations in only 10 patients. PET-CT showed positive FDG signals in 5/7 patients (71%) and intracardiac echocardiography a vegetation in 1/1 patient (100%). Eleven cases (48%) had a hemodynamically relevant pulmonary stenosis at IE presentation. Nine early and 6 late percutaneous or surgical re-interventions were performed. No IE related deaths occurred. CONCLUSIONS: IE after Melody® valve PPVI is associated with a relevant need of re-interventions. Communication to patients and physicians about risk factors is essential in prevention. The modified Duke criteria underperformed in diagnosing definite IE, but inclusion of new imaging modalities might improve diagnostic performance.

Ventricular assist device implantation in patients with a failing systemic right ventricle: a call to expand current practice.

Ventricular assist device (VAD) implantation is an established treatment modality for patients with end-stage heart failure, and improves symptoms and survival. In the Netherlands, it is not yet routinely considered in patients with congenital heart disease and failing systemic right ventricle (SRV). Recently, a VAD was implanted in 2 SRV patients, one who underwent a Mustard procedure during infancy for transposition of the great arteries (male, 47 years old) and one with a congenitally corrected transposition of the great arteries (male, 54 years old). The first patient is doing well >1 year after implantation; the second patient will be discharged home soon. These examples and other reports demonstrate the feasibility of adopting VAD implantation into routine care for SRV failure. In conclusion, patients with SRV failure may be suitable candidates for VAD implantation: they are relatively young, usually have a preserved subpulmonary left ventricular function, and their specific anatomical and physiological characteristics often make them unsuitable for cardiac transplantation. Therefore it is important to recognise the possibility of VAD implantation early in the process of SRV failure, and to timely refer these patients to a heart failure clinic with experience in VAD implantation in this group of patients for optimisation, screening, and implantation.

Cancer After Heart Transplantation: A 25-year Single-center Perspective.

BACKGROUND: Cancer is a major cause of morbidity and mortality after heart transplantation. METHODS: We studied 541 heart transplant patients from a single center over a period of 25 years, with a mean follow-up of 10.7 years. We determined incidence, type, risk factors, and prognosis for cancer after heart transplantation. RESULTS: Cancer was diagnosed in 181 patients, at a mean of 7.7 years after transplantation. Cumulative incidence of cancer at 5, 10, and 20 years was 14%, 29%, and 60%, respectively. The most frequent cancers were spinocellular skin cancer (22%), basocellular skin cancer (19%), lung cancer (16%), lymphoma (11%) and prostate cancer (10%). Age at transplantation > 50 years (hazard ratio, 2.9; P < .001) and male recipient gender (hazard ratio, 1.7; P = .038) were significant risk factors for posttransplant malignancy on multivariate Cox proportional hazards analysis. Median patient survival after diagnosis of cancer was 2.9 years for patients with noncutaneous cancer, versus 13.1 years for patients with only skin cancer (P < .001).

Xenon anaesthesia for patients undergoing off-pump coronary artery bypass graft surgery: a prospective randomized controlled pilot trial.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements. METHODS: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile. RESULTS: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100ß and erythropoietin. CONCLUSIONS: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12).

A cardiovascular simulator tailored for training and clinical uses.

OBJECTIVE: In the present work a cardiovascular simulator designed both for clinical and training use is presented. METHOD: The core of the simulator is a lumped parameter model of the cardiovascular system provided with several modules for the representation of baroreflex control, blood transfusion, ventricular assist device (VAD) therapy and drug infusion. For the training use, a Pre-Set Disease module permits to select one or more cardiovascular diseases with a different level of severity. For the clinical use a Self-Tuning module was implemented. In this case, the user can insert patient's specific data and the simulator will automatically tune its parameters to the desired hemodynamic condition. The simulator can be also interfaced with external systems such as the Specialist Decision Support System (SDSS) devoted to address the choice of the appropriate level of VAD support based on the clinical characteristics of each patient. RESULTS: The Pre-Set Disease module permits to reproduce a wide range of pre-set cardiovascular diseases involving heart, systemic and pulmonary circulation. In addition, the user can test different therapies as drug infusion, VAD therapy and volume transfusion. The Self-Tuning module was tested on six different hemodynamic conditions, including a VAD patient condition. In all cases the simulator permitted to reproduce the desired hemodynamic condition with an error<10%. CONCLUSIONS: The cardiovascular simulator could be of value in clinical arena. Clinicians and students can utilize the Pre-Set Diseases module for training and to get an overall knowledge of the pathophysiology of common cardiovascular diseases. The Self-Tuning module is prospected as a useful tool to visualize patient's status, test different therapies and get more information about specific hemodynamic conditions. In this sense, the simulator, in conjunction with SDSS, constitutes a support to clinical decision - making.

20 years of arterial switch operation for simple TGA.

BACKGROUND: Arterial switch operation became the golden treatment for simple transposition of the great arteries (sTGA). We describe our experience with the arterial switch operation regarding long-term outcome and the need for re-intervention. Nevertheless, supravalvular pulmonary stenosis (SPS) remains a concern in the long run. We assess the evolution of SPS over time and evaluate the effect of technical modifications on SPS during our experience. METHODS: We performed a retrospective study on 133 patients operated with ASO for TGA between October 1991 and November 2009. Last report method was used. We reviewed our pediatric cardiology and cardiac surgery database to examine the echocardiographic data and electrocardiograms. A mean follow-up of 9.2 years (+/- 5.83 SD) was reached. RESULTS: One (0.8%) patient deceased postoperatively due to cardiogenic shock. The overall actuarial freedom from reoperation (open and percutaneous) was 88.1%, 78.5% and 76.9% at 1, 5 and 10 years. SPS needed to be treated in 17 patients. Valve regurgitation at final investigation was maximal moderate in 5 patients for the aortic valve, 10 for pulmonary valve and 3 in tricuspid valve. CONCLUSIONS: ASO shows excellent long-term results in sTGA with a very low morbidity and mortality and is therefore the procedure of choice. Re-intervention rate is determined by SPS. Since the extensive mobilization of the pulmonary arteries and the creation of a longer neo-pulmonary root, reduction in SPS was seen with no re-interventions in the second half of the group. To obtain a final comparison with the atrial switch operation, a longer Follow-up is necessary.

Cost of 1-year left ventricular assist device destination therapy in chronic heart failure: a comparison with heart transplantation.

OBJECTIVE: To analyse overall cost involved with destination therapy (DT) in comparison to transplantation (HTX) and bridging to transplantation. METHODS: Three groups of patients at one hospital were considered for this cost analysis: (1) patients included in the BENEMACS study starting May 2009 (n = 6); (2) all patients from May 2009 till May 2010 undergoing heart transplantation (n = 19); or (iii) undergoing Heartmate II implantation as a bridge to transplant (n = 13). Patients undergoing bridging were more sick (lower Intermacs class). DT patients were older (64±8 years). Cost was derived from actual hospital invoices, device, organ procurement and medical cost, and follow-up care during 1 year from implantation. Costs are presented in euro, by their mean values and standard deviation. RESULTS: One-year survivals were 83, 84, and 77%, respectively, for DT, HTX, and bridging. Costs for initial and re-hospitalizations were not different between groups. Costs for medical follow-up and medication were significantly higher for transplanted patients. The 1-year total cost was €85 531±19 823 for HTX, €125 108±32 399 for bridging, and €137 068±29 007 for DT. As 42% of the transplanted patients were bridged, the cost of the medical pathway HTX was €138 076±19 823. Assuming a 5-year survival and a similar yearly follow-up cost, the average cost per year is €42 153 for HTX, €53 637 for transplantation including the bridging cost, and €47 487 for DT. CONCLUSION: Direct transplantation without bridging is the most cost-efficient treatment. The cost per patient per year for DT is similar to HTX considering its bridging activity.

A decision support system for the treatment of patients with ventricular assist device support.

BACKGROUND: Heart failure (HF) is affecting millions of people every year and it is characterized by impaired ventricular performance, exercise intolerance and shortened life expectancy. Despite significant advancements in drug therapy, mortality of the disease remains excessively high, as heart transplant remains the gold standard treatment for end-stage HF when no contraindications subsist. Traditionally, implanted Ventricular Assist Devices (VADs) have been employed in order to provide circulatory support to patients who cannot survive the waiting time to transplantation, reducing the workload imposed on the heart. In many cases that process could recover its contractility performance. OBJECTIVES: The SensorART platform focuses on the management and remote treatment of patients suffering from HF. It provides an interoperable, extendable and VAD-independent solution, which incorporates various hardware and software components in a holistic approach, in order to improve the quality of the patients' treatment and the workflow of the specialists. This paper focuses on the description and analysis of Specialist's Decision Support System (SDSS), an innovative component of the SensorART platform. METHODS: The SDSS is a Web-based tool that assists specialists on designing the therapy plan for their patients before and after VAD implantation, analyzing patients' data, extracting new knowledge, and making informative decisions. RESULTS: SDSS offers support to medical and VAD experts through the different phases of VAD therapy, incorporating several tools covering all related fields; Statistics, Association Rules, Monitoring, Treatment, Weaning, Speed and Suction Detection. CONCLUSIONS: SDSS and its modules have been tested in a number of patients and the results are encouraging.

Liver transplantation in a patient with an intraabdominally located left ventricular assist device: surgical aspects--case report.

The presence of a cardiac assist device in a liver transplantation candidate should not be considered to be an absolute contraindication to transplantation. In this first case report of liver transplantation in a patient with an intraabdominally located left ventricular assist device, we have described the surgical aspects and discussed the timing of the liver transplantation and the removal of the left ventricular assist device.

Failure of epicardial pacing leads in congenital heart disease: not uncommon and difficult to predict.

AIMS: We evaluate the incidence of epicardial lead failure and try to identify risk factors in patients with congenital heart disease. METHODS: All patients with a congenital heart defect and an epicardial pacing system, implanted within a timeframe of 25 years, were included in this study. Patients' medical records and lead data were reviewed. Lead failure was defined as the primary endpoint. RESULTS: In total 198 active epicardial leads (atrial 40, ventricular 158) were implanted in 93 patients (median age at implantation 4.4 years (range 0-58.6)). During a total follow-up of 1235 lead-years, 29 lead failures (14.6%, 4 atrial, 25 ventricular) were documented in 22 patients (23.7%). Lead failure occurred at a median time period of 4.8 years (range 1.2-24.1) after implantation. Five-year freedom of lead failure was 88%. The only independent predictor for lead failure was the age at implantation (HR 0.44; 95%CI 0.20-0.97, p = 0.04), other characteristics failed to predict lead failure. Sudden cardiac death occurred in four patients (4.3%), in one a lead failure was documented. CONCLUSION: A high incidence of epicardial lead failures is found in patients with congenital heart disease. Unfortunately, it is difficult to predict this potentially life-threatening complication.

Intima sarcoma of the pulmonary artery mimicking takayasu disease.

Pulmonary artery intima sarcoma is an uncommon but fatal tumor, which often masquerades chronic thromboembolic pulmonary hypertension (CTEPH) and in the present case Takayasu arteritis. Pulmonary arterial pressure is mildly elevated in the presence of extensive proximal lesions. A parenchyma thin-walled cavitary lesion may be a sign of pulmonary extravasation of the tumor.

Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block in congenital heart disease: fact or fluke?

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block with congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular (AV) conduction following pacemaker implantation. METHODS: A retrospective study of patients with congenital heart disease needing pacemaker implantation was performed between 1977 and 2008 at our institution. The postoperative course of all patients with complete heart block, in whom a permanent pacemaker was implanted, was followed on a semi-annual basis by clinical follow-up. RESULTS: A total of 56 patients with complete heart block underwent pacemaker implantation. Indications for pacemaker implantation could be categorized in primary AV conduction block (n = 28 ; 50%) and surgically-induced AV conduction block (n = 28 ; 50%). After pacemaker insertion, recovery of AV conduction was recognized in two patients. The first patient was operated for atrial septal defect type ostium secundum with complete heart block preoperatively. AV block resolved 2 days after pacemaker implantation. The second patient underwent mitral valve replacement. Postoperatively, the patient developed second degree heart block, which progressed 3 years later into complete heart block. A recovery of AV conduction was seen 7.5 years later. In these patients, no late recurrence of complete heart block was found during follow-up after 8 and 4 months, respectively. CONCLUSIONS: Recovery of AV conduction was observed in one patient with primary AV conduction block and in one patient with complete heart block after congenital heart surgery. Lifelong cardiac pacing in these specific subsets of patients may not be necessary.

Partial mechanical long-term support with the CircuLite Synergy pump as bridge-to-transplant in congestive heart failure.

BACKGROUND: Full mechanical support with a left ventricular assist device (LVAD) is often limited to very sick patients, as the only survival option. This European multicenter study analyzes the effect of partial mechanical support as bridge-to-transplant in a less sick heart failure patient group. METHODS: The CircuLite Synergy device is implanted via a small right-sided thoracotomy with an inflow cannula in the left atrium and an outflow graft connected to the right subclavian artery without the use of extracorporeal circulation. The pump itself sits in a "pacemaker" pocket subcutaneously in the right clavicular groove. It is able to pump up to 3.0 l/min and partially unload the left ventricle. RESULTS: The device was implanted in 25 patients on the cardiac transplant waiting list (20 males), aged 55.5 +/- 9.6 yrs with an ejection fraction of 21.6 +/- 6.0 %, a mean arterial pressure of 73.5 +/- 8.5 mmHg, a pulmonary capillary wedge pressure of 27.2 +/- 7.8 mmHg and cardiac index of 1.9 +/- 0.4 l/min/m (2). Duration of support ranged from 6 to 238 days. Right heart catheterization showed significant hemodynamic improvement in the short- and intermediate-term after implantation with increases in arterial pressure from 72.6 +/- 11.0 to 79.4 +/- 8.6 mmHg ( P = 0.04) and in cardiac index from 2.0 +/- 0.4 to 2.7 +/- 0.6 l/min/m (2) ( P = 0.003) with a reduction in pulmonary capillary wedge pressure from 28.5 +/- 6.0 to 19.7 +/- 6.9 mmHg ( P = 0.012). CONCLUSIONS: The CircuLite Synergy device is a partial support pump, which is easy to implant and which provides hemodynamic benefits in bridging heart failure patients to cardiac transplant.

Deformation imaging describes right ventricular function better than longitudinal displacement of the tricuspid ring.

AIMS: To quantify right ventricular (RV) function in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after pulmonary endarterectomy (PEA). METHODS: Out of 33 patients, 16 were evaluated clinically and with echocardiography (conventional and myocardial deformation parameters) before PEA (preop) and at 1 week, 1 month, 3 months and 6 months after PEA. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) as well as mid-apical and basal peak ejection strain (S) and strain rate (SR) of the RV free wall were measured. Left ventricular (LV) apical lateral wall motion was regarded as indicating changes in overall heart rocking motion (RM). Heart catheterisation was performed before, within 1 week and at 6 months after PEA. RESULTS: Clinical and haemodynamic parameters improved significantly after PEA. This correlated with the improvement in RVFAC, S and SR. TAPSE, on the other hand, showed a biphasic response (14.5 (4) mm preop, 8.5 (2.7) mm at 1 week and 11 (1.5) mm at 6 months). Changes in LV apical motion explain this finding. At baseline, TAPSE was enhanced by rocking motion of the heart as a result of the failing RV. Unloading the RV by PEA normalised the rocking motion and TAPSE decreased. CONCLUSIONS: RV function of CTEPH patients improves steadily after PEA. Unlike S, SR and RVFAC, this is not reflected by TAPSE because of postoperative changes in overall heart motion. Motion independent deformation parameters (S, SR) appear superior in the accurate description of regional RV function.

Therapy for foetal pericardial tumours: survival following in utero shunting, and literature review.

We report the first case of foetal pericardial teratoma, treated successfully in utero by pericardio-amniotic shunting, and review the relevant literature. Foetal treatment improves survival in case of hydrops. Foetal pericardio-amniotic shunting could possibly be an alternative to serial pericardiocentesis.

Transapical left ventricular access for difficult to reach interventional targets in the left heart.

OBJECTIVE: Interventional targets may be virtually "excluded" due to vascular access problems or complex previous surgical procedures. This study reviews our experience using transapical ventricular puncture to gain direct access to the systemic ventricle. PATIENTS: Patient 1 (74 years, 2 previous sternotomies), patient 2 (66 years, 5 previous sternotomies), and patient 5 (69 years, 3 previous sternotomies) with prosthetic valves had paravalvular mitral valve leaks. Patient 3 (6.3 years, 2 previous sternotomies) with an extracardiac Fontan conduit, had a significant residual leak after two previous surgical attempts of patch closure of a severely regurgitant right atrioventricular valve. Patient 4 (10 months) had failure of standard ablation of the posteroseptal region of the mitral valve with persistent life-threatening episodes of ventricular tachycardia. METHODS: Procedures were performed under general anesthesia. Entry site was percutaneous in three patients and in two (and one conversion) a mini-thoracotomy was used. Sheaths were placed (6 F) using standard Seldinger technique, followed by the procedure as required. Direct surgical closure of the puncture site was done in 4 patients and in patient 3, a percutaneous vascular occlusion device was used. RESULTS: Easy and immediate access was obtained in all patients. The paravalvular leaks were crossed within seconds and completely closed with Amplatzer occluders. In patient 3 the valve was crossed using a Brokenbrough needle and a 12-mm Amplatzer device was placed in the patch leak. Patient 4 was successfully ablated using a 7-F irrigated catheter endo- and epicardially. Complications were in the percutaneous puncture group: in one patient a coronary artery was punctured and in one a hemothorax developed. CONCLUSION: Direct left ventricular puncture offers a very useful alternative access site in selected patients to reach "inaccessible" targets for certain percutaneous interventions in patients where standard approaches may be impossible or difficult.

Surgical closure of the patent ductus arteriosus and its effect on the cerebral tissue oxygenation.

AIM: Surgical patent ductus arteriosus (PDA) ligation is considered after failure or contraindication of medical treatment. Till now ligation of the PDA has been associated with low morbidity and mortality although recently concerns have been raised about the possible association of ductal clipping and neurodevelopmental abnormalities later in life. By means of near-infrared spectroscopy (NIRS), we analysed the changes in the cerebral tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) at the time of clipping as well as after clipping. METHOD: Ten preterm infants with a symptomatic PDA who underwent surgical ligation were continuously monitored for heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen saturation (SaO(2)) and TOI from 1 h before up to 1 h after clipping. FTOE and haemoglobin difference (HbD) were calculated. Changes in parameters at 5 min after ligation represent the effect of the clipping itself whereas changes up to 1 h-post-clipping represent the post-clipping effect. RESULTS: At the exact time of clipping, over the entire group, we found a significant increase in TOI of 2.9% (p = 0.037), in HbD of 12.5 micromol/l (p = 0.047) and in HR of 6.5 bpm (p = 0.012). FTOE significantly decreased by 0.02% (p = 0.013). One hour post-clipping, the cerebral and peripheral parameters were not significantly different from the control values before clipping. CONCLUSION: The ductal clipping in se has no negative effect on the cerebral oxygenation.

Extracorporeal membrane oxygenation: experience in an adult medical ICU.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a technology that can provide extracorporeal gas exchange to patients with severe pulmonary or cardiac dysfunction. We report on our clinical experience with ECMO in critically ill patients. METHODS: We performed a retrospective analysis of 23 patients treated with ECMO in a medical intensive care unit in a tertiary referral academic centre. RESULTS: 13 patients were considered immunocompetent and 10 were immunocompromised when extracorporeal membrane oxygenation was started. 16 patients presented with acute respiratory distress syndrome (ARDS), 2 patients had intractable cardiac failure, and 5 patients had combined respiratory and cardiac failure. In 16 patients, a veno-venous bypass was constructed; in 7 patients, the initial bypass was venoarterial. 11 patients survived. In 2 patients technical complications were fatal. CONCLUSIONS: Our data indicate that patients with community-acquired pneumonia and no underlying disease will benefit most from this technique. However, long-term survival is possible in immunocompromised patients. Venoarterial bypass can carry a higher risk for technical complications. Increasing experience apparently also reduces the risk of technical complications.