Acute mechanical circulatory support for cardiogenic shock in India.

Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.

Experience with pulmonary endarterectomy: Lessons learned across 17 years.

BACKGROUND: Pulmonary endarterectomy is potential curative therapy for chronic thromboembolic pulmonary hypertension patients. Here, we present our experience with pulmonary endarterectomy spanning 17 years and detail our management strategy. METHODS: This is a single-centre retrospective study conducted on chronic thromboembolic pulmonary hypertension patients who underwent pulmonary endarterectomy at our centre across 17 years. RESULTS: Between 2004 and 2020, 591 patients underwent pulmonary endarterectomy. Amongst them 429 (72.4%) were males with a male to female ratio of 2.6:1, the median age was 38 (range, 14-73) years. The median length of hospital stay was 11 days (IQR, 8-16). Extra corporeal membranous oxygenation was used in 82 (13.9%) patients during/after surgery, out of whom 28 (34.1%) survived. There were 70 (11.8%) in-hospital deaths. Female gender (p < 0.01), pulmonary artery systolic pressure >100 mmHg (p < 0.05) and use of extra corporeal membrane oxygenation (p < 0.001) were significant risk factors for in-hospital mortality. The mortality in the first period (2004-2012) was 15.7% which reduced to 9.1% in the later period (2013-2020). The reduction in mortality rate was 42% (p < 0.05). Following pulmonary endarterectomy, there was a significant reduction in pulmonary artery systolic pressure (86.68 ± 24.38 vs. 39.71 ± 13.13 mmHg; p < 0.001) and improvement in median walk distance as measured by 6-min walk test on follow-up (300 vs. 450 meters; p < 0.001). The median duration of follow-up was 8 months (inter-quartile range: 2-24). CONCLUSIONS: pulmonary endarterectomy has a learning curve, high pulmonary vascular resistance alone is not a contraindication for surgery. Patients following surgery have improved survival and quality of life.

Oversized donor heart transplantation-clinical experience with an underestimated problem.

PURPOSE: Heart transplantation is the definitive treatment for end-stage heart failure. With respect to donor-recipient size matching, the problems with undersized heart transplantation have been widely discussed, but there is a paucity of information on oversized transplants due to the presumed advantage of large hearts. We intend to share our center's experience with oversized heart transplantation and its associated problems which would help to expand the knowledge on oversized cardiac allografts. METHODS: Patients who underwent isolated heart transplantation at our hospital between March 1, 2008, and March 1, 2020, were included. For adults, a donor-recipient predicted heart mass percentage difference exceeding 30% and for children, a donor-recipient weight ratio < 0.8 and > 2.0 was considered a mismatch. We collected data from the in-patient medical records and analyzed the in-hospital outcomes and survival post-transplant among various other parameters. RESULTS: Out of the 43 patients included in this study, 32 (74.4%) patients received a matched heart and 11 (25.6%) patients received oversized hearts. None of the patients received an undersized heart. The in-hospital mortality rate of oversized transplants was 18.2% whereas that of matched transplants was 9.4% (p = 0.432). The post-operative characteristics and 1-year survival were comparable between the groups. We encountered problems specific to oversizing in 5 of the 11 patients (45.4%) which are discussed. CONCLUSION: With the liberalization of donor criteria to overcome organ shortage, oversized heart transplantation poses certain unique challenges, which when efficiently managed offers acceptable outcomes.

Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.

Methemoglobinemia Unmasked by Use of Sodium Nitroprusside and Hypothermia in a Case of Chronic Thromboembolic Pulmonary Hypertension During Pulmonary Endarterectomy: A Case Report.

In performing pulmonary endarterectomy (PEA) for a patient with chronic thromboembolic pulmonary hypertension (CTEPH), we encountered methemoglobinemia that was unmasked by hypothermia while on cardiopulmonary bypass (CPB). The patient on dapsone therapy for antiphospholipid antibody syndrome had developed acquired methemoglobinemia that went undiagnosed because her cyanosis was believed to be due to CTEPH and the resulting ventilation-perfusion (V/Q) mismatch. Although pharmacological triggers for methemoglobin are well known, causation by hypothermia is not described. Monitoring saturation while on CPB was challenging because of nonpulsatile blood flow but was overcome using cerebral oximetry.

Single-stage repair for multiple muscular septal defects: a single-centre experience across 16 years.

OBJECTIVES: Multiple muscular ventricular septal defects (VSDs) are surgically challenging and its management remains controversial. We present a technique of surgical repair for muscular VSDs, which includes surgical exposure and detection of these defects and has excellent clinical outcomes. METHODS: We have analysed consecutive patients who underwent surgical repair of isolated multiple muscular VSDs under cardiopulmonary bypass over a 16-year period (from January 2001 to November 2016) in a single centre from the southern part of India. These defects were accessed through the right atrium in most cases and closed directly; completeness of closure was confirmed by pressurizing the left ventricle with blood cardioplegia. There were no haemodynamically significant residual VSDs following repair. RESULTS: One hundred and two patients with an average time of follow-up of 4.1 years (1 month-12 years) were included. The mean age of our patients at the time of operation was 23.5 months (3 months-22 years) with a mean weight of 7.9 kg (2-55 kg). The mean cardiopulmonary bypass and cross-clamp time was 118.8 ± 39.2 min (mean ± SD) and 76.5 ± 29.4 min (mean ± SD), respectively. There were 10 (9.8%) hospital deaths and 3 late deaths in the entire study group. Permanent pacemaker was implanted in 2 patients. Seventy patients could be followed up after discharge. Postoperative pulmonary artery pressure was normal in 52% of the patients, mild-to-moderate hypertension in 27% and severe in 7% of the patients. The ejection fraction was >60% among the survivors, and there were no reoperations or reinterventions. CONCLUSIONS: This surgical approach to multiple muscular VSDs is safe and effective with minimal risk of complete heart block and diminution of ventricular function.

A novel treatment for pulmonary hemorrhage during thromboendarterectomy surgery.

Injury to the pulmonary artery during thromboendarterectomy is a rare but potentially fatal complication with no reported surgical techniques to combat it. Treatment is only supportive and morbidity is high. We report the intraoperative diagnosis and surgical management of pulmonary hemorrhage in 3 patients after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

Distal carotid perfusion in combined carotid endarterectomy and OP-CABG.

An alternative method of maintaining carotid perfusion during combined carotid endarterectomy and off-pump coronary artery bypass grafting involves insertion of a cannula in the ascending aorta after a median sternotomy. This cannula is connected to a perfusion cannula, the distal end of which is inserted into the carotid artery beyond the carotid arteriotomy. This technique of aortico-carotid shunting and carotid perfusion was utilized in nine patients who underwent successful combined carotid endarterectomy and off-pump coronary artery bypass grafting.

Marsupialization of intramyocardial left anterior descending artery: a novel approach for easy access during revascularization.

The left anterior descending (LAD) artery is the most important vessel bypassed during coronary revascularization procedures. This artery usually runs a superficial course, making it easy for localization and grafting. However, many times it takes a course deep in the myocardium or is embedded in thick epicardial fat, which results in technical challenges to the surgeon for localization and grafting. So far, many techniques are described for overcoming these problems, but all require cardiopulmonary bypass (CPB), and in fact, intramyocardial LAD is considered a relative contraindication for off-pump coronary artery bypass grafting (OPCAB). In the present era of enhanced interest in OPCAB, these techniques are not as helpful as they are for conventional CABG with CPB. Here, we describe a novel approach of marsupialization of the LAD for revascularization of intramyocardial LAD that is useful for off-pump as well as conventional revascularization procedures and makes grafting simple and reproducible.