Efficacy and safety of post-closure technique using Perclose ProGlide/ProStyle device for large-bore mechanical circulatory support access sites.

PURPOSE: Mechanical circulatory support (MCS) using a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device or a catheter-type heart pump (Impella) is critical for the rescue of patients with severe cardiogenic shock. However, these MCS devices require large-bore cannula access (14-Fr and larger) at the femoral artery or vein, which often requires surgical decannulation. METHODS: In this retrospective study, we evaluated post-closure method using a percutaneous suture-mediated vascular closure system, Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, IL, Perclose), as an alternative procedure for MCS decannulation. Closure of 83 Impella access sites and 68 VA-ECMO access sites performed using Perclose or surgical method between January 2018 and March 2023 were evaluated. RESULTS: MCS decannulation using Perclose was successfully completed in all access sites without surgical hemostasis. The procedure time of ProGlide was shorter than surgical decannulation for both Impella and VA-ECMO (13 min vs. 50 min; p < 0.001, 21 min vs. 65 min; p < 0.001, respectively). There were no significant differences in the 30-day survival rate and major adverse events by decannulation including arterial dissection requiring endovascular treatment, hemorrhage requiring a large amount of red blood cell transfusion, and access site infection. CONCLUSION: Our results suggest that the post-closure technique using the percutaneous suture-mediated closure system appears to be a safe and effective method for large-bore MCS decannulation.

Fibromuscular dysplasia of the brachial artery in patients with spontaneous coronary artery dissection: a case series and literature review.

Spontaneous coronary artery dissection (SCAD) is diagnosed in a very small percentage of patients with suspected acute coronary syndromes who undergo emergency coronary angiography. Although fibromuscular dysplasia (FMD) is known to coexist in patients with SCAD, the vascular sites of FMD and their frequency have not yet been clarified. We retrospectively reviewed the medical records of 16 patients who were diagnosed with and treated for SCAD at our hospital between 1 January 2011 and 31 January 2023. We have summarized their baseline and clinical characteristics and medical variables, including coronary and upper extremity angiography and in-hospital outcomes. One of our patients had concurrent cardiac tamponade requiring pericardial drainage, and another went into hemorrhage shock the following day from dissection of the gastric retroperitoneal artery. Characteristic angiographic features of partial or diffuse nonatherosclerotic stenosis were observed mainly in the distal parts of the coronary arteries or their branches. Notably, in six patients with SCAD who underwent upper extremity angiography, FMD of the brachial artery was revealed. For the first time, to our knowledge, we found a high prevalence of multifocal FMD of the brachial artery in patients with SCAD.

Incidence, Risk Factors, and Treatment of Venous Thromboembolism after a Serious Disaster: The Kumamoto Twin Earthquakes.

Objective: On April 16, 2016, earthquakes struck Kumamoto. In this report, the incidence and treatment of venous thromboembolism (VTE) in patients presenting to our hospital are summarized. Materials and Methods: We reviewed the details of 22 consecutive patients who were diagnosed with VTE at our hospital during the 2 weeks after the earthquakes. Results: Nineteen of the 22 patients stayed in their cars overnight after the earthquakes. Particularly, during the first 4 days, seven consecutive patients were hospitalized for pulmonary thromboembolism. All seven patients had sheltered in their cars after the earthquakes. The two patients transported on days 2.42 and 3.54 were the most severe cases. One patient was admitted after emergency initiation of venoarterial extracorporeal membrane oxygenation for treatment of hemodynamic collapse, whereas the other patient was admitted after resuscitation. By contrast, deep vein thrombosis (DVT) alone occurred within 5-9 days of the earthquakes. Bilateral DVT was the most common, which was followed by DVT on the right side only. Conclusion: The incidence of VTE might be higher after an earthquake, and an overnight stay in a car might be a risk factor for VTE. Stable patients based on the D-dimer concentration can be managed with nonwarfarin oral anticoagulants.

Impella Motor Current Amplitude Reflects the Degree of Left Ventricular Unloading under ECPELLA Support.

The combination of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella, referred to as ECPELLA, is a powerful transient mechanical circulatory support for patients with severe cardiogenic shock (CS). During ECPELLA support, VA-ECMO loads the left ventricle (LV) and Impella unloads the LV. Therefore, evaluating the degree of LV unloading during ECPELLA may be a prerequisite to protect the injured myocardium. Here we report a patient with CS due to an inferior ST-elevation myocardial infarction in which the degree of LV unloading on ECPELLA was confirmed by direct LV pressure (LVP) measurement. After the percutaneous coronary intervention for the right coronary artery on ECPELLA, the aortic pressure became nonpulsatile and the peak systolic LVP was reduced at approximately 10 mmHg with 20 mA of the Impella motor current (MC) amplitude, which we referred to as the total LV unloading condition. We maintained the condition in the early phase of ECPELLA by monitoring the Impella MC amplitude at 20 mA and less with nonpulsatile aortic pressure. The patient was successfully weaned off VA-ECMO on day 3, and Impella was explanted on day 8. Prior to the Impella explant, the Impella MC amplitude increased more than 100 mA and the estimated pressure gradient between the aortic pressure and LVP was well matched with the directly measured LVP. In this case, the patient was successfully treated by ECPELLA with the total LV unloading condition, and we showed that the degree of LV unloading on ECPELLA can be estimated from the aortic pressure and Impella MC amplitude at given Impella flows.

Impact of extracorporeal CPR with transcatheter heart pump support (ECPELLA) on improvement of short-term survival and neurological outcome in patients with refractory cardiac arrest - A single-site retrospective cohort study.

Aim: Extracorporeal cardiopulmonary resuscitation (E-CPR) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest. Although VA-ECMO preserves end-organ perfusion, it may affect left ventricular (LV) recovery due to increased LV load. An emerging treatment modality, ECPELLA, which combines VA-ECMO and a transcatheter heart pump, Impella, can simultaneously provide circulatory support and LV unloading. In this single-site cohort study, we assessed impact of ECPELLA support on clinical outcomes of refractory cardiac arrest patients. Method: We retrospectively reviewed 165 consecutive cardiac arrest patients, who underwent E-CPR by VA-ECMO with or without intra-aortic balloon pump (IABP) or ECPELLA from January 2012 to September 2021. We assessed 30-day survival rate, neurological outcome, hemodynamic data, and safety profiles including hemolysis, acute kidney injury, blood transfusion and embolic cerebral infarction. Results: Among 165 E-CPR patients, 35 patients were supported by ECPELLA, and 130 patients were supported by conventional VA-ECMO with or without IABP. Following propensity score matching of 30 ECPELLA and 30 VA-ECMO patients, the 30-day survival (ECPELLA: 53%, VA-ECMO: 20%, p < 0.01) and favorable neurological outcome determined by the Cerebral Performance Category score 1 or 2 (ECPELLA: 33%, VA-ECMO: 7%, p < 0.01) were significantly higher with ECPELLA. Patients receiving ECPELLA also showed significantly higher total mechanical circulatory support flow and lower arterial pulse pressure for the first 3 days (p < 0.01) of treatment. There were no statistical differences in safety profiles between treatment groups. Conclusion: ECPELLA may be associated with improved 30-day survival and neurological outcome in patients with refractory cardiac arrest.

Predictors of hypoxemia in type-B acute aortic syndrome: a retrospective study.

Acute aortic syndrome (AAS) can be life-threatening owing to a variety of complications, and it is managed in the intensive care unit (ICU). Although Stanford type-B AAS may involve hypoxemia, its predictors are not yet clearly understood. We studied clinical factors and imaging parameters for predicting hypoxemia after the onset of type-B AAS. We retrospectively analyzed patients diagnosed with type-B AAS in our hospital between January 2012 and April 2020. We defined hypoxemia as PaO2/FiO2 ≤ 200 within 7 days after AAS onset and used logistic regression analysis to evaluate prognostic factors for hypoxemia. We analyzed 224 consecutive patients (140 males, mean age 70 ± 14 years) from a total cohort of 267 patients. Among these, 53 (23.7%) had hypoxemia. The hypoxemia group had longer ICU and hospital stays compared with the non-hypoxemia group (median 20 vs. 16 days, respectively; p = 0.039 and median 7 vs. 5 days, respectively; p < 0.001). Male sex (odds ratio [OR] 2.87; 95% confidence interval [CI] 1.24-6.63; p = 0.014), obesity (OR 2.36; 95% CI 1.13-4.97; p = 0.023), patent false lumen (OR 2.33; 95% CI 1.09-4.99; p = 0.029), and high D-dimer level (OR 1.01; 95% CI 1.00-1.02; p = 0.047) were independently associated with hypoxemia by multivariate logistic analysis. This study showed a significant difference in duration of ICU and hospital stays between patients with and without hypoxemia. Furthermore, male sex, obesity, patent false lumen, and high D-dimer level may be significantly associated with hypoxemia in patients with type-B AAS.

The first described case of late infective endocarditis after implantation of Figulla Flex â ¡ ASD occluder.

Infective endocarditis is one of the complications following the percutaneous occlusion of an atrial septal defect (ASD) with a closure device. To the best of our knowledge, no case reports have been published of infective endocarditis associated with the Figulla Flex Ⅱ ASD occluder (FSO; Occlutech GmbH, Jena, Germany). We present the case of a 50-year-old woman who underwent a transcatheter closure of an ASD with FSO almost 2 years prior to presentation to our institution. Echocardiography showed a mobile vegetation (20 × 10 mm), and her blood culture grew ß-hemolytic streptococci. Magnetic resonance imaging revealed acute cerebral infarction. Those findings were diagnosed as late infective endocarditis associated with the ASD closure device. The patient was treated with antibiotics and underwent surgical removal of the FSO, which showed incomplete endothelialization, and surgical repair of ASD. After surgery, the patient made a complete recovery without complications or residual shunts. This case highlights the risk of late infective endocarditis in patients after closure of ASD with an FSO with incomplete endothelialization. .

A case of acute coronary syndrome caused by a giant saddle thrombus at left main coronary artery bifurcation.

An 87-year-old woman who had metastatic lung cancer presented with intermittent chest discomfort. The emergent coronary angiogram showed a giant saddle thrombus at the left main coronary artery bifurcation without flow limitation. We performed thrombolysis with unfractionated heparin and warfarin under careful observation of the thrombus with a 320-row area detector computed tomography (ADCT). Ten days later, the second examination with ADCT revealed complete resolution of the saddle thrombus. During the follow-up, neither chest pain nor enzymatic cardiac damage was reported. In this carefully observed case, a less invasive strategy instead of catheter intervention or strong thrombolysis might have led to a favorable clinical outcome.

An autopsy case of the rupture of a giant aneurysm in a saphenous vein graft: 18 years after CABG.

The saphenous vein is a widely used blood vessel for arterial bypass procedures. Failures of saphenous vein aortocoronary bypass grafts are predominantly the result of subsequent vein graft atherosclerotic disease. Rarely saphenous vein grafts undergo aneurysmal degeneration. This report describes a case of a ruptured aneurysm in a saphenous vein graft that occurred in an 82-year-old female who underwent a coronary artery bypass operation 18 years previously. We could not resuscitate her, but describe the autopsy findings in detail.

Successful stenting to superior mesenteric artery (SMA) after endovascular aneurysm repair (EVAR) of abdominal aorta.

A 70-year-old man complained of abdominal angina after endovascular aneurysm repair (EVAR). He had a history of successful treatment of abdominal aortic aneurysm with Zenith endovascular graft 12 months prior to the index abdominal symptoms. The endovascular graft had been placed with special attention for keeping blood flow of major abdominal branches to the intestine. However, both duplex sonographic study and enhanced computed tomography (CT) revealed a critical stenosis at the ostium of the superior mesenteric artery (SMA). The limited intestinal blood flow seemed to be a cause of his symptoms. Palmatz stent was selected to dilate the stenosis. A right trans-femoral artery approach was selected to avoid interaction with the Zenith stent graft because it was landed at the left external iliac artery. There was no difficulty in passing of the stent through the uncovered Z-stent area at the proximal end of the graft. Three-dimensional-CT image was useful for the precise ostial stenting. In treatment of SMA ostial stenosis after EVAR, percutaneous trans-catheter treatment with stent could be a feasible and effective strategy to be considered.

Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection.

BACKGROUND: Although type B aortic dissection has been treated with beta blockers to lower the arterial blood pressure (BP), there has been little evidences about reduction in heart rate (HR). We assessed whether tight HR control improved the outcome of medical treatment in patients with aortic dissection. METHODS AND RESULTS: From 1997 to 2005, 171 patients with acute aortic dissection medically treated and controlled to lower BP under 120 mm Hg were enrolled. Based on the average HR at 3, 5, and 7 days after the onset, patients were divided into tight HR (<60 beat per minute) control group (32 patients; mean HR of 56.6+/-3.1 beat per minute) and conventional HR (>/=60 beat per minute) control group (139 patients; mean HR of 71.7+/-8.2 beat per minute). We compared the frequency of aortic events including late organ or limb ischemia, aortic rupture, recurrent dissection, and aortic expansion of >5 mm, and surgical requirement between two groups. During a median follow-up of 27.0 months, late organ or limb ischemia, aortic rupture, recurrent dissection, pathological aortic expansion, and aortic surgery occurred in 0, 8, 14, 39, and 26 patients, respectively. Reduction in aortic events was observed in tight HR control group (12.5%) compared to conventional HR control group (36.0%), (Odds ratio: 0.25, C.I.: 0.08 to 0.77, P<0.01). CONCLUSIONS: The present study demonstrated that tight heart rate control improved the outcome of medical treatment in patients with aortic dissection.