Quality of life and functional status after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: A Swedish single-center study.

Little is known about long-term quality of life (QOL) and functional status after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We investigated QOL and functional status late after PEA. All patients who underwent PEA for CTEPH 1993-2020 at one Swedish center were included. Baseline characteristics and data from right heart catheterization, 6-min walk test, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) were obtained from patient charts and national registers. The RAND 36-Item Health Survey was sent by post, and Karnofsky Performance Status (KPS) was evaluated by telephone. A total of 110 patients were included. The survey was completed by 49/66 (74%) patients who were alive in 2020. In all domains except for bodily pain, QOL was slightly lower than that of an age-matched reference population. The KPS score was obtained from 42/49 (86%) patients; of these, 31 patients (74%) had a KPS score of ≥80% (able to carry on normal activity). All 42 patients were able to live at home and care for personal needs. The median postoperative CAMPHOR scores were: 4 for symptoms, 4 for activity, and 2.5 for QOL. We observed that QOL after PEA approached the expected QOL in a reference population and that CAMPHOR scores were comparable to those of a large UK cohort after PEA. Functional status improved when assessed late after PEA. Three-quarters of the study population were able to conduct normal activities at late follow-up. Our findings suggest that many patients enjoy satisfactory QOL and high functional status late after PEA.

Association of residual pulmonary hypertension with survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

This study investigated whether residual pulmonary hypertension (PH), defined as early postoperative mean pulmonary artery pressure (mPAP) of ≥30 mmHg, after undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) was associated with long-term survival. All patients who underwent PEA for CTEPH at two Scandinavian centers were included in this study. Baseline characteristics and vital statuses were obtained from patient charts and national health-data registers. The patients were then categorized based on residual PH measured via right heart catheterization within 48 h after undergoing PEA. Crude and weighted flexible parametric survival models were used to estimate the association between residual PH and all-cause mortality and to quantify absolute survival differences. From 1992 to 2020, 444 patients underwent surgery. We excluded 6 patients who died on the day of surgery and 12 patients whose early postoperative pulmonary hemodynamic data was unavailable. Of the total study population (n = 426), 174 (41%) and 252 (59%) patients had an early postoperative mPAP <30 and ≥30 mmHg, respectively. After weighting, there was a significant association between residual PH and all-cause mortality (hazard ratio: 2.49; 95% confidence interval [CI]: 1.60-3.87), and the absolute survival difference between the groups at 10 and 20 years was -22% (95% CI: -32% to -12%) and-32% (95% CI: -47% to -18%), respectively. A strong and clinically relevant association of residual PH with long-term survival after PEA for CTEPH was found. After accounting for differences in baseline characteristics, the absolute survival difference at long-term follow-up was clinically meaningful and imply careful surveillance to improve clinical outcomes in these patients. Early postoperative right heart catheter measurements of mPAP seem to be helpful for prognostication following PEA for CTEPH.

Acetylsalicylic Acid Is Associated With a Lower Prevalence of Ascending Aortic Aneurysm and a Decreased Aortic Expression of Cyclooxygenase 2.

Background Acetylsalicylic acid (ASA) therapy has been associated with a reduced prevalence and growth rate of abdominal as well as intracranial aneurysms, but the relationship between ASA and ascending aortic aneurysm formation remains largely unknown. The aim of the present study was to investigate whether ASA therapy is associated with a lower prevalence of ascending aortic aneurysm in a surgical cohort. Methods and Results One thousand seven hundred patients undergoing open-heart surgery for ascending aortic aneurysm and/or aortic valve disease were studied in this retrospective cross-sectional study. Aortic dilatation was defined as an aortic root or ascending aortic diameter ≥45 mm. Medications were self-reported by the patients in a systematic questionnaire. Cyclooxygenase gene expression was measured in the intima-media portion of the ascending aorta (n=117). In a multivariable analysis, ASA was associated with a reduced prevalence of ascending aortic aneurysm (relative risk, 0.68 [95% CI, 0.48-0.95], P=0.026) in patients with tricuspid aortic valves, but not in patients with bicuspid aortic valves (relative risk, 0.93 [95% CI, 0.64-1.34], P=0.687). Intima-media cyclooxygenase expression was positively correlated with ascending aortic dimensions (P<0.001 for cyclooxygenase-1 and P=0.05 for cyclooxygenase-2). In dilated, but not nondilated tricuspid aortic valve aortic specimens, ASA was associated with significantly lower cyclooxygenase-2 levels (P=0.034). Conclusions Our findings are consistent with the hypothesis that ASA treatment may attenuate ascending aortic aneurysmal growth, possibly via cyclooxygenase-2 inhibition in the ascending aortic wall and subsequent anti-inflammatory actions.

Long-term follow-up of passive containment surgery in patients with aortic regurgitation.

The goal of this case-control study was to evaluate the long-term effects on cardiac dimensions, cardiac function and coronary circulation in patients with aortic regurgitation (AR) and left ventricular dilatation undergoing aortic valve replacement and application of the Acorn CorCap cardiac support device Of 10 patients with AR and ventricular dilatation who had a mechanical aortic valve implanted, 5 in addition received the cardiac support device. Cardiac dimensions and cardiac function were measured by echocardiography preoperatively and 1, 5 and 10 years postoperatively. The coronary circulation was assessed by computed tomography angiography. After aortic valve replacement, there was a rapid and sustained decrease in cardiac dimensions. This result did not differ after application of the cardiac support device. Improvement in cardiac function remained unchanged in both groups at the 10-year follow-up. None of the patients had developed any signs of coronary artery disease. Application of the Acorn CorCap cardiac support device in patients with AR and left ventricular dilatation did not add to the reversed remodelling or cardiac function at the long-term follow-up compared to aortic valve replacement alone.

Sex and survival following pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a Scandinavian observational cohort study.

Studies have suggested sex-related survival differences in chronic thromboembolic pulmonary hypertension (CTEPH). Whether long-term prognosis differs between men and women following pulmonary endarterectomy for CTEPH remains unclear. We investigated sex-specific survival after pulmonary endarterectomy for CTEPH. We included all patients who underwent pulmonary endarterectomy for CTEPH at two Scandinavian centers and obtained baseline characteristics and vital statuses from patient charts and national health-data registers. Propensity scores and weighting were used to account for baseline differences. Flexible parametric survival models were employed to estimate the association between sex and all-cause mortality and the absolute survival differences. The expected survival in an age-, sex-, and year of surgery matched general population was obtained from the Human Mortality Database, and the relative survival was used to estimate cause-specific mortality. A total of 444 patients were included, comprising 260 (59%) men and 184 (41%) women. Unadjusted 30-day mortality was 4.2% in men versus 9.8% in women (p = 0.020). In weighted analyses, long-term survival did not differ significantly in women compared with men (hazard ratio: 1.36; 95% confidence interval: 0.89-2.06). Relative survival at 15 years conditional on 30-day survival was 94% (79%-107%) in men versus 75% (59%-88%) in women. In patients who underwent pulmonary endarterectomy for CTEPH, early mortality was higher in women compared with men. After adjustment for differences in baseline characteristics, female sex was not associated with long-term survival. However, relative survival analyses suggested that the observed survival in men was close to the expected survival in the matched general population, whereas survival in women deviated notably from the matched general population.

[Chronic thromboembolic pulmonary hypertension may be cured with surgery]. / Kronisk lungembolism kan botas med kirurgi.

Chronic thromboembolic pulmonary hypertension is a subtype of pulmonary hypertension that affects 0,5-4% of patients who have had a pulmonary embolism. Emboli in the pulmonary arteries lead to fibrosis, obstruction and remodeling of the pulmonary arteries which causes increased pulmonary arterial blood pressure and increased pulmonary vascular resistance. Cardiac ultrasound is used as initial screening in order to identify high pulmonary artery pressures and right heart dysfunction. Lung scintigraphy, computed tomography, and pulmonary angiography are used to verify and describe disease severity. Surgical treatment entails circulatory arrest with endarterectomy starting proximal in the pulmonary arteries and continuing distally throughout the pulmonary arterial tree. Removal of obstruction leads to decreased pulmonary artery pressure and pulmonary vascular resistance, resulting in improved quality of life and near normal life expectancy.

Life expectancy after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a Swedish single-center study.

Pulmonary endarterectomy is the guideline recommended treatment for chronic thromboembolic pulmonary hypertension, in addition to life-long anticoagulation therapy. The aim was to analyze long-term relative survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. We included all patients who underwent pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at Karolinska University Hospital between 1997 and 2018 (n = 100). We obtained baseline characteristics and vital status from patient charts and national health-data registers. The expected survival from the general Swedish population matched by age, sex, and year of surgery was obtained from the Human Mortality Database. The relative survival was used as an estimate of cause-specific mortality. The mean age of the patients was 62 years and 39% were women. Most patients were severely symptomatic (95% in New York Heart Association functional class III-IV), and mean preoperative systolic/diastolic (mean) pulmonary artery pressure was 78/27 (45) mmHg. The mean and maximum follow-up time was 7.2 and 22.1 years, respectively. Early (30-day) mortality was 7%. The 15-year observed, expected, and relative survival was 55% (95% confidence interval, 40%-68%), 71%, and 77% (95% confidence interval, 56%-95%), respectively. The 15-year relative survival conditional on 30-day survival was 83% (95% confidence interval, 60%-100%). Although the life expectancy following pulmonary endarterectomy was shorter compared to the general population, the difference was small in those who survived the operation and the early postoperative period. Patients with chronic thromboembolic pulmonary hypertension who are surgical candidates should undergo pulmonary endarterectomy to improve prognosis.

Extracorporeal membrane oxygenation as a rescue of intractable ventricular fibrillation and bridge to heart transplantation.

Extracorporeal membrane oxygenation (ECMO) systems have undergone rapid technological improvements and are now feasible options for medium-term support of severe cardiac or pulmonary failure. Intractable ventricular arrhythmia is a rare but well-established indication for heart transplantation. We report a case of persistent ventricular fibrillation (VF) that was rescued by insertion of peripheral veno-arterial ECMO during cardiopulmonary resuscitation, which provided support for 30 h of continuous VF and subsequently permitted urgent heart transplantation.

Midterm results of passive containment surgery using the acorn Cor Cap cardiac support device in dilated cardiomyopathy.

BACKGROUND AND AIM: To evaluate the echocardiographic, functional, and quality of life improving effects of passive containment surgery using the CorCap cardiac support device (CSD; Acorn Cardiovascular Inc., St. Paul, MN, USA) in patients with dilated cardiomyopathy and to investigate the possible differences in ischemic versus idiopathic (i.e., normal angiograms) cardiomyopathy. METHODS: Twenty patients with dilated cardiomyopathy (10 with ischemic and 10 with idiopathic disease) were subjected to application of the cardiac support device, between June 2001 and October 2006. Preoperatively and at follow-up cardiac dimensions, cardiac function, functional capacity, and quality of life were evaluated. Follow-up is complete with a mean follow-up time of 32 +/- 5 months. RESULTS: All patients survived the surgery; four patients died during the follow-up time. Following surgery, there was a significant reduction in cardiac dimensions, improved functional capacity, and improved quality of life. No significant differences could be seen between patients with ischemic versus idiopathic disease. CONCLUSION: Application of the CSD is safe and simple in patients with dilated cardiomyopathy and without any apparent negative effects. Further studies are needed to identify optimal patient selection criteria as well as optimal timing of surgery and to assess the long-term effects of this treatment.

Changes in natriuretic peptides following passive containment surgery in heart failure patients with dilated cardiomyopathy.

To evaluate the influence on circulating plasma levels of natriuretic peptides following passive containment surgery in heart failure patients with dilated cardiomyopathy, thirteen patients with dilated cardiomyopathy subjected to cardiac surgery received the Acorn Cardiac Support Device. Patients with ischemic cardiomyopathy (n=7) underwent coronary artery bypass surgery receiving 2-3 bypass grafts. In the idiopathic cardiomyopathy group (n=6), mitral valve plasty was performed in five patients while one patients received the Cardiac Support Device only. Circulating plasma atrial natriuretic peptide, brain natriuretic peptide and C-type natriuretic peptide were measured in all patients before surgery and 12 months postoperatively. Following surgery there was a significant decrease in circulating plasma levels of brain natriuretic peptide (0.14+/-0.04 ng/ml vs. 0.06+/-0.03 ng/ml, P<0.05). No significant changes were seen in circulating plasma levels of atrial natriuretic peptide or C-type natriuretic peptide. NYHA functional class improved (2.7+/-0.1 vs. 1.8+/-0.2, P<0.001). The 6-min-walk increased (354+/-35 m vs. 473+/-31 m, P<0.01). There was a decrease in left ventricular end diastolic diameter (73+/-2 mm vs. 65+/-2 mm, P<0.001) and left ventricular end systolic diameter (65+/-2 mm vs. 56+/-3 mm, P<0.01). Following passive containment surgery using the ACORN Cardiac Support Device functional improvement and reversed remodelling is accompanied by decreased BNP levels.

No additive effect of passive containment surgery in patients with aortic regurgitation and left ventricular dilation.

BACKGROUND: After valve replacement in patients with aortic regurgitation short-term and long-term improvement of left ventricular function are related to early reduction of left ventricular dilatation. This case-control study was conducted to investigate the potential beneficial effects by concomitant application of the Acorn Cor Cap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) on reduction of ventricular dilatation in patients with aortic regurgitation and advanced ventricular dilatation undergoing aortic valve replacement. METHODS: Of ten patients with longstanding aortic regurgitation and ventricular dilatation subjected to aortic valve replacement using mechanical valve prostheses, five were in addition subjected to application of the Cardiac Support Device (Acorn). Cardiac function and dimensions were measured by echocardiography preoperatively and 3 and 12 months postoperatively. RESULTS: After aortic valve replacement, there was a rapid and sustained decrease in end-diastolic and end-systolic diameters (before operation 72 +/- 4 and 54 +/- 8 mm, to 54 +/- 10 and 40 + 11 mm at 3 months; and 53 +/- 9 and 35 +/- 6 mm, 12 months after operation). This did not differ after Cardiac Support Device (Acorn) application (before operation 74 +/- 1 and 56 +/- 5 mm; 52 +/- 8 and 39 +/- 9 mm, 3 months after operation; and 54 +/- 6 and 39 +/- 8 mm, at 12 months). The left ventricular ejection fraction remained unchanged in both groups. CONCLUSIONS: Application of the Acorn Cor Cap Cardiac Support Device in patients with aortic regurgitation and severe ventricular dilatation does not influence reverse remodeling or cardiac function compared with aortic valve replacement alone.

Experiences of levosimendan as an inotropic agent in conjunction with passive containment surgery.

OBJECTIVES: Levosimendan is a calcium sensitizer with a positive inotropic effect without increasing oxygen consumption. We have evaluated the immediate effects of levosimendan on cardiac index when given peri-operatively to patients with dilated cardiomyopathy in conjunction with passive containment surgery. DESIGN: Ten patients with dilated cardiomyopathy undergoing passive containment surgery with the ACORN Cardiac Support Device, either as the sole procedure or in combination with other open heart surgery, were after anaesthesia induction given levosimendan as a bolus dose of 12 microg/kg followed by an infusion of 0.1microg/kg/min for 24 hours. Cardiac index were measured before extra corporal circulation, immediately after extra corporal circulation, at arrival to the intensive care unit and on post operative day 1. The need for inotropic support was recorded. RESULTS: Nine of ten patients were preoperatively in a low cardiac output situation. At postoperative day 1 there was a significant increase in cardiac index from 2.1+/-0.1 to 2.8+/-0.2. CONCLUSIONS: This study confirms the theoretical benefits of levosimendan judged by an immediate significant positive effect on cardiac index.

Reversed remodelling in dilated cardiomyopathy by passive containment surgery is associated with decreased circulating levels of endothelin-1.

OBJECTIVE: To evaluate the influence on circulating levels of endothelin-1 and big endothelin-1 in relation to echocardiographic findings and functional assessment, by passive containment surgery in heart failure patients with dilated cardiomyopathy. METHODS: Thirteen patients with dilated cardiomyopathy subjected to cardiac surgery received the Acorn Cardiac Support Device. Patients with ischemic dilated cardiomyopathy (n=6) underwent coronary artery bypass surgery receiving one to three bypass grafts. In the idiopathic dilated cardiomyopathy group (n=7), mitral valve plasty was performed in five patients while two patients received the cardiac support device only. Circulating plasma levels of endothelin-1 and big endothelin-1 were measured in all patients before surgery and 12 months after surgery. Concomitantly New York Heart Association functional class and 6-min walk were evaluated and cardiac dimensions measured with echocardiography. RESULTS: Following surgery there was a significant decrease in circulating plasma levels of endothelin-1 (5.9+/-0.6 pM preoperatively vs 4.3+/-0.3 pM postoperatively, P<0.05). New York Heart Association functional class improved (2.8+/-0.2 preoperatively vs 1.8+/-0.2 postoperatively, P<0.05). The 6-min walk increased (384+/-24 m preoperatively vs 465+/-33 m postoperatively, P<0.05). There was also a decrease in left ventricular end diastolic diameter (69+/-2mm preoperatively vs 62+/-2mm postoperatively, P<0.05) and left ventricular end systolic diameter (60+/-2mm preoperatively vs 54+/-3mm postoperatively, P<0.05). Linear correlation revealed a relationship between decreased left ventricular end diastolic diameter and decreased endothelin-1 levels (R=0.56; P<0.05). CONCLUSIONS: Following passive containment surgery using the Acorn Cardiac Support Device there is a decrease in circulating levels of endothelin-1 concomitant with a decrease in cardiac dimensions and function improvement.

Echocardiographic findings using tissue velocity imaging following passive containment surgery with the Acorn CorCap cardiac support device.

OBJECTIVE: To echocardiographically evaluate the effects of passive containment surgery using the CorCap Cardiac Support Device in heart failure patients with dilated cardiomyopathy. METHODS: Twelve patients with dilated cardiomyopathy subjected to cardiac surgery received the Cardiac Support Device. Patients with ischemic cardiomyopathy (n=5) underwent coronary artery bypass surgery receiving 1-3 bypass grafts. In the idiopathic cardiomyopathy group (n=7), mitral valve annuloplasty was performed in five patients while two patients received the Cardiac Support Device only. RESULTS: Following surgery there was a gradual, sustained improvement in cardiac dimensions (decreased left ventricular end-diastolic diameter and left ventricular end-systolic diameter) combined with an increase in functional status (6-min walk and NYHA class). Concomitantly there was a marked decrease in right ventricular function (decrease in tricuspid annular systolic and diastolic velocities) while the left ventricular function (mitral annular systolic and diastolic velocities) and output (ejection fraction, stroke volume) remained unchanged. CONCLUSIONS: Addition of the Cardiac Support Device to conventional cardiac surgery improves patient status and decreases left ventricular size in heart failure patients with dilated cardiomyopathy. The positive effect on left ventricular dimensions is not accompanied by any improvement in cardiac output but rather right ventricular dysfunction, although the functional significance of this is unclear.

Attenuation of postoperative noradrenaline need by nitric oxide inhibition using L-NMMA.

In the present report we describe that NG-monomethyl-L-arginine acetate, a non-specific nitric oxide synthesis inhibitor, administered at 1 mg kg(-1) h(-1) to a patient with critical hypotension following mitral valve surgery combined with passive containment surgery, increased the urinary output and arterial blood pressure while the need for noradrenaline was rapidly attenuated. Again increasing the noradrenaline infusion in the presence of NG-monomethyl-L-arginine acetate caused a dramatic increase of the blood pressure.

[ECMO treatment saved life of a young woman with acute pulmonary embolism]. / Behandling med ECMO räddade livet på ung kvinna med akut lungemboli.

A 42-year old obese female using contraceptive medication was admitted to the emergency room because of sudden onset of dyspnoea and hypoxia. Computed tomography showed massive pulmonary emboli. Despite initial treatment with thrombolysis her condition deteriorated further and she was referred for acute surgery to our clinic. Before putting the patient to sleep extracorporeal circulation was instituted with access from the groin. After anaesthesia a median sternotomy was performed. With the heart beating, the main pulmonary artery was incised and a 9 cm long thrombus was removed. Immediate weaning from the heart-lung machine was not possible, mainly because of bleeding to the airways. The right atrium and the aorta was therefore cannulated and an extracorporeal circulation membrane oxygenator (ECMO) was used for three days. The patient required several re-entries for bleeding and a tracheotomy during the postoperative course. She was fully recovered three months after the operation.

Early results with cardiac support device implant in patients with ischemic and non-ischemic cardiomyopathy.

OBJECTIVE: To evaluate the possible beneficial echocardiographic, functional and quality of life improving effects of passive containment surgery using the CorCap Cardiac Support Device in heart failure patients with dilated cardiomyopathy. DESIGN: Eight patients with dilated cardiomyopathy subjected to cardiac surgery received the Cardiac Support Device. Patients with ischemic cardiomyopathy (n = 4) underwent coronary artery bypass surgery receiving one to three bypass grafts. In the idiopathic cardiomyopathy group (n = 4) mitral valve plasty was performed in two patients while two patients received the Cardiac Support Device only. RESULTS: All patients survived the surgery and were discharged to home. There was a gradual, sustained improvement in cardiac dimensions (left ventricular end-diastolic diameter, left ventricular end-systolic diameter) and functional improvement (ejection fraction, 6-min walk, NYHA functional class) as well as quality of life. These beneficial effects developed more rapidly and more extensively in the idiopathic cardiomyopathy group. CONCLUSION: Addition of the Cardiac Support Device to conventional cardiac surgery, or applied alone, is safe and simple. The device seems to reverse ventricular dilatation and improve functional capacity and well-being of heart failure patients with dilated cardiomyopathy. Further studies will delineate what patient population will best benefit from passive containment surgery using the CorCap Cardiac Support Device.

Cardiovascular function during the first 24 hours after off pump coronary artery bypass grafting--a prospective, randomized study.

We hypothesized that cardiovascular performance during the first 24 postoperative hours would be better in patients after off pump coronary artery bypass grafting compared to conventional on pump surgery. Fifty-nine patients were randomized to on or off pump coronary artery bypass grafting. Hemodynamic parameters, including cardiac index and systemic vascular resistance index were measured before and at 1, 4, and 20 h after surgery. Troponin T and creatine kinase-MB (CK-MB) were measured before and at 1, 6, and 20 h after surgery. There was no difference in age, sex, ejection fraction or number of grafts between groups. Cardiac index was higher (p=0.05) and systemic vascular resistance index was lower (p=0.007) in the off pump group 1 h after arrival in the intensive care unit. CK-MB and troponin T were significantly lower in the off pump group after 1 h (CK-MB p<0.001, troponin T p<0.001) and after 6 h (CK-MB p=0.02, troponin T p<0.001). After 24 h there was no difference between the two groups. In conclusion, immediately after surgery there was better cardiovascular performance and less release of markers of myocardial damage after off pump coronary surgery. After 24 h all differences were eliminated.