Modified T-Graft for Extracorporeal Membrane Oxygenation in a Patient with Small-Caliber Femoral Arteries

Extracorporeal membrane oxygenation (ECMO) is generally used as a last resort to provide cardiopulmonary support in patients whose advanced cardiac or respiratory failure does not respond to less invasive treatments. Lower-limb ischemia secondary to the large diameter of the arterial cannula is one of ECMO''s major limitations: in patients who have small-caliber arteries, the cannulas can reduce native blood flow. The creation of a T-graft—a well-described technique to avoid limb ischemia—enables flow into the ECMO cannula without jeopardizing blood flow to the limb. However, leaving the graft exposed through an open groin wound can result in dislodgment, and it increases the risk of infection.We describe our modification of a conventional T-graft in an 18-year-old woman who had systolic heart failure, acute respiratory distress syndrome, and small-caliber femoral vessels. We tunneled a polytetrafluoroethylene graft inside a Dacron graft, then ran the combined graft through a subcutaneous tunnel similar to that created for a peripheral bypass. Thus, the graft was protected from environmental exposure and the risk of infection. Our technique seems safer and more secure than the original T-graft technique, and we recommend its consideration during ECMO cannulation.     

Use of a Vascular Sheath in the Axillary Artery as an Alternative Access Approach for Placing an Impella 5.0 Device

Many patients who are in cardiogenic shock need mechanical support for clinical stabilization after acute insults such as myocardial infarction. However, the placement of advanced devices can be hindered by anatomic constraints or the physiologic sequelae of shock, as we describe in this report.A 67-year-old woman with prior coronary artery bypass grafting and extensive chest-wall scarring from previous defibrillator implantations presented with myocardial infarction and refractory cardiogenic shock. The patient''s vascular anatomy and prior surgery precluded conventional percutaneous implantation of an Impella 5.0 ventricular support device. We delivered the Impella device through the patient''s tortuous, vasoconstricted axillary artery with use of a vascular sheath and other percutaneous techniques. The success of this approach suggests that combining the expertise of cardiologists and cardiovascular surgeons can improve the outcomes of patients with complex anatomic issues.     

Sustained Use of the Impella 5.0 Heart Pump Enables Bridge to Clinical Decisions in 34 Patients

We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes.We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned.Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.     

Left Ventricular Aneurysm Repair with Use of a Bovine Pericardial Patch

Left ventricular aneurysm, which can impair systolic function, has a reported incidence of 10% to 35% in patients after myocardial infarction. In a 58-year-old woman who had a history of myocardial infarction, we excised a large left ventricular aneurysm and restored left ventricular geometry with use of a bovine pericardial patch. The aneurysm''s characteristics and the patient''s preoperative left ventricular ejection fraction of 0.25 had indicated surgical intervention. The patient had an uneventful postoperative course, and her left ventricular ejection fraction was 0.50 to 0.55 on the 4th postoperative day. This case illustrates the value of surgical treatment for patients who have a debilitating left ventricular aneurysm.     

Extracorporeal Membrane Oxygenation as a Bridge to Surgery for Infective Endocarditis Complicated by Aorto-Atrial Fistula and Cardiopulmonary Collapse

The timing of surgery for active infective endocarditis is challenging when patients exhibit mechanical dysfunction and hemodynamic compromise. Extracorporeal membrane oxygenation has been described in treating sepsis but not, insofar as we know, in treating the acute mechanical sequelae that arise from infective endocarditis. We report perhaps the first case that shows the usefulness of extracorporeal membrane oxygenation as a bridge to definitive treatment in a 35-year-old man who had infective endocarditis followed by aorto-atrial fistula and cardiopulmonary collapse.     

No Electromagnetic Interference Occurred in a Patient with a HeartMate II Left Ventricular Assist System and a Subcutaneous Implantable Cardioverter-Defibrillator

The use of subcutaneous implantable cardioverter-defibrillators is a novel option for preventing arrhythmia-mediated cardiac death in patients who are at risk of endovascular-device infection or in whom venous access is difficult. However, the potential for electromagnetic interference between subcutaneous defibrillators and left ventricular assist devices is largely unknown. We report the case of a 24-year-old man in whom we observed no electromagnetic interference between a subcutaneous implanted cardioverter-defibrillator and a HeartMate II Left Ventricular Assist System, at 3 different pump speeds. To our knowledge, this is the first report of such findings in this circumstance.     

TandemHeart as a Bridge to Recovery in Legionella Myocarditis

Legionnaires'' disease is the designation for pneumonia caused by the Legionella species. Among the rare extrapulmonary manifestations, cardiac involvement is most prevalent, in the forms of myocarditis, pericarditis, postcardiotomy syndrome, and prosthetic valve endocarditis. Mechanical circulatory support has proved to be a safe and effective bridge to myocardial recovery in patients with acute fulminant myocarditis; however, to our knowledge, this support has not been used in infectious myocarditis specifically related to Legionellosis.We describe a case of Legionella myocarditis associated with acute left ventricular dysfunction and repolarization abnormalities in a 48-year-old man. The patient fully recovered after left ventricular unloading with use of a TandemHeart percutaneous ventricular assist device. In addition, we review the English-language medical literature on Legionella myocarditis and focus on cardiac outcomes.     

Subcutaneous Implantable Cardioverter-Defibrillator Implantation in a Patient with a Left Ventricular Assist Device Already in Place

A 56-year-old man with ischemic cardiomyopathy, a biventricular implantable cardioverter-defibrillator (ICD), and a left ventricular assist device (LVAD) developed a pocket hematoma and infection after an ICD generator change. The biventricular ICD was extracted, and the patient was given a full course of antibiotics. Because he had no indications for bradycardia pacing or biventricular pacing, he was implanted with a subcutaneous ICD under full anticoagulation. There was no interference in sensing or shock delivery from the ICD. The LVAD readings were unchanged during and after the procedure. The patient had an uneventful postoperative course, and both devices were functioning normally.To our knowledge, this is the first reported case of the implantation of a subcutaneous ICD in the presence of an LVAD. This report illustrates that both devices can be implanted successfully in the same patient. In addition, the subcutaneous ICD minimizes the risk of bloodstream infections, which can be fatal in patients who have life-supporting devices such as an LVAD.     

Multidrug-Resistant Organism Infections in Patients with Left Ventricular Assist Devices

Left ventricular assist devices improve survival prospects in patients with end-stage heart failure; however, infection complicates up to 59% of implantation cases. How many of these infections are caused by multidrug-resistant organisms is unknown. We sought to identify the incidence, risk factors, and outcomes of multidrug-resistant organism infection in patients who have left ventricular assist devices.We retrospectively evaluated the incidence of multidrug-resistant organisms and the independent risk factors associated with them in 57 patients who had permanent left ventricular assist devices implanted at our institution from May 2007 through October 2011. Outcomes included death, transplantation, device explantation, number of subsequent hospital admissions, and number of subsequent admissions related to infection. Infections were categorized in accordance with criteria from the Infectious Diseases Council of the International Society for Heart and Lung Transplantation.Multidrug-resistant organism infections developed in 18 of 57 patients (31.6%)—a high incidence. We found 3 independent risk factors: therapeutic goal (destination therapy vs bridging), P=0.01; body mass index, P=0.04; and exposed velour at driveline exit sites, P=0.004. We found no significant differences in mortality, transplantation, or device explantation rates; however, there was a statistically significant increase in postimplantation hospital admissions in patients with multidrug-resistant organism infection. To our knowledge, this is the first report in the medical literature concerning multidrug-resistant organism infection in patients who have permanent left ventricular assist devices.     

Improved Systemic Saturation after Ventricular Assist Device Implantation in a Patient with Decompensated Dextro-Transposition of the Great Arteries after the Fontan Procedure

We report the successful implantation of a HeartMate II left ventricular assist device after a failed Fontan procedure in a patient with dextro-transposition of the great arteries. The patient had developed significant intrapulmonary arteriovenous shunting. Despite the theoretical risk of worsening intrapulmonary shunting due to the decrease in systemic vascular resistance after device implantation, our patient did well. He was discharged from the hospital in stable condition and had better oxygen saturation than before the device was implanted. To our knowledge, ours is the 2nd report of the use of a ventricular assist device after the failure of a Fontan procedure, and the first report concerning the effect of ventricular assist device implantation on intrapulmonary shunting.     

Two Cases of Transcatheter Closure of Central Aortopulmonary Shunts: One with an Amplatzer Duct Occluder II and One with an Amplatzer Vascular Plug I

When total correction is not possible in infants who have a cyanotic congenital heart disease, creation of a palliative aortopulmonary shunt is essential. A central aortopulmonary shunt is preferable, because of its technical and hemodynamic advantages. Overcirculation, thrombosis, and stenosis of the shunt are the main postoperative sequelae that necessitate urgent reintervention. Percutaneous transcatheter closure of aortopulmonary shunts can eliminate the need for reoperation and substantially decrease postoperative morbidity and mortality rates. We report our successful transcatheter closures of central aortopulmonary shunts in a 3-month-old infant and a 15-year-old girl, with use of an Amplatzer Duct Occluder II and an Amplatzer Vascular Plug I, respectively. To our knowledge, this is the first report of the transcatheter closure of central aortopulmonary shunts with these 2 devices.     

Heart Failure in Remission for More than 13 Years after Removal of a Left Ventricular Assist Device

Mechanical cardiac unloading with use of a left ventricular assist device (LVAD) is associated with substantial improvements in left ventricular function and enables subsequent LVAD explantation in some patients. We describe the case of a 35-year-old man with dilated nonischemic cardiomyopathy who was supported with an LVAD for 9 months. After the device was removed, he led a normal life for 13 years and 4 months. However, at 49 years of age, he presented with new signs and symptoms of heart failure, necessitating implantation of a 2nd LVAD. Afterwards, he has remained asymptomatic. This case is unique in that the patient lived a normal life for longer than a decade before renewed left ventricular decompensation necessitated repeat LVAD therapy. Histologic examination revealed few changes between the first device''s removal in 1999 and the 2nd device''s implantation in 2012.     

Endovascular Abdominal Aortic Aneurysm Repair by Means of the Chimney Technique in a Patient with Crossed Fused Renal Ectopia

Crossed fused renal ectopia, a congenital anomaly in 1 of 7,000 individuals, presents a challenge during endovascular treatment of abdominal aortic aneurysm. Most treatment approaches in these patients have involved open surgical repair of the aneurysm or endovascular repair with coverage of the ectopic renal artery. We present what we think is the first case of endovascular abdominal aortic aneurysm repair with use of the chimney technique (parallel stent-grafting) to preserve an ectopic renal artery, in an 88-year-old man who was at high risk for open surgery. In addition to the patient''s case, we discuss the relevant medical literature.     

Association Between Timing of Extracorporeal Membrane Oxygenation and Clinical Outcomes in Refractory Cardiogenic Shock

ObjectivesThe aim of this study was to investigate whether earlier extracorporeal membrane oxygenation (ECMO) support is associated with improved clinical outcomes in patients with refractory cardiogenic shock (CS).BackgroundThe prognosis of patients with refractory CS receiving ECMO remains poor. However, little is known about the association between the timing of ECMO implantation and clinical outcomes in these patients.MethodsFrom a multicenter registry, 362 patients with refractory CS who underwent ECMO between January 2014 and December 2018 were identified. Participants were classified into 3 groups according to tertiles of shock-to-ECMO time (early, intermediate, and late ECMO). Inverse probability of treatment weighting was conducted to adjust for baseline differences among the groups, followed by a weighted Cox proportional hazards regression analysis to calculate hazard ratios and 95% confidence intervals for 30-day mortality associated with each ECMO time group.ResultsThe overall 30-day mortality rate was 40.9%. The risk for 30-day mortality was lower in the early group than in the late group (hazard ratio: 0.53; 95% confidence interval: 0.28 to 0.99). Early ECMO support was also associated with lower risk for in-hospital mortality, ECMO weaning failure, composite of all-cause mortality or rehospitalization for heart failure at 1 year, all-cause mortality at 1 year, and poor neurological outcome at discharge. However, the incidence of adverse events, including stroke, limb ischemia, ECMO-site bleeding, and gastrointestinal bleeding, did not differ significantly among the groups.ConclusionsEarlier ECMO support was associated with improved clinical outcomes in patients with refractory CS.     

Percutaneous Closure of a Coronary Artery-to-Vein Graft Anastomotic Pseudoaneurysm Presenting as Acute Coronary Syndrome after Recent Coronary Artery Bypass Grafting

Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described.We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery–saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization.     

Early-Onset Cardiomyopathy After Pacemaker Implanted in a Preterm Infant With Congenital Complete Heart Block and Anti-Ro/SSA Antibodies

Congenital complete heart block is a potentially fatal complication that can occur in neonates whose mothers have autoimmune disorders; it has rarely been reported in the presence of Sjögren syndrome. Pacemaker implantation is recommended to treat rhythm abnormalities in these neonates. We report the case of a late-preterm infant with Sjögren-syndrome-antibody–induced complete heart block who underwent temporary bipolar epicardial pacing as a bridge to permanent pacemaker implantation. Soon after the pacemaker was implanted, takotsubo cardiomyopathy developed. To our knowledge, this is the first report of reversible cardiomyopathy after pacemaker implantation in an infant.     

Endovascular Treatment of Bilateral Pulmonary Artery Stenoses and Superior Vena Cava Syndrome in a Patient with Advanced Mediastinal Fibrosis

Vascular stenosis is a relatively uncommon and often fatal sequela of mediastinal fibrosis. There are very few reports in the medical literature of endovascular treatment for concomitant bilateral pulmonary artery stenoses and superior vena cava syndrome. We report the endovascular treatment of these conditions in a 54-year-old man, and the long-term outcome.