Right ventricular assist device implantation--a new transcutaneous approach

The necessity for a secondary right heart assist device (RVAD) is a disastrous complication in left ventricular assist device (LVAD) support with respect to both complications and outcome. We have developed a new technique for inflow and outflow cannulation via a transcutaneous cannula in the femoral vein and a prosthesis-supported arterial cannula into the pulmonary artery, which does not necessitate rethoracotomy for device explantation. In addition to the simplified RVAD removal this transcutaneous approach may reduce the complications in patients requiring RVAD support.     

Successful Use of Surgically Placed Impella 5.0 and Central Extracorporeal Membrane Oxygenation Circuit in a Patient with Postcardiotomy Shock

The Impella 5.0, a percutaneously inserted left ventricular assist device, has been used to support patients who have severe heart failure or who are undergoing high-risk percutaneous coronary intervention. We report our surgical placement of the Impella 5.0, through a graft sewn to the aorta, to unload the left ventricle of a 59-year-old man who was undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy shock. The patient underwent successful placement of a long-term left ventricular assist device before his discharge from the hospital. The versatility of the Impella 5.0 is exemplified in this patient who was successfully bridged to long-term support.     

End-stage heart failure with multiple intracardiac thrombi: a rescue strategy

The use of ventricular assist devices as a bridge to transplantation has become a widely used option for patients with end-stage heart failure. In contrast to total artificial hearts, ventricular assist devices support the failing heart by bypassing one or both ventricles. In certain cases (myocardial tumors, graft failure, transplant rejection, endocarditis, intracardiac thrombus formation), however, it may be advantageous to excise the heart and replace it with an artificial device. Total artificial hearts are intracorporeal devices designed for this purpose. Unfortunately, some patients are too small or are, for other reasons, ineligible for a total artificial heart. We describe the case of a 55-year-old woman who had ischemic cardiomyopathy and thrombus formation in all 4 cardiac chambers. To reduce the risk of thromboembolic events, we elected to replace her heart completely with 2 extracorporeal ventricular assist devices. The heart was excised via a median stemotomy approach, and the outflow cannulae (from device to patient) were connected to both atrial remnants. The 2 inflow cannulae (from patient to device) were anastomosed end-to-end to the aorta and the pulmonary artery, respectively. After attaining a flow of more than 5 L, the 2 extracorporeal assist devices effectively and efficiently performed the work of the native heart. Thus re-established, organ perfusion was improved by this mechanically driven circulation, as signified by an initial decrease in creatinine and blood urea nitrogen levels. The patient, however, did not recover from postoperative neurological dysfunction and died of respiratory insufficiency and multiple-organ failure on the 26th postoperative day.     

Intraoperative TandemHeart implantation as an adjunct to high-risk valve surgery

Newer generations of assist devices for postcardiotomy support in patients with ventricular failure have eliminated bearings and incorporated suspended impellers, smaller cannulae and hardware, and simplified insertion techniques. We describe the use of a surgically implanted, percutaneous, continuous-flow centrifugal pump (the TandemHeart percutaneous ventricular assist device) as part of a planned, pre-emptive approach for postcardiotomy support in a patient with severe mitral regurgitation, moderate tricuspid regurgitation, and biventricular failure. To our knowledge, this report documents the 1st use of a percutaneous ventricular assist device as an elective support device in a patient undergoing high-risk mitral or tricuspid valve surgery.     

A successful implantation of a dual-chambers cardioverter defibrillator for a patient with severe tortuous persistent left superior vena cava

We report a case of successful implantation of a dual-chambers transvenous cardioverter defibrillator for a dilated cardiomyopathy patient with severe tortuous persistent left superior vena cava and a very small innominate vein. After confirming the presence of a right superior vena cava, a dilated sheath was advanced into the narrow innominate vein to increase the lumen of innominate vein. The active atrial and ventricular leads were successfully inserted into right atrium and right ventricle through innominate bridge by the support of steerable long sheaths.     

Morphological changes in porcine bioprosthetic valves of a HeartMate left ventricular assist device

A 27-year-old man who received a HeartMate (Thoratec Corporation, USA) left ventricular assist device for progressive heart failure as a bridge to orthotopic heart transplantation is described in the present report. The device failed (mechanical failure) after almost 19 months. The porcine bioprosthetic valves in the inflow and outflow cannulae showed hemorrhage, cusp tears and inflammatory cells, located largely on the inflow valve cusps. The role of the inflammatory cell reaction in the bioprosthetic valve is discussed.     

Friedreich's ataxia associated with idiopathic hypertrophic subaortic stenosis

Friedreich's ataxia and idiopathic hypertrophic subaortic stenosis (IHSS), both diseases of unknown etiology, both result in hypertrophy and degenerative changes of the myocardium. Both diseases lead to nearly identical electrocardiographic changes. We report a patient who developed classical signs of Friedreich's ataxia several years after he was found to have moderately severe IHSS. This observation prompted a hemodynamic study of five other patients with Friedreich's ataxia in search of a more common association and thus a possible etiological link between the two diseases. Cardiac catheterization was performed under local anesthesia. Catheters were inserted into the right ventricle, the pulmonary artery, the left ventricle, and the aorta. Isuprel infusion up to 6 μg per minute was used in an attempt to induce an abnormal pressure gradient across the right or left ventricular outflow tract. Both right and left ventricular cineangiograms were obtained for evaluation of ventricular kinetics and wall thickness. Right and left heart pressures were normal at rest in all patients. During Isuprel infusion a 40 mm. pressure gradient was induced across the left ventricular outflow tract in only one patient. A second patient developed a 16 mm. gradient across the right ventricular outflow tract. All patients had low normal cardiac outputs. The angiograms demonstrated increased left ventricular wall thickness in all patients. It is concluded that systolic left and/or right ventricular out-flow tract obstruction is only infrequently present in Friedreich's ataxia and is mild in degree. An etiological link between Friedreich's ataxia and IHSS is not known at the present but may possibly exist and should be investigated.     

Measurements of conduction times with catheter electrodes during pacing from different ventricular sites.

Filtered bipolar catheter electodes, I mm apart, were used to pace and record from the high right atrium, right ventricular apex, right ventricular outflow tract, right ventricular inflow tract, middle cardiac vein, great cardiac vein, and endocardium of the left ventricular septal surface. Right ventricular apex to middle cardiac vein and the middle cardiac vein to right ventricular apex conduction intervals gave a rough estimate of anteroposterior and posteroanterior "transseptal plus free left ventricular wall" conduction times, respectively. On the other hand, the right ventricular apex to left ventricular septal surface and left ventricular septal surface to right ventricular apex intervals represented pure "transseptal" conduction times, since both sets of electrodes were in contact with the respective septal surface. During stimulation of the intermediately located right ventricular inflow tract propagation to the right ventricular apex and right ventricular outflow tract was longer than between these two sites. Moreover, conduction was almost as delayed to the right ventricular apex and right ventricular outflow tract as it was to the left ventricular septal surface. These findings were attributed to the peculiar electrophysiological behaviour of the right ventricular inflow tract muscle. Pacing from different segments of the great cardiac vein produced QRS morphologies and arrival of excitation patterns consistent with the relation between the anatomical location of this structure and the recording electrodes. However, from this study no inferences could be drawn regarding the conduction velocity or specific conduction pathways used by the stimulus in its journey from stimulating to recording areas.     

Measurements of conduction times with catheter electrodes during pacing from different ventricular sites.

Filtered bipolar catheter electodes, I mm apart, were used to pace and record from the high right atrium, right ventricular apex, right ventricular outflow tract, right ventricular inflow tract, middle cardiac vein, great cardiac vein, and endocardium of the left ventricular septal surface. Right ventricular apex to middle cardiac vein and the middle cardiac vein to right ventricular apex conduction intervals gave a rough estimate of anteroposterior and posteroanterior "transseptal plus free left ventricular wall" conduction times, respectively. On the other hand, the right ventricular apex to left ventricular septal surface and left ventricular septal surface to right ventricular apex intervals represented pure "transseptal" conduction times, since both sets of electrodes were in contact with the respective septal surface. During stimulation of the intermediately located right ventricular inflow tract propagation to the right ventricular apex and right ventricular outflow tract was longer than between these two sites. Moreover, conduction was almost as delayed to the right ventricular apex and right ventricular outflow tract as it was to the left ventricular septal surface. These findings were attributed to the peculiar electrophysiological behaviour of the right ventricular inflow tract muscle. Pacing from different segments of the great cardiac vein produced QRS morphologies and arrival of excitation patterns consistent with the relation between the anatomical location of this structure and the recording electrodes. However, from this study no inferences could be drawn regarding the conduction velocity or specific conduction pathways used by the stimulus in its journey from stimulating to recording areas.     

Postocardiotomy failure after Ross operation: implantation of intravascular flow pump through pulmonary autograft

We report a case of a patient with severe aortic stenosis, who underwent replacement of the aortic valve as a Ross procedure. Postoperatively the patient suffered postcardiotomy failure. Despite prolonged reperfusion and other methods of circulatory support, the patient could not be weaned from cardiopulmonary bypass (CPB). Therefore, an Impella intravascular flow pump was implanted, which is technically easy and has good weaning attributes. For implantation, a vascular prosthesis was sewn to the ascending aorta and the microaxial flow pump was placed under echocardiographic guidance across the pulmonary autograft into the left ventricle. With this support, the patient could be weaned from CPB. The report evaluates the Impella microaxial hemopump as a device that is technically easy to implant with no injury to the pulmonary autograft in patients after Ross operation. Surgeons should consider the device as a short-term support in borderline indications.     

Infective endocarditis of pulmonary valve. Considerations apropos of a case associated with interventricular communication and aortic insufficiency

We report the case of a 23 year old patient in whom heart disease was detected in childhood. He began to have suddenly fever and symptoms of right side heart failure. There were signs of aortic regurgitation, a systodiastolic murmur in the left parasternal region and a diastolic murmur in the left 4th intercostal space. The bidimensional and Doppler Echocardiogram showed a saccular dilatation in the right ventricular outflow tract. He was submitted to catheterisation which confirmed aortic regurgitation and detected ventricular septal defect and pulmonary hypertension. During surgery, a subaortic ventricular septal defect was seen as well as a dilatation of the right coronary aortic cusp which prolapsed through the defect to the right ventricular outflow tract. Vegetations were seen in the pulmonary valve. The aortic valve and a pulmonary cusp were excised and a Bj?rk Shiley aortic prosthetic valve was inserted. The septal defect was closed. The patient is still alive, symptomless, with 40 months of follow up. We discuss some problems related to this case, particularly the surgical indication and the rarity of the morphology discovered.     

Endovascular repair of ventricular assist device outflow cannula stenosis

This report describes a case of endovascular repair of an outflow cannula obstruction in a heart failure patient with biventricular assist devices. The patient presented with cardiogenic shock and was diagnosed via multimodality imaging with outflow cannula obstruction of the left ventricular assist device, likely from a hematoma. A transesophageal echocardiogram‐guided endovascular approach was undertaken. A 10.0 mm × 38 mm covered stent was successfully deployed and post‐dilated. Normal flow in the outflow cannula was restored. Hemodynamic and left ventricular flow parameters returned close to baseline post‐procedure. The growth in ventricular assist device implantation and associated complications will create new opportunities for endovascular repair. © 2016 Wiley Periodicals, Inc.     

Double outlet right ventricle with 1-malposition of the aorta.

Four patients are described with a recently recognized variant of double outlet right ventricle. Clinical examination favoured tetralogy of Fallot, but the chest X-ray suggested corrected transposition. Catheterization and angiocardiography showed that the aorta was to the left of the main pulmonary artery, and both arose from a normally positioned morphological right ventricle. Egress of blood from the left ventricle was through a subaortic ventricular septal defect. In all patients severe pulmonary stenosis was present and the right coronary artery ran an anomalous course anterior to the pulmonary valve ring. Two children had successful total correction, and one a palliative Blalock-Taussing shunt. Necropsy material from the fourth patient allowed confirmation of the ventricular morphology and the conducting tissued was examined. In corrective surgery, blood from the left ventricle was rerouted into the aorta by an intraventricular baffle. Pulmonary stenosis was relived by infundibulectomy and outflow tract patch.     

Double outlet right ventricle with 1-malposition of the aorta.

Four patients are described with a recently recognized variant of double outlet right ventricle. Clinical examination favoured tetralogy of Fallot, but the chest X-ray suggested corrected transposition. Catheterization and angiocardiography showed that the aorta was to the left of the main pulmonary artery, and both arose from a normally positioned morphological right ventricle. Egress of blood from the left ventricle was through a subaortic ventricular septal defect. In all patients severe pulmonary stenosis was present and the right coronary artery ran an anomalous course anterior to the pulmonary valve ring. Two children had successful total correction, and one a palliative Blalock-Taussing shunt. Necropsy material from the fourth patient allowed confirmation of the ventricular morphology and the conducting tissued was examined. In corrective surgery, blood from the left ventricle was rerouted into the aorta by an intraventricular baffle. Pulmonary stenosis was relived by infundibulectomy and outflow tract patch.     

Pulmonary atresia with intact atrial and ventricular septums, unroofed coronary sinus, and absent aortocoronary arterial connections

A stillborn fetus with pulmonary valvar atresia and intact atrial and ventricular septums also had absence of coronary arterial connections from the aorta and an unroofed coronary sinus. A left superior caval vein drained to the dilated coronary sinus. The left coronary artery was anomalously connected to the proximal branch of the right pulmonary artery, and a fistula from the right ventricle supplied the right coronary artery.     

Off-pump insertion of an extracorporeal LVAD through a left upper-quadrant incision

Insertion of an extracorporeal left ventricular assist device for temporary ventricular support via median sternotomy can be challenging in patients with a history of cardiac surgery, because these patients often poorly tolerate the lengthy dissection and cardiac manipulation necessary for exposure of the left ventricular apex and ascending aorta. Our approach, transdiaphragmatic left ventricular inflow cannulation with return through a graft sewn to the supraceliac aorta, can be accomplished through a left upper-quadrant abdominal incision without entering the peritoneal cavity, mediastinum, or left hemithorax. Repeated sternotomy and mediastinal dissection are thus avoided. To our knowledge, this report documents the 1st use of this technique for insertion of an extracorporeal pulsatile ventricular assist device for temporary ventricular support.     

Double outlet right ventricle with left ventricular outflow tract obstruction due to small ventricular septal defect

This is a report of the seventh and eighth known cases of double outlet right ventricle with left ventricular outflow tract stenosis due to a small ventricular septal defect. Case 1 is the second patient with this uncommon anomaly who has undergone successful surgical correction by enlargement of the ventricular septal defect and reconstruction of the outflow tract from the left ventricle to the aorta by means of a teflon tunnel. Case 2 was studied at autopsy and illustrates well the anatomic features of this malformation. It is suggested that this type with left ventricular outflow tract stenosis be incorporated into current classifications of double outlet right ventricle.     

Effects of bathing on cardiac function in patients with myocardial infarction: hemodynamic and Doppler echocardiographic studies

Hemodynamic changes during bathing in patients with myocardial infarction were studied using a Swan-Ganz catheter and Doppler echocardiography. The subjects consisted of 14 patients with myocardial infarction (mean age 55.6 years), including the six extensive ones of the anterior wall, five of the anteroseptal wall, two of the inferior wall, and one of the inferoposterior wall. Bathing was by means of 42 degrees C tap water for five min in the supine position in a Hubbard tank. Pulsed wave Doppler was used to analyze left and right ventricular inflow velocity patterns, and continuous wave Doppler was employed to measure right ventricular outflow velocity. Blood pressure, pulmonary arterial pressure, pulmonary arterial wedge pressure and right atrial pressure increased significantly during bathing. After bathing, these parameters decreased and remained lower than the baseline levels before bathing. Heart rate and the cardiac index increased significantly during bathing, but decreased after bathing. The systemic vascular resistance index and pulmonary vascular resistance index decreased significantly during bathing, but increased after bathing. The A/R ratio at the left and right ventricular inflow tracts increased during bathing, and right ventricular outflow velocity increased significantly. However, when the subjects were categorized into two groups, i.e., those whose pulmonary arterial pressure consistently increased to the higher level than the average during bathing and those who did not show any increase, the A/R ratio at the inflow tract of the left ventricle increased significantly during bathing in the former group, but there was no significant change in the latter group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Natural history of supravalvular aortic stenosis and pulmonary artery stenosis

Data from 35 patients with supravalvular aortic stenosis or pulmonary artery stenosis, or both, undergoing cardiac catheterization between 1973 and 1989 were analyzed retrospectively. Twenty-seven patients had supravalvular aortic stenosis: 11 required surgery after the first investigation and 8 (80%) of 10 others undergoing serial investigation showed an increase in the left ventricle to aorta pressure gradient. Angiographic measurements showed that the increase in the aortic pressure gradient was related to failure of normal growth of the ascending aorta lumen. Nineteen patients had pulmonary artery stenosis, with a right ventricular pressure greater than 33 mm Hg. At restudy, right ventricular pressure had decreased in 9 (82%) of 11 patients. This decrease in right ventricular pressure was associated with an increase in the systolic distensibility of the proximal pulmonary arteries, although there was no increase in the diastolic diameters. One patient had a rapid early increase in right ventricular pressure and no pulmonary artery growth. In two patients, multiple peripheral pulmonary artery stenoses became evident with time and produced persistent right ventricular hypertension. Supravalvular aortic stenosis is usually a progressive lesion, with an increase in left ventricular outflow tract pressure gradient related to poor growth of the ascending aorta. Pulmonary artery stenosis usually improves and only rarely limits prognosis.     

Subaortic obstruction after the use of an intracardiac baffle to tunnel the left ventricle to the aorta.

Postoperative hemodynamic studies in five patients document subaortic obstruction after surgical repair utilizing an intracardiac baffle to establish continuity between the left ventricle and the aorta. Four of the patients had a Rastelli procedure for D-transposition of the great arteries with a ventricular septal defect and pulmonary stenosis; one patient had repair of double outlet right ventricle with a ventricular septal defect and pulmonary stenosis. The left ventricular outflow was shown to be a long narrow tunnel by angiography in four of five patients and by echocardiography in one patient. Resting aortic peak systolic pressure gradient ranged from 10 to 42 mm Hg (mean 24). The obstruction was localized to the proximal end of the left ventricule to aorta tunnel (i.e., at the site of ventricular septal defect) in five patients. One patient with a gradient of 42 mm Hg has angina and decreased exercise tolerance. Subaortic obstruction is a newly described sequelae after the Rastelli procedure for transposition or repair of double outlet right ventricle. The obstruction may be hemodynamically significant and should be searched for at postoperative cardiac catheterization.