BACKGROUND:Recent data have suggested an increased risk of stroke with the utilization of Impella 5.5 (Abiomed, Danvers, MA, USA) devices for bridging Status 2 heart transplant patients. The purpose of our study was to investigate the relationship between the duration of Impella 5.5 support and the incidence of stroke after heart transplant. METHODS:An analysis of the UNOS database was performed on heart transplant recipients that were bridged with an Impella 5.5 from January 2022 to March 2025. Patients were divided into two cohorts according to duration of support (<30 and >30 days). A propensity score matched adjustment model was used to ascertain stroke probabilities across analyzed groups. RESULTS:A total of 1580 patients that received an Impella 5.5 as a bridge to heart transplant were identified, of which 1186 (75%) were supported for <30 days and 394 (25%) >30 days. Age, male sex, previous cardiac surgery, higher BMI and functional status at listing were significant factors for the occurrence of stroke in both groups (<30 and >30 days). Propensity score matched stroke rate in the <30-day cohort was 3.5% and in the >30-day group was 6.2% (p = 0.043). In patients with post-transplant stroke, pre-transplant history of stroke was present in 22.4% of patients supported <30 days and 19% of patients on Impella for >30 days. CONCLUSIONS:Prolonged duration of support, in excess of 30 days, with an Impella 5.5 is associated with a significantly higher risk of stroke after heart transplantation.

Anecdotally, over the past 2 years, many transplant centers in the United States have shifted toward using Impella 5.5 instead of intra-aortic balloon pumps (IABP) for less sick patients. The aim of our study is to determine if Impella 5.5 devices are now used more liberally for status 2 heart transplant candidates and whether this confers any benefit to post heart transplant outcomes. We evaluated the United Network for Organ Sharing Database (UNOS) database and analyzed status 2 patients who underwent heart transplantation after being bridged with an Impella 5.5 or IABP from October 2019 to March 2024. The rate of Impella implants for supporting status 2 candidates significantly increased from 9% to 35% ( p < 0.001). More patients in the Impella cohort were on inotropic support at the time of transplant (63% vs . 58%; p = 0.013) and were more likely to have undergone previous cardiac surgery (25% vs. 20%; p = 0.04). The Impella 5.5 patients had an overall shorter length of hospital stay compared with the IABP patients (20.4 vs . 22.5 days; p = 0.05), but there was a significantly higher rate of stroke in the Impella 5.5 group (5% vs . 3%, p = 0.016). A more detailed cost-effective analysis is required to determine if the increased utilization of this device is justified based on its increased cost.

Background: There has been an exponential increase in the utilization of temporary mechanical support devices for bridging Status 2 heart transplant candidates. The aim of our study is to determine outcomes in dual organ heart/kidney recipients for patients bridged with an Impella 5.5 versus IABP. Methods: We evaluated the UNOS database and analyzed Status 2 patients who underwent dual organ heart/kidney transplantation after being bridged with an Impella 5.5 or IABP from October 2019 (time of Impella 5.5 FDA approval) until March 2024. Results: A total of 457 patients who underwent Heart/Kidney transplant (HKT) were identified, of which 73% (334/457) were bridged with an IABP and 27% (123/457) with an Impella 5.5. Within the IABP cohort, 37% (122/334) were on dialysis pre-transplant compared to 43% (53/123) in the Impella group ( p = 0.409). Patients in the Impella group had worse functional status, liver function, and filling pressures. There was no difference in the need for dialysis post-transplant (32% vs 29%, p = 0.613). Survival at 30, 180, and 360 days and the rates of primary graft dysfunction, acute, and chronic rejection were similar between the two groups. Conclusion: Both IABP and Impella appear to be safe for bridging dual organ heart and kidney transplant candidates, with comparable post-transplant heart and kidney graft function, complications, and survival up to 2 years. Patients receiving Impella 5.5 appear to be sicker and as a result, this percutaneous temporary mechanical circulatory support device may confer some advantages, especially for patients with dual organ failure who undergo transplantation.

There has been a worldwide rapid adoption of transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis. Currently, more TAVR explants with SAVRs are performed than TAVR-in TAV. TAVR explantation is a technically hazardous procedure mainly due to significant aortic neo-endothelialization which incorporates the TAVR valve. Surgical techniques for TAVR explantation are not well established and surgeon experience at present is limited. In this manuscript, we describe our technique for surgical explantation of transcatheter aortic bioprosthesis. Familiarity with the procedure and its clinical implications is essential for all cardiac surgeons.

Mechanical circulatory support for cardiogenic shock complicated by acute severe aortic regurgitation poses a unique challenge for traditional veno arterial extracorporeal membrane oxygenation (ECMO) because of rapidly rising left ventricular pressures accentuated by the increased afterload from retrograde flow in femoral cannulation. This process necessitates rapid left ventricular unloading while also allowing for adequate native left ventricular function. Herein, we describe a case of cardiogenic and septic shock secondary to methicillin-resistant Staphylococcus aureus complicated by acute severe aortic regurgitation temporized by left atrial-veno arterial (LA-VA) ECMO via the Livanova TandemHeart system. Left ventricular unloading created a window of hemodynamic stability allowing for optimization of multiorgan failure and infectious source control before surgical aortic valve replacement.

Recently, the utilization of Impella 5.5, especially in the axillary position, has increased exponentially. The device provides excellent hemodynamic support for patients in cardiogenic shock, as a bridge to recover, transplant, or durable left ventricular device. However, small size arteries remain its main limitation. With a maximum diameter of 19 Fr (6.33 mm), the recommended artery size needed for implantation is 7 mm. In this case, we discuss the successful implantation and removal of the Impella 5.5 device into a patient, with a subclavian artery diameter of 4 mm, whose other short- and mid-term options for mechanical circulatory support were limited.

The shortcomings of expense, power requirements, infection, durability, size, and blood trauma of current durable LVADs have been recognized for many years. The LVADs of tomorrow aspire to be fully implantable, durable, mitigate infectious risk, mimic the pulsatile nature of the native cardiac cycle, as well as minimize bleeding and thrombosis. Power draw, battery cycle lifespan and trans-cutaneous energy transmission remain barriers to completely implantable systems. Potential solutions include decreases in pump electrical draw, improving battery lifecycle technology and better trans-cutaneous energy transmission, potentially from Free-range Resonant Electrical Energy Delivery. In this review, we briefly discuss the history of LVADs and summarize the LVAD devices in the development pipeline seeking to address these issues.

Background Emergency resternotomy in the intensive care unit for a patient who has undergone cardiac surgery can be daunting for surgeons and critical care staff. Clinicians involved are often unfamiliar with the surgical instruments and techniques needed. Local Problem After an emergency intensive care unit resternotomy resulted in suboptimal performance and outcome, protocols for emergency resternotomy were established and improved. Methods Education and simulation training were used to improve staff comfort and familiarity with the needed techniques and supplies. The training intervention included simulations to provide hands-on experience, improve staff familiarity with resternotomy trays, and streamline emergency sternotomy protocols. Preintervention and postintervention surveys were used to assess participants’ familiarity with the implemented plans and algorithms. Results All 44 participants (100%) completed the preintervention survey, and 41 of 44 participants (93%) returned the postintervention survey. After the intervention, 95% of respondents agreed that they were prepared to be members of the team for an emergency intensive care unit sternotomy, compared with 52% of respondents before the intervention. After the intervention, 95% of respondents strongly agreed or agreed that they could identify patients who might need emergency sternotomy, compared with 50% before the intervention. The results also showed improvement in staff members’ understanding of team roles, activation and use of the emergency sternotomy protocol, and differences between guidelines for resuscitating patients who experience cardiac arrest after cardiac surgery and the post–cardiac arrest Advanced Cardiovascular Life Support protocol. Conclusion Results of this quality improvement project suggest that simulation training improves staff comfort with and understanding of emergency resternotomy.

Bartter syndrome is a rare, renal tubulopathy caused by defective salt reabsorption in the thick ascending limb of the loop of Henle which results in salt wasting, hypokalemia, and metabolic disturbances. The electrolyte disturbances associated with this condition can be difficult to manage in the postoperative setting, especially in patients undergoing cardiac surgery. We report a case of a 62-year-old male with a history of diabetes, hypertension, coronary artery disease, and Bartter syndrome who underwent coronary artery bypass grafting and who developed severe lactic acidemia and severe electrolyte abnormalities postoperatively. Treatment consisted of aggressive resuscitation with crystalloid and intravenous (IV) electrolyte replacement.

Recent advances in veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) technology and management have enabled us to support patients with cardiac and/or pulmonary failure, who may have previously been considered untreatable. VA ECMO and VV ECMO are by definition transient therapies and serve as a bridge to recovery, bridge to decision, bridge to transplant, or bridge to no recovery. Weaning ECMO should be considered for all patients once native cardiac and pulmonary function show signs of recovery. Currently, there are no universally accepted protocols for weaning VA and VV ECMO, and consequently, each individual center follows their own weaning protocols. The aim of this review article is to describe different approaches to safely wean from VA and VV ECMO.

It was with great interest that we read the article published by Delmas et al.,1 which is a European multicenter survey on the use of Impella devices as a bridge to surgical repair, bridge to percutaneous closure, or bridge to recovery/no intervention. This study included 28 patients with postmyocardial infarction ventricular septal ruptures (post-MI VSRs), who were all in cardiogenic shock upon presentation. Impella devices used were Impella 2.5 (3.5%, 1/28), Impella CP (71%, 20/28), Impella 5.0 (18%. 5/28), and unknown for 7% (2/28). Additional temporary mechanical circulatory support (MCS) was required in 50% of cases, mainly extracorporeal membrane oxygenation (ECMO) (32%). Definitive treatment of post-MI VSR for patients supported with Impella was surgical in 36%, percutaneous in 21%, and conservative management in 43%. In-hospital mortality was 75%, and survival at 1 year was also 25%. Only patients who were definitively treated with surgery survived. Access site severe bleeding (50%) and hemolysis (11%) were the most common Impella-associated complications. Because primary percutaneous coronary intervention (PCI) became the mainstay for treating acute ST elevation myocardial infarctions (STEMI), the occurrence of post-MI VSRs has steadily declined, with a current incidence of approximately 0.3%.2 Nevertheless, when it does occur, it is associated with extremely high mortality, owing to a combination of cardiogenic shock and technical difficulties of repairing these defects, given that surgeons must often deal with poorly delineated, infarcted, and fragile tissue.3 Delayed surgical repair (>7 days) is associated with better survival (54%) compared to early repair (18%).4 Furthermore, 38% of VSRs repaired with early surgery have evidence of recurrent ventricular septal defect (VSD).5 As a result, it is important to wait for at least a week from the occurrence of the VSR until definitive surgical repair, as this is associated with higher rates of survival. Traditionally, most patients have been supported with an intra-aortic balloon pump (IABP). However, IABP may not be sufficient to hemodynamically support a patient,6 but is also associated with peripheral thrombotic complications and does not allow patients to ambulate. Veno-arterial (VA) ECMO can increase left ventricular (LV) afterload, worsen left-to-right shunting, and is usually avoided as a sole means of MCS in post-MI VSRs. Nonetheless, few case series, including this study by Delmas et al.,1 have demonstrated successful LV unloading and hemodynamic support with Impella, for patients with post-MI VSRs, before surgical repair.7,8 The use of Impella devices for VSRs is relatively contraindicated, as it can theoretically reverse the shunt causing hypoxia and can also dislodge the fragile infarcted septal tissue causing distal embolization, including stroke. Our experience has not shown this and we feel that these devices should be strongly considered, when balancing the management of VSRs between stabilization of hemodynamics, organ recovery, and surgical timing for improved outcomes. The use of Impella devices, as a bridge to surgery in post-MI VSR patients, has become even more advantageous with the introduction of the Impella 5.5, especially in the axillary artery position. Of course, one must weigh the risks of surgically implanting an Impella 5.5 for patients in cardiogenic shock against the potential benefits. We do feel that these risks are minimal and the benefits are great, especially given that the procedure is generally quick and straightforward. Many of these patients will already be intubated, and placing an Impella 5.5, will allow for early potential extubation and even ambulation, which is of critical importance for maximizing postoperative survival. Traditionally, most VSR patients receive an IABP. Intra-aortic balloon pump insertion, especially in the femoral position, requires patient immobilization, which is detrimental for surgical candidates, owing to worsening pulmonary function from V/Q mismatch, muscle wasting, and malnutrition, and is also associated with a higher risk of deep vein thrombosis/pulmonary embolism (DVTs/PE), peripheral/visceral thrombotic complications, worsening end-organ perfusion (renal, hepatic, mesenteric failure), inability to maintain hemodynamics and perfusion and resultant higher pressor and inotropic requirements. This is also true of earlier generation Impella devices placed in the femoral position. We strongly feel that these limitations are mitigated with an axillary Impella 5.5, and should be considered in all patients with post-MI VSR, especially those in cardiogenic shock. There has only been one report in which Impella support resulted in a right-to-left shunt.9 Right-to-left shunt should only happen with high Impella flows, and this can be easily managed by decreasing the amount of support. Sato et al.10 demonstrated that shunt reversal only occurred at support levels of P8 or higher and by lowering support to P6, they were able to convert the shunt back to left-to-right, thus eliminating systemic deoxygenation. There have been no reports of systemic embolization or strokes using Impella in post-MI VSRs. Direct intake of tissue by the device is doubtful. If tissue fragments enter the pump, it would alarm and shut off, which makes embolization through the Impella highly unlikely. Recently, Ruiz Duque et al.8 published a case series of four patients with post-MI VSRs who were supported with Impella before surgical repair. All of their patients survived postoperatively. They also demonstrated a decrease in wedge pressure, decrease in left-to-right shunting, reduction in trans-VSD gradients, and improvement in end-organ perfusion before VSR closure. The authors proposed the use of Impella in patients with Qp/Qs of greater than 2.5. Despite our endorsement for using Impella devices in patients with post-MI VSRs, we have some comments on this article by Delmas et al.1 The inclusion of the Impella 2.5 and Impella 5 in the study, is clinically irrelevant, because both devices are rarely, if ever, used and have been largely replaced by their successors, the Impella CP and the Impella 5.5, respectively, which are both far superior. They report that severe access site hemorrhage was their most common complication (50%), followed by hemolysis (12%). The new generation Impella 5.5, which runs bicarbonate in the purge, lessens the need for early systemic heparinization and significantly reduces the risk of bleeding. Also, the risk of hemolysis with the larger 5.5 device has been significantly reduced compared with previous generation Impellas. They also mention that VSD patch closure is performed through a double ventriculotomy, which seems unnecessary, as most VSRs can generally be repaired through a single left or right ventriculotomy, depending on the location of the infarct and resultant VSR. The lack of hemodynamic and echocardiographic data is a shortcoming, as it would have been instructive to see the changes in LV loading, LV dimensions, LV pressures, VSR gradients, and Qp/Qs ratios before and after Impella therapy, both with and without additional MCS. These data would have shown the true benefit of Impella support in patients with post-MI VSRs. Finally, this study clearly confirms that surgical repair is the best and possibly only definitive treatment for VSRs. Successful transcatheter device closure is rarely possible owing to the larger size of typical post-MI VSRs, their challenging anatomic location for percutaneous closure, and the poor quality of tissue which constitutes the rim on which the device will be secured. In conclusion, Impella support for patients with post-MI VSRs should be strongly considered, especially in the context of cardiogenic shock and high Qp/Qs gradients. These heart pumps are well-established for shifting LV pressure-volume loops by decreasing filling pressures and volumes. It comes as no surprise that Impella devices decrease shunting across VSRs and increase total systemic flow to the body. This allows for end-organ recovery and for ischemic septal tissue to delineate and mature, making surgical VSR repairs much safer and durable. The usage of axillary Impella 5.5 is even more advantageous, given its association with less bleeding complications and less hemolysis. Additionally, and perhaps most importantly, the Impella 5.5 allows for early ambulation and preoperative optimization in a critically ill patient population.

Objective Stroke remains a frequent and devastating complication after left ventricular assist device (LVAD) implantation, despite recent advances in device technology. The aim of this study was to analyze risk factors and outcomes of stroke following implantation of 200 continuous-flow LVADs at our institution. Methods We retrospectively analyzed patients who underwent LVAD implantation from 2011-2016. Data were available for a total of 200 patients. Results Post-LVAD stroke occurred in 13% of patients (26 of 200). Ischemic stroke occurred in 50% of patients (13 of 26), and hemorrhagic stroke in 50% (13 of 26). The median duration of LVAD support at the time of stroke was 257.4 days. Baseline characteristics did not differ significantly between the stroke and stroke-free cohorts. The mean international normalized ratio (INR) at the time of embolic stroke was 1.86 (range, 1.23-3.25) and 4.62 (range, 1.4-21.4) in patients with hemorrhagic stroke (P = .014). Mortality within 30 days of stroke was 31% (8 of 26). Mortality for hemorrhagic stroke was 63% (5 of 8) and 37% (3 of 8) for ischemic stroke (P = .03). Among the 18 patients that survived stroke, 28% (5 of 18) received a heart transplant, 39% (7 of 18) are receiving ongoing LVAD support, and 33% (6 of 18) have died from unrelated causes. Multivariate analysis showed that INR level, aortic cross-clamping, a history of previous stroke, and postoperative infection were significant predictors for post-LVAD stroke. Conclusion The occurrence of stroke significantly increases morbidity and mortality after LVAD implantation. Despite an adverse impact on survival and quality of life, several patients who suffered stroke still received a heart transplant. Furthermore, none of our patients had recurrence of a neurological event. Strict implementation of anticoagulation protocols is likely the mainstay of preventing this devastating complication.

Objective LVAD-related strokes occur at a much higher rate compared to traditional open heart surgery. The pathophysiology of ischemic and hemorrhagic strokes after LVAD implantation is not well defined. The aim of this study was to better describe the etiopathogenesis of strokes during continuous flow LVAD support based on our institutional experience. Methods We performed a retrospective analysis of 200 patients, with and without stroke that underwent implantation of a continuous flow LVAD from 2011 to 2016. Results The incidences of stroke in our patient population were 13% (26/200), of which 50% (13/26) were ischemic and 50% hemorrhagic (13/26). Only 8% of strokes occurred within the first 48 h from LVAD implantation, all of which were ischemic. The median duration of support was 148 days for ischemic and 351 days (p = 0.012) for hemorrhagic strokes. The average mean arterial pressure measurements at the time of hospital discharge were 89 mmHg for patients who subsequently developed stroke and 72 mmHg (p = 0.03) for stroke-free patients. The average outpatient pressure measurements were 96 mmHg and 76 mmHg (p = 0.02) for the stroke and stroke-free patients, respectively. The mean velocity index showed the potential impairment of cerebral autoregulation. Multivariate analysis demonstrated that INR, COPD, aortic cross clamping, previous stroke, and device infections were statistically significant risk factors for stroke occurrence after LVAD implantation. Conclusions In addition to LVAD-related thrombogenicity, the subsequent need for anticoagulation, and an acquired von Willebrand syndrome, several clinical factors, such as deviation from the anticoagulation regimen, hypertension, COPD, device infections, and aortic cross clamping, appear to have an influence on the extremely high rate of postoperative ischemic and hemorrhagic strokes.

Objective The aim of this study was to analyze risk factors and outcomes of vasoplegia after cardiac surgery based on our experience with almost 2000 cardiac operations performed at our institution. Methods We retrospectively analyzed patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) between 2011 and 2013. Data were available for a total of 1992 patients. We defined vasoplegia as hypotension with persistently low systemic vascular resistance (<800 dyn/s/cm) and preserved Cardiac Index (>2.5). Results The rate of vasoplegia in our cohort was 20.3% (n = 405). The incidences of mild, moderate, and severe vasoplegia were 13.2, 5.7, and 1.5%, respectively. Factors that increased risk of vasoplegia included valve operations, heart transplants, dialysis-dependent renal failure, age >65, diuretic therapy, and recent myocardial infarction. B blocker therapy was protective against vasoplegia. Conclusion Vasoplegic syndrome is still a frequently occurring adverse event following cardiac surgery. In high risk patients for vasoplegia, it may be sensible to proceed with preoperative volume loading (instead of diuresis), initiation of low dose vasopressin therapy if needed, and attempting to up titrate beta-blocker therapy.

The clinical use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LTx) has greatly increased in recent years. However, clinical practices for ECMO as a bridge to LTx vary widely between LTx centers. To better define the current practice of ECMO as a bridge to LTx, we surveyed pre-LTx ECMO practices among all adult LTx programs in the United States. All US LTx centers were surveyed (n = 57) between January and December 2014. Responses were received from 33 of 57 centers (58%). Of 33 responding centers, six (18%) performed ≥50 LTxs per year (defined as high volume) and two (6%) performed <10 LTxs per year (low volume). Two-third of responding centers, 22/33 (67%), reported use of ECMO as a bridge to LTx. Of these 22 centers, 18 (82%) successfully used venovenous (VV) ECMO as a bridge to LTx using the dual-lumen Avalon cannula. Patient >65 years of age was judged an ECMO contraindication in 15/33 (45%) of responding centers, but 12/33 (36%) centers, including the six high-volume centers, had no official age cutoff for ECMO candidacy. There was no consensus on the maximum acceptable duration of pre-LTx ECMO therapy; although 18/33 (55%) of programs had no defined maximal duration of ECMO pre-LTx, 10/33 (30%) considered >10 days on ECMO support contraindicated. Our survey suggests that in the United States, ECMO is used frequently pre-LTx, particularly VV ECMO at high-volume centers. However, criteria for ECMO initiation, age eligibility, bedside care, and maximum duration of support varied significantly between survey respondents.

BACKGROUND:A lack of donor hearts remains a major limitation of heart transplantation. Hearts from Centers for Disease Control (CDC) high-risk donors can be utilized with specific recipient consent. However, outcomes of heart transplantation with CDC high-risk donors are not well known. We sought to define outcomes, including posttransplant hepatitis and human immunodeficiency virus (HIV) status, in recipients of CDC high-risk donor hearts at our institution.METHODS:All heart transplant recipients from August 2010 to December 2014 (n = 74) were reviewed. Comparison of 1) CDC high-risk donor (HRD) versus 2) standard-risk donor (SRD) groups were performed using chi-squared tests for nominal data and Wilcoxon two-sample tests for continuous variables. Survival was estimated with Kaplan-Meier curves.RESULTS:Of 74 heart transplant recipients reviewed, 66 (89%) received a SRD heart and eight (11%) received a CDC HRD heart. We found no significant differences in recipient age, sex, waiting list 1A status, pretransplant left ventricular assist device (LVAD) support, cytomegalovirus (CMV) status, and graft ischemia times (p = NS) between the HRD and SRD groups. All of the eight HRD were seronegative at the time of transplant. Postoperatively, there was no significant difference in rejection rates at six and 12 months posttransplant. Importantly, no HRD recipients acquired hepatitis or HIV. Survival in HRD versus SRD recipients was not significantly different by Kaplan-Meier analysis (log rank p = 0.644) at five years posttransplant.CONCLUSION:Heart transplants that were seronegative at the time of transplant had similar posttransplant graft function, rejection rates, and five-year posttransplant survival versus recipients of SRD hearts. At our institution, no cases of hepatitis or HIV occurred in HRD recipients in early follow-up.

Background. Debate regarding the optimal cannulation site for aortic surgery continues. We report our recent experience with a simple and rapid open Seldinger-guided technique for femoral cannulation. Aside from speed and simplicity (no need for arterial incision or suture closure), this technique has the added benefit that the distal limb continues to be perfused, as no arterial snare is required.Methods. We recently began routinely utilizing an open Seldinger-guided technique for femoral artery cannulation. The artery is exposed surgically but cannulated by guidewire inside a pursestring without arterial incision. The pursestring is simply tied when decannulation is performed. We report our experience with the routine application of this technique from August 2011 to April 2015.Results. We reviewed the outcome of 337 consecutive peripheral arterial cannulations performed for thoracic aortic surgery (303 femoral, 34 axillary) using the open Seldinger technique. Within the femoral cannulation group, the hospital survival rate was 97% (295 of 303). The survival rate for elective operations was 98% (277 of 283), and 90% (18 of 20) for emergent/urgent. Seldinger-guided femoral cannulation was performed for replacement of the ascending/aortic arch in 88% (266 of 303), the descending thoracic aorta in 7% (22 of 303), and the thoracoabdominal aorta in 5% (15 of 303). There were no instances of intraoperative malperfusion phenomena, arterial dissection, or vascular injury or rupture. No patients had postoperative acute limb ischemia. Local wound complications were observed in 1% of patients (3 of 303). The stroke rate was 1.6% (5 of 303). The same open Seldinger technique was also used without complication in the axillary cannulation group.Conclusions. An open Seldinger-guided femoral (or axillary) cannulation technique is quick and easy to perform, with minimal vascular or other complications and extremely low risk of stroke. This technique is recommended for its speed, simplicity, and effectiveness, and for its preservation of distal arterial flow (which is occluded with the traditional arterial incision/arterial snare technique). (C) 2016 by The Society of Thoracic Surgeons

Continuous-flow (CF) left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure refractory to optimal medical therapy. The goal of this study was to review our 7 year single institutional experience with CF LVADs. Mean age was 50.4 + 12.5 (17-69) years for bridge-to-transplantation (BTT) patients and 57.6 + 10.4 (31-81) years for destination therapy (DT) patients (p < 0.001). Overall, 38 patients (26%) were female and 58 (41%) were African American. Etiology of heart failure was ischemic in 54 patients (37%) and nonischemic in 93 patients (63%). Overall survival at 30 days, 6 months, 12 months, and 2 years was 93%, 89%, 84%, and 81%, respectively. Gastrointestinal bleeding (GIB) was the most common complication (24%), followed by stroke (18%), right ventricular (RV) failure (18%), ventilator-dependent respiratory failure (10%), reoperation for bleeding (10%), and driveline infection (9%). These data demonstrate excellent survival with low mortality for both BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become the gold standard for long-term treatment of end-stage heart failure and a plausible alternative to heart transplantation, we need to continue to improve the incidence of frequent postoperative complications, such as RV failure, driveline infections, strokes, and GIB.

Previous studies have grouped together both patients requiring right ventricular assist devices (RVADs) with patients requiring prolonged milrinone therapy after left ventricular assist device (LVAD) implantation. We retrospectively identified 149 patients receiving LVADs and 18 (12.1%) of which developed right ventricular (RV) failure. We then separated these patients into those requiring RVADs versus prolonged milrinone therapy. This included 10 patients who were treated with prolonged milrinone and eight patients who underwent RVAD placement. Overall, the RV failure group had worse survival compared with the non-RV failure cohort (p = 0.038). However, this was only for the subgroup of patients who required RVADs, who had a 1, 6, 12, and 24 month survival of 62.5%, 37.5%, 37.5%, and 37.5%, respectively, versus 96.8%, 92.1%, 86.7%, and 84.4% for patients without RV failure (p < 0.001). Patients treated with prolonged milrinone therapy for RV failure had similar survivals compared with patients without RV failure. In the RV failure group, age, preoperative renal failure, and previous cardiac surgery were predictors of the need for prolonged postoperative milrinone. As LVADs become a more widely used therapy for patients with refractory, end-stage heart failure, it will be important to reduce the incidence of RV failure, as it yields significant morbidity and increases cost.

Continuous-flow (CF) left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure refractory to optimal medical therapy. The goal of this study was to review our 7 year single institutional experience with CF LVADs. Mean age was 50.4 + 12.5 (17-69) years for bridge-to-transplantation (BTT) patients and 57.6 + 10.4 (31-81) years for destination therapy (DT) patients (p < 0.001). Overall, 38 patients (26%) were female and 58 (41%) were African American. Etiology of heart failure was ischemic in 54 patients (37%) and nonischemic in 93 patients (63%). Overall survival at 30 days, 6 months, 12 months, and 2 years was 93%, 89%, 84%, and 81%, respectively. Gastrointestinal bleeding (GIB) was the most common complication (24%), followed by stroke (18%), right ventricular (RV) failure (18%), ventilator-dependent respiratory failure (10%), reoperation for bleeding (10%), and driveline infection (9%). These data demonstrate excellent survival with low mortality for both BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become the gold standard for long-term treatment of end-stage heart failure and a plausible alternative to heart transplantation, we need to continue to improve the incidence of frequent postoperative complications, such as RV failure, driveline infections, strokes, and GIB.