Background Myocardial bridging is a congenital coronary anomaly in which a segment of an epicardial artery is tunneled within the myocardium. Although many cases remain asymptomatic, hemodynamically significant bridges may require surgical intervention. Case Summary A 57-year-old man with a history of an unrepaired ventricular septal defect presented with recurrent chest pain. Initial imaging identified a 4.7-cm myocardial bridge in the left anterior descending artery. Functional testing with fractional flow reserve, instantaneous wave-free ratio, and diastolic hyperemia-free ratio confirmed hemodynamic significance. Optical coherence tomography was performed to further visualize the segment. The patient underwent successful surgical unroofing, resulting in complete symptom resolution. Discussion This case highlights a multimodal intracoronary approach incorporating intracoronary anatomical and physiological testing to determine the hemodynamic significance of myocardial bridging. Take-Home Message Multimodal intracoronary anatomical and physiological testing is imperative for diagnosing myocardial bridges in patients presenting with undifferentiated angina, thereby influencing management.

BackgroundVeno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used for refractory cardiogenic shock, yet optimal weaning strategies and the role of left ventricular (LV) venting remain unclear. The TWEET-1 study was designed as an early feasibility investigation to define processes, timelines, and clinical parameters for future interventional trials evaluating Impella 5.5 for LV venting during V-A ECMO support.MethodsThis prospective, single-center observational study from 2021 to 2025 included patients who received standard-of-care V-A ECMO and Swan-Ganz monitoring. Patients were assigned to the ECPELLA + group (defined as the addition of Impella 5.5 to V-A ECMO to provide left ventricular unloading) when pulmonary artery (PA) diastolic pressure exceeded 20 mm Hg; other individuals served as controls. The primary outcome was survival to discharge. Secondary outcomes included V-A ECMO duration, complications, and SAVE score-adjusted survival.ResultsAmong 117 screened patients, 43 were enrolled (25 ECPELLA +, 18 controls). Overall survival to discharge was 53% with no significant difference between groups. ECPELLA + patients had higher pulmonary pressures and longer V-A ECMO support but demonstrated appropriate selection for unloading. Both groups exceeded the SAVE score-predicted survival. Subgroup analysis suggested potential benefit of Impella venting in the most severe patients (SAVE -14 to -10).DiscussionHemodynamic-guided LV venting with Impella 5.5 during V-A ECMO was feasible and enabled prompt LV unloading (ECPELLA). While survival to discharge did not differ significantly between groups, patients with higher PA diastolic pressures and SAVE scores below -10 demonstrated a significant reduction in mortality with LV unloading.ConclusionEarly hemodynamic-guided LV unloading may improve risk-adjusted V-A ECMO outcomes.

Patients undergoing salvage cardiac surgery experience markedly elevated mortality, often exceeding the risk predicted by the Society of Thoracic Surgeons Predicted Risk of Mortality score. These patients are typically taken to the operating room while supported by extracorporeal membrane oxygenation (ECMO). In this context, we transitioned from a traditional preoperative mechanical circulatory support strategy using venoarterial ECMO to left atrial venoarterial ECMO (LAVA-ECMO) in patients with cardiogenic shock secondary to valvular dysfunction. We report a single-center, retrospective case series of four high-risk patients with acute severe mitral regurgitation or obstructive aortic stenosis, all with prohibitive Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) scores, who were supported by LAVA-ECMO as a bridge to salvage valve surgery. Left atrial venoarterial-ECMO facilitated hemodynamic stabilization by improving end-organ perfusion and pulmonary decongestion before definitive surgical intervention. All patients survived to hospital discharge, with 0% 30 day mortality despite an extreme predicted operative risk. Our initial experience suggests that LAVA-ECMO may be an effective rescue strategy for patients in cardiogenic shock requiring surgical valve replacement. When combined with a multidisciplinary heart team approach, this cannulation strategy may help improve outcomes in carefully selected patients.

Background Surgical arteriovenous (AV) fistulas provide vascular access for hemodialysis in patients with end-stage renal disease, but this low-resistance pathway can lead to high-flow circulation and cardiac decompensation. Case Summary A 42-year-old woman with end-stage renal disease from chronic glomerulonephritis and a failed renal transplant resumed hemodialysis via a 22-year-old left-arm brachiocephalic AV graft. She developed high-output heart failure. We ligated the AV graft and placed a peritoneal dialysis catheter. Hemodynamic parameters were normal 6 months postligation. Discussion Treatment of high-output heart failure and pulmonary hypertension via permanent surgical ligation of an AV fistula is complicated. Ligation can improve cardiac function, but studies are not adequately powered to change practice. The risks and benefits of AV fistula ligation or removal must be reviewed carefully. Take-Home Message This case highlights that high-output heart failure is a serious complication of AV access in patients on dialysis, requiring careful diagnosis and multidisciplinary management.

While veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become central in the management of patients in advanced stages of cardiogenic shock due to its relative ease of deployment, there is no standardized practice for left ventricular venting. This study evaluated the relative impact of distinct left ventricular venting strategies-no venting (control), unloading (intra-aortic balloon pump or Impella CP), and offloading (Impella 5.0/5.5)-on successful device weaning and overall hospital survival. A retrospective analysis of 232 patients (2018 to 2021) with refractory cardiogenic shock was conducted, with patients matched using propensity scores based on initial Survival After Veno-artErial ECMO (SAVE) scores. Overall survival to discharge was 39% (92 of 232), with 72% of survivors achieving full neurologic recovery. Univariate analysis identified age, SAVE score, extracorporeal cardiopulmonary resuscitation status, initial lactate levels, and arterial pulsatility as primary survival predictors. After propensity matching for baseline SAVE score, the OFFLOAD configuration (Impella 5.0/5.5) significantly outperformed V-A ECMO alone. This strategy was associated with a marked increase in survival days until device removal, yielding a hazard ratio of 9.57 (95% CI 2.80 to 32.7; p <0.001). In patients with refractory cardiogenic shock, active left ventricular offloading via Impella 5.0/5.5 may facilitate more successful V-A ECMO weaning. These findings suggest that an offloading strategy provides a distinct early survival advantage compared to alternative venting configurations.

BACKGROUND Acute coronary syndrome is the most common cause of death in the United States. Successful intervention often requires a multi-therapeutic approach, including percutaneous coronary intervention (PCI) and antiplatelet agents such as ticagrelor. However, the use of antiplatelet agents can cause life-threatening bleeding, particularly during emergency procedures. Therapeutic plasma exchange (TPE) is a procedure that selectively removes the patient's plasma to eliminate harmful substances. Here, we present 2 cases of novel TPE implementation in the setting of uncontrolled ticagrelor-induced bleeding. CASE REPORT Our first case was a 52-year-old man who presented with ST-elevation myocardial infarction. He underwent emergency percutaneous coronary intervention and was started on dual antiplatelet therapy (aspirin 81 mg/day, and ticagrelor 90 mg twice daily). A post-infarction ventricular septal defect required emergency surgical repair. After the surgery, uncontrolled bleeding persisted despite all conventional treatment methods. Following TPE, the bleeding was controlled, hemostasis was achieved, and platelet function was increased within days. Our second case was a 66-year-old man who received single doses of ticagrelor (180 mg) and eptifibatide (180 mcg/kg) during an attempted PCI. After complication by left main coronary artery dissection, emergency 2-vessel coronary artery bypass surgery was performed. In the immediate postoperative period, TPE was performed for persistent uncontrolled bleeding. Platelet reactivity increased immediately following the procedure; bleeding was stabilized, and no further blood products were required after postoperative day 1. CONCLUSIONS TPE may be an effective novel option for emergency removal of circulating ticagrelor in refractory bleeding cases.

INTRODUCTION:While Impella percutaneous temporary left ventricular assist devices (LVADs) have revolutionized the management of cardiogenic shock, the incidence and risk factors for aortic insufficiency (AI) remain unclear. METHODS:This single-center, retrospective cohort study evaluated the risk of AI in all patients who received Impella support, Impella with subsequent durable LVAD (Impella+LVAD), and durable LVAD without prior Impella support between January 1, 2019 and August 31, 2023. Given the distinct clinical pathways among these groups, analyses were conducted using 2 separate frameworks. Impella Framework: patients without progressive AI before Impella implantation were included. Incidence of progressive AI was compared between the Impella+LVAD and Impella-Only groups. LVAD Framework: patients without progressive AI before LVAD implantation were included. Incidence of progressive AI was compared between the Impella+LVAD and LVAD-Only groups. In both analyses, progressive AI (moderate or severe AI on echo) was the primary endpoint, and risk factors for progressive AI were evaluated with multivariable modeling. RESULTS:During the study period, 315 patients received ≥1 Impella, and 167 underwent LVAD implantation. In the Impella Framework, progressive AI incidence was higher in the Impella+LVAD group (n = 59) than in the Impella-Only group (n = 256) at both 12 months (36.4% vs 12.1%) and 24 months (46.8% vs 12.1%; aHR: 3.27, 95% cumulative incidence [CI]: 1.57-6.82, p = 0.002). In the LVAD Framework, progressive AI incidence in the Impella+LVAD group (n = 46) was also higher than in the LVAD-Only group (n = 121) at 12 (16.6% vs 0.9%) and 24 months (46.8% vs 12.1%; aHR: 7.87, 95% CI: 2.66-23.25, p < 0.001). DISCUSSION:Prior Impella support was associated with an increased risk of progressive AI after LVAD implantation; this hypothesis-generating finding warrants prospective studies to evaluate whether a lower threshold for aortic valve replacement at the time of LVAD implantation could improve outcomes.

Sleeve gastrectomy is safe and effective in patients with left ventricular assist devices (LVADs) and morbid obesity to improve candidacy for transplantation and increase survival rates. Literature describing warfarin anticoagulation in this population is limited. A single-center, propensity score-matched, retrospective cohort study was conducted to determine if sleeve gastrectomy in LVAD-implanted patients has an effect on warfarin dose requirements in the outpatient setting. Patients were eligible for inclusion if they were 18 years of age or older, underwent LVAD implant at the study center, and were discharged from the hospital on warfarin therapy. They must have at least 8 weeks of available follow-up data post-discharge. Propensity matching was utilized to identify a non-sleeve gastrectomy LVAD-only patients for comparison. A total of 96 LVAD-only patients and 48 LVAD plus sleeve gastrectomy patients were included in the final analysis. Outpatient warfarin requirements increased from baseline over time in both groups, with no significant differences between groups except at month 12, with a mean total weekly dose of 38.1 ± 21.4 mg in the LVAD only group and 46.8 ± 18.6 mg in the LVAD with sleeve gastrectomy group ( p = 0.05). The sleeve gastrectomy group had a significantly lower warfarin doses per kilogram of body weight until month 6 post-discharge. The percent time in therapeutic range was significantly lower in the SG group at the 8 week, 3 month, and 6 month interval time point. There were no significant differences in the incidence of bleeding or thromboembolic events.

Objective Left ventricular assist device (LVAD) implantation is a life-saving procedure for patients with advanced heart failure. However, postimplantation complications such as driveline infections (DLIs) can significantly affect patient outcomes. We assessed whether placing an extracellular matrix (ECM) scaffold around the driveline during LVAD implantation reduces the incidence of DLIs in patients with LVADs. Methods This retrospective observational study included 196 consecutive patients with LVADs between January 2018 and June 2022. We compared the data of patients who received ECM implantation during LVAD implantation (ECM group, n = 69) with those who did not (control group, n = 127). Results During the study period, 24 of 196 (12.2%) patients with LVADs developed a DLI. Patients who underwent ECM placement exhibited a significantly lower incidence of DLIs than those in the control group (ECM 3/69 vs control 21/127; P = .012). Conclusions Patients who received ECM implantation at the time of LVAD implantation had a significantly lower rate of DLIs than patients who did not receive ECM around the driveline. These results suggest that ECM may be a valuable adjunctive strategy to reduce the risk of DLIs in LVAD recipients.

Study: The long-term effects of COVID-19 continue to be identified and have had undoubtedly devastating morbidity and mortality consequences. Despite the publication of numerous papers in the last several years, the definite morbidities that worsen mortality remain uncertain. The role of COVID-19 cholangiopathy is largely undefined. As more people survive severe COVID-19 infections, it is crucial to gain more insight into this disease process in order to improve management. Patients with any degree of COVID-19 infection are at risk for developing cholangiopathy, but those who experience severe infection necessitating extra-corporeal membrane oxygenation (ECMO) may be especially vulnerable to increased morbidity and mortality due to cholangiopathies. Methods: A retrospective chart review was performed on 94 patients with COVID-19 who were placed on ECMO for any period of time while in the ICU at a single academic institution between 2019-2020. Total bilirubin levels at admission, total bilirubin levels at discharge from the hospital, and highest total bilirubin levels during hospital stay were recorded as primary outcome to quantify the extent of cholangiopathy in patients who survived and those who did not survive. AST, ALT, INR, and right ventricle dysfunction during the same hospital stay were also recorded as secondary outcomes. A total of 658 instances of lab data were analyzed in these patients. Survival curves were generated by Kaplan-Meier method. Student’s t-test and descriptive statistics were used to analyze the data. Results: There was a 37% survival rate among the 94 patients. We found a significant difference in total bilirubin level at hospital discharge among survivors versus non-survivors (p=.0000904). There was also a significant difference in maximum INR between survivors and non-survivors (p=.027). A difference in highest total bilirubin level was observed in non-survivors, although it was not significant. No difference between AST and ALT values were observed between the two groups. Conclusion: The observed difference in total bilirubin levels at hospital discharge among patients with COVID-19 on ECMO suggests a real relationship between COVID-19 and hyperbilirubinemia. We recognized that ECMO can cause unconjugated hyperbilirubinemia due to hemolysis; however, we observed increases in conjugated bilirubin. Further investigation of this relationship may be used to guide preventive treatments and post-hospitalization recovery care.

BACKGROUND: Although outcomes of patients supported with venovenous extracorporeal membrane oxygenation (ECMO) are well documented, outcomes of those who are referred but do not undergo cannulation remain limited. RESEARCH QUESTION: Among patients with COVID-19-related ARDS referred for venovenous ECMO, how do outcomes compare between those who undergo cannulation and those who do not? STUDY DESIGN AND METHODS: This single-center retrospective study of a prospective registry evaluated all adult patients with COVID-19-related ARDS who underwent venovenous ECMO consultation through a multidisciplinary approach between March 2020 and October 2022. The primary outcome was 90-day survival after ECMO consultation, comparing cannulated patients with a propensity-matched noncannulated cohort. Secondary outcomes included unadjusted 90-day survival and survival to hospital discharge with and without Respiratory ECMO Survival Prediction (RESP) score stratification. For propensity score matching, covariates were age, pH, PaCO2, PaO2 to FIO2 ratio, acute kidney injury, vasopressor or inotropic requirement, and RESP score. RESULTS: Of 247 patients referred for venovenous ECMO, 90-day survival after ECMO consultation-the primary outcome-was higher in the cannulated group (n = 86) than the propensity-matched noncannulated group (n = 86; 48.8% vs 23.3%; hazard ratio, 0.40 [95% CI, 0.28-0.59]; P < .001). Secondary analyses demonstrated similar findings: unadjusted 90-day survival was 48.8% vs 15.5% (hazard ratio, 0.31 [95% CI, 0.22-0.43]; P < .001), and survival to hospital discharge in matched cohorts was 43.0% vs 24.4% (P < .001). When stratified by RESP scores, survival to discharge for the so-called sick patients remained higher among cannulated patients (RESP score of 3 to 5: 63.6% vs 19.3% [P < .001]; RESP score of-1 to 2, 28.6% vs 7.8% [P = .016]). INTERPRETATION: Our results show that among select patients with severe COVID-19-related ARDS referred for venovenous ECMO, cannulation was associated with higher observed survival. However, despite matching, residual confounding-particularly from clinical judgement factors affecting cannulation decisions-limits causal inference. These findings underscore the need for cautious interpretation and further prospective studies to better define ECMO candidacy and outcomes.

Background and Aims Coronary flow capacity (CFC) is associated with an observed 10-year survival probability for individual patients before and after actual revascularization for comparison to virtual hypothetical ideal complete revascularization.Methods Stress myocardial perfusion (mL/min/g) and coronary flow reserve (CFR) per pixel were quantified in 6979 coronary artery disease (CAD) subjects using Rb-82 positron emission tomography (PET) for CFC maps of artery-specific size-severity abnormalities expressed as percent left ventricle with prospective follow-up to define survival probability per-decade as fraction of 1.0.Results Severely reduced CFC in 6979 subjects predicted low survival probability that improved by 42% after revascularization compared with no revascularization for comparable severity (P = .0015). For 283 pre-and-post-procedure PET pairs, severely reduced regional CFC-associated survival probability improved heterogeneously after revascularization (P < .001), more so after bypass surgery than percutaneous coronary interventions (P < .001) but normalized in only 5.7%; non-severe baseline CFC or survival probability did not improve compared with severe CFC (P = .00001). Observed CFC-associated survival probability after actual revascularization was lower than virtual ideal hypothetical complete post-revascularization survival probability due to residual CAD or failed revascularization (P < .001) unrelated to gender or microvascular dysfunction. Severely reduced CFC in 2552 post-revascularization subjects associated with low survival probability also improved after repeat revascularization compared with no repeat procedures (P = .025).Conclusions Severely reduced CFC and associated observed survival probability improved after first and repeat revascularization compared with no revascularization for comparable CFC severity. Non-severe CFC showed no benefit. Discordance between observed actual and virtual hypothetical post-revascularization survival probability revealed residual CAD or failed revascularization.

Introduction: Patients with durable left ventricular device (LVAD) malfunction require emergent LVAD exchange or heart transplant (HT). We present a case in which Impella 5.5 (Abiomed, Danvers, MA) was used to support a patient with LVAD malfunction as bridge-to-decision and elaborate on the challenges we encountered.

Transcatheter aortic valve replacement (TAVR) has been recommended as the standard treatment for elderly patients with severe aortic stenosis (AS) and those at increased risk for conventional surgical procedures. Recently, TAVR has been recognized as the treatment of choice for intermediate-risk patients or even low-risk populations with AS. Our study aimed to identify factors influencing adverse events after TAVR procedures. This single-center, retrospective cohort study involved patients with severe AS treated with TAVR from 2016 to 2019. The patient’s electronic medical record was reviewed, and those with valve-in-valve replacements and missing demographical data were excluded. We analyzed risk factors related to in-hospital adverse outcomes after the TAVR procedure. Among 953 screened patients, 889 were included in the study. The complication rates were relatively low. Factors that significantly influenced the outcome included age, chronic kidney disease (CKD), dialysis, mitral stenosis, Katz test for frailty, surgical risk score, and calculated operability. Multivariate logistic regression analysis showed that only CKD predicts the likelihood of the composite adverse outcome in TAVR patients during hospitalization. Our study showed that TAVR is an effective and safe option for aortic valve replacement. Perioperative complications depend on different risk factors, particularly CKD, and the results of the Katz test. Identification of risk factors influencing the TAVR outcome is crucial to prevent perioperative complications and mortality.