Advanced respiratory failure with tracheostomy requirement is common in heart recipients. The aim of the study is to assess the tracheostomy rate after orthotopic heart transplantation and identify the subgroups of patients with the highest need for tracheostomy and these groups’ association with mortality at a single centre through a retrospective analysis of 140 consecutive patients transplanted between December 2012 and July 2018. As many as 28.6% heart recipients suffered from advanced respiratory failure with a need for tracheostomy that was performed after a median time of 11.5 days post-transplant. Tracheostomy was associated with a history of stroke (OR 3.4; 95% CI) 1.32–8.86; p = 0.012), previous sternotomy (OR 2.5; 95% CI 1.18–5.32; p = 0.017), longer cardiopulmonary bypass time (OR 1.01; 95% CI 1.00–1.01; p = 0.007) as well as primary graft failure (OR 6.79; 95% CI2.93–15.71; p < 0.001), need of renal replacement therapy (OR 19.2; 95% 2.53–146; p = 0.004) and daily mean SOFA score up to 72 h (OR 1.50; 95% 1.23–1.71; p < 0.01). One-year mortality was significantly higher in patients requiring a tracheostomy vs. those not requiring one during their hospital stay (50% vs. 16%, p < 0.001). The need for tracheostomy in heart transplant recipients was 30% in our study. Advanced respiratory failure was associated with over 3-fold greater 1-year mortality. Thus, tracheostomy placement may be regarded as a marker of unfavourable prognosis.

BACKGROUND:Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients.METHODS:This is a retrospective observational single-center study.RESULTS:Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0).CONCLUSIONS:Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.

Aims Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care. Methods and results RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 +/- 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean +/- standard deviation; -20.4 +/- 6.7) and subcostal views (-21.1 +/- 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 +/- 6.7 vs. VVECMO -23.2 +/- 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R-2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16). Conclusion RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.

Background The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardised practice. This single centre retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into 2 groups: a) ascending aorta (interposition) graft (AAG) without valve replacement; and b) non-valve-sparing aortic root replacement (ARR). Pre-operative covariates were compared, as well as operative characteristics and post-operative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, 9 developed severe aortic regurgitation and 2 patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p=0.004). Conclusions With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Aim: Hyperlactatemia is common post-heart transplantation. Lactate measurements in the first 24 h were analyzed with respect to mortality. Methods: A total of 153 consecutive cardiac transplant patients were reviewed. Recipients of organs maintained in a state of ex vivo perfusion were included. Results: A total of 143 heart recipients were included. Hyperlactatemia (>2 mmol/l) was present in all patients. Despite maximum lactate and lactate clearance being significantly higher in nonsurvivors (p = 0.002, p = 0.004), neither receiver operator curve analysis nor multivariate logistic regression showed association with 1-year mortality. In comparison, the minimum lactate was significantly associated with mortality (area under the curve 0.728 [p < 0.001]; odds ratio 1.28 [95% 1.01-162; p = 0.04]). Conclusion: The minimum lactate, a surrogate of persistent hyperlactatemia, was demonstrated to be superior compared with maximum lactate and lactate clearance in determining patient prognosis.

We thank the authors for their kind and thoughtful comments on our work. We reported the pattern and degree of right ventricular (RV) dysfunction in 90 consecutive mechanically ventilated patients (42.2% VV-ECMO) with severe COVID-19 infection [1Bleakley C. Singh S. Garfield B. Morosin M. Surkova E. Mandalia M.S. et al.Right ventricular dysfunction in critically ill COVID-19 ARDS.Int. J. Cardiol. 2021; 327: 251-258Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar]. The authors raise the important issue of whether use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) could impact RV function differently to conventional invasive ventilation. During VV ECMO, 'rest' ventilator settings minimise energy delivery to the lungs by reducing volumes but maintaining positive end expiratory pressure (PEEP). Therefore, overall intrathoracic pressures are lower than in conventional 'protective' low volume strategies that are limited by oxygenation requirements and acceptable carbon dioxide levels. Thus, differences in ventilation data between the groups demonstrated lower tidal volumes per ideal body weight (6.6 ± 1.3 vs 3.3 ± 1.4 ml/kg, p ≤ 0.001) and lower driving pressure (11.27 ± 2.9 vs 12.88 ± 3.7cmH2O, p = 0.01) in those on VV-ECMO. However, we do not have measures of total intrathoracic pressure, which is perhaps more relevant in the impact of ventilation on the RV. Indeed, there was no difference in pulmonary vascular resistance (PVR) (2.3 ± 0.9 vs 2.4 ± 0.9WU, p = 0.59) between groups. Therefore, it is not necessarily unexpected that measures of RV function did not differ significantly. Specifically, there were no differences in PA coupling by fractional area change (FAC) versus RV systolic pressure (RVSP) (0.61 ± 0.29 vs 0.69 ± 0.33, p = 0.26), or FAC (28 ± 11 vs 29 ± 8%, p = 0.82). As described [1Bleakley C. Singh S. Garfield B. Morosin M. Surkova E. Mandalia M.S. et al.Right ventricular dysfunction in critically ill COVID-19 ARDS.Int. J. Cardiol. 2021; 327: 251-258Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar], we believe that the correlation between markers of cardiac stress and deterioration in RV radial function indicates a degree of intrinsic myocardial injury or inflammation. Therefore, whilst the excellent points raised have been interesting to report on, we did not find that the mode of ventilation significantly impacted RV function. "This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation".

BACKGROUND Post-pericardiectomy right ventricular (RV) failure has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy. METHODS We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support. RESULTS A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674–0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001). CONCLUSIONS We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient.

Aims: Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). Methods: Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. Results: Ninety patients (25.6% female), mean age 52.0 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p <= 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). Conclusions: Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort. <(c)> 2020 Elsevier B.V. All rights reserved.

Background: Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions. Methods: One hundred eighteen (mean age, 67.4 +/- 9.2 years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up. Results: There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR] = 1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR = 4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6 years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR] = HR = 1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR = 4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up. Conclusions: During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up. (C) 2020 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

We report a challenging clinical case of an atypical supravalvular mitral remnant in recent mitral and aortic valve replacement with mechanical valve prostheses, associated with postoperative recurrent inflammatory episodes overlapped with difficult anticoagulation. Negative myocardial scintigraphy was associated with persistence of negative blood cultures. Serial echocardiographic evaluation was performed before and after antimicrobial treatment, and at 3 months follow-up a transesophageal echocardiography showed the persistence of the mass. Diagnostic suspect was finally confirmed.

A 68-year-old woman with failure of a biologic mitral valve (Carpentier-Edwards Perimount Magna; Edwards Lifesciences, Irvine, CA) underwent redo mitral surgery 22 months after the first operation. The biologic valve was replaced with a St Jude mechanical valve prosthesis (Abbott Laboratories, North Chicago, IL). Although the postoperative period after the first operation was uneventful, except for transitory left hemiparesis, immediately after the second operation high doses of inotropic agents were needed to treat a low cardiac output associated with apical ballooning1Vernick W.J. Hargrove W.C. Augoustides J.G. et al.Takotsubo cardiomyopathy associated with cardiac arrest following cardiac surgery: New variants of an unusual syndrome.J Card Surg. 2010; 25: 679-683Google Scholar, 2Yamane K. Hirose H. Reeves G.R. et al.Left ventricular dysfunction mimicking Takotsubo cardiomyopathy following cardiac surgery.J Heart Valve Dis. 2011; 20: 471-473Google Scholar detected by transesophageal echocardiography. Anterolateral T-wave inversion was shown at electrocardiographic assessment and left ventricular dysfunction was detected, as well as apical ballooning was confirmed with transthoracic echocardiography (Fig 1). No coronary stenosis was found at coronary angiography. Both the clinical symptoms and monitoring changes disappeared within 2 weeks (Fig 2).Fig 2Echocardiographic and electrocardiographic normalization.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The present authors have no convincing theories to explain the early calcific degeneration of the biologic valve, nor to explain the onset of the Takotsubo-like syndrome following the second valve replacement. In addition to hypertension and chronic lung disease, the patient suffered from no relevant comorbidities, except for post-traumatic epilepsy on pharmacologic therapy and atrophic gastritis needing periodic transfusions. Between the first and the second cardiac operation, the patient underwent total thyroidectomy (Hürthle cell carcinoma), which was combined with surgical excision of the inferolateral parathyroid glands. Because there were frequent episodes of hypocalcemia postoperatively, and one hospital admission from vitamin D intoxication, significant imbalance of calcium metabolism despite hormone replacement therapy was hypothesized.3Tsuchihashi K. Takizawa H. Torii T. et al.Hypoparathyroidism potentiates cardiovascular complications through disturbed calcium metabolism: Possible risk of vitamin D(3) analog administration in dialysis patients with end-stage renal disease.Nephron. 2000; 84: 13-20Google Scholar, 4Wittstein I.S. Thiemann D.R. Lima J.A. et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Google Scholar, 5Nef H.M. Möllmann H. Troidl C. et al.Abnormalities in intracellular Ca2+ regulation contribute to the pathomechanism of Tako-Tsubo cardiomyopathy.Eur Heart J. 2009; 30: 2155-2164Google Scholar There is no conflict of interest to declare.

Oesophago-pericardial fistula following any electrophysiological procedure is a rare, and potentially, life-threatening condition. Initial presentation can easily be misdiagnosed, as symptoms vary and are not specific. Echocardiography is an invaluable tool to diagnose and rule out complications. We present the case of a 68-year-old patient who developed an oesophago-pericardial fistula complicated with purulent pericarditis, sepsis and cerebral air embolism. In conclusion, this case report encourages physicians to use strategies that may help with early diagnosis and lead to potential lifesaving interventions.

Abstract Background The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure. Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven. There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation. To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times. Methods We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively. Results Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p<0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p<0,001), PAP mean (40 vs 22 mmHg, p<0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p<0,001). However, there was no significant increase in peak VO2 after 6 months. 12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1). Conclusion Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.

We report an unusual clinical case of a 66-year-old patient with cardiac involvement from a metastatic melanoma, causing the formation of a large right atrial mass with extensive infiltration of the right atrial free wall, the interatrial septum, the coronary sinus, and up to the mitral annulus and posterior wall of the right ventricle, unamendable to complete surgical excision. As secondary cardiac tumors are not part of routine daily clinical practice, we thought that this clinical case would be a good educational opportunity for the practicing clinicians, both specialists and nonspecialists.

Introduction Durable continuous-flow left ventricular assist devices (CF-LVAD) are used increasingly as both destination and bridge to heat transplant (HTx), in end stage heart failure. Data on long-term survival post-HTx in patients supported with CF-LVAD compared to those undergoing de novo heart transplantation are inconsistent. Some studies show no difference and others indicate increased long-term mortality in patients on mechanical circulatory support (MCS) pre-transplant.1,2,3 Methods We retrospectively reviewed all 153 patients who had OHT in the last 5 years in a tertiary cardiac hospital. Patients were divided into two groups (1) those without mechanical circulatory support pre-transplant (n = 90), (2) and those who were bridged with implantable long-term CF-LVAD (n = 34), all other patients were excluded. Pre-transplant and peri-operative factors, as well as early and late outcomes were then compared between groups. Results Baseline pre-transplant factors were the same between groups, though patients bridged with MCS were more likely to have had a previous stroke (8.9% vs 29.4%, p = 0.008). The time spent on cardiopulmonary bypass was longer (168 vs 202 minutes, p = 0.004) in MCS group. Intraoperative haemoglobin was significantly lower in the MCS group (85g/l vs 79g/l, p = 0.01), and intraoperative lactate was significantly higher (7.9 vs 10.6, p = 0.002). The initial post-operative LVEF was lower (p = 0.004), and there was a trend towards developing severe PGD (18.9 % vs 32.3%, p = 0.054) in the MCS group. Early outcomes were similar with an equal need for renal replacement therapy (p = 0.19) and similar length of stay in ITU (p = 0.17). Despite similar 30-day mortality (p = 0.213), 60-day (p = 0.058) and 1-year mortality (Non-MCS 11.1% versus MCS 32.4%, p = 0.008)(Log-rank (Mantel-Cox) p = 0.11) were significantly higher in the MCS group. Kaplan Mayer curves show significant difference in estimated survival between the groups (Fig 1). Discussion Our results in agreement with present literature show comparable 30-d mortality in both subpopulations, however, indicate increased risk of death in 1-year follow-up.

Patients presenting with INTERMACS-1 cardiogenic shock and necessitating VA-ECMO, often undergo coronary angiography and percutaneous coronary intervention (PCI). Therefore, a substantial subset of VA-ECMO patients will have an indication for dual antiplatelet therapy (DAPT) plus unfractionated heparin (UFH). According to atrial fibrillation registry data, bleeding incidence on DAPT combined with oral anticoagulation is significantly higher as compared to anticoagulation alone. Although it has been reported that the addition of low dose aspirin to UFH did not increase bleeding or transfusion in VenoVenous (VV)-ECMO patients, it remains to be elucidated whether the addition of DAPT to UFH on VA-ECMO-therapy enhances bleeding. We report single center data for 100 VA-ECMO patients between 2011 and 2019. VA-ECMO-patients post-surgery were excluded. Patient demographics, blood product transfusions and reported/radiographically diagnosed bleeding or thrombotic complications were analysed. All VA-ECMO patients received UFH, aiming for an anti-Xa levels of at least 0,3 U/ml. Targets were hemoglobin 7 g/dl, fibrinogen 100 mg/dl (or 150 mg/dl when active bleeding) and platelet counts above 50/fL. DAPT-patients were on a low dose aspirin plus a P2Y12-inhibitor (clopidogrel or ticagrelor). 51% Of the VA-ECMO-group received DAPT (59% clopidogrel and 41% ticagrelor). UFH-levels were comparable between both groups. Patients on DAPT were significantly older (DAPT 52.8 vs. Control 41.3; p<0.001) and predominantly male (DAPT 76% vs. Control 63%). Total bleedings (DAPT 52% vs. Control 55%; p=0,68) and major bleedings (BARC score of 3 or more; DAPT 41% vs. Control 45%; p=0,71) did not differ significantly. We observed a significant lower number of clinically or radiographically overt arterial/venous thromboses (DAPT 13.7% vs. Control 36.2%; p=0,02) in the DAPT-group. When comparing fresh frozen plasma (FFP), red blood cell and platelet pool transfusions between both groups, only FFP-tranfusion (DAPT 0.47 units/day vs. Control 1.18 units/day; p=0,047) intends to be lower for the DAPT-group. DAPT (plus UFH) vs control (plus UFH) Haemorrhage is frequent during extracorporeal support. However, in our cohort, DAPT on top of UFH in the treatment of VA-ECMO-supported ischemic cardiogenic shock does not increase the risk of major bleeding. Therefore, DAPT should not necessarily be witheld in the setting of VA-ECMO. Interestingly, our data support a lower incidence of overt thromboses and a trend towards less FFP-transfusion. These findings suggest DAPT-induced platelet inhibition being protective against both thrombotic events and posibly consumptive coagulopathy without paying a price for major bleeding.

Objective: Aortic Valve Resuspension (AVS) at the time of dissection repair is a technique with excellent early outcomes in terms of aortic valve (AV) function. However, limited data is available with regard to medium-term durability of the resuspended valve and behaviour of the aortic root. The purpose of this study was to report the early- and medium-term outcomes of patients having AVS and to compare these with patients having AV replacement or aortic root replacement (Group-2) in the context of acute type A aortic dissection (AAAD). Methods: The aortic dissection database was interrogated for patients who had AVS as part of AAAD repair, and was analysed for early and mid-term echocardiographic function of the resuspended AV and aortic root dimensions and compared with patients belonging to Group-2. Inclusion criteria were the availability of echocardiographic images both prior to discharge and after 6 months from the operation. Aortic regurgitation (AR) was graded following a semiquantitative scale (none=0, trivial-mild=1, moderate=2, and severe=3). Aortic root diameters were measured by echocardiogram. Results: Of 181 patients having dissection repair, sufficient echocardiographic follow up was available in 46, of whom 28 had AVS and 18 belonged to Group-2. The median follow up period was 23.47 (13.87; 40.22) months. In AVS group, the prevalence of AR grade ≥2 at discharge and at last follow up was 7.14% and 21.42% respectively. In Group-2, no patient had AR grade ≥2. Overall, the aortic root diameters were larger in AVS-group compared to Group-2. By univariate analysis the only predictor of AR progression to AR grade ≥2 was a sinus of Valsava diameter >40mm at last follow up (OR=12, 95% CI 1.5-97, p<0.05). Conclusions: Compared to AV replacement or aortic root replacement, AVS has sub-optimal medium-term outcomes in terms of AV function especially when the aortic root diameter enlarges over time.

Introduction A 62-year-old man was admitted to a local hospital for heart failure. An echo showed severe biventricular dysfunction, severe LV dilatation and a large and mobile finger-like aspect thrombus extending from septum, across apex and posterior wall. He presented severe instability and therefore was transferred to our centre for further management. On arrival, he suffered electrical VT storm and a VA-ECMO was inserted. At this point, heart catheterization and angiography were considered unsafe. After multidisciplinary discussion, a Levitronix LVAD with filters was inserted as bridge to decision. Due to rapid RV function deterioration an intraoperative decision was made to add an RVAD with an oxygenator. He was inserted on the transplant list, but unclear capacity to cope with treatment and significant psychiatric issues emerged after family discussion. Refractory VF developed which lead to a fully thrombosed LV. In the evaluation for candidacy, a total artificial heart (TAH) was implanted. After the procedure, the patient experienced a stroke leading to left hemiplegia and fluctuating level of consciousness. After a period of relative clinical stability, the patient developed a catastrophic intestinal bleeding. Given the multiple complications developed during the ITU stay (renal failure, multi-drug resistant infections, neurological impairment and unsuitability for transplant) a laparotomy appeared not to be in the patient's best interest. After family discussion, palliation was commenced. Native heart histology revealed extensive multifocal sub-endocardial myocardial infarction involving the LV. Right and left coronary arteries showed significant atherosclerotic disease. Discussion Over recent years, mechanical circulatory support devices have revolutionized cardiovascular therapeutics. In the present case, the initial issue was the severe haemodynamic instability condition in which the patient presented, which lead to an unwanted incomplete assessment of the underlying disease. A multidisciplinary discussion was made about further management after VA-ECMO insertion: in order to discuss with the patient and assess candidacy to transplant, no other ways appeared to be reasonable than implanting a Levitronix, which could have allowed to awake the patient. As soon as the medical team was able to discuss with the patient and the family about further management, neuropsychiatric issues arose, delaying the decision to a definitive insertion of the patient to the transplant list. During this assessment period, massive LV thrombus developed rising the issue of Levitronix occlusion, leading to two main life-treating options: heart transplant or total artificial heart. This case shows how complex the management of a severe heart failure with cardiogenic shock may be and how different types of mechanical circulatory support devices may be required for similar severity of the original disease depending on the phase of the treatment and the comorbidities.