Treatment strategies for patients with an INTERMACS I profile

Treatment of patients with INTERMACS class I heart failure can be very challenging, and temporary long-term device support may be needed. In this article, we review the currently available temporary support devices in order to support these severely ill patients with decompensated heart failure. Strategies of using a temporary assist as a bridge to long-term device support are also discussed

Case Report: Delayed Type A Aortic Dissection Following Complete Debranching of the Aortic Arch and Stent Graft Placement

Treatment options for aortic arch disease in high-risk patients includes supra-aortic debranching and thoracic endovascular aortic repair (TEVAR). Acute ascending aortic dissection is a concerning complication of this approach and has been reported to occur in a retrograde fashion. We report a case of a 60-year-old gentleman who had undergone thoracic endovascular aortic repair with debranching and presented 31 months later with acute isolated ascending aortic dissection. The patient underwent successful total replacement of the ascending aorta with a 30-mm gelwave Valsalva(™) graft using cardiopulmonary bypass

Right Atrial Tumor Resection and Reconstruction with Use of an Acellular Porcine Bladder Membrane

Malignant cardiac tumors typically have a grave prognosis; their resection with negative margins is optimal. We present the case of a 21-year-old woman in whom we surgically resected a primary cardiac sarcoma and reconstructed the right atrium with use of a porcine urinary bladder membrane-the MatriStem(®) Surgical Matrix PSMX. The patient recovered uneventfully. Six months postoperatively, the right atrial wall had retained its integrity. In addition to our patient's case, we discuss the benefits of using the MatriStem membrane in cardiac reconstruction

Case Report: Cardiac Tumor Resection And Repair With Porcine Xenograft

Primary cardiac sarcomas are rare and carry a grave prognosis. Improved survival requires a complete margin negative resection of the tumor. These surgical resections are often large and complex, requiring extensive reconstructive procedures. The appropriate material for cardiac reconstruction is not known. We have used glutaraldehyde-fixed bovine pericardium in our early series but have recently employed the MatriStem(®) Surgical Matrix PSMX membrane (ACell(®), Inc.; Columbia, MD), a unique proprietary urinary bladder matrix derived from porcine urinary bladder with the potential for viability and tissue ingrowth. In our study of six patients at this institution, all six underwent successful surgical resection and repair with the MatriStem acellular porcine urinary bladder membrane (ACell). The postoperative course was uncomplicated in all patients, and they are still alive at this time. An aggressive surgical approach to cardiac tumors can possibly lead to complete resection but often requires reconstruction of the cardiac tissue with a membrane. We were able to achieve acceptable results in our cardiac reconstruction by using the ACell extracellular matrix to reconstruct the defect following tumor resection. Longer-term follow-up in these patients, including imaging studies, will be necessary to demonstrate the durability and integrity of the reconstruction

Lung Procurement from a Donor on ECMO Support

We report the case of a 50-year-old man with congestive heart failure who became a candidate for organ donation after anoxic brain injury after cardiopulmonary resuscitation (CPR) who was on a venoarterial extracorporeal membrane oxygenation (ECMO) support. On visualization, the donor's lung was acceptable for lung transplantation to a 68-year-old male patient with a chronic history of pulmonary fibrosis. Right single-lung implantation was successfully performed in the recipient. Herein, we report a case that highlights our institution's result suggesting that the use of a lung previously on ECMO support can safely and potentially expand the donor lung pool in carefully selected patients

Development of a Severe Mitral Valve Stenosis Secondary to the Treatment of Mitral Regurgitation with a Single MitraClip

We report a patient with class III heart failure symptoms due to mitral regurgitation (MR) subsequent to nonischemic cardiomyopathy. The patient underwent percutaneous transcatheter mitral valve repair using a single MitraClip, which reduced the MR; however it created mild-to-moderate mitral stenosis, which progressed to severe mitral stenosis. Subsequently the patient underwent mitral valve replacement surgery

Left Ventricular Assist Device Implantation After Intracardiac Parachute Device Removal

Left ventricular assist device implantation is a proven and efficient modality for the treatment of end-stage heart failure. Left ventricular assist device versatility as a bridge to heart transplantation or destination therapy has led to improved patient outcomes with a concomitant rise in its overall use. Other less invasive treatment modalities are being developed to improve heart function and morbidity and mortality for the heart failure population. Percutaneous ventricular restoration is a new investigational therapy that deploys an intracardiac parachute to wall off damaged myocardium in patients with dilated left ventricles and ischemic heart failure. Clinical trials are under way to test the efficacy of percutaneous ventricular restoration using the parachute device. This review describes our encounter with the parachute device, its explantation due to refractory heart failure, and surgical replacement with a left ventricular assist device

Total Artificial Heart Implantation after Excision of Right Ventricular Angiosarcoma

Primary cardiac sarcomas, although rare, are aggressive and lethal, requiring thorough surgical resection and adjuvant chemotherapy for the best possible outcome. We report the case of a 32-year-old woman who underwent total artificial heart implantation for right-sided heart failure caused by right ventricular angiosarcoma. For the first several weeks in intensive care, the patient recovered uneventfully. However, a postoperative liver biopsy indicated hepatocellular injury consistent with preoperative chemotherapy. She developed continuing liver failure, from which she died despite good cardiac function

Macrophage bone morphogenic protein receptor 2 depletion in idiopathic pulmonary fibrosis and Group III pulmonary hypertension

Idiopathic pulmonary fibrosis (IPF) is a lethal lung disease of unknown etiology. The development of pulmonary hypertension (PH) is considered the single most significant predictor of mortality in patients with chronic lung diseases. The processes that govern the progression and development of fibroproliferative and vascular lesions in IPF are not fully understood. Using human lung explant samples from patients with IPF with or without a diagnosis of PH as well as normal control tissue, we report reduced BMPR2 expression in patients with IPF or IPF+PH. These changes were consistent with dampened P-SMAD 1/5/8 and elevated P-SMAD 2/3, demonstrating reduced BMPR2 signaling and elevated TGF-β activity in IPF. In the bleomycin (BLM) model of lung fibrosis and PH, we also report decreased BMPR2 expression compared with control animals that correlated with vascular remodeling and PH. We show that genetic abrogation or pharmacological inhibition of interleukin-6 leads to diminished markers of fibrosis and PH consistent with elevated levels of BMPR2 and reduced levels of a collection of microRNAs (miRs) that are able to degrade BMPR2. We also demonstrate that isolated bone marrow-derived macrophages from BLM-exposed mice show reduced BMPR2 levels upon exposure with IL6 or the IL6+IL6R complex that are consistent with immunohistochemistry showing reduced BMPR2 in CD206 expressing macrophages from lung sections from IPF and IPF+PH patients. In conclusion, our data suggest that depletion of BMPR2 mediated by a collection of miRs induced by IL6 and subsequent STAT3 phosphorylation as a novel mechanism participating to fibroproliferative and vascular injuries in IPF