Should we still be doing Heart Transplants? Transplantation in the Era of the Machines

At the conclusion of this presentation the participant should be able to: Understand the expected survival of patients receiving a heart transplant or Ventricular Assist Device (VAD) Know the contraindications to heart transplantation or VAD Compare the costs of heart transplant to VAD therapy Presentation: 30 minute

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD).

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD). CHRIS RIZZI, BS, Linda Bogar, MD, Jay Jenoff, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Thomas Jefferson University, Philadelphia, PA. Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. The LVAD patients with complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 patients underwent Heartmate II LVAD placement for end-stage heart failure as either bridge to transplant or destination therapy in our institution. Among them, 5 patients underwent PEG tube placement for long-term nutritional support in the operating room or intensive care unit. Procedure management consisted of cessation of anticoagulation and correction of abnormal coagulation before the procedure; a cardiothoracic surgeon or intensivist in the operating room to communicate with the surgeon who performed PEG; and VAD coordinator or perfusionist in the operating room to assist in monitoring the VAD. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of 3 males and 2 females with mean age of 58 +/- 5.0. The interval of LVAD to PEG placement was a mean 21 +/- 8.8 days. PEG was successfully performed in the operating room in all patients. There were no LVAD device or driveline injuries related to the PEG procedure. There were no postoperative short-term or long-term PEG related complications such as acute gastric bleeding or dislodgement of the PEG tube. Concussions: PEG placement for Heartmate II LVAD patients can be done without increasing the risk of device or intraabdominal organ injury with carefully coordinated efforts from both the mechanical support team and surgical services

Rigid Sternal Fixation Improves Postoperative Recovery

INTRODUCTION: During the past five years, ridged sternal fixation has been utilized for sternal closure after cardiac surgery. It is known that this procedure provides better sternal stability; however, its contribution to patient recovery has not been investigated. METHODS: Retrospective chart review was conducted for patients who underwent CABG and/or valve surgery in our institution between 2009 and 2010. Preoperative, perioperative, and follow-up data of patients with ridgid fixation (group R, n=89) were collected and compared with those patients with conventional sternal closure (group C, n=133). The decision regarding the sternal closure method was based on the surgeon\u27s preferences. Univariate followed by multivariate analyses were performed to evaluate the dominant factor of sternal lock usage and to evaluate postoperative recoveries. The factors included in the analyses were; age, sex, coronary risk factors, urgency of surgery, ejection fraction, coronary anatomy, preoperative stroke, renal function, and preoperative presence of heart failure. All statistical analyses were performed by JMP software. RESULTS: Group R was younger (62 ± 9 in group R vs 69 ± 11 in group C, p CONCLUSION: Rigid sternal fixation systems were more frequently applied to low risk young male patients. Among these selected patients, ridgid sternal fixation can contribute to early patient recovery

An old problem with a new therapy: GI bleeding in VAD patients and deep bowel enteroscopy (Double balloon. Spiral enteroscopy).

An old problem with a new therapy: GI Bleeding in VAD patients and deep bowel enteroscopy (Spiral and Double Balloon Enteroscopy) Purpose: Evidence suggests that patients treated with non-pulsatile ventricular assist devices (VAD) are at an increased risk for gastrointestinal bleeding (GIB) beyond what is expected from routine anticoagulation. Diagnostic and treatment algorithms are currently undefined. We reviewed our experience of GIB in VAD patients and propose a new algorithm utilizing deep bowel enteroscopy (DBE) aimed to speed diagnosis and limit transfusions. (471) Methods & Procedures From 2004 to 2011, we studied 62 patients who received a non-pulsatile VAD at our center for episodes of GIB. GIB was defined as heme-positive stool, hematemeisis, or drop in Hgb\u3e1gm. All patients were anticoagulated and no patient had any previous bleeding history. The diagnostic and treatment modalities utilized consisted of standard GIB tests but evolved into an algorithm based primarily on DBE. DBE consists of double-balloon and spiral enteroscopy that allow us to see and treat pathology in the small bowel upt o 400 cm beyond the Ligament of Treitz. (723) Results: There were 41 individual episodes of GIB in 14 patients. Separating the episodes into two groups based on days to diagnosis and days to treatment, we found that when the diagnosis was made and treated within 2 hospital days, patients received half (3.53 v. 7.33 with

Dr. Mary Edwards Walker: years ahead of her time.

Women phsycians in the United States were virtually nonexistent in the early to mid-1800s. Traditional medical schools still did not accept women, and few secretarian or eclectic medical schools were beginning to open their doors to female students. In 1849 at Geneva College, Elizabeth Blackwell became the first woman to achieve a medical degree in the United States.1 At the time of the Civil War, the few women who had managed to obtain medical degrees mainly served as nurses in the war, because society was not yet ready to accept the female physician.2 Dr. Mary Edwards Walker would help change the role of women physicians, becoming not only a valuable surgeon for the Union Army, but also a catalyst for the introduction and advancement of women in medicine

Recovery of end-organs and improved mortality in adult patient on ECMO.

Title: Recovery of End-Organs and Improved Mortality in Adult Patients on ECMO Joshua K Wong, BS1, Vei Shaun Siow, BS1, Thomas N Smith, BS1, Harrison Pitcher, MD2, Linda Bogar, MD2, Hitoshi Hirose, MD2 and Nicholas C Cavarocchi, MD2. 1Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States, 19107 and 2Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States, 19107. Body: With increasing use of ECMO in adults, we seek to objectively measure End-Organ recovery and correlate intensive care mortality scores and complications with patient survival. This is a retrospective review of patients who were placed on ECMO from Oct 2010 to Dec 2011. End-Organ function was measured through Pa02/Fi02 ratios, lactate levels, MELD and mortality scores (SAPSII/APACHEII/SOFA). Complications were recorded and analyzed. Twenty-three patients were placed on VA-ECMO and 5 on VV-ECMO. 22 (73%) patients were successfully weaned off ECMO, and 13 (46%) survived to discharge. In 12 patients with liver injury pre-ECMO, the median MELD score was 21 vs 13 post-ECMO (

Sternal pain after rigid fixation: a pilot study of randomization rigid vs conventional wire closure.

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among the total of 26 patients, 11 patients were in Group R (10 male and 1 female, age 67 ± 8.0) and 15 patients were in Group C (13 male and 2 female, age 66 ± 9.9). Preoperative risk factors and procedure were identical between the two groups. Pain scores were not significantly different between 2 groups. Narcotic requirement was smaller in group R (15.7 mg intravenous morphine equivalent in group R in day 1vs 18.4 mg intravenous morphine equivalent in day 1 in group C in day 1, 13.1 mg vs 12.5 mg in day 2, 9.4 mg vs 10.5 mg in day 3, 6.9 mg vs 7.7 mg in day 4, and 6.2 mg vs 6.9 mg in day 5) than group C. Total iv narcotic given over 5 days was 24 ± 41 mg in group R and 34 mg ± 54 mg in group C (p=0.60). Conclusion: Randomized data rom this ongoing study showed a trend of fewer narcotic requirement especially intravenous narcotics in group R than in group C. Implications: Rigid fixation may potentially improve immediate sternal pain after open heart surgery. Less narcotic requirement potentially facilitate early return to the daily activity

An old problem with a new therapy: gastrointestinal bleeding in ventricular assist device patients and deep overtube-assisted enteroscopy.

Conventional algorithms for diagnosis and treatment of gastrointestinal bleeding (GIB) in patients with nonpulsatile ventricular assist devices (VADs) may take days to perform while patients require transfusions. We developed a new algorithm based on deep overtube-assisted enteroscopy (DOAE) to facilitate a rapid diagnosis and treatment. From 2004 to 2012, 84 patients who underwent VAD placement in our institution, were evaluated for episodes of GIB. Our new algorithm for the management of GIB using DOAE was evaluated by dividing the episodes into three groups: group A (traditional management without enteroscopy), group B (traditional management with enteroscopy performed \u3e24 hours after presentation), and group C (new management algorithm with enteroscopy performedpresentation). Gastrointestinal bleeding was observed in 14 (17%) of our study patients for a total of 45 individual episodes of which 28 met our criteria for subanalysis. Forty-one (84%) lesions were confined to the upper gastrointestinal tract with more than 91% of these lesions being arteriovenous malformations. Average number of transfusions in groups A, B, and C were 4.1, 6.3, and 1.3, respectively (p = 0.001). The number of days to treatment was significantly shorter in group C than group B (0.4 vs. 5.3 days, p = 0.0002). Our new algorithm for the management of GIB using DOAE targets the most common locations of bleeding found in this patient population. When performed early, DOAE has the potential to decrease the need for transfusions and allow for an early diagnosis of GIB in VAD recipients

Efficacy of miniaturized imacor trans-esophageal echocardiografm (TEE) prove in mechanical circulatory support.

Application of the miniaturized ImaCor Trans-Esophageal Echocardiogram (TEE) probe in Heart Transplant/Mechanical Cardiac Support Patients In the surgical cardiac care unit (SCCU), therapeutic interventions often need to be done at the bedside, necessitating the need for a rapidly employable diagnostic tool for the cardiac intensivist. We report the clinical utility of the miniature ImaCor TEE-probe in guiding management of post heart transplant (H-Txp) and mechanical cardiac support patients (MCS) and describe the economic benefit of such a device. This is an IRB approved retrospective review of MCS/H-Txp patients who had ImaCor TEE monitoring in the SCCU of our institution in 2011. The effect on management was stratified into 3 categories; Major (tamponade/device selection/RV failure), Moderate (weaning support device guidance/ inotrope management/fluid management/hemodynamic instability) and Minor (line placement/useful data). The ImaCor TEE-Probe was utilized in a total of 34 patients, of which 21 were either supported by MCS or were post H-Txp. Of these, 13 were on ECMO, 9 were post-VAD, 3 supported by the Impella device and 4 were post-H-Txp. 6 patients were placed on more than 1 method of MCS and 1 patient was supported by ECMO after a H-Txp. The device had a Major effect on management in 4 patients (19%), Moderate effect in 13 (62%) and a Minor effect in 4 (19%). The cost difference between this new device and the traditional TEE is also significant (900 USD vs 4000 USD). Our institution saved in excess of 150,000 USD with the use of this device instead of traditional TEE. This figure did not include the ability of this probe to be used repeatedly within a 72-hour time frame, and the potential cost of going to the operating theatre for further management. This device has proven to be an invaluable new adjunct in the SCCU by allowing previously unobtainable continuous real time monitoring of the MCS/H-Txp patient. Use of the ImaCor TEE-probe provides the cardiac intensivist with timely important clinical data that improves patient care and is economically advantageous

Thoratec HeartMate II(®) Left Ventricular Assist Device Implantation in Patient with Patent Ventriculoperitoneal Shunt.

We report a case of HeartMate II® left ventricular assist device (LVAD) implantation as a destination therapy in a patient with a patent ventriculoperitoneal (VP) shunt after being suffered from subarachnoid hemorrhage. Because the patient\u27s VP shunt was running through her right anterior chest and abdominal wall, a driveline exit site was selected in her left upper quadrant to avoid unnecessary perioperative complication in relation to the patent VP shunt tube. Tailored driveline placement was a key element of this LVAD implantation in this already sick patient with multiple comorbidities