Transapical aortic valve implantation in patients with severely depressed left ventricular function

ObjectivesTransapical aortic valve implantation significantly reduces operative risk in elderly patients with aortic valve stenosis and comorbidities. However, it is unknown whether this procedure is feasible in patients with advanced heart failure.MethodsBetween April 2008 and July 2010, 258 patients underwent transapical aortic valve implantation. Twenty-one patients had advanced heart failure with decompensation and a left ventricular ejection fraction of 10% to 25%. The mean age of these patients was 74 ± 11 years (range, 36-88 years). The mean left ventricular ejection fraction was 20% ± 5% (range, 10%-25%). Mean logistic EuroSCORE was 66% ± 21% (range, 27%-97%) and mean Society of Thoracic Surgeons score 33% ± 25% (range, 4%-90%). Nine patients were operated on using femorofemoral cardiopulmonary bypass and 12 without.ResultsTechnical success of the procedure was 100% with no conversion to conventional surgery. The mean time of cardiopulmonary bypass was 27 ± 25 minutes (range, 6-81 minutes). Postoperatively, the left ventricular ejection fraction increased to 38% ± 12% (range, 20%-60%). There were no postoperative neurologic complications. A new pacemaker implantation was needed in 2 (10%) patients. The 30-day mortality was 4.8%. Survival at 1, 3, 12, and 24 months was 95%, 81%, 76%, and 62%, respectively.ConclusionsTransapical aortic valve implantation can be performed safely in patients with decompensated heart failure or even in the presence of cardiogenic shock

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device

Contribution of quantitative intra-operative echocardiography to risk stratification in innovative cardiac surgery

Die Transösophageale Echokardiographie (TEE) hat sich in letzen 10 Jahren zur etablierten Methode für intraoperative Diagnostik und Monitoring in der Kardioanästhesie entwickelt. Über die ursprüngliche Aufgabe der Aufklärung intraoperativer Komplikation hinaus sind die Ziele der standardmäßigen intraoperativen Untersuchung mittels TEE heute folgendermaßen definiert: 1\. Bestätigung und Verfeinerung der präoperativen Diagnostik 2\. Erkennung neuer oder unvermuteter Pathologien 3\. Unterstützung der chirurgischen sowie pharmakologischen intraoperativen Therapieplanung 4\. Bewertung der Ergebnisse der Intervention Das Ziel der in dieser Habilitationsschrift zusammengefassten wissenschaftlichen Untersuchungen war, quantitative echokardiographische Parameter zu identifizieren, die einen Einfluss auf die chirurgische Planung haben, die unmittelbare Beurteilung der Ergebnisse ermöglichen, auf die Notwendigkeit einer Therapieerweiterung hinweisen oder das Überleben der Patienten beeinflussen. Dies wurde für Patientengruppen durchgeführt, bei welchen entweder ein linksventrikuläres Unterstützungssystem (LVAD) oder eine Bioprothese der Aortenklappe im Trans-Katheter-Verfahren (TAVI) implantiert wurde. Bei LVAD Implantation ist das enddiastolische Durchmesserverhältnis von rechtem zu linkem Ventrikel (R/L-ratio) ein Prädiktor für postoperatives Rechtsherzversagen. Ist die R/L-ratio bei Patienten im Endstadium der chronischen Herzinsuffizienz erhöht, wird zunächst die pharmakologische Therapie unmittelbar nach LVAD-Implantation entsprechend optimiert und, falls dies für eine ausreichende RV Funktion nicht genügt, eine zusätzliche mechanische Unterstützung für den RV implantiert. Ein vergrößerter Durchmesser des Anulus der Trikuspidalklappe wurde als Prädiktor für das mittelfristige Überleben nach Implantation eines LVAD identifiziert. Zukünftig könnte aufgrund dieses Parameters die Indikation für eine zusätzliche Trikuspidalklappenchirurgie gestellt werden. Nach Transkatheter Aortenklappenimplantation (TAVI) wurden zunächst die hämodynamischen Eigenschaften dieser neuartigen Klappen in situ an einer großen Patientenzahl charakterisiert. Detaillierte Analysen zeigten, dass ein schwerwiegendes Patienten-Prothesen Missverhältnis, bestimmt als indizierte effektive Klappenöffnungsfläche (iEOA), von weniger als 0,65 cm2/m2 mit einer reduzierten 3-Monats Überlebensrate assoziiert ist. Die Berechnung der iEOA mittels Kontinuitätsgleichung und Patienten-Oberfläche ermöglicht somit die Identifikation der Patienten mit erhöhtem postoperativem Mortalitätsrisiko. Die in den vorgestellten Arbeiten beschriebenen Ergebnisse unterstreichen die Notwendigkeit von weiteren quantitativen echokardiographischen Studien in definierten Patientengruppen, verbunden mit möglichst langen Nachbeobachtungszeiten, um die Risikostratifizierung bei diesen kardial schwerstkranken Patienten zu optimieren.Transesophageal echocardiography (TEE) has evolved over the last 10 years into an established method for intra-operative diagnostics and monitoring in cardiac anesthesia. Beyond the original purpose of detecting and managing intra-operative complications, the aims of routine intra-operative examination by TEE today are defined as follows: 1\. Confirmation and refinement of preoperative diagnoses 2\. Detection of new or unsuspected pathologies 3\. Support of surgical and pharmacological intra-operative decision making 4\. Assessment of the results of the intervention The goal of the studies summarised in this habilitation thesis was to identify quantitative echocardiographic parameters that have an impact on the surgical planning, enable immediate evaluation of the results, indicate the need for additional intervention and affect patient survival. This was carried out for groups of patients in which either a left ventricular assist device (LVAD) or a transcatheter guided aortic valve implantation was performed. In patients pre- selected for LVAD implantation, preoperatively calculated right to left end- diastolic ventricular diameter ratio (R/L Ratio) was identified as a predictor for postoperative RV failure. At presence of an increased R/L ratio in patients with end-stage chronic heart failure, the post-operative pharmacological RV-support is optimised and, if the RV function remains insufficient, an additional mechanical support (right ventricular assist device) will be implanted. An enlarged diameter of the annulus of the tricuspid valve (>43 mm) was identified as predictor of mid-term survival after LVAD implantation. In the future this parameter could serve as indication for additional tricuspid valve annuloplasty. After transcatheter aortic valve implantation (TAVI), first the in situ hemodynamic properties of these new bioprostheses were analysed in a large number of patients. Detailed analyses showed that a severe patient-prosthesis mismatch, determined as indexed effective valve area (iEOA) of less than 0.65 cm2/m2, is associated with a reduced three-month cumulative survival rate. The calculation of iEOA by the continuity equation and patient body surface area thus allows the identification of patients with increased postoperative risk. The results described above underline the need for further quantitative echocardiographic studies in defined patient groups combined with follow-up periods as long as possible in order to optimise the risk stratification in these critically ill cardiac patients

Quantitative echocardiographic assessment of patients with left ventricular assist device

Einleitung: Die Implantation ventrikulärer Unterstützungssysteme (ventricular assist device, VAD) gehört heute zur Standardtherapie für das Endstadium der chronischen Herzinsuffizienz. Ziel dieser Arbeit war die Bedeutung der perioperativen Echokardiographie für Risikostratifizierung, Therapiekontrolle und Beurteilung des Langzeitverlaufs bei Patienten mit Implantation eines LVAD zu untersuchen. Methoden: Quantitative Funktionsparameter wurden mittels transösophagealer (intraoperativ) bzw. transthorakaler (prä- und postoperativ) Echokardiographie nach international standardisierten Methoden erhoben. In drei Studien wurden Prädiktoren für postoperatives Rechtsherzversagen bestimmt, die akuten Auswirkungen der LVAD-Implantation auf die rechtsventrikuläre Funktion mit und ohne inhalatives NO untersucht sowie die Erholung des Myokards im Langzeitverlauf nach Transplantation autologer Knochenmarkzellen beobachtet. Ergebnisse: Schwergradige Trikuspidalinsuffizienz und Veränderung der rechtsventrikulären Geometrie konnten als signifikante Risikofaktoren für die Entwicklung einer Rechtsherzinsuffizienz identifiziert werden. LVAD-Implantation induziert eine sofortige Entlastung auch des rechten Ventrikels mit deutlicher Verbesserung von Funktion und Geometrie, die durch inhalatives NO nicht weiter gesteigert wurde. Je schlechter die präoperative Rechtsherzfunktion, desto ausgeprägter war diese Verbesserung. Bei einem von 10 Patienten mit Transplantation autologer Knochenmarkzellen erholte sich der linke Ventrikel ausreichend, um den LVAD entfernen zu können. Da dieser Patient aufgrund seiner Krankengeschichte eine positive Prognose hatte, kann somit kein Effekt der Zelltransplantation nachgewiesen werden. Schlussfolgerung: Die quantitative perioperative Echokardiographie bei Patienten mit Implantation eines LVAD liefert wertvolle Daten für die Risikostratifizierung und klinische Entscheidungsfindung sowie für die akute und langfristige Therapiekontrolle.Introduction: Implantation of left ventricular assist device (LVAD) is an establish treatment of patients with end- stage chronic heart failure. The aim of our studies was to determine the relevance of quantitative peri-operative echocardiography for clinical decision making, intra-operative monitoring and assessment of left ventricular recovery on LVAD. Methods: Parameters for assessment of right and left ventricular geometry and function using transthoracic and transesophageal echocardiography were acquired. We used retrospective multivariate analyses to determine the preoperative predictors of right ventricular failure after LVAD implantation. In a prospective study the immediate improvement of RV function after LVAD implantation was quantified in patients with or without inhaled nitric. In an explorative study the effect of intramyocardial delivery of bone marrow mononuclear cells during LVAD implantation on LV recovery was assessed . Results: In the retrospective study we identified severe tricuspid regurgitation and changes in RV geometry and function as independent predictors of RV failure after LVAD implantation. Accordingly, an algorithm for implantation of LVAD versus a biventricular system was developed. RV function, assessed as fractional area change or ejection fraction improved immediately after LVAD implantation secondary to unloading of the LV. There was no additional effect of inhaled nitric oxide on RV function. In the explorative study one out of ten patients recovered under LVAD therapy and additional mononuclear cell application and was successfully weaned from LVAD. Stem cell therapy had no effect on recovery. Conclusion: Quantitative peri-operative echocardiography in patients with implantation of an LVAD provides valuable data for clinical decision making and post-operative risk stratification

Evaluation of Post-Cardiopulmonary Bypass Coagulation Disorders by Differential Diagnosis with a Multichannel Modified Thromboelastogram: A Pilot Investigation

We assessed a modified multichannel thromboelastogram for differentiation of the causes of coagulopathy after cardiopulmonary bypass and its suitability as a therapy guide. Thirty adult patients undergoing surgery with cardiopulmonary bypass, who revealed a coagulopathy as observed by a prolonged activated clotting time of >150 sec after the application of protamine, were enrolled. Therapy was based on the results obtained by the computerized four-channel thromboelastogram with baseline, heparinase (2 IU/mL), heparinase/abciximab (5 µg/mL), and heparinase/fresh frozen plasma (25%) channels. The mean activated clotting time before therapy was 162.2 ± 7.8 sec. Based on differential diagnosis with the modified multichannel thromboelastogram, two patients received protamine (30 mg), five desmopressin (0.4 µg/kg), 19 patients three units of fresh frozen plasma, two patients platelet transfusions, and two patients both protamine (30 mg) and three units of fresh frozen plasma. After therapy, there was a significant (p < .01) decrease of the activated clotting time to a mean value of 127 ± 8.3 sec. Therapy based on the synoptic modified multichannel thromboelastogram analysis provides a guide for effective therapy of coagulopathy. However, elaboration is desirable, and larger clinical trials are necessary for a final evaluation of the protocol

Assessment of the Resonance Thromboelastograph CS-3 for Differentiation of Coagulation Disorders: A Pilot in vitro Investigation of Simulated Post-Cardiopulmonary Bypass Coagulopathies

Resonance thromboelastography (RTG), a further development of the thromboelastogram (TEG), has been designed for improved differentiation of the effect of the plasmatic coagulation factors (increasing F-leg) and platelets (decreasing P-leg) on clot formation. It is based on the effect of clot elasticity on the resonance of a swinging wire. We assessed the RTG for its ability to differentiate coagulation disorders that frequently occur after cardiac surgery. The RTG was performed with a CS-3 Analyzer. Samples from 10 healthy volunteers were investigated after the following preparations: (1) baseline values, (2) dilution to a hematocrit of 30% and 20% with either hydroxyl ethyl starch (HES) 10% or plasma; (3) addition of 0.25, 0.5, and 1.0 IU/mL porcine heparin with and without heparinase; and (4) addition of 1.0, 3.0, 4.0, and 5.0 µg/mL of the antiplatelet agent abciximab (ReoPro™). Increasing concentrations of abciximab led to a slower decrease or in the case of higher concentrations, to a persistent elevation of the platelet leg of the RTG. Dilution of the hematocrit with plasma had no effect on the fibrin and platelet leg; whereas, dilution with HES 10% led to an inhibition of the fibrin and platelet leg. Dilution of the plasmatic coagulation factors resulted in an inhibition of both the fibrin and the platelet leg. The addition of 0.25 and 0.5 IU/mL of heparin led to an increased coagulation time and inhibition of the fibrin and platelet legs. These effects were eliminated by the addition of heparinase. The RTG enables the evaluation of platelet function under the condition of a nonimpaired plasma coagulation system. Depletion of plasma coagulation factors and the administration of small amounts of heparin do not enable the distinction between residual effects of an anticoagulant, coagulation factor deficiency, or impaired platelet function. However, the heparin effects can be eliminated by the addition of heparinase. Further improvement may be achieved using a modified RTG by adding plasma coagulation factors in one channel for an improved evaluation of platelet function, even under the condition of a loss of procoagulants

How Would We Treat Our Own Heart Transplantation Surgery: A Perioperative Look

Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room

Transapical aortic valve implantation in patients with poor left ventricular function and cardiogenic shock

ObjectivesIn line with our institutional no exclusion policy we accept patients with very poor left ventricular performance and cardiogenic shock for transcatheter aortic valve implantation (TAVI). The purpose of our study was to analyze outcome in these patients and to identify what happens to the left ventricular function after TAVI in patients with failing ventricles.MethodsBetween April 2008 and August 2013, 730 patients underwent transapical TAVI at our institution. The study group consisted of all 104 patients who presented with severely depressed left ventricular function, defined as left ventricular ejection fraction (LVEF) ≤ 30%. Based on the Society of Thoracic Surgeons predicted risk of mortality, the arithmetic risk for surgery in the study cohort was 23% ± 19% (2%-90%), and 23 patients (22%) were in cardiogenic shock.ResultsExcluding patients in cardiogenic shock, the survival rates in the study group at 1, 2, and 4 years were 81% ± 5%, 65% ± 6%, and 45% ± 8%, respectively. Patients in cardiogenic shock showed significantly worse outcome (P = .048). Improvement in LVEF of 50% or more was found in 74 patients (71%) and 100% or more improvement in 45 patients (43%). Early improvement in LVEF was significantly (P = .049) greater in patients with preoperative values of LVEF ≤ 20%.ConclusionsIn the majority of patients with failing ventricles, left ventricular function is quickly restored after TAVI and elimination of aortic stenosis. Without the additional trauma of cardioplegic arrest, TAVI is the potentially superior treatment option in patients with poor and very poor left ventricular performance

Transapical aortic valve implantation after previous aortic valve replacement: Clinical proof of the “valve-in-valve” concept

ObjectiveThe “valve-in-valve” concept may be applied in patients with previously implanted biological aortic valve prostheses. There are few reports of individual cases and as yet no clinical proof of safety and feasibility in a larger group of patients. We report the single-center outcome of transapical implantation of aortic valves into degenerated biological aortic valve prostheses (“valve-in-valve”) in very high-risk patients.MethodsSince October 2008, 14 patients were treated by transapical valve implantation into degenerated biological aortic valve prostheses. Edwards SAPIEN (Edwards Lifesciences, Irvine, Calif) transcatheter heart valves were used in all patients. Mean (± standard deviation) patient age was 73.3 ± 13.1 years. Mean (± standard deviation) Society of Thoracic Surgeons score was 21.9% ± 10.9% (range, 4.2%–42.2%), and logistic euroSCORE was 45.3% ± 22.2%. Preoperatively, all patients were in New York Heart Association functional class III or IV.ResultsThe procedural success was 100%. Preoperative transthoracic echocardiography mean transvalvular gradient was reduced from 37.1 ± 25.7 mm Hg to 13.1 ± 6.4 mm Hg, and mean aortic valve area increased from 0.68 ± 0.23 cm2 to 1.35 ± 0.48 cm2. There was no postoperative valve insufficiency. The postoperative course was short and uneventful in all but 1 patient. One patient underwent reoperation 3 months later because of endocarditis. Up to 20 months postoperatively, the patients were in New York Heart Association functional class I or II.ConclusionsTransapical aortic valve implantation after previous aortic valve replacement was feasible and safe in our patients. The results are excellent with improvements in hemodynamics, but longer follow-up with more patients is needed