Pediatric Biventricular Assist Device for Myocarditis and Complicated Left Ventricular Thrombus

An 8-year-old girl presenting with fulminant myocarditis and cardiogenic shock underwent peripheral extracorporeal membrane oxygenation. She was switched to central extracorporeal membrane oxygenation because of inadequate venous drainage, and an echocardiogram showed left ventricular (LV) thrombus. She underwent removal of the LV thrombus with LV venting. An echocardiogram showed LV thrombus again 2 days later. The LV thrombus was again removed, and a biventricular assist device support was initiated to avoid further thrombus formation. The patient was completely weaned from mechanical circulatory support after 7 days. She recovered fully without any neurologic deficit.

Omental and deep inferior epigastric artery perforator flap coverage after heart transplantation to manage wide left ventricular assist device exposure with pocket infection

Infection is a serious potential complication after left ventricular assist device (LVAD) implantation. In general, infection of the device pocket, with device exposure, should be managed by early device removal and heart transplantation. However, because of the small number of donors in Japan, accelerating access to heart transplantation is often difficult and the LVAD can be widely exposed during the waiting period. We report our experience of successful heart transplantation in a patient with a widely exposed LVAD with pocket infection. A 48-year-old man suffered from heart failure due to idiopathic dilated cardiomyopathy. An LVAD was implanted, but postoperative infection led to blood pump exposure. Heart transplantation was performed 4 months after LVAD exposure, at which time the epigastric skin defect measured 14 × 8 cm. The skin defect could not be closed after heart transplantation, so it was covered by an omental flap with split-thickness skin grafts. 7 days postoperatively, the peritoneal suture broke and the intestinal tract prolapsed outside the body. Reintroduction of the prolapsed intestinal tract and deep inferior epigastric artery perforator (DIEP) flap coverage of the omental flap were performed. The postoperative course was uneventful. There have been no reports of the management of wide skin defects in the presence of infection when heart transplantation is performed. Omental flap placement was useful for controlling long-lasting infection. An omental flap placed in a patient with a wide epigastric skin defect should be covered by durable skin flap, such as a DIEP flap, to avoid intestinal prolapse.

Axillo-iliac artery bypass for recurrent aortic coarctation to reduce cardiac afterload

A 13-year-old girl, who had undergone interrupted aortic arch repair with an 8-mm graft as a neonate and Fontan completion in childhood, developed ventricular fibrillation due to long-QT syndrome. Cardioverter defibrillator implantation was planned. Preoperative catheterization showed a 45-mmHg aortic pressure gradient and ventricular end-diastolic pressure of 11 mmHg. This indicated that recurrent coarctation had adversely affected ventricular function. After consideration of the patient's age, symptoms and anatomical/surgical complexities, axillo-iliac bypass with cardioverter defibrillator implantation was performed. Postoperative ventricular end-diastolic pressure was 6 mmHg. Axillo-iliac bypass is a surgical option for coarctation that can reduce cardiac afterload.

[The Role of Extracorporeal Ventricular Assist Device is Changing in the Era of Implantable Ventricular Assist Device]

In the era of implantable ventricular assist device (VAD), the role of extracorporeal VAD is changing. The extracorporeal VAD was ever the mainstream of treatment for severe heart failure. Now, it is mainly applied to patients with severe cardiogenic shock. Recently the centrifugal pump available for cardiopulmonary bypass system has been often used as the extracorporeal VAD because of its simplicity of management. Although the implantable VAD plays the pivotal role for bridge to transplantation since its clinical introduction in 2011, the extracorporeal VAD still has the important role for end-stage heart failure and cardiogenic shock. We have experienced 47 cases of the extracorporeal VAD until now. Here, based on our experience, we describe the "past and present" role of the extracorporeal VAD and mention the future aspect of the extracorporeal VAD.

Pulmonary valve replacement after repaired Tetralogy of Fallot

In this review article, we describe pulmonary valve replacement (PVR) late after repaired Tetralogy of Fallot (TOF). Since the introduction of surgical intervention for patients with TOF in 1945, surgical management of TOF has dramatically improved early survival with mortality rates, less than 2-3%. However, the majority of these patients continue to experience residual right ventricular outflow tract pathology, most commonly pulmonary valve regurgitation (PR). The patients are generally asymptomatic during childhood and adolescence and, however, are at risk for severe PR later which can result in exercise intolerance, heart failure, arrhythmias, and sudden death. While it has been shown that PVR improves symptoms and functional status in these patients, the optimal timing and indications for PVR after repaired TOF are still debated. This article reviews the current state of management for the patient with PR after repaired TOF.

Acute torrential mitral regurgitation during transcatheter aortic valve replacement: a case report

Background

Transcatheter aortic valve replacement (TAVR) is a minimally invasive approach to aortic valve replacement. However, critical cardiovascular collapse can occur during the procedure for various reasons.

Case presentation

A 90-year-old man with severe aortic stenosis and left circumflex artery stenosis developed acute torrential mitral regurgitation (MR) during TAVR. The valve deployment process induced left ventricular dyssynchrony due to left bundle-branch block and myocardial ischemia in the left circumflex artery region with torrential MR. Transesophageal echocardiography clearly demonstrated the mechanisms of MR, which was successfully bailed out by left ventricular pacing and intra-aortic balloon pumping.

Conclusions

MR can be seriously exaggerated by various and complicated mechanisms during TAVR and should be rapidly assessed and appropriately managed depending on its mechanisms.

Electronic supplementary material

The online version of this article (10.1186/s40792-018-0446-z) contains supplementary material, which is available to authorized users.

Acute Swine Model for Assessing Biocompatibility of Biomedical Interface Materials

We established an acute animal model for early, straightforward, and reproducible assessment of a biocompatible material interface. Bilateral femoral artery-to-vein shunts were created in 12 pigs: two tubes per shunt, the left two coated and the right two uncoated. We evaluated two groups: uncontrolled flow (UF; shunt flow unregulated) and controlled flow (CF; shunt flow ∼50 mL/min). For each case on each side, two shunts were evaluated: one for 1 h and the other for 3 h. Arterial blood gas and complete blood count were recorded at baseline, 1, and 3 h. Mean shunt flows were 532 ± 88 mL/min UF and 52 ± 8 mL/min CF. Differences in flow were much smaller in CF (0.5 mL/min; 1% of mean flow) than UF (24.8 mL/min; 5% of mean flow). In UF, significant changes occurred: in pH, from start of shunting through 1 h; in pO₂ and pCO₂, from start through 3 h. This swine model using bilateral femoral shunts with controlled blood flow provides a reliable, reproducible, easily implemented method by which to evaluate biocompatibility of device coatings at an early stage of investigation.

[Management of Right Heart Failure after Cardiac Surgery]

Perioperative right heart failure(RHF) is an important problem, especially in the field of heart failure surgery. Right ventricular performance is determined by the combination of preload, contractility, heart rate, rhythm and afterload. Many factors influence on these parameters in the perioperative period, and the deterioration of one of them can cause RHF. Recently, we often encounter perioperative RHF after left ventricular assist device (LVAD) implantation, and prompt LVAD pump speed optimization and treatment for RHF is required to avoid complications and hemodynamic deterioration. Concomitant tricuspid annulus plasty may be effective for selected patients. In this review, we show the factors determining the performance of right ventricle, and then summarize the etiology and management strategies of perioperative RHF.

Venovenous Extracorporeal Membrane Oxygenation in Two Morbidly Obese Patients

Case studies on the use of venovenous extracorporeal membrane oxygenation in the obese patient have been infrequently reported. We report the successful utilization of venovenous extracorporeal membrane oxygenation in two obese patients with acute respiratory distress syndrome. The first patient had a body mass index of 93 and developed acute respiratory distress syndrome in the setting of pneumonia and aspiration while the second patient had a body mass index of 47 and developed acute respiratory distress syndrome in the setting of gastrografin aspiration. Both were successfully managed with venovenous extracorporeal membrane oxygenation and discharged from the hospital.

[The Present Situation and Clinical Topics of Ventricular Assist Device and Heart Transplantation in Japan]

Surgical treatment for heart failure includes coronary artery bypass grafting to ischemic heart disease, valvular disease surgery such as mitral valvuloplasty, left ventricular restoration, ventricular assist device (VAD), and heart transplantation. In addition, HeartSheet which is regenerative medicine using autologous skeletal myoblast sheets has been started from the spring of 2016. Formal insurance reimbursement of implantable LVAD was obtained in April 2011, and the life prognosis of patients with severe heart failure improved markedly. However, the indication for implantable LVAD is limited to bridge use for heart transplantation. Implantable LVAD cannot be implanted in patients over 65 years old under health insurance because the adaptive age of heart transplantation in Japan is under 65 years old. It is a problem that the indication of implantable LVAD is identical to that of heart transplantation. Clinical trial of destination therapy is in progress for the purpose of optimizing the implantable LVAD indication. I strongly pray that VAD treatment including destination therapy (DT) and transplant medical treatment based on good intentions will be accepted socially as general treatment.

The Impact of Alemtuzumab and Basiliximab Induction on Patient Survival and Time to Bronchiolitis Obliterans Syndrome in Double Lung Transplantation Recipients

We examined the effect of alemtuzumab and basiliximab induction therapy on patient survival and freedom from bronchiolitis obliterans syndrome (BOS) in double lung transplantation. The United Network for Organ Sharing database was reviewed for adult double lung transplant recipients from 2006 to 2013. The primary outcome was risk-adjusted all-cause mortality. Secondary outcomes included time to BOS. There were 6117 patients were identified, of whom 738 received alemtuzumab, 2804 received basiliximab, and 2575 received no induction. Alemtuzumab recipients had higher lung allocation scores compared with basiliximab and no-induction recipients (41.4 versus 37.9 versus 40.7, p < 0.001) and were more likely to require mechanical ventilation before to transplantation (21.7% versus 6.5% versus 6.2%, p < 0.001). Median survival was longer for alemtuzumab and basiliximab recipients compared with patients who received no induction (2321 versus 2352 versus 1967 days, p = 0.001). Alemtuzumab (hazard ratio 0.80, 95% confidence interval 0.67-0.95, p = 0.009) and basiliximab induction (0.88, 0.80-0.98, p = 0.015) were independently associated with survival on multivariate analysis. At 5 years, alemtuzumab recipients had a lower incidence of BOS (22.7% versus 55.4 versus 55.9%), and its use was independently associated with lower risk of developing BOS on multivariate analysis. While both induction therapies were associated with improved survival, patients who received alemtuzumab had greater median freedom from BOS.