A rare etiology of frequent ventricular ectopy: Embolic complication of a venous iliac stent to the right ventricle

Peripheral venous stent migration is an exceedingly rare complication of endovascular stenting. In this clinical vignette, we present a case of a 74-year-old male with a history of endo-venous laser ablation therapy of the right greater saphenous vein complicated with an occlusion requiring a left iliac vein stent. The patient presented to the clinic months after the procedure with complaints of palpitations. Multimodality imaging revealed a stent that had become dislodged and was now located in the right ventricle, trapped within the tricuspid valve apparatus.

Three consecutive cases of fatal intraoperative intracardiac thrombosis associated with the initiation of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin

Central venoarterial extracorporeal membrane oxygenation has been used since the 1970s to support patients with cardiogenic shock following cardiac surgery. Despite this, in-hospital mortality is still high, and although rare, thrombus within the cardiac chambers or within the extracorporeal membrane oxygenation circuit is often fatal. Aprotinin is an antifibrinolytic available in Europe and Canada, though not currently in the United States. Due to historical safety concerns, use of aprotinin is generally limited and is commonly reserved for patients with the highest bleeding risk. Given the limited availability of aprotinin over the last decade, it is not surprising to find a complete absence of literature describing the use of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin. We present three consecutive cases of rapid fatal intraoperative intracardiac thrombosis associated with post-cardiotomy central venoarterial extracorporeal membrane oxygenation in patients receiving aprotinin.

Unexplained Obstruction of an Integrated Cardiotomy Filter During Cardiopulmonary Bypass

Cardiopulmonary bypass (CPB) is considered relatively safe in most cases, yet is not complication free. We present a case of an integrated cardiotomy filter obstruction during CPB, requiring circuit reconfiguration. Approximately an hour after uneventful initiation of CPB the integrated cardiotomy filter became obstructed over several minutes, requiring circuit reconfiguration using an external cardiotomy filter to maintain functionality. Following reconfiguration, CPB was maintained with a fully functional circuit allowing safe patient support throughout the remainder of CPB. Postoperatively, there was no sign of thrombus or mechanical obstruction of the filter, which was sent to the manufacturer for analysis. The cause of the obstruction was unclear even after chemical analysis, visual inspection, and a review of all techniques and products to which the patient was exposed. The patient had a generally routine hospital stay, with no signs or symptoms related to the incident. To our knowledge, this is the first report describing an obstructed integrated cardiotomy filter. An appropriate readiness plan for such an incident includes proper venting of the filter chamber, a method for detecting an obstruction, and a plan for circuit reconfiguration. This case illustrates the need for a formal reporting structure for incidents or "near miss" incidents during CPB.

Microbubble transmission during cardiotomy infusion of a hardshell venous reservoir with integrated cardiotomy versus a softshell venous reservoir with separated cardiotomy: an in vitro comparison

An important mechanism for postoperative cognitive impairment after cardiac surgery using cardiopulmonary bypass (CPB) is microemboli. One component of the CPB circuit-the cardiotomy-is a major source of gaseous microemboli because it aspirates significant volumes of air with blood from the operative field and intracardiac chambers. Cardiotomies are either integrated within an open hardshell venous reservoir (IC-HSVR) or are a separate canister attached to a softshell collapsible venous reservoir bag (SC-SSVR). The purpose of this study was to compare the Medtronic IC-HSVR (Affinity NT CVR) with Medtronic's SC-SSVR (CB 1351, CBMVR 1600) in terms of relative microbubble transmission during cardiotomy infusion. A recirculating in vitro circuit primed with blood was used to compare the two cardiotomy-reservoir systems with the venous reservoir in the SC-SSVR further assessed in a fully closed or partially open state (SC-SSVR-closed; SC-SSVR-open). Microbubbles were detected using a GAMPT BC100 Doppler system in the outflow line of the venous reservoir. Measurements were taken before (baseline) and after aerated prime was pumped into the cardiotomy while altering pump flow rates (3 L/min; 5 L/min) and reservoir prime volumes (400 mL; 900 mL). Infusing cardiotomy blood into the venous reservoir was associated with an increase in microbubbles and bubble volume transmitted by both cardiotomy-reservoir systems with the magnitude rising with reduced prime volumes. The effect was markedly greater with the IC-HSVR. The IC-HSVR also transmitted larger bubbles, particularly with reduced prime volumes. There was no significant difference in microbubble transmission seen between the SC-SSVR-closed and SC-SSVR-open. The SC-SSVR transmits fewer microbubbles than the IC-HSVR during cardiotomy infusion and should be considered as the preferential system. Because both cardiotomy-reservoir systems transmitted microbubbles during cardiotomy infusion, particularly at the lower venous reservoir volume, it is important to use strategies to minimize cardiotomy microbubble infusion.

Post-arterial filter gaseous microemboli activity of five integral cardiotomy reservoirs during venting: an in vitro study

During a previously published study on gaseous microemboli (GMEs) and perfusionist interventions, it was noted that emboli could be detected after the arterial filter when blood/air challenges entered the membrane oxygenator's integral cardiotomy. The findings indicated that further study into the oxygenator's integral cardiotomy reservoir was warranted. This is the first know published report that connects the vent return to GME activity after the arterial filter. To study the air handling ability of the membranes integral cardiotomy, an in vitro study was conducted on five hard shell coated membrane oxygenators (Terumo Capiox SX25, X coated; Sorin Synthesis, phosphorylcholine coated; Gish Vision, GBS coated; Medtronic Affinity NT, trillium coated; Maquet Quadrox, bioline coated). The oxygenators were matched with their own manufacturer's coated arterial filters (Medtronic 351T Arterial Filter, Sorin Synthesis Integrated Arterial Filter, Terumo CXAF200X Arterial Filter, Gish GAF40GBS-2 Arterial Filter, and Maquet Quart HBF140 Arterial Filter). There were three arms to the study, and three separate oxygenator/filter combinations were used in each arm. The first arm consisted of a pump flow of 4.0 L/min with only the filter purge blood entering the integral cardiotomy. In the second arm, 500 mL/min of simulated vent blood was added to the filter purge blood entering the integral cardiotomy. During the final arm, 200 mL/min of air was added to the vent blood as it entered the integral cardiotomy, to more closely simulate vent return during cardiopulmonary bypass. All GME activity in the oxygenator/filter combinations was examined using the Hatteland CMD20 Microemboli Counter. Placement of the Hatteland probes was 4 in after the hard shell reservoir outlet (PRO) and 12 in after the arterial filter (PAF). When vent blood flow was turned on, there was a significant increase in the PRO microemboli activity detected in all reservoirs. In the PAF position, three of the oxygenator/filter combinations were able to remove 98-99% of the GME, one removed 84.3%, and another removed only 55.5% of the GMEs coming out of the oxygenator's reservoir. All oxygenators were found to have a dramatic increase in reservoir GME activity when the vent was turned on. Depending on the oxygenator/filter combination, vent return into the oxygenator's integral cardiotomy resulted in the presence of significant amounts of GMEs after the arterial filter.