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Fatima E, Hill I, Fatima S, Akay MH, Ratnani I. A Case of Pneumocephalus Due to an Untreated Atrial-Esophageal Fistula Post-Left Atrial Ablation Therapy. Cureus 2024; 16:e73538. [PMID: 39669825 PMCID: PMC11636948 DOI: 10.7759/cureus.73538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2024] [Indexed: 12/14/2024] Open
Abstract
Air embolisms can be caused by trauma, barotrauma, or due to surgical procedures in neurosurgery, vascular surgery, and cardiac surgery. An atrial-esophageal fistula (AEF) is a life-threatening complication that can occur following left atrial ablation therapy, which is used to treat refractory atrial fibrillation (Afib). AEF, if left untreated, can lead to serious neurological complications such as pneumocephalus. We present a rare case of pneumocephalus in a 60-year-old male who recently underwent left atrial ablation therapy after which he presented to the ER following a fall. On examination, the patient was confused and had difficulty getting up. A left hemiparesis and a rightward gaze preference were also observed. The CT scan of the head confirmed pneumocephalus. Our report is unique as it explores a very rare entity and highlights the implications of a delay in the treatment of AEF. Early surgical intervention is the key to ensuring the survival of patients with an AEF.
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Bhardwaj A, Salas de Armas IA, Bergeron A, Sauer RM, Gilley C, Reeves K, Patarroyo-Aponte M, Akay MH, Patel M, Kumar S, Patel J, Marcano J, Nathan S, Gregoric ID, Kar B. Prehabilitation Maximizing Functional Mobility in Patients With Cardiogenic Shock Supported on Axillary Impella. ASAIO J 2024; 70:661-666. [PMID: 38483812 DOI: 10.1097/mat.0000000000002170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
Physical therapy (PT) benefits for critically ill patients are well recognized; however, little data exist on PT in patients receiving temporary mechanical circulatory support. In this single-center retrospective study (February 2017-January 2022), we analyzed 37 patients who received an axillary Impella device (Abiomed, Danvers, MA) and PT to "prehabilitate" them before durable left ventricular assist device (dLVAD) implantation. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility tool assessed the functional status at different points during admission. Immediately after Impella placement, the median AM-PAC score was 12.7 (interquartile range [IQR], 9-15), and the scores continued to significantly increase to 18.4 (IQR, 16-23) before dLVAD and up to 20.7 (IQR, 19-24) at discharge, indicating improved independence. No PT-related complications were reported. Thus, we hypothesize that critically ill patients initially deemed equivocal candidates may safely participate in PT while maximizing functional activities before dLVAD placement.
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Akay MH, De Armas IAS, Kar B, Gregoric ID. Is Sternal Sparing Left Ventricular Assist Device Implantation "Minimally" Invasive? ASAIO J 2023; 69:e441-e442. [PMID: 37527626 DOI: 10.1097/mat.0000000000001987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
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Al Rameni D, Patel MK, Salas De Armas IA, Akay MH, Marwan JF, Kar B, Gregoric ID. Open Surgical Insertion of TandemHeart Device for Left Ventricular Unloading. ASAIO J 2023; 69:e437-e440. [PMID: 37220217 DOI: 10.1097/mat.0000000000001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
TandemHeart (Cardiac Assist Inc., Pittsburgh, PA) is a valuable mechanical circulatory support (MCS) device that provides left atrial to femoral artery bypass and directly unloads the left ventricle. The device is inserted under fluoroscopic guidance in the cardiac catheterization laboratory without requiring invasive surgical exposure. However, this device is unique because it directly unloads the oxygenated blood from the left atrium and may be needed for postoperative support in patients undergoing various open cardiac surgeries. In this article, we provide a detailed description of the open surgical insertion of a TandemHeart device.
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Salas De Armas IA, Marcano J, Akay MH, Patel MK, Patel J, Al Rameni D, Kar B, Gregoric ID. Surgical Explantation of Impella 5.5 With Inflow Thrombus in Patients Undergoing Durable Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:489-493. [PMID: 37710981 PMCID: PMC11046142 DOI: 10.1177/15569845231196862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The Impella 5.5® (Abiomed, Danvers, MA, USA) is a microaxial flow pump that promotes left ventricular unloading and improves end-organ perfusion before durable left ventricular assist device (LVAD) implantation. Thrombus formation after Impella 5.5 insertion can occur and represents a significant challenge to device explantation. Durable LVAD implantation is typically performed without aortic cross-clamping, so a dislodged thrombus can potentially embolize and lead to catastrophic events. We describe our technique to safely explant an Impella 5.5 in patients who develop a thrombus on the inflow portion of the device before surgical LVAD implantation.
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Salas de Armas IA, Holifield L, Janowiak LM, Akay MH, Patarroyo M, Nascimbene A, Akkanti BH, Patel M, Patel J, Marcano J, Kar B, Gregoric ID. The use of veno-arterial extracorporeal membrane oxygenation in the octogenarian population: A single-center experience. Perfusion 2023; 38:1196-1202. [PMID: 35766358 DOI: 10.1177/02676591221111506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Advanced age is a known risk factor for poor outcomes after veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for cardiac support. The use of ECMO support in patients over the age of 80 is controversial, and sometimes its use is contraindicated. We aimed to assess the use of ECMO in octogenarian patients to determine survival and complication rates. METHODS A single-center, retrospective analysis was completed at a large, urban academic medical center. Patients requiring V-A ECMO support between December of 2012 and November of 2019 were included as long as the patient was at least 80 years of age at the time of cannulation. Post cardiotomy shock patients were excluded. RESULTS A total of 46 patients met eligibility criteria; all received V-A ECMO support. Overall, the majority of patients (71.7%; 33/46) survived to decannulation, and 43.5% (20/46) survived to discharge. Patients who were previously rescued from percutaneous interventions tend to have a better survival than other patients (p = .06). The most common complications were renal and hemorrhagic. CONCLUSIONS We demonstrated that advanced age alone should not disqualify patients from cannulating and supporting with V-A ECMO.
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Salas De Armas IA, Bergeron A, Akkanti B, Akay MH, Scovell A, Patel MK, Patel J, Bhardwaj A, Al Rameni D, Marcano J, Nascimbene A, Kar B, Gregoric ID. Use of Percutaneous Left Ventricular Assist Device Before Durable Device Implantation in Patients With Cardiac Cachexia: Case Series. ASAIO J 2023; 69:e354-e359. [PMID: 37039827 DOI: 10.1097/mat.0000000000001902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Frailty and malnutrition in patients with heart failure are barriers to durable left ventricular assist device (D-LVAD) support and heart transplantation. Moreover, cachexia in patients with advanced heart failure carries a high mortality risk. There are no guidelines for these patients other than increased caloric intake and rehabilitation. Patients suffering from cardiac cachexia and heart failure may benefit from temporary, percutaneous assist device support to improve the underlying heart disease and reverse the catabolic state. We retrospectively reviewed patients from January 2017 to January 2022. All patients who received Impella support (5.0 or 5.5, Abiomed) before D-LVAD implantation were screened. Those who met the criteria for cardiac cachexia were included. Patient demographics, nutritional and biochemical markers, and survival data were collected. A total of 14 patients were included. The majority of patients were male (85.7%) with ischemic cardiomyopathy (64.3%). Caloric intake, physical strength, and ambulation improved. Prealbumin levels improved from a median of 13.7-18.0 mg/dl ( p < 0.006) while on Impella 5.0 or 5.5 support. All patients survived to discharge and the 6 month follow-up. In conclusion, use of the Impella device improves cardiogenic shock symptoms and, consequently, may improve cachexia status prior to D-LVAD implantation.
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Gregoric ID, Patel M, Akay MH, Salas De Armas I, Patel J, Jezovnik MK, Radovancevic R, Kar B. Off-pump Left Ventricular Assist Device Implantation Through Median Sternotomy Versus Sternal Sparing Approach. ASAIO J 2023; 69:e265-e266. [PMID: 36521006 DOI: 10.1097/mat.0000000000001847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Mubashir T, Zaki J, Yeong An S, Salas De Armas IA, Liang Y, Markham T, Feng H, Akay MH, Nascimbene A, Akkanti B, Williams GW, Zasso F, Aponte MP, Gregoric ID, Kar B. Does the Type of Chronic Heart Failure Impact In-Hospital Outcomes for Aortic Valve Replacement Procedures? Tex Heart Inst J 2023; 50:493363. [PMID: 37270296 DOI: 10.14503/thij-21-7775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND This study assessed in-hospital outcomes of patients with chronic systolic, diastolic, or mixed heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). METHODS The Nationwide Inpatient Sample database was used to identify patients with aortic stenosis and chronic HF who underwent TAVR or SAVR between 2012 and 2015. Propensity score matching and multivariate logistic regression were used to determine outcome risk. RESULTS A cohort of 9,879 patients with systolic (27.2%), diastolic (52.2%), and mixed (20.6%) chronic HF were included. No statistically significant differences in hospital mortality were noted. Overall, patients with diastolic HF had the shortest hospital stays and lowest costs. Compared with patients with diastolic HF, the risk of acute myocardial infarction (TAVR odds ratio [OR], 1.95; 95% CI, 1.20-3.19; P = .008; SAVR OR, 1.38; 95% CI, 0.98-1.95; P = .067) and cardiogenic shock (TAVR OR, 2.15; 95% CI, 1.43-3.23; P < .001; SAVR OR, 1.89; 95% CI, 1.42-2.53; P ≤ .001) was higher in patients with systolic HF, whereas the risk of permanent pacemaker implantation (TAVR OR, 0.58; 95% CI, 0.45-0.76; P < .001; SAVR OR, 0.58; 95% CI, 0.40-0.84; P = .004) was lower following aortic valve procedures. In TAVR, the risk of acute deep vein thrombosis and kidney injury was higher, although not statistically significant, in patients with systolic HF than in those with diastolic HF. CONCLUSION These outcomes suggest that chronic HF types do not incur statistically significant hospital mortality risk in patients undergoing TAVR or SAVR.
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Akay MH, Jezovnik MK, Salas De Armas IA, Ilic M, Karabulut MN, Alagoz M, Patel M, Radovancevic R, Kar B, Gregoric ID. Delayed versus primary sternal closure for left ventricular assist device implantation: Impact on mechanical circulatory support infections. J Heart Lung Transplant 2022; 42:645-650. [PMID: 36641296 DOI: 10.1016/j.healun.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delayed sternal closure may be required after left ventricular assist device (LVAD) implantation due to coagulopathy or hemodynamic instability. There is conflicting data regarding infection risk. METHODS We performed a single-center, retrospective analysis of patients who received their first LVAD between May 2012 and January 2021. Patients were divided into delayed sternal closure (DSC) and primary sternal closure (PSC) groups. We used chi-squared or Fisher Exact tests, as appropriate, to compare the incidence of postoperative LVAD-related infections (mediastinal/sternal wound) and LVAD-specific infections (driveline and pump pocket) after definitive chest closure between these two groups. RESULTS A total of 327 patients met eligibility criteria, including 127 (39%) patients that underwent DSC and 200 (61%) patients that had a PSC. Demographic and clinical characteristics were similar except for an overrepresentation of men (87% vs. 75%, p = .016), Interagency Registry of Mechanically Assisted Circulatory Support class I-II patients (89% vs 66%, p < .001), patients with a previous sternotomy (43% vs 13%, p < .001), and patients with chronic kidney disease (55% vs 43%, p = .030) in the DSC group. The median DSC time was 24 (IQR: 24-48) hours. The incidence of LVAD-related mediastinal/sternal wound infection was similar between the DSC and PSC groups (4.7% vs 3.0%, p = .419). There was no difference between DSC and PSC groups in the incidence of driveline infection (6.3% vs 9%, p = .411) and pump pocket infection (1.6% vs 1.5%, p =.901), respectively. CONCLUSIONS DSC does not seem to increase the incidence of LVAD-related or LVAD-specific infection rates in heart failure patients undergoing device implantation surgery.
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Salas de Armas I, Bergeron A, Bhardwaj A, Patarroyo M, Akay MH, Al Rameni D, Nascimbene A, Patel MK, Patel J, Marcano J, Kar B, Gregoric ID. Surgically Implanted Impella Device for Patients on Impella CP Support Experiencing Refractory Hemolysis. ASAIO J 2022; 68:e251-e255. [PMID: 35348311 DOI: 10.1097/mat.0000000000001712] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The Impella CP (Abiomed Inc., Danvers, MA) is widely used in cardiac catheterization laboratories for patients presenting with cardiogenic shock, but it is also known to cause significant hemolysis. The risk of hemolysis can be reduced by properly positioning the device, ensuring an adequate volume status, and using full anticoagulation strategies; however, in some cases hemolysis persists. We present a case series of eight patients that were diagnosed with cardiogenic shock, underwent Impella CP placement, and then suffered from refractory hemolysis which was treated by upgrading the Impella device to the 5.0 or 5.5 version. Fifty percent (4/8) of the patients in this series were already receiving continuous renal replacement therapy, and the levels of plasma free hemoglobin (pFHb) and lactate dehydrogenase continued to increase after the implantation of the Impella CP. The median time between Impella CP placement and the diagnosis of refractory hemolysis was 16.5 hours (interquartile range [IQR], 8.0-26.0). The median time between the diagnosis of hemolysis to Impella upgrade was 6.0 hours (IQR, 4.0-7.0). A total of 87.5% (7/8) of patients experienced a drop in pFHb to below 40 mg/dl at 72 hours post-Impella upgrade, and they were discharged without any further need of dialysis. One patient expired due to irreversible multiple organ failure. We propose that early identification of hemolysis by close monitoring of pFHb and upgrading to the Impella 5.5 reduces hemolysis, prevents further kidney damage, and significantly improves clinical outcomes.
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Salas De Armas IA, Buja LM, Patel MK, Patel J, Akay MH, Gok E, Gregoric ID. Aortic Root Dissection Due to an Automated Fastener Device. Tex Heart Inst J 2022; 49:488734. [PMID: 36450144 PMCID: PMC9809097 DOI: 10.14503/thij-20-7531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Minimally invasive aortic valve replacement through a right thoracotomy is frequently performed in patients with aortic valve disease. The Cor-Knot Device (LSI Solutions) is an automated fastener that secures valve sutures. This case report is for a patient who developed postcardiotomy shock during a minimally invasive aortic valve surgery. The patient was found to have an aortic root dissection involving 90% of the aortic root circumference, including bilateral coronary ostia. The autopsy revealed that the aortic damage could be explained by a direct aortic intimal tear from the distal tip of the device shaft. The device was most likely not in perfect apposition to the sewing ring because of the restricted angle and space between the ribs.
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Salas de Armas IA, Shirafkan A, Akay MH, Patel J, Patel MK, Marcano J, Al Rameni D, Zaki J, Gregoric ID. Transaortic Placement of Percutaneous Mechanical Support Device via Partial Sternotomy: Feasible Option for Unsuitable Axillary Artery Access. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:377-381. [DOI: 10.1177/15569845221123535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Acute decompensated refractory cardiogenic shock is an emergency in which the prompt instauration of mechanical circulatory support improves outcomes. The typical, initial approach for device delivery is via femoral vessels due to easy access and safety. If longer support is needed, the femoral access will severely impair the patient’s mobility and can also limit the amount of support given as the new-generation devices are too large for direct arterial insertion. Upper-body arterial conduits (UBACs) are used for the delivery of larger, percutaneous ventricular assist devices (pVADs). The Impella 5.5 (Abiomed, Danvers, MA, USA) is a pVAD that can be deployed through a UBAC by either axillary/subclavian access or a transaortic approach. The latter approach is typically used in cases of postcardiotomy shock, in which the ascending aorta is already exposed through a full sternotomy. However, in some cases, the axillary artery is not suitable due to size (<6 mm in diameter), and a smaller pVAD is delivered into the heart. To avoid providing suboptimal support, we present an alternative, minimally invasive approach in which the larger device is delivered through the ascending aorta. This article summarizes the details of this approach through a mini upper partial sternotomy and reviews the relevant technical considerations.
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Kumar R, Ellis S, Salas De Armas IA, Patel MK, Akay MH, Bajwa KS, Liang Y, Gregoric ID. Intraoperative Management for Left Ventricular Assist Device Implantation With Concurrent Laparoscopic Sleeve Gastrectomy: A Case Series. A A Pract 2021; 15:e01545. [PMID: 34752439 DOI: 10.1213/xaa.0000000000001545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The increasing coincidence of obesity with heart failure may preclude eligibility for orthotopic heart transplantation, requiring continuous-flow left ventricular assist devices (LVADs) as destination therapy. This report describes intraoperative considerations for patients who underwent LVAD implantation with concurrent laparoscopic sleeve gastrectomy (LSG) to promote weight loss. In particular, right ventricular dysfunction associated with acute left ventricular unloading may be compounded by pneumoperitoneum for LSG due to the difficulty in ventilating patients with obesity, hypercarbia-mediated increase in pulmonary vascular resistance, and variable cardiac loading conditions. We identify specific anesthetic challenges and discuss methods of monitoring and management.
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Gok E, Akay MH, de Armas IS, Klein K, Tint H, Allison PM, Chen AJ, Akkanti B, Kar B, Gregoric ID. Aortic root repair in a patient with acquired hemophilia A: case report. Surg Case Rep 2021; 7:176. [PMID: 34347197 PMCID: PMC8339152 DOI: 10.1186/s40792-021-01256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background Patients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients. Case presentation A 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful. Conclusion Cardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.
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Kumar R, Patel MK, Zaki JF, Salas de Armas IA, Akay MH, Kar B, Gregoric ID. Intraoperative Management of Carotid Endarterectomy in Patients With Left Ventricular Assist Devices-The Challenge of Continuous Flow: A Case Report. A A Pract 2021; 14:e01355. [PMID: 33278087 DOI: 10.1213/xaa.0000000000001355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Symptomatic carotid artery disease stenosis warrants open surgical carotid endarterectomy (CEA). However, patients with continuous-flow left ventricular assist devices (CF-LVADs) present unique challenges when vasopressors and volume are used to maintain cerebral perfusion pressure after carotid cross-clamping. This report describes patients with CF-LVADs who underwent CEA. We identify how preload, contractility, afterload, pump speed, mean arterial pressure, and anticoagulation should be addressed to maintain CF-LVAD outflow and cerebral perfusion during the procedure. Anesthesiologists can combine an understanding of continuous-flow physiology with invasive monitors to optimize cardiac output and cerebral blood flow during CEA procedures.
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Salas De Armas IA, Patel JA, Akay MH, Patel MK, Rajagopal K, Karabulut MN, Kar B, Gregoric ID. Off-Pump Continuous-Flow Left Ventricular Assist Device Implantation. Tex Heart Inst J 2021; 48:464664. [PMID: 33946106 DOI: 10.14503/thij-19-7033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Continuous-flow left ventricular assist device implantation is the typical treatment for end-stage heart failure. Improvements in device engineering and technology, surgical experience and technique, and perioperative management have advanced the field, and short-term results approach those of heart transplantation. Further improvements may be achieved by minimizing adverse physiologic effects associated with cardiopulmonary bypass. Therefore, we have developed an off-pump implantation approach for continuous-flow left ventricular assist devices. We detail our surgical technique for off-pump implantation of the HeartWare device.
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Nathan SS, Iranmanesh P, Gregoric ID, Akay MH, Kumar S, Akkanti BH, Salas de Armas IA, Patel M, Felinski MM, Shah SK, Bajwa KS, Kar B. Regression of severe heart failure after combined left ventricular assist device placement and sleeve gastrectomy. ESC Heart Fail 2021; 8:1615-1619. [PMID: 33491335 PMCID: PMC8006616 DOI: 10.1002/ehf2.13194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/03/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
Patients who suffer morbid obesity and heart failure (HF) present unique challenges. Two cases are described where concomitant use of laparoscopic sleeve gastrectomy (LSG) and left ventricular assist device (LVAD) placement enabled myocardial recovery and weight loss resulting in explantation. A 29‐year‐old male patient with a body mass index (BMI) of 59 kg/m2 and severe HF with a left ventricular ejection fraction (LVEF) of 20–25% underwent concomitant LSG and LVAD placement. Sixteen months after surgery, his BMI was reduced to 34 kg/m2 and his LVEF improved to 50–55%. A second 41‐year‐old male patient with a BMI of 44.8 kg/m2 with severe HF underwent the same procedures. Twenty‐four months later, his BMI was 31.1 kg/m2 and his LVEF was 50–55%. In both cases, the LVAD was successfully explanted and patients remain asymptomatic. HF teams should consult and collaborate with bariatric experts to determine if LSG may improve the outcomes of their HF patients.
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Salas de Armas IA, Akkanti BH, Janowiak L, Banjac I, Dinh K, Hussain R, Cabrera R, Herrera T, Sanger D, Akay MH, Patel J, Patel MK, Kumar S, Jumean M, Kar B, Gregoric ID. Inter-hospital COVID ECMO air transportation. Perfusion 2020; 36:358-364. [PMID: 33233987 DOI: 10.1177/0267659120973843] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has required rapid and effective protocol adjustments at every level of healthcare. The use of extracorporeal membrane oxygenation (ECMO) is pivotal to COVID-19 treatment in cases of refractory hypoxemic hypercapnic respiratory failure. As such, our large, metropolitan air ambulance system in conjunction with our experts in advanced cardiopulmonary therapies modified protocols to assist peripheral hospitals in evaluation, cannulation and initiation of ECMO for rescue and air transportation of patients with COVID-19 to our quaternary center. The detailed protocol is described alongside initial data of its use. To date, 14 patients have been placed on ECMO support at an outside facility and successfully transported via helicopter to our hub hospital using this protocol.
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Akay MH, Patel MK, Gregoric ID. Coronary sinus injury resulting from endarterectomy during multivessel bypass surgery. Interact Cardiovasc Thorac Surg 2017; 24:804-805. [PMID: 28453800 DOI: 10.1093/icvts/ivw393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/01/2016] [Indexed: 11/14/2022] Open
Abstract
Coronary sinus injury is a very rare complication of cardiac surgery and is usually related to coronary sinus perfusion catheter placement for retrograde cardioplegia infusion. It can be either a catheter-related perforation or high-perfusion pressure-related injury to the coronary sinus. Primary repair of the coronary sinus or over-sewing are two possible options to resolve this complication. Decellularized extracellular matrix from porcine intestinal submucosa is widely used as an approved material for repairing cardiac structures. We report a case of coronary sinus stenosis resulting from coronary artery endarterectomy during multivessel coronary artery bypass surgery, causing injury to the proximal part of the middle cardiac vein (MCV). Closure of the MCV resulted in a coronary sinus obstruction that was bypassed with a CorMatrix tube graft from the coronary sinus of the MVC to the right atrium.
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Akay MH, Gregoric I, Cohn WE, Frazier OH. HeartMate-II left ventricular assist device infections resulting from gastrointestinal-tract fistulas. J Card Surg 2012; 27:643-5. [PMID: 22978845 DOI: 10.1111/j.1540-8191.2012.01517.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with a left ventricular assist device (LVAD), pump-related infection can cause adverse effects that may result in death. METHODS We describe three patients who had infections related to a fistula between the gastrointestinal (GI) tract and the LVAD pocket and who subsequently underwent successful heart transplantation without developing sepsis. In no case did the LVAD-related infection adversely affect the outcome of transplantation. CONCLUSIONS For detecting the fistulas, full upper-GI endoscopy and colonoscopy were superior to other types of diagnostic imaging studies.
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Akay MH, Cooley DA, Frazier OH. Implantation of the heartmate II in a patient of 34 years after a Mustard procedure. J Card Surg 2012; 27:769-70. [PMID: 22957930 DOI: 10.1111/j.1540-8191.2012.01521.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A growing number of patients have undergone the Mustard procedure for transposition of the great arteries, after which the morphologic right ventricle serves as the systemic ventricle. If this ventricle fails, ventricular assist device support may be necessary, but implanting the inflow cannula can be challenging in these patients because of the moderator band and trabeculation of the morphologic right ventricle. We describe successful assist device implantation in a 34-year-old patient who had undergone the Mustard procedure in infancy.
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Abstract
Thoracic compartment syndrome has been observed after trauma and after mediastinal and cardiac procedures; however, an adult respiratory distress syndrome (ARDS)-like presentation has not been described as a part of thoracic compartment syndrome. We describe the case of an obese patient who underwent coronary artery bypass (his third such procedure) and hiatal hernia reduction during the same operation, followed by transmyocardial laser revascularization and full chest closure the next day. The patient was hypoxic after chest closure. Two days later, his peak airway pressure increased, and his cardiac and urine outputs decreased. Chest radiography findings suggested ARDS without hemodynamic instability. After we reopened the sternal incisions, the patient's symptoms reversed. Although our patient initially appeared to have ARDS, we believe the organ-volume displacement that occurred during the lengthy dual operation produced a thoracic and abdominal compartment syndrome that responded to decompression of the chest.
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Akay MH, Gregoric ID, Radovancevic R, Cohn WE, Frazier OH. Timely use of a CentriMag heart assist device improves survival in postcardiotomy cardiogenic shock. J Card Surg 2012; 26:548-52. [PMID: 21951040 DOI: 10.1111/j.1540-8191.2011.01305.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCS) is often fatal despite inotropic and circulatory support. We compared our experience with the CentriMag left ventricular assist device (LVAD) for patients with PCS at two time periods: in the operating room (OR) after unsuccessful weaning from cardiopulmonary bypass (CPB) and after transfer to the intensive care unit (ICU). METHODS We reviewed 22 patients' records (13 men, nine women; age, 65 ± 12 years) who underwent open heart surgery (January 2004 to September 2009) and required LVAD support for PCS despite maximal inotropic and intra-aortic balloon pump (IABP) support. In ten patients who could not be weaned from CPB despite high-dose inotropic therapy (≥ 3 agents) and IABP support, the CentriMag was implanted in the OR (immediate group). The other 12 patients were weaned from CPB with high-dose inotropic therapy and IABP but became increasingly unstable or had a cardiac arrest in the ICU, and the CentriMag was implanted for circulatory support (delayed group). RESULTS Preoperatively, the average ejection fraction was 40% ± 12%, the creatinine level was 1.6 ± 0.6 mg/dL, and the European Systematic Coronary Risk Evaluation was 13.1 ± 4.6. The duration of CentriMag support was 5 ± 3 days. The immediate group had significantly better survival (7/10 vs. 2/12, p = 0.027), higher cardiac index (2.4 ± 0.3 L/min/m(2) vs. 1.7 ± 0.3 L/min/m(2), p = 0.001), and lower pulmonary capillary wedge pressure (20 ± 6 mmHg vs. 29 ± 8 mmHg, p = 0.024) than the ICU group. No perioperative complications related to device implantation occurred. CONCLUSION In patients with PCS, timely placement of a CentriMag LVAD may increase the chance of eventual recovery.
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Akay MH, Sirlak M, Gregoric ID, Frazier OH. Infected right atrial thrombus after explantation of a left ventricular assist device. Tex Heart Inst J 2012; 39:390-392. [PMID: 22719151 PMCID: PMC3368460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Finding the source of a fungal infection and selecting the most appropriate treatment for candidemia is often challenging for physicians, especially when the patient has a complex medical history. We describe the case of a 48-year-old woman who had persistent candidemia after undergoing explantation of a left ventricular assist device. The source of the infection was found to be a right atrial thrombus. The mass was removed, and the patient underwent aggressive treatment with micafungin. Removal of the right atrial mass, followed by potent antifungal treatment, resulted in a successful recovery.
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