Neurological complications of cardiac surgery.

As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing.

Mesenchymal precursor cells as adjunctive therapy in recipients of contemporary left ventricular assist devices.

Background: Allogeneic mesenchymal precursor cells (MPCs) injected during left ventricular assist device (LVAD) implantation may contribute to myocardial recovery. This trial explores the safety and efficacy of this strategy.

Methods And Results: In this multicenter, double-blind, sham-procedure controlled trial, 30 patients were randomized (2:1) to intramyocardial injection of 25 million MPCs or medium during LVAD implantation.

Risk-adjusted survival after tissue versus mechanical aortic valve replacement: a 23-year assessment.

Background And Aim Of The Study: Detailed analyses of risk-adjusted outcomes after mitral valve surgery have documented significant survival decrements with tissue valves at any age. Several recent studies of prosthetic aortic valve replacement (AVR) also have suggested a poorer performance of tissue valves, although analyses have been limited to small matched series. The study aim was to test the hypothesis that AVR with tissue valves is associated with a lower risk-adjusted survival, as compared to mechanical valves.

Trends in the use and outcomes of ventricular assist devices among medicare beneficiaries, 2006 through 2011.

Objectives: This study sought to examine trends in mortality, readmission, and costs among Medicare beneficiaries receiving ventricular assist devices (VADs) and associations between hospital-level procedure volume and outcomes.

Background: VADs are an option for patients with advanced heart failure, but temporal changes in outcomes and associations between facility-level volume and outcomes are poorly understood.

Methods: This is a population-based, retrospective cohort study of all fee-for-service Medicare beneficiaries with heart failure who received an implantable VAD between 2006 and 2011.

Valvular heart disease in patients supported with left ventricular assist devices.

Patients with advanced HF and coexisting VHD who undergo LVAD implantation constitute a growing population and pose unique challenges in clinical and surgical management. Contemporary continuous-flow LVADs alter blood flow dynamics and cardiovascular physiology and can induce progression of preexisting VHD or lead to de novo VHD. Although we have defined our recommendations for treatment options (Table 2), continued changes to device technology, patient selection, and surgical techniques will undoubtedly lead to further changes in practice.

Simulated electronic health record (Sim-EHR) curriculum: teaching EHR skills and use of the EHR for disease management and prevention.

Electronic health records (EHRs) can improve many aspects of patient care, yet few formal EHR curricula exist to teach optimal use to students and other trainees. The Simulated EHR (Sim-EHR) curriculum was introduced in January 2011 at Oregon Health & Science University (OHSU) to provide learners with a safe hands-on environment in which to apply evidence-based guidelines while learning EHR skills. Using an EHR training platform identical to the OHSU EHR system, learners review and correct a simulated medical chart for a complex virtual patient with chronic diseases and years of fragmented care.

Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of pump thrombosis in the HeartMate II left ventricular assist device.

Background: Pump thrombosis remains an uncommon but potentially catastrophic complication of durable continuous-flow left ventricular assist devices (LVAD). A perceived increase in the incidence of pump thrombosis in the HeartMate II (HMII) LVAD (Thoratec, Pleasanton, CA) by clinicians prompted this analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database.

Methods: Between 2006 and June 2013, 8,988 United States patients aged older than 18 years received a durable LVAD.

Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices.

Background: Preexisting valve pathology is common in patients with end-stage heart failure undergoing left ventricular assist device (LVAD) placement. The indications and subsequent benefits of performing valvular procedures in these patients are unclear. The objective of this study was to determine the impact of performing concurrent surgical valve procedures in a large cohort of patients receiving LVADs.

Mitral valve repair for ischemic mitral regurgitation: review of current techniques.

Introduction: Ischemic mitral regurgitation can be defined as moderate to severe mitral leak precipitated by acute myocardial infarction. Valve repair is now the procedure of choice, but some cases can pose difficult anatomy. This review will illustrate current techniques for repairing complex ischemic mitral regurgitation.

Thrombolytic therapy for thrombosis of continuous flow ventricular assist devices.

Background: Despite chronic systemic anticoagulation, advanced heart failure patients treated with a continuous-flow left ventricular assist device (LVAD) remain at risk for pump thrombosis. Pump thrombosis may initially be suspected in the setting of clinical and biochemical evidence for intravascular hemolysis, putatively related to shear stress on red blood cells propelled through a partially occluded pump. Limited data exist to guide management in these patients.

Minithoracotomy versus sternotomy for mitral surgery in patients with chronic renal impairment: a propensity-matched study.

Objective: Compared with median sternotomy, a right thoracotomy (RT) approach to mitral surgery is associated with decreased postoperative acute renal failure. Therefore, we examined propensity-matched patients with chronic renal impairment to compare outcomes.

Methods: A retrospective review at a single institution identified patients who underwent mitral valve surgery from 1986 to 2010.

Pre-operative risk factors of bleeding and stroke during left ventricular assist device support: an analysis of more than 900 HeartMate II outpatients.

Objectives: This study sought to determine the pre-operative risk factors related to late bleeding, stroke, and pump thrombosis in patients with HeartMate II (HMII) left ventricular assist devices (LVADs) (Thoratec Corporation, Pleasanton, California) that might influence tailored improvements in patient management.

Background: Adverse events in LVAD patients remain high. It is unclear whether pre-operative characteristics influence the likelihood of the development of post-operative hemorrhagic or thrombotic complications.

Unexpected abrupt increase in left ventricular assist device thrombosis.

Background: We observed an apparent increase in the rate of device thrombosis among patients who received the HeartMate II left ventricular assist device, as compared with preapproval clinical-trial results and initial experience. We investigated the occurrence of pump thrombosis and elevated lactate dehydrogenase (LDH) levels, LDH levels presaging thrombosis (and associated hemolysis), and outcomes of different management strategies in a multi-institutional study.

Methods: We obtained data from 837 patients at three institutions, where 895 devices were implanted from 2004 through mid-2013; the mean (±SD) age of the patients was 55±14 years.

Outcomes after implantable left ventricular assist device replacement procedures.

As the duration of support increases for patients with continuous flow left ventricular assist devices (LVADs), device replacement may still be necessary for a variety of indications. Outcomes after replacement LVAD surgeries have not been extensively described, and whether these patients experience outcomes similar to primary LVAD implant patients remains unclear. From 2003 to 2012, 342 consecutive implantable LVAD procedures took place at a single institution, of which 201 were considered destination therapy.

Current readings: Surgical management of heart failure.

There are a myriad of surgical therapies for patients with end-stage congestive heart failure. Coronary revascularization and mitral valve repair have clear clinical benefits in appropriately selected patients. Further investigation is required before the widespread adoption of volume-reduction strategies.

A crisis of the heart: an acute reversible cardiomyopathy bridged to recovery in a patient with Addison's disease.

Primary adrenal insufficiency or Addison's disease is a rare disorder often difficult to diagnose on presentation by the nature of its associated nonspecific symptoms, such as nausea or weakness. Cardiovascular complications of the condition are usually limited to hypovolemic hypotension; however, we highlight here a rare, dramatic case of a fulminant adrenal crisis in a young man primarily marked by acute biventricular systolic failure and cardiogenic shock. The patient was successfully treated with corticosteroid replacement and bridged with temporary mechanical circulatory support to eventual complete the recovery of native myocardial function.

Intraoperative magnesium administration does not improve neurocognitive function after cardiac surgery.

Background And Purpose: Neurocognitive decline occurs frequently after cardiac surgery and persists in a significant number of patients. Magnesium is thought to provide neuroprotection by preservation of cellular energy metabolism, blockade of the N-methyl-D-aspartate receptor, diminution of the inflammatory response, and inhibition of platelet activation. We therefore hypothesized that intraoperative magnesium administration would decrease postoperative cognitive impairment.

Ten-year experience with extended criteria cardiac transplantation.

Background: Extended criteria cardiac transplant (ECCT) programs expand the transplant pool by matching donors and recipients typically excluded from the transplant process because of age or comorbidity. There is a paucity of data examining long-term outcomes with this strategy.

Methods And Results: Between January 2000 and December 2009, adult patients undergoing isolated heart transplant were prospectively classified as ECCT based on prespecified criteria.

Impact of donor cardiac arrest on heart transplantation.

Background: Cardiac transplantation is an effective therapy for patients with end-stage heart failure, but it is still hindered by the lack of donor organs. A history of donor cardiac arrest raises trepidation regarding the possibility of poor post-transplant outcomes. The impact of donor cardiac arrest following successful cardiopulmonary resuscitation on heart transplant outcomes is unknown.

Surgical correction of aortic valve insufficiency after left ventricular assist device implantation.

Objectives: New-onset aortic insufficiency (AI) can be encountered after instituting mechanical circulatory support and seems more common and severe with continuous flow (CF) left ventricular assist devices (LVADs) compared with pulsatile devices. Treatment algorithms for de novo, post-LVAD AI have not been well defined. In the present report, we have described 6 patients who underwent aortic valve surgery for new-onset post-LVAD AI.

Dysphagia in the setting of left ventricular assist device hemolysis.

A 69-year-old man with advanced heart failure treated with a continuous-flow left ventricular assist device presented for evaluation of dark urine and severe dysphagia. Because of evidence of ongoing intravascular hemolysis with device dysfunction, there was a clinical suspicion for pump thrombosis. He had progressive end-organ dysfunction and was therefore treated with tissue plasminogen activator with prompt resolution in hemolysis and dysphagia.

Zebrafish churchill regulates developmental gene expression and cell migration.

Background: Regulation of developmental signaling pathways is essential for embryogenesis. The small putative zinc finger protein, Churchill (ChCh) has been implicated in modulation of both TGF-β and FGF signaling.

Results: We used zinc finger nuclease (ZFN) mediated gene targeting to disrupt the zebrafish chch locus and generate the first chch mutations.

Twenty-five-year outcomes after multiple internal thoracic artery bypass.

Objective: Coronary artery bypass grafting with multiple internal thoracic artery grafts is currently controversial. This study assessed single institutional outcomes with multiple internal thoracic artery grafting for guidance with future clinical decisions.

Methods: In 19,482 patients undergoing multivessel coronary artery bypass grafting (1984-2009), baseline characteristics were recorded in a prospective databank, and follow-up was obtained by questionnaires, phone contact, or National Death Index.