Cardiovascular System Commons^™

David Taylor Memorial Lecture: Insights Into The Origins Of Intracardiac Surgery, James K. Kirklin

The VAD Journal

David Taylor was an eminent luminary in the field of advanced heart failure and transplantation. As past president of the International Society for Heart and Lung Transplantation, he significantly impacted the field and was a mentor to many young heart failure cardiologists. In addition to many professional activities, David was an integral part of Brano meetings, including numerous eastern European trips promoting education and training in advanced heart failure, mechanical circulatory support, and transplantation

Heartmate 3 As A Bridge To Transplant In An Adult With Failing Fontan Circulation, Kengo Z. Soghoyan, Stephen Cook, Maya Guglin

The VAD Journal

Mechanical circulatory support devices have demonstrated efficacy in adult congenital patients with biventricular repairs. The off-label use of ventricular assist devices may be invaluable for managing end-stage single ventricle failure. We present the case of a 27-year-old male who developed heart failure, congestive hepatopathy, and, ultimately, cardiogenic shock. He received a HeartMate 3 (Abbott, Chicago, IL, USA) without complications one year after the surgery.

Left Atrial Venoarterial Extracorporeal Membrane Oxygenation Strategy In Postcardiotomy Cardiogenic Shock: A Case Series, Daniel Manzur-Sandoval Md, Gian Manuel Jiménez-Rodríguez Md, José Luis Elizalde-Silva Md, Meredith Fernanda Sánchez-Torres Md, Uriel Encarnación-Martínez Md, Cristhian Josué Gaytán-García Md, José Octavio Salazar-Delgado Md, Guadalupe Lisseth Hernández-González Md, Gustavo Rojas-Velasco Md

The VAD Journal

Postcardiotomy cardiogenic shock is a rare complication with high mortality. When patients do not respond to the placement of an intra-aortic balloon pump or pharmacological treatment, therapy with peripheral venoarterial extracorporeal membrane is a viable option that allows active resuscitation. The adjunct use of Impella® (Abiomed, Danvers, MA, USA) allows active unloading of the dysfunctional left ventricle. However, left atrial venoarterial extracorporeal membrane oxygenation (LAVA-ECMO) is an appealing and effective strategy in cases of aortic dissection, aortic valve replacement, or bioprosthesis of the aorta. Insertion of an extraction cannula that can discharge both atria or only the left atrium allows …

Hemoadsorption With Cytosorb As Part Of A Strategy To Improve Outcomes In Patients On Extracorporeal Membrane Oxygenation, Ruzica Mrkonjic

The VAD Journal

The exposure of a patient’s blood to the non-endothelialized surface of the extracorporeal membrane oxygenation (ECMO) system results in the production of pro-inflammatory and anti-inflammatory cytokines. This imbalance in pro- and anti-inflammatory cytokines leads to inflammatory response syndrome, which contributes to edema, vasoplegia, and multiple organ failure among other complications. Hemoadsorption therapy, with the use of CytoSorb^® (CytoSorbents) has emerged as a well-accepted treatment option that helps control pro-inflammatory response and improve outcomes for patients on ECMO. However, studies have shown that the potential of hemoadsorption is controversial and that it is crucial for clinicians to weigh the pros …

Splenic Artery Aneurysm Masquerading As Chest Pain: A Case Report Of A Rare Clinical Presentation, Emily Forester, Anjeanette Brown

Rowan-Virtua Research Day

Background: Splenic artery aneurysms most commonly present with vague epigastric or left upper quadrant abdominal pain that may radiate to the left shoulder. Chest pain associated with splenic artery aneurysm is an unusual phenomena. This case presents a rare occurrence of a splenic artery aneurysm originally presenting as atypical chest pain. Case Presentation: A 46 year old G3P2 AAF patient with family history of hypertension presented to the ER with pleuritic left chest pain, episodes of shortness of breath, and new onset hypertension. Chest x-ray and ECG were unremarkable. Pertinent labs included a hemoglobin of 10.6 and D-dimer of 4.10. …

Highlights Of The 2023 Brano Heart Failure Forum, Bela Merkely, Rajko Radovancevic, Bojan Vrtovec, Igor D. Gregoric

The VAD Journal

Since 2007, the Branislav “Brano” Radovancevic Heart Failure Forum (BHFF) has been held annually to provide a venue for experts to present and discuss “Innovations and New Treatment Strategies in Heart Failure.” Clinicians and researchers gather yearly in a different Eastern European city to discuss the latest in heart failure diagnostics and therapeutics. The 2023 BHHF forum was held on the 13^th thru 15^th of September 2023 in Budapest, Hungary. It was attended by over 100 faculty from 16 countries. In addition, participation through online streaming was available. Throughout the forum, 16 sessions focused on challenges and solutions …

What Did We Learn About Vads In 2023?, Maya Guglin

The VAD Journal

This is our 10^th annual literature review on mechanical circulatory support (MCS) devices. All of our previous reports were well received by the readers.^1-9

In this paper, we summarized the most interesting and important, from our standpoint, publications from 2023. There may be some slight overlap with the end of 2022, because some papers were published online first, and the year of publication changed when they became available in print.

For the seventh time this year, we wrote a section on extracorporeal membrane oxygenation (ECMO), which primarily addresses new developments in veno-arterial ECMO.

Readers who wish to supplement …

Late Cardiotoxicity From The Tyrosine Kinase Inhibitor, Dasatinib: Pleural Effusions, Pulmonary Arterial Hypertension, And Right Heart Failure, Mark Jay Zucker, Andrew M. Zucker

The VAD Journal

Despite the remarkable progress made over the past few decades in the management of patients with both solid and hematologic malignancies, radiation- and chemotherapy-related cardiotoxicity remains an ongoing problem. This is true even for newer highly targeted therapies, including tyrosine kinase inhibitors (TKIs). This report presents a case of late/severe right heart dysfunction secondary to pulmonary hypertension, developed after ten years of therapy with dasatinib. We also review the history of this known, but often unrecognized, and potentially reversible complication, and we suggest treatment options. Additionally, this case highlights the remarkable effectiveness of TKIs in patients with chronic myelogenous leukemia …

A Case Report And Review On The Anesthetic Considerations Of Anterior Mediastinal Masses, Carter A. Schulz, Joshua D. Mohs, Andrew M. Reuter

Aesculapius Journal (Health Sciences & Medicine)

Case summary: A 15-year-old female presented with chest pain, dyspnea, and weight loss. A chest X-ray and subsequent CT scan revealed a large anterior mediastinal mass with cervical lymphadenopathy and pericardial effusion. Two biopsies under general anesthesia were performed, with the latter confirming classic Hodgkin lymphoma, nodular sclerosis subtype.

Discussion: This case underscores the significant clinical challenges posed by anterior mediastinal masses due to their proximity to vital cardiovascular and respiratory structures. Physiologic changes during general anesthesia can exacerbate these challenges. Preoperative assessment, including imaging and symptom evaluation, is crucial to guide operative planning. It is key to individualize the …

Ultrasound – An Underutilized Diagnostic Tool For Ventricular Assist Device Driveline Infections, Kristina Krzelj, Tomislav Tokic, Tomislav Kopjar, Maja Cikes, Davor Milicic, Hrvoje Gasparovic

The VAD Journal

Patients with ventricular assist device (VAD) driveline infections (DLI) have reduced quality of life and increased risk of severe complications, such as sepsis, hemorrhagic or ischemic stroke, and wound infections. The management of VAD patients imposes a significant financial burden due to prolonged in-hospital stays, frequent re-admissions, expensive diagnostics, and the need for antibiotic therapy and/or surgical intervention. There is considerable room for improvement in DLI management, particularly in the early detection and treatment stages. Ultrasound, an easily applicable device available in almost every hospital, offers an unrecognized potential for the early detection of DLI. By increasing awareness about the …

Treatment Of Refractory Ventricular Tachycardia With Radiofrequency Ablation And Temporary Mechanical Circulatory Support, Som P. Singh, Alejandro Vidal Margenat, David L. Boone, Ellen Condoure, Ramesh Hariharan

The VAD Journal

Catheter-based radiofrequency ablation has long been recognized as an effective treatment for refractory ventricular tachycardia (VT). A 57-year-old male with severe coronary artery disease underwent percutaneous mechanical circulatory support because of worsening cardiogenic shock after failed revascularization attempts. Despite aggressive medical management, the patient experienced refractory VT episodes, leading to the decision to proceed with radiofrequency catheter ablation. Notably, the Impella 5.5 device (Abiomed) provided critical left ventricular support during the ablation procedure. This case underscores the potential benefits of Impella support during radiofrequency ablation of complex ventricular arrhythmias.

Seeing Into The Future: Heartmate 3 To The Systemic Right Ventricle In A Completely Blind Patient With Congenitally-Corrected Transposition Of The Great Arteries, Juhi Ramchandani, Chirag Dipak Shah, Kashif Saleem, Maya Guglin, Roopa Rao

The VAD Journal

A 24-year-old, blind male with congenitally-corrected transposition of the great arteries and systemic right ventricular failure presented with New York Heart Association class IV heart failure despite home inotropic therapy. He was not a transplant candidate due to psychosocial issues. He underwent a successful HeartMate 3 (Abbott Laboratories) placement with the implementation of techniques to guide home ventricular assist device care despite blindness.

Partial Support In Chronic Heart Failure, Bart Meyns, Walter Droogne, Steven Jacobs

The VAD Journal

Partial left ventricular assist device (LVAD) support offers several advantages in treating chronic heart failure. It also raises concerns about insufficient support, worsening symptoms, and impediment of myocardial recovery. The clinical trial results for the CircuLite device (Medtronic) have shown that close monitoring can ensure improved outcomes for partial support. Another study on the ovine model demonstrated that partial and full support have similar effects regarding reverse remodeling. Thus, patients receiving partial LVAD support need regular follow-up care. Clinical assessment of symptoms and organ function must be used alongside objective judgment of patients’ needs to ensure support levels are appropriately …

Highlights Of The 2022 Brano Heart Failure Forum: Part Two, Ugolino Livi, Rajko Radovancevic, Bojan Vrtovec, Igor D. Gregoric

The VAD Journal

Since 2007, the Branislav “Brano” Radovancevic Heart Failure Forum (BHFF) has been held annually to provide a venue for experts to present and discuss “Innovations and New Treatment Strategies in Heart Failure.” Clinicians and researchers gather yearly in a different Eastern European city to discuss the latest in heart failure diagnostics and therapeutics. The 2022 BHFF forum was held on the 6^th thru 8^th of September 2022 in Trieste, Italy. It was attended by over 94 faculty from 14 countries. In addition, participation through online streaming was available. Throughout the forum, 17 sessions focused on challenges and solutions …

Highlights Of The 2022 Brano Heart Failure Forum: Part One, Ugo Livi, Rajko Radovancevic, Bojan Vrtovec, Igor D. Gregoric

The VAD Journal

Since 2007, the Branislav “Brano” Radovancevic Heart Failure Forum (BHFF) has been held annually to provide a venue for experts to present and discuss “Innovations and New Treatment Strategies in Heart Failure.” Clinicians and researchers gather yearly in a different Eastern European city to discuss the latest in heart failure diagnostics and therapeutics. The 2022 BHHF forum was held on the 6^th thru 8^th of September 2022 in Trieste, Italy. It was attended by over 94 faculty from 14 countries. In addition, participation through online streaming was available. Throughout the forum, 17 sessions focused on challenges and solutions …

Thrompella: Acute Impella Thrombosis During Ecpella Support, Faris Araj, Hurst M. Hall, Amy E. Hackmann

The VAD Journal

We present a case of acute Impella thrombosis during Ecpella support in a 48-year-old man listed for a heart transplant. After two weeks of Ecpella support, echocardiography revealed a 2.6 x 1.1 cm mobile thrombus attached to the Impella inlet (Video). The Impella and attached thrombus were pulled across the aortic valve into the descending aorta and removed without systemic thromboembolism. Due to the ongoing need for left ventricular venting, a new Impella CP was placed.

Quality Assurance In Extracorporeal Membrane Oxygenation Patients, Ruzica Mrkonjic

The VAD Journal

The selection of patients for extracorporeal membrane oxygenation (ECMO) support is a critical component of any perfusion program. Teams must evaluate when to start the support, how long to support the patient, and when is the ideal time to wean. The timing of ECMO support is debated. While some programs emphasize prompt timing, others suggest the conservative approach is better (>7 hours). Delaying ECMO support could increase complications; thus, more evidence has been attained for prompt support. Importantly, complications are common with ECMO support. Despite advances in ECMO support over the last ten years, bleeding remains a high risk. …

Delayed Thoracodorsal Artery Perforator Free Flap For Calcaneal Degloving Injury Reconstruction, Mallorie L. Huff, Ahmed M. Mansour, Mamtha S. Raj, Robert J. Allen, Sean J. Wallace

School of Medicine Faculty Publications

The thoracodorsal artery perforator (TDAP) flap has a long vascular pedicle that is ideal for lower extremity reconstruction, but it generally relies on the presence of a dominant septocutaneous perforator vessel. Surgical delay optimizes flap survival by creating relative ischemia to augment perforator vessels. In this report, we describe the use of a delayed free TDAP flap in the setting of an absent dominant perforator vessel for the reconstruction of a calcaneal degloving injury. A 22-year-old actively smoking patient with a body mass index of 33.5 presented with a nonhealing left heel wound with overlying necrotic changes after traumatic degloving …

What Did We Learn About Vads In 2022?, Maya Guglin

The VAD Journal

This is our 9^th annual literature review on mechanical circulatory support devices. Our previous reports were well received by the readers.

In this paper, we summarized the most interesting and important, from our standpoint, publications from 2022. There may be some slight overlap with the end of 2021 because some papers were published online first, and the year of the publication changed when they became available in print.

For the sixth time, we wrote a section on extracorporeal membrane oxygenation (ECMO) which primarily addresses new developments in veno-arterial ECMO.

Readers who wish to supplement this review, argue with the …

Glucocentric Drugs In Cardiovascular Disease Protection And Heart Failure, Khawaja M. Talha, Gregg C. Fonarow, Salim S. Virani, Javed Butler

Office of the Provost

Evidence for cardiovascular outcomes with older-generation antihyperglycemic drugs in the management of type 2 diabetes is based on aggregated data from prior randomized controlled trials and observational studies that were not focused on prespecified cardiovascular end points. Newer antihyperglycemic medications have undergone a rigorous evaluation of cardiovascular outcomes through randomized controlled trials since the US Food and Drug Administration imposed a mandatory requirement for all glucose-lowering drugs in 2008. The three classes of drugs that have been most extensively studied are dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors, the latter two reporting significant …

Predicting Left Ventricular Assist Device Outcomes Utilizing The Stanford Integrated Psychosocial Assessment For Transplant Measure, Nicholas Chesher, Kristina L. Greenwood, Candace Fanale, Cody Gustaveson, Brian Jaski, Hirsch S. Mehta, Peter Hoagland, Kristine Ortiz, Marc Verlasky, Robert Adamson, Walter Dembitsky

The VAD Journal

Objective: Durable mechanical circulatory support is a proven therapy to extend survival for patients with end-stage heart failure (HF). The International Society for Heart and Lung Transplantation guidelines recommend a detailed psychosocial assessment when selecting candidates for durable mechanical circulatory support. Currently, there are no formally validated psychosocial evaluation tools for left ventricular assist device (LVAD) candidacy. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) uses a multidisciplinary algorithm to evaluate the impact of pre-transplant risk factors on post-transplant outcomes. Emerging literature suggests that the SIPAT might be useful for assessing psychosocial risk factors for LVAD outcomes.

Methods: A total …

Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (Lava-Ecmo): Percutaneous Bi-Atrial Drainage To Avoid Pulmonary Edema In A Patient With Left Ventricular Systolic Dysfunction, Kenneth R. Dulnuan, Joseph B. Zwischenberger, John G. Gurley, Maya Guglin

The VAD Journal

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used in patients with severe cardiogenic shock refractory to medical therapy. During V-A ECMO, retrograde flow in the aorta towards the left ventricle (LV) causes increased left-sided filling pressures, which may lead to pulmonary edema. Different strategies have been proposed to decompress the left heart, including placement of an intraaortic balloon pump (IABP), Impella® (Abiomed), or TandemHeart® (Cardiac Assist). Percutaneous decompression of the left atrium via placement of a transseptal cannula incorporated into the existing venous limb had also been previously done. We describe the novel use of the VFEM venous femoral cannula …

Highlights Of The 2021 Brano Heart Failure Forum, Rajko Radovancevic, Bojan Vrtovec, Igor D. Gregoric

The VAD Journal

Since 2007, the Branislav “Brano” Radovancevic Heart Failure Forum has been held annually to provide a venue for experts to present and discuss “Innovations and New Treatment Strategies in Heart Failure.” Clinicians and researchers gather yearly in a different Eastern European city to discuss the latest in heart failure diagnostics and therapeutics. The forum was postponed in 2020 due to the COVID-19 pandemic and then resumed in September of 2021 in Graz, Austria. It was attended by over 75 faculty from 13 countries. Due to the ongoing pandemic, 13 presentations were given virtually. Throughout the forum, 17 separate sessions focused …

Successful Percutaneous Management Of Lvad Outflow Graft Stenosis: Role Of Invasive Hemodynamics In Decision Making, Tarun Dalia, Amandeep Goyal, Harsh Mehta, Henedine C. Foster, Eric Hockstad, Aaron Rohr, Philip Johnson, Travis Abicht, Bhanu Gupta

The VAD Journal

Left ventricular assist device (LVAD) outflow graft stenosis (OGS) is a rare but lethal complication. We present a case of a 79-year-old male with pertinent past medical history of an LVAD implanted as destination therapy, stage III chronic kidney disease, and hypertension. He was admitted for low-flow alarms, and the echocardiogram showed stable right ventricle function and no pericardial effusion. Invasive hemodynamic assessments demonstrated a peak-to-peak gradient of 90 mm Hg in the outflow graft between the mid and distal ends of the graft on pullback. Contrast angiography confirmed OGS. The OGS was successfully treated with a VBX-covered stent (Gore). …

A Unique Case Of Inflow Cannula Obstruction By A Tissue Membrane, Roopa A. Rao, Kashif Saleem, Bistees George, Maya Guglin

The VAD Journal

The use of a left ventricular assist device has increased and is a primary surgical treatment for heart failure. However, one major complication of left ventricular assist device support is an obstruction in the blood flow pathway. Pump thrombosis and outflow graft occlusion are some of the common causes of such obstructions. Here, we describe a unique case of HeartMate II (Abbott Laboratories) inflow cannula obstruction from a membranous structure without evidence of thrombus. The histology showed evidence of fibrous tissue and heart muscle tissue in the membrane. The patient underwent a successful device exchange with a HeartMate 3 (Abbott …

Intra-Aortic Balloon Pump May Attenuate Adverse Hemodynamic Effects Of Negative Intrathoracic Pressure In Cardiogenic Shock, Faris Araj

The VAD Journal

High negative intrathoracic pressure (NIP), as occurs during obstructive sleep apnea or hiccups, results in adverse hemodynamic consequences, specifically a decrease in left ventricle (LV) performance. These untoward effects can potentially be catastrophic in the case of an already compromised LV in cardiogenic shock. The interplay of intra-aortic balloon pump counter pulsation during abrupt high NIP in cardiogenic shock is described.

The Role And Outcomes Of Thoracodistal Bypass, Andrea Mcsweeny, Anthony Feghali, Tuong Nguyen, Michael Nooromid, Dawn Salvatore, Paul Dimuzio, Babak Abai

Department of Surgery Faculty Papers

Objectives

Endovascular procedures for lower extremity revascularization are becoming more commonplace due to low morbidity, mortality, and shorter length of stay. The role of open bypass must be reconsidered. Aortobifemoral bypass is the gold standard for extensive aortoiliac occlusive disease (AIOD); however, thoracodistal bypass holds a niche position. We investigate indications and outcomes of thoracodistal bypass.

Methods

Medical records of five patients who underwent thoracodistal bypass at Thomas Jefferson University Hospital (TJUH) between 2012 and 2019 were reviewed. Contemporary and historical literature was reviewed.

Results

Indications included calcified paravisceral pathology, previous failed or infected bypass grafts, and prior abdominal operations. …

Impact Of Atrial Fibrillation On Outcomes After Left Ventricular Assist Device Implantation: Systematic Review And Meta-Analysis, Chandan Buttar, Sofia Lakhdar, Mahmood Nassar, Nso Nso, Giovina Collura, Most Sirajum Munira

The VAD Journal

Background: Atrial fibrillation (AF) is a common finding in patients with heart failure and is well-known for its deleterious effects on cardiac function and hemodynamics; however, there are gaps in knowledge regarding the impact of AF on patients with left ventricular assist devices (LVADs).

Methods: In this study, we searched PubMed/Medline, Embase, and Cochrane Library databases through September 2021 to find articles that assessed the outcomes of AF in patients with LVADs.

Results: A total of 12 studies that underwent systematic review evaluated the outcomes of 7853 adult patients. The meta-analysis analyzed findings from a total of 1003 patients. Pooled …

Heart To Heart, Mom To Mom, Karis L. Tekwani

Journal of Patient-Centered Research and Reviews

This essay describes the human connection forged between two young moms, one the physician and one the patient, when their paths collided one night in the emergency department of a busy hospital. It describes a challenging and most memorable care experience in the career of a young emergency physician, the clinical outcome, and the patient’s appreciative follow-up message years later.

Pulsatility Is A Predictive Marker Of Improved Cardiac Function In Patients With Liquid Matrix-Treated Left Ventricular Assist Devices, Philemon Mikail, Rinku Skaria, Marvin Slepian, Janny Garcia, Richard Smith, Zain Khalpey

The VAD Journal

Objective: Left ventricular assist devices (LVADs) are utilized as a bridge to transplant or as destination therapy for patients with end-stage heart failure. Although cardiac offloading from these devices rarely leads to complete remodeling and functional recovery, the use of mesenchymal cells to modulate heart failure has been explored in recent years due to its intrinsic regenerative properties. Current methods of evaluating cardiac function have too much variability, difficulty of access, or require too frequent follow up to create universal weaning protocols. We hypothesized that the administration of amniotic allograft liquid matrix (LM) containing amnion-derived mesenchymal stem cells (aMSCs) in …