Department of Surgery Faculty Papers & Presentations

Extracorporeal Membranous Oxygenation Mimics Aortic Dissection on CAT Scan.

Philip Batista et al. — Mon, 21 Jan 2013 07:11:11 PST

A 66 year-old female presented with refractory acute congestive heart failure, cardiogenic shock, and ventricular tachyarrhythmia. Veno-arterial extracorporeal membrane oxygenation (ECMO) was placed via femoral cannulation for salvage and stabilized. CAT scan of the chest performed as a part of heart transplant work-up, demonstrated an unequal distribution of intravenous contrast in the aortic arch (Figure 1). Radiologist’s preliminary reading was of “aortic dissection” while in fact this is truly “normal ECMO flow”.

Successful management of severe liver failure on venoarterial extracorporeal membrane oxygenation using molecular adsorbent recirculating systeme.

Shigeki Tabata et al. — Wed, 19 Dec 2012 07:50:57 PST

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy.

Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on ECMO day #9 (Figure 1). Molecular adsorbent recirculating system (MARS) was initiated on ECMO day 9 thru 14. The bilirubin improved dramatically with MARS. Liver biopsy performed while on ECMO provided a definitive diagnosis of cholestasis without cirrhosis. The patient underwent Heart Mate II left ventricular assist device (LVAD) placement and ECMO removal on ECMO day 20. There was no further episode of liver failure, and the patient was eventually discharged from hospital.

[i] Harrison M, Cowan S, Cavarocchi N, Hirose H. Massive hemoptysis on veno-arterial extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2012 Mar 30. [Epub ahead of print].

Thickened ascending aortic wall mimicking intramural hematoma.

Kentaro Yamane et al. — Thu, 15 Nov 2012 07:41:20 PST

A 45-year-old Hispanic woman presented with a 3-day history of ‘‘burning’’ chest pain. A computed tomo- graphic angiogram of the chest revealed the ascending aorta had a maximum diameter of 40 mm with marked thickening of the aortic wall (Figure 1), which we con- cluded was an intramural hematoma. On entering the pericardium, a milky-white plaque-like area on the ascending aorta was encountered (Figure 2). The ascending aorta was firm to palpation. Intraoperative transesophageal echocardiography and epiaortic ultra- sound showed a hyperechoic aortic wall with no find- ings compatible with aortic dissection. The ascending aorta had an irregular surface contour, which was unli- kely to be a finding of aortic dissection (Figure 3A, arrow). The transverse arch, proximal innominate artery, and left carotid artery also showed thickened walls (Figures 3B and 3C). We decided not to replace the ascending aorta. Pathology of the surface of the ascending aorta revealed a chronic inflammatory infiltrate with lymphocytes and plasma cells, dense fibrosis, and granulation. Serological studies were inconclusive. The patient was started on steroid therapy for possible isolated aortitis or aortitis syndrome, and her symptoms subsided with a normalized erythrocyte sedimentation rate and C-reactive protein level. She was doing well with a stable chest radiograph 10 months after the surgery.

Massive haemoptysis on veno-arterial extracorporeal membrane oxygenation.

Meredith Harrison et al. — Thu, 15 Nov 2012 07:31:21 PST

A 49-year old female presented with severe heart failure with end-organ dysfunction and was placed on veno-arterial extracorporeal membrane oxygenation (ECMO) as a bridge to a decision for end-organ recovery. While on ECMO, the patient developed massive haemoptysis after a Swan-Ganz catheter manipulation. The haemoptysis was not controllable by conventional methods including bronchoscopy with cold saline and epinephrine lavage, bronchial blocker or angiography. The endotracheal tube was clamped to provide tamponade and the patient relied on full ECMO support for 36 h. After the haemoptysis resolved, the endotracheal tube was unclamped. The patient developed adult respiratory distress syndrome and was ventilated using the ARDSnet protocol with continued support from ECMO. On post-ECMO day 20, the patient underwent a successful ECMO wean and a Heart Mate II left ventricular assist device placement.

Cerebral and Lower Limb Near-Infrared Spectroscopy in Adults on Extracorporeal Membrane Oxygenation

Joshua K Wong et al. — Thu, 15 Nov 2012 07:11:55 PST

Percutaneous femoral venoarterial (VA) or jugular venovenous (VV) extracorporeal membrane oxygenation (ECMO) can result in delivery of hypoxic blood to the brain, coronaries, and upper extremities. Additionally, VA-ECMO by percutaneous femoral artery cannulation may compromise perfusion to the lower limbs. Use of near-infrared spectroscopy (NIRS) detects regional ischemia and warns of impending hypoxic damage. We report the first known series with standardized monitoring of this parameter in adults on ECMO. This is an institutional review board-approved single institution retrospective review of patients with NIRS monitoring on ECMO from July 2010 until June 2011. Patients were analyzed for drops in NIRS tracings below 40 or >25% from baseline. VA-ECMO and VV-ECMO were initiated by percutaneous cannulation of the femoral vessels and the internal jugular vein, respectively. Sensors were placed on the patients' foreheads and on the lower limbs. NIRS tracings were recorded, analyzed, and correlated with clinical events. Twenty patients were analyzed (median age: 47.5 years): 17 patients were placed on VA-ECMO, and three patients on VV-ECMO. The median duration on ECMO was 7 days (range 2-26). One hundred percent of patients had a significant drop in bilateral cerebral oximetry tracings resulting in hemodynamic interventions, which involved increasing pressure, oxygenation, and/or ECMO flow. In 16 patients (80%), these interventions corrected the underlying ischemia. Four patients (20%) required further diagnostic intervention for persistent decreased bilateral and/or unilateral cerebral oximetry tracings, and were found to have a cerebrovascular accident (CVA). Six (30%) patients had persistent unilateral lower limb oximetry events, which resolved upon placement or replacement of a distal perfusion cannula. No patient was found to have either lower limb ischemia or a CVA with normal NIRS tracings. Use of NIRS with ECMO is important in detecting ischemic cerebral and peripheral vascular events. This allows for potential correction of the underlying process, thus preventing permanent ischemic damage.

Adult ECMO and gastrointestinal bleeding from small bowel arteriovenous malformations: A novel treatment using spiral enteroscopy.

Konrad Sarosiek et al. — Thu, 15 Nov 2012 06:51:33 PST

Hemorrhagic complications on extracorporeal membrane oxygenation (ECMO) are common because of the need for anticoagulation to maintain the oxygenator and circuitry. Gastrointestinal bleeding (GIB) is reported to occur in 3-6% of ECMO patients, ¹ requiring frequent transfusions as well as multiple diagnostic and therapeutic interventions. Multiple transfusions can result in volume overload, coagulopathies and infections leading to significant morbidity and mortality. We present the first published case of GIB from an arteriovenous malformation (AVM) treated with a novel therapy termed spiral enteroscopy while the patient remained on venoarterial (VA) ECMO.

Tension pneumothorax on extracorporeal membrane oxygenation leading to significant pneumoperitoneum.

Hitoshi Hirose et al. — Wed, 14 Nov 2012 06:51:16 PST

Veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) therapy is used to support the cardiac and pulmonary systems in the setting of acute failure. Maintaining adequate ECMO flow is crucial for the success of the therapy. Sudden decrease in venous return on ECMO has multiple etiologies, such as intravascular hypovolemia, malposition or kink of the venous cannula, suction occlusion of a cannula, and venous or arterial thrombi. Pathology within the chest, including pneumothorax, tension hemothorax and pericardial tamponade, may also decrease the ECMO flow because of compression of the cannula and decreased atrial volume. Air from a tension pneumothorax may be transmitted from the pleural space to the pericardial and contralateral pleural spaces, as well as the peritoneal cavity if significant pressure is applied to either side of the diaphragm, even without diaphragmatic disruption. The case presented here represents a unique presentation of sudden and sustained decrease of ECMO flow secondary to tension pneumothorax, as well as pneumoperitoneum, following a central venous catheter insertion.

Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation.

Hitoshi Hirose et al. — Tue, 13 Nov 2012 08:55:59 PST

Placement of the Avalon Elite bicaval dual lumen cannula for venovenous extracorporeal membrane oxygenation (VV-ECMO) via the internal jugular vein requires precise positioning of the cannula tip in the inferior vena cava with echocardiography or fluoroscopy guidance. Correct guidewire placement is clearly the key first step in assuring proper advancement of the cannula. We report a case of unexpected wire migration into the right ventricle at the time of final cannula advancement, resulting in right ventricular rupture and tamponade. Transesophageal echocardiography is an important monitoring modality for appropriate placement of the VV-ECMO guidewire and Avalon cannula, and in particular, for early identification of potential complications.

Current trend of off-pump coronary artery bypass grafting.

Hitoshi Hirose — Tue, 13 Nov 2012 08:16:14 PST

Published in "Front Lines of Thoracic Surgery", Edited by Stefano Nazari, ISBN 978-953-307-915-8, Published: February 3, 2012 under CC BY 3.0 license

Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) and
cardioplegic arrest has been performed safely over several decades. Cardiac surgery under
cardiac arrest provides a bloodless stable operative field, that can facilitate anastomosis. In
last decade, CABG without CPB, off-pump CABG (OPCAB) has become more common with
advances in surgical instruments and technique. This chapter summarizes the surgical
technique, risks and benefits of OPCAB.

Venoarterial extracorporeal membrane oxygenation (ECMO) for support during whole lung lavage for pulmonary alveolar proteinosis.

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:51:14 PST

INTRODUCTION ECMO as support during whole lung lavage (WLL) for pulmonary alveolar proteinosis is reserved for severe cases where oxygenation is inadequate to support the patient using the ventilator alone. While most publications describe a venovenous cannulation with variable results we present a successful case using venoarterial cannulation and discuss the potential benefits of this mode of ECMO support. CASE PRESENTATION We present the case of a 44 year old female with a past medical history of Behcets disease and a BMI of 37 who was diagnosed with pulmonary alveolar proteinosis (PAP) on a lung biopsy after presenting with dyspnea. As her supplemental oxygen needs escalated she was intubated and was difficult to oxygenate on a conventional ventilator. She was urgently taken to the operating room for venoarterial ECMO support and whole lung lavage. The patient was cannulated femorally using a 20 french venous catheter and an 18 french arterial catheter, with a retrograde arterial catheter to preserve distal perfusion to the right lower extremity. ECMO flow was satisfactory at 4L/min. The whole lung lavage was performed bilaterally using 12 liters of normal saline in one liter instillations with chest physiotherapy between liters. The character and color of the fluid was initially opaque and sero-sanguinous; at the conclusion of the 12 liter lavage the fluid was serous and transparent. Her oxygenation improved immediately post operatively and she was decannulated from ECMO on the fifth post-operative day without complications. DISCUSSION We propose that venoarterial ECMO is superior to venovenous ECMO during whole lung lavage because total cardiopulmonary support can be provided to the patient to maintain adequate oxygenation and hemodynamics. During whole lung lavage while the pulmonary vascular resistance increases, strain on the right ventricle increases and can be avoided with venoarterial ECMO. CONCLUSIONS Venoarterial ECMO for support during whole lung lavage for PAP may provide a superior alternative to venovenous ECMO in patients who are difficult to ventilate and/or oxygenate due to the severity of their disease. REFERENCES 1. Cohen ES, Elpern E, Silver MR. Pulmonary alveolar proteinosis causing severe hypoxemic respiratory failure treated with sequential whole-lung lavage utilizing venovenous extracorporeal membrane oxygenation: a case report and review. Chest. 2001 Sep;120(3):1024-6. 2. Centella T, Oliva E, Andrade IG, Epeldegui A. The use of a membrane oxygenator with extracorporeal circulation in bronchoalveolar lavage for alveolar proteinosis. Interact Cardiovasc Thorac Surg. 2005 Oct;4(5):447-9. Epub 2005 Jun 27. 3. Rogers RM, Szidon JP, Shelburne J, Neigh JL, Shuman JF, Tantum KR. Hemodynamic response of the pulmonary circulation to bronchopulmonary lavage in man. N Engl J Med. 1972 Jun 8;286(23):1230-3.

Novel approach to monitoring renal perfusion with the use of continuous renal oximetery in the setting of aortic dissection

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:45:58 PST

INTRODUCTION: Aortic dissections commonly extend beyond the renal arteries with varying effects ranging from asymptomatic to renal failure. We report a case of aortic dissection with initial renal compromise, which was continuously monitored utilizing direct renal oximetry for evaluation of real-time renal perfusion and function. CASE PRESENTATION: A 65 year-old female with a long history of uncontrolled hypertension presented with acute retrosternal chest pain radiating to the back for 12 hours. She was in stable condition except for a serum creatinine of 1.6mg/dl. Magnetic resonance angiography (MRA) demonstrated a type A dissection extending from the aortic root to the left common iliac artery. The only vessel originating from the false lumen was the left renal artery. The patient was emergently taken to the operating room for aortic root repair with graft. The patient sustained no intra-operative complications and underwent standard post-operative care. Due to initial elevation in serum creatinine and false lumen perfusion of the left kidney, FORE-SIGHT oximetry monitoring was placed on each kidney utilizing pre-operative imaging. Absolute renal tissue oxygen saturation was recorded for 3 consecutive days post-operatively. The right kidney spent a total 1858 minutes (89%) at greater than 60% saturation while the left kidney spent 1915 minutes (92%) (Figure 1). Neither kidney recorded saturations below 52% and serum creatinine cleared to baseline of 1.0 mg/dl. Computed tomography (CT) angiography confirmed perfusion in both kidneys. DISCUSSION: Distal organ perfusion can be a difficult assessment to make in the setting of aortic dissection. The laser technology utilized by FORE-SIGHT implements precise and narrow wavelengths proven to provide more accurate and absolute oxygen saturation values.1 By utilizing FORE-SIGHT oximetry in conjunction with imaging for precise placement, our group was able to accurately monitor renal perfusion in real time as opposed to waiting for contrast CT scan or traditional secondary markers such as serum creatinine and urine output. Saturations were maintained at expected levels throughout the post-operative course and renal function improved. This novel approach may serve a role in adjusting for renal oxygenation and subsequent perfusion in order to prevent renal failure in variety of settings from aortic injury to open cardiac procedures. CONCLUSIONS: Renal oximetry may serve as an additional tool in evaluating, and potentially preventing, renal injury in the setting of aortic dissection.

Sternal pain after rigid fixation: a pilot study of randomization rigid vs conventional wire closure.

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:41:08 PST

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among the total of 26 patients, 11 patients were in Group R (10 male and 1 female, age 67 ± 8.0) and 15 patients were in Group C (13 male and 2 female, age 66 ± 9.9). Preoperative risk factors and procedure were identical between the two groups. Pain scores were not significantly different between 2 groups. Narcotic requirement was smaller in group R (15.7 mg intravenous morphine equivalent in group R in day 1vs 18.4 mg intravenous morphine equivalent in day 1 in group C in day 1, 13.1 mg vs 12.5 mg in day 2, 9.4 mg vs 10.5 mg in day 3, 6.9 mg vs 7.7 mg in day 4, and 6.2 mg vs 6.9 mg in day 5) than group C. Total iv narcotic given over 5 days was 24 ± 41 mg in group R and 34 mg ± 54 mg in group C (p=0.60). Conclusion: Randomized data rom this ongoing study showed a trend of fewer narcotic requirement especially intravenous narcotics in group R than in group C. Implications: Rigid fixation may potentially improve immediate sternal pain after open heart surgery. Less narcotic requirement potentially facilitate early return to the daily activity.

Fate of the lower extremity in patients with VA-ECMO via femoral cannulation

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:36:09 PST

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Femoral cannulation is associated with limb complications including ischemia, limb loss, arterial infections and wound infections. This study aims to evaluate these complications and management related to successful outcomes. Methods: A retrospective review was conducted in 17 patients requiring VA- ECMO support via femoral cannulation from 1/ 2010 till 4/2012. After cannulation, all patients had near infared spectroscopy (NIRS) monitoring after cannula placement and most had placement of distal arterial perfusion catheters (DPC). At decannulation, all patients had femoral cutdown with closure of arteriotomies by primary repair or patch angioplasty with bovine pericardium. Primary study endpoints included ischemia, limb loss, arterial infection; secondary endpoints were wound infection and post-discharge symptoms. Results: Seventeen patients were supported with VA-ECMO during the study period with arterial cannula size of 16-20 French. All patients had NIRS monitoring after cannula placement and 13/17 patients had DPC placement, with no subsequent ischemia. Two of 4 patients without DPC developed ischemia; one was decannulated and the other resolved spontaneously. At decannulation, open arterial repair was performed as described. In this study population, simple wound infection occurred in 3/17with Vacuum Assisted Closure (VAC) devices were placed at the timed if appropriate. There were no arterial infections and no instances of limb ischemia requiring amputation. There were no complaints of rest pain during outpatient follow-up. Conclusions: Limb complications related to femoral cannulation for VA-ECMO can lead to prolonged morbidity and limb loss. NIRS and placement of DPC, primary repair of arteriotomy or patch angioplasty, along with aggressive wound care, can dramatically decrease rates of limb ischemia, limb loss and infection.

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD).

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:31:12 PST

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD). CHRIS RIZZI, BS, Linda Bogar, MD, Jay Jenoff, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Thomas Jefferson University, Philadelphia, PA. Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. The LVAD patients with complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 patients underwent Heartmate II LVAD placement for end-stage heart failure as either bridge to transplant or destination therapy in our institution. Among them, 5 patients underwent PEG tube placement for long-term nutritional support in the operating room or intensive care unit. Procedure management consisted of cessation of anticoagulation and correction of abnormal coagulation before the procedure; a cardiothoracic surgeon or intensivist in the operating room to communicate with the surgeon who performed PEG; and VAD coordinator or perfusionist in the operating room to assist in monitoring the VAD. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of 3 males and 2 females with mean age of 58 +/- 5.0. The interval of LVAD to PEG placement was a mean 21 +/- 8.8 days. PEG was successfully performed in the operating room in all patients. There were no LVAD device or driveline injuries related to the PEG procedure. There were no postoperative short-term or long-term PEG related complications such as acute gastric bleeding or dislodgement of the PEG tube. Concussions: PEG placement for Heartmate II LVAD patients can be done without increasing the risk of device or intraabdominal organ injury with carefully coordinated efforts from both the mechanical support team and surgical services.

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:25:58 PST

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement. SHIGEKI TABATA, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Division of Cardiothoracic Surgery Thomas Jefferson University Hospital, Philadelphia, PA Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the patients with cardiogenic shock. We present a patient who developed severe complications while on ECMO. Case presentation: A 49-year-old female presented with severe heart failure and was placed on veno-arterial ECMO for bridge to decision. While on ECMO, the patient developed massive hemoptysis after Swan-Ganz catheter manipulation. After the endotracheal tube was clamped and the patient relied on full ECMO support for 36 hours, the hemoptysis resolved. The patient also developed liver failure with peak total bilirubin of 56 mg/dl. The molecular adsorbents recirculating system (MARS) device was performed from ECMO day 9 to ECMO day 14. Liver function improved and the value of total bilirubin decreased to 9.9 mg/dl on ECMO day 19. On ECMO day 20, the patient underwent a Heart Mate II LVAD placement and successful ECMO wean. During the course of surgical recovery, the patient had two episodes of sepsis and VAD pocket infection, which was finally controlled with antibiotic beads placement into the pocket. The patient was transferred to an acute rehabilitation facility on ECMO day 77. Discussion: Among the many possible hematologic complications, hemoptysis is often difficult to control. In our patient, the hemoptysis was not controllable by conventional treatment, thus the endotracheal tube was clamped to allow the entire airway to tamponade using the advantage of ECMO. Liver function is most important risk factors to determines patient survival. The MARS is a cell-free extracorporeal liver support device which eliminates albumin-bound substances, such as bilirubin. Using MARS, the patient recovered liver function to allow to perform LAD placement safely. While these mechanical circulatory support, control of sepsis isolating the source of infection was essential for patient survival.

Recovery of end-organs and improved mortality in adult patient on ECMO.

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:21:07 PST

Title: Recovery of End-Organs and Improved Mortality in Adult Patients on ECMO Joshua K Wong, BS1, Vei Shaun Siow, BS1, Thomas N Smith, BS1, Harrison Pitcher, MD2, Linda Bogar, MD2, Hitoshi Hirose, MD2 and Nicholas C Cavarocchi, MD2. 1Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States, 19107 and 2Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States, 19107. Body: With increasing use of ECMO in adults, we seek to objectively measure End-Organ recovery and correlate intensive care mortality scores and complications with patient survival. This is a retrospective review of patients who were placed on ECMO from Oct 2010 to Dec 2011. End-Organ function was measured through Pa02/Fi02 ratios, lactate levels, MELD and mortality scores (SAPSII/APACHEII/SOFA). Complications were recorded and analyzed. Twenty-three patients were placed on VA-ECMO and 5 on VV-ECMO. 22 (73%) patients were successfully weaned off ECMO, and 13 (46%) survived to discharge. In 12 patients with liver injury pre-ECMO, the median MELD score was 21 vs 13 post-ECMO (p

Efficacy of miniaturized imacor trans-esophageal echocardiografm (TEE) prove in mechanical circulatory support.

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:16:03 PST

Application of the miniaturized ImaCor Trans-Esophageal Echocardiogram (TEE) probe in Heart Transplant/Mechanical Cardiac Support Patients In the surgical cardiac care unit (SCCU), therapeutic interventions often need to be done at the bedside, necessitating the need for a rapidly employable diagnostic tool for the cardiac intensivist. We report the clinical utility of the miniature ImaCor TEE-probe in guiding management of post heart transplant (H-Txp) and mechanical cardiac support patients (MCS) and describe the economic benefit of such a device. This is an IRB approved retrospective review of MCS/H-Txp patients who had ImaCor TEE monitoring in the SCCU of our institution in 2011. The effect on management was stratified into 3 categories; Major (tamponade/device selection/RV failure), Moderate (weaning support device guidance/ inotrope management/fluid management/hemodynamic instability) and Minor (line placement/useful data). The ImaCor TEE-Probe was utilized in a total of 34 patients, of which 21 were either supported by MCS or were post H-Txp. Of these, 13 were on ECMO, 9 were post-VAD, 3 supported by the Impella device and 4 were post-H-Txp. 6 patients were placed on more than 1 method of MCS and 1 patient was supported by ECMO after a H-Txp. The device had a Major effect on management in 4 patients (19%), Moderate effect in 13 (62%) and a Minor effect in 4 (19%). The cost difference between this new device and the traditional TEE is also significant (900 USD vs 4000 USD). Our institution saved in excess of 150,000 USD with the use of this device instead of traditional TEE. This figure did not include the ability of this probe to be used repeatedly within a 72-hour time frame, and the potential cost of going to the operating theatre for further management. This device has proven to be an invaluable new adjunct in the SCCU by allowing previously unobtainable continuous real time monitoring of the MCS/H-Txp patient. Use of the ImaCor TEE-probe provides the cardiac intensivist with timely important clinical data that improves patient care and is economically advantageous.

An old problem with a new therapy: GI bleeding in VAD patients and deep bowel enteroscopy (Double balloon. Spiral enteroscopy).

Hitoshi Hirose et al. — Tue, 13 Nov 2012 07:11:11 PST

An old problem with a new therapy: GI Bleeding in VAD patients and deep bowel enteroscopy (Spiral and Double Balloon Enteroscopy) Purpose: Evidence suggests that patients treated with non-pulsatile ventricular assist devices (VAD) are at an increased risk for gastrointestinal bleeding (GIB) beyond what is expected from routine anticoagulation. Diagnostic and treatment algorithms are currently undefined. We reviewed our experience of GIB in VAD patients and propose a new algorithm utilizing deep bowel enteroscopy (DBE) aimed to speed diagnosis and limit transfusions. (471) Methods & Procedures From 2004 to 2011, we studied 62 patients who received a non-pulsatile VAD at our center for episodes of GIB. GIB was defined as heme-positive stool, hematemeisis, or drop in Hgb>1gm. All patients were anticoagulated and no patient had any previous bleeding history. The diagnostic and treatment modalities utilized consisted of standard GIB tests but evolved into an algorithm based primarily on DBE. DBE consists of double-balloon and spiral enteroscopy that allow us to see and treat pathology in the small bowel upt o 400 cm beyond the Ligament of Treitz. (723) Results: There were 41 individual episodes of GIB in 14 patients. Separating the episodes into two groups based on days to diagnosis and days to treatment, we found that when the diagnosis was made and treated within 2 hospital days, patients received half (3.53 v. 7.33 with p

Parenthood with Exposure to Mycophenolic Acid Products

Sophia M. Termimi et al. — Fri, 09 Nov 2012 12:29:11 PST

Successful pregnancy outcomes have been reported in all solid-organ transplant recipients on a variety of immunosuppressive medication regimes. In October 2007, the FDA pregnancy category of mycophenolic acid products (MPA) was changed from category C to D, based on registry and post-marketing data which revealed a higher incidence of spontaneous abortions and structural birth defects. The purpose of this abstract is to describe pregnancy outcomes with exposure to MPA and pregnancies fathered by male transplant recipients conceived while taking MPA. Data were collected by the National Transportation Pregnancy Registry (NTPR) via questionnaires, telephone interview and medical records. There were 152 conceptions in female recipients with exposure to MPA (discontinued <6 weeks prior to conception or with use during pregnancy).

Outcomes included: 78 live births, 70 spontaneous abortions, 3 stillbirths and 1 therapeutic abortion. Among the live births, there were 14 malformations reported for an incidence of (18%) compared to the incidence of malformations in transplant recipients not exposed to MPA, which is approximately 4.9%. There were 146 male recipients who have fathered 199 pregnancies with 202 outcomes (including twins). Outcomes included: 188 live births, 14 spontaneous abortions, and no therapeutic abortions or stillbirths. Among the live births there were 6 malformations reported, for an incidence of 3.2%.

Conclusions: Reports to the NTPR reveal an increased incidence of non-viable outcomes and a pattern of structural malformations in pregnancies exposed to MPA in female transplant recipients compared to those without exposure to MPA. Those pregnancies fathered by male recipients appear similar to that of the general population. Healthcare providers are encouraged to report all pregnancy outcomes in transplant recipients to the NTPR.

Massive Retroperitoneal Hematoma Caused by Retroperitoneal Ectopic Pregnancy

Jay Goldberg et al. — Thu, 06 Sep 2012 08:53:46 PDT

A massive retroperitoneal hematoma caused by a retroperitoneal ectopic pregnancy is managed successfully utilizing multidisciplinary cooperation and transfusion of blood products. The authors report an unusual case of a retroperitoneal ectopic pregnancy presenting as a massive retroperitoneal hematoma in a hemodynamically unstable patient.