Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support

Laparoscopic Cholecystectomy in Cardiogenic Shock And Heart Failure

Background: Patients with cardiogenic shock (CS) or heart failure can develop ischemic cholecystitis from a systemic low-flow state. Cholecystectomy in high-risk patients is controversial. Percutaneous cholecystostomy tube (PCT) is often the chosen intervention; however, data on PCT as definitive treatment are conflicting. Data on cholecystectomy in these patients are limited. This study discusses outcomes following laparoscopic cholecystectomy (LC) in this patient population. Methods: This is a retrospective review of patients who underwent LC from 2015 to 2019 while hospitalized for CS or heart failure. Surgical services are provided by fellowship-trained minimally invasive surgeons at a single, academic, tertiary-care center. Patient characteristics are reported as frequencies' percentages for categorical variables. Odds ratio is used to determine the association between comorbidities and complications. Results: Twenty-four patients underwent LC. Around 83% were white and 79% were male. Many were anticoagulated (88%), with Class IV heart failure (63%), and required vasopressors (46%) at the time of surgery. Fourteen of 24 (58%) had at least one circulatory device at the time of surgery: extracorporeal membrane oxygenation, left ventricular assist device, Impella, tandem heart, and total artificial heart. Four patients (17%) had PCT preoperatively. Fifteen days were the average interval between diagnosis and surgery. Pneumoperitoneum was tolerated by all, and 0% converted to open. Most common complication was bleeding (52%). Nine patients (37.5%) underwent 21 reoperations, one of which (4%) was related to cholecystectomy. Mortality occurred in 5 patients (20.8%); interval between cholecystectomy and mortality ranged 6-30 days. Conclusion: Although high risk, LC is a treatment option in patients with ischemic cholecystitis at risk for death from sepsis.

Common Complications and Cardiopulmonary Resuscitation in Patients with Left Ventricular Assist Devices: A Narrative Review

Heart failure remains a major global burden regarding patients' morbidity and mortality and health system organization, logistics, and costs. Despite continual advances in pharmacological and resynchronization device therapy, it is currently well accepted that heart transplantation and mechanical circulatory support represent a cornerstone in the management of advanced forms of this disease, with the latter becoming an increasingly accepted treatment modality due to the ongoing shortage of available donor hearts in an ever-increasing pool of patients. Mechanical circulatory support strategies have seen tremendous advances in recent years, especially in terms of pump technology improvements, indication for use, surgical techniques for device implantation, exchange and explantation, and postoperative patient management, but not in the field of treatment of critically ill patients and those undergoing cardiac arrest. This contemporary review aims to summarize the collected knowledge of this topic with an emphasis on complications in patients with left ventricular assist devices, their treatment, and establishing a clear-cut algorithm and the latest recommendations regarding out-of-hospital or emergency department management of cardiac arrest in this patient population.

A Comprehensive Review of Mechanical Circulatory Support Devices

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Strategies for immune regulation in iPS cell-based cardiac regenerative medicine

Cardiac regenerative therapy is expected to be a promising therapeutic option for the treatment of severe cardiovascular diseases. Artificial tissues or organoids made from cardiovascular cell lineages differentiated from human induced pluripotent stem cells (iPSCs) are expected to regenerate the damaged heart. Even though immune rejection rarely occurs when iPSC-derived graft and the recipient have the same HLA type, in some cases, such as tissue transplantation onto hearts, the HLA matching would not be sufficient to fully control immune rejection. The present review introduces recent immunomodulatory strategies in iPSC-based transplantation therapies other than MHC matching including the induction of immune tolerance through iPSC-derived antigen-presenting cells, simultaneous transplantation of syngeneic mesenchymal stem cells, and using the universal donor cells such as gene editing-based HLA modulation in iPSCs to regulate T cell compatibility. In addition, we present future perspectives for proper adjustment of immunosuppression therapy after iPSC-derived tissue/organoid-based cardiac regenerative therapies by identifying biomarkers monitoring immune rejection.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.