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Risk of AKI after cardiac surgery is not influenced by the time between coronary angiogram and cardiac surgery. These results do not support the notion of delaying cardiac surgery for the sole purpose of renal recovery after coronary angiogram.

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Background: Despite advances in reperfusion times, patients presenting with acute myocardial infarction carry an unacceptably high rate of mortality and morbidity. Mechanical unloading of the left ventricle (LV) has been suggested to reduce infarct size after acute myocardial infarction. Although prior studies have investigated LV unloading during ischemia with a delay in reperfusion, little is known about the optimal timing for LV unloading in the setting of acute myocardial infarction. Methods: Studies were conducted in 17 adult Yorkshire swine weighing 67±5 kg. A coronary balloon was inflated in the mid left anterior descending for 60 minutes to induce a myocardial infarction. The coronary balloon was then deflated for 120 minutes (reperfusion). The animals were stratified into 3 groups: group 1 (control, reperfusion with no LV unloading, n=5), group 2 (LV unloading during ischemia with delayed reperfusion, n=6), and group 3 (simultaneous LV unloading and reperfusion, n=6). Staining the hearts with Evans blue and 2,3,5-triphenyltetrazolium chloride was used to identify the area at risk and the infarct area respectively. Infarct percent size was defined as the area of infarcted myocardium divided by the area at risk. Results: Of the 3 groups, group 3 demonstrated significantly smaller infarct percent size compared with controls (54.7±20.3% versus 22.2±13.4%; P =0.03). Comparison between group 1 and group 2 did not reveal significant difference (54.7±20.3% versus 43.3±24.6%; P =0.19). Conclusions: In our large animal experimental model, simultaneous reperfusion and mechanical LV unloading yielded the smallest infarct size compared with no LV unloading or LV unloading with delayed reperfusion. In the context of prior studies showing benefit to unloading before reperfusion, these findings raise questions about how this strategy may be translated to humans.

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Purpose: Beginning January 2009 to present, all NYHA class IV, and all INTERMACS II patients referred for surgical therapy, had heart transplantation only in presence of LVAD contra indications (severe pulmonary hypertension, apical thrombus, aortic valve incompetence, non compliance) Therefore, all LVAD implanted were classified as destination therapy. Results are here reviewed. Methods: January 2009 to October 2015 90 NYHA class IV pts. (60% males vs 40% females, affected either by DCMP, 45%, or by IHD ,50%, or other, 5%, aged 25 to 73 years, mean 49 y.), had either heart transplant (G 1, 55 pts.) or Heart Mate II type LVAD implanted, (35 pts. ,G2 pts.) Entire population was followed up from 1 to 60 mos. Results: 1 mo. survival was 93% in G1 vs. 96 % in G2, while 60 mos. survival was in G1.69% vs 82% in G2, p.v.:n.s. One mo freedom from RVF was 69% in G1 vs. 79 % in G2, p.v.: n.s. 60 mos freedom from hospital readmission (25% in G1vs. 32% in G2), from infections (G1: 40%, vs. G2 34%), and from renal failure (G1: 52%, vs. G2 82%,) were not significant. Otherwise, freedom from neoplasia (G1: 76%, vs. G2 100 %, from bleeding G1: 89%, vs. G2 25%, 12 mos. and survival on the waiting list gone from 35% in 2009 to 49% i 2015 had .p.v.: < 0.005. Conclusion: Although our experience is still limited, better controlled mortality on the waiting list and acceptable results in terms of survival, and of freedom from main complications seems to indicate that use of LVAD as destination therapy should be expanded. Further experience is needed.( 761)