No abstract

VA-ECMO appears to be an effective tool to optimize end-organ function as a bridge to recovery or intervention, with excellent outcomes. This approach may allow clinicians to better triage patients with massive pulmonary embolism to the appropriate therapy on the basis of recovery of RV function, residual thrombus burden, operative risk, and neurologic status.

Background. Up to 30% of patients presenting with ascending aortic disease are deemed inoperable. Ascending aortic endovascular repair provides an alternative option for these patients.Methods. From 2018 to 2019, 13 patients who were considered to have prohibitive risk for open ascending aortic repair underwent endovascular repair. Aortic disease included type A dissection (n [ 8), pseudoaneurysm (n [ 3), penetrating ulcer (n [ 3), and chronic aortic aneurysm (n [ 1). Ascending aortic stent placement with thoracic endovascular aortic repair was performed in 9 patients, endovascular cuff extension was inserted in 3, and in 1 patient endovascular coil embolization was undertaken. Preoperative and follow-up electrocardiogram-gated computed tomographic analysis was performed to compare the remodeling effect of the stent on the aorta. The median follow-up time was 13 months.Results. The stent graft was successfully implanted in all patients (100%). Operative mortality and stroke rate were 15% (2 of 13) and 8% (1 of 13), respectively. One patient required transcatheter aortic valve replacement for severe aortic insufficiency 5 months after ascending thoracic endovascular aortic repair. The location of the aortic pathologic process was in zone 0A in 2 patients, zone 0B in 7 patients, and zone 0C in 3 patients. No endoleak was observed after the ascending endovascular repair in 9 patients (70%). Follow-up computed tomographic scan analysis revealed a tendency of favorable aortic remodeling in the mid-ascending and descending aorta.Conclusions. Ascending aortic stent placement for ascending aortic disease is feasible and is associated with favorable aortic remodeling. Despite persistent perfusion to the false lumen in a subset of patients, there is minimal aortic dilation at short-term follow-up with excellent survival.

Objectives: To evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device.Methods: This is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal.Results: After a mean duration of VA-ECMO support of 7.4 AE 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation.Conclusions: Percutaneous decannulation from VA-ECMO using the MANTA largebore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results. (JTCVS Techniques 2021;6:75-81) MANTA closure device deployed for percutaneous closure of a femoral arterial cannulation site.

OBJECTIVES Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation continues to be a morbid complication. In this study, we hypothesized that a less invasive approach to implantation would preserve RV function relative to a conventional sternotomy (CS) approach. METHODS All patients (2013–2017) who underwent LVAD implantation were reviewed. Patients were stratified by surgical approach: less invasive left thoracotomy with hemi-sternotomy (LTHS) and CS. The primary outcome was severe RV failure. RESULTS Eighty-three patients (LTHS: 37, CS: 46) were identified. The median Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score was significantly worse in the LTHS compared to the CS cohort, and there was a trend towards higher RV failure scores and HeartMate II mortality scores. Preoperative RV dysfunction, in pulmonary artery pulsatility index and RV stroke work index were similar between the 2 groups. Though operative time did not significantly differ between the 2 groups, cardiopulmonary bypass time was significantly shorter in the LTHS group (61 vs 95 min, P < 0.001). The incidence of postoperative severe RV failure was significantly reduced in the LTHS group (16% vs 39%, P = 0.030), along with the need for temporary right ventricular assist device (3% vs 26%, P = 0.005). Improvement in RV function, along with a change in pulmonary artery pulsatility index, was significantly greater in the LTHS cohort. There was a trend towards improved Kaplan–Meier 1-year survival in the LTHS cohort (91% vs 56%, P = 0.056). CONCLUSIONS In this cohort, less invasive LVAD implantation appears to be associated with reduced postoperative RV failure, and equivalent or improved survival compared to conventional LVAD implantation.