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Preexisting organ dysfunctions are known factors of death after placement of implantable mechanical circulatory support (MCS). Extracorporeal membrane oxygenation (ECMO) may able to stabilize organ function in patients with cardiogenic shock before MCS implantation. Between 2008 and 2012, 17 patients with cardiogenic shock were supported with ECMO before implantable MCS placement. Patient's end-organ functions were assessed by metabolic, cardiac, hepatic, renal, and respiratory parameters. Survival data after MCS implantations were analyzed for overall survival to discharge, complications, and breakpoint in days on ECMO to survival. Before MCS implantation, lactate, hepatic, and renal functions were improved and pulmonary edema was resolved. The interval between ECMO initiation and MCS placement was 12.1 ± 7.9 days. Overall survival rate to discharge after left ventricular assist device/total artificial heart placement was 76%. The survival of patients transitioned from ECMO to MCS within 14 days was 92% and was significantly better than the survival of patients from ECMO to MCS supported longer than 14 days, 25%, p < 0.05. ECMO support can immediately stabilize organ dysfunction in patients with cardiogenic shock. After improvement of organ function, MCS implantation should be done without delay, since the patients supported for longer than 14 days with ECMO had inferior survival compared to national data.

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Conventional algorithms for diagnosis and treatment of gastrointestinal bleeding (GIB) in patients with nonpulsatile ventricular assist devices (VADs) may take days to perform while patients require transfusions. We developed a new algorithm based on deep overtube-assisted enteroscopy (DOAE) to facilitate a rapid diagnosis and treatment. From 2004 to 2012, 84 patients who underwent VAD placement in our institution, were evaluated for episodes of GIB. Our new algorithm for the management of GIB using DOAE was evaluated by dividing the episodes into three groups: group A (traditional management without enteroscopy), group B (traditional management with enteroscopy performed >24 hours after presentation), and group C (new management algorithm with enteroscopy performed <24 hours after presentation). Gastrointestinal bleeding was observed in 14 (17%) of our study patients for a total of 45 individual episodes of which 28 met our criteria for subanalysis. Forty-one (84%) lesions were confined to the upper gastrointestinal tract with more than 91% of these lesions being arteriovenous malformations. Average number of transfusions in groups A, B, and C were 4.1, 6.3, and 1.3, respectively (p = 0.001). The number of days to treatment was significantly shorter in group C than group B (0.4 vs. 5.3 days, p = 0.0002). Our new algorithm for the management of GIB using DOAE targets the most common locations of bleeding found in this patient population. When performed early, DOAE has the potential to decrease the need for transfusions and allow for an early diagnosis of GIB in VAD recipients.

Background: Hemothorax after lung transplantation may result in increased post-operative morbidity and mortality. Risk factors for developing hemothorax and the outcomes of patients who develop hemothorax have not been well studied. Methods: A retrospective chart review was performed on all patients who underwent lung transplantation at a single center between March 2009 and July 2014. Comparison was made between patients with and without hemothorax post-transplant. Results: There were 132 lung transplantations performed during the study period. Hemothorax was a complication in 17 (12.9 %) patients, occurring an average of 9 days after transplant. No difference was found between the hemothorax and non-hemothorax groups with respect to age, preoperative anticoagulation, lung allocation score, prior thoracotomy, coagulation profile, use of cardiopulmonary bypass, ischemic time, or postoperative P/F ratio. There was a trend towards a higher incidence of hemothorax in patients with underlying sarcoidosis and re-transplantation (p = 0.13 and 0.17, respectively). Hemothorax developed early (<48 h post-operatively) in 5 patients and presented in a delayed manner (≥48 h post-operatively) in 12 patients. Delayed hemothorax occurred primarily in the setting of anticoagulation (10 out of 12 patients). The hemothorax group had decreased ventilator-free days (p = 0.006), increased ICU length of stay (p = 0.01) and increased hospital length of stay (p = 0.005). Hemothorax was also associated with reduced 90-day survival (p = 0.001), but similar 1, 3, and 5-year survival (p = 0.63, p = 0.30, and p = 0.25), respectively). Conclusion: The development of hemothorax is associated with increased morbidity and decreased short-term survival. Hemothorax may present either within the first 48 h after surgery or in a delayed fashion, most commonly in the setting of anticoagulation.

Practice patterns in the early postoperative care of lung transplant recipients differ considerably among centers. Many of the reported practices do not conform to consensus guidelines on management of critically ill patients.

Background: Because of the rising expectation of prolonged life in the general population and the recent recognition of undertreated aortic valve disease in the elderly, updating the available results of aortic valve surgery is imperative, especially considering the rapid evolution of the transcatheter valve implantation procedure. Methods and Results:Between 1997 and 2010, 308 patients aged 70 years or older underwent aortic valve replacement (AVR) for aortic stenosis (AS). Short- and long-term results were analyzed and risk factors for long-term mortality were determined. Mean age was 78.5 years and 124 patients were aged 80 or older. Concomitant coronary artery bypass grafting (CABG) was performed in 46% of the cases. Mean left ventricular ejection fraction (LVEF) was 52%. Overall observed and expected operative mortality using the Society of Thoracic Surgeons-Predicted Risk of Mortality score was 3.9% and 4.8%, respectively. Overall survival rates at 1, 5, and 10 years were 88.6%, 71.6%, and 31.8%, respectively. Predictors of long-term mortality included diabetes; preoperative shock; LVEF ≤40%; New York Heart Association functional class III or IV; and age.Conclusions: Short- and long-term results of conventional AVR in the elderly prove it to be durable and, especially in relatively low-risk patients and patients who require concomitant CABG, operative mortality is reasonably low. Conventional AVR ± CABG remains the gold standard for elderly patients with AS. (Circ J 2011; 75: 2692 - 2698