Charles T. Klodell

Recent reports suggested that HeartMate II (HMII) thrombosis rates may be higher in implants after 2011. We characterize events at HMII centers (>100 HMII implants) whose device thrombosis rates are equivalent or lower than reported by INTERMACS. Seven centers pooled implants from 2011 through June 2013 to examine pump thrombus and identify characteristics and clinical strategies that potentially mitigate the risk. A total of 666 patients (age 59 ± 13 years; 81% male) were studied (support duration: 13.7 ± 8.3 months, cumulative: 759 patient years). Median target INR was 2.25 (range 2.0 to 2.5), and median pump speed was 9200 rpm (range 8600 to 9600). Pump thrombus was suspected with clinical evidence (e.g., hemolysis, positive ramp test) requiring intervention (e.g., anticoagulation therapy, pump exchange) or patient death. Suspected pump thrombus occurred in 24/666 (3.6%) patients within three months of implant. At six months, 38/666 (5.7%) had suspected pump thrombus including 24 (3.6%) resulting in pump exchange or death. Stroke (hemorrhagic: 0.049, and ischemic: 0.048 events/patient year) and survival (six months: 88 ± 1%; 1 year: 81 ± 2%) were consistent with national averages. Suspected pump thrombus patients were younger (55 ± 13 vs. 59 ± 13, p = 0.046) and had more females (31.6% vs. 18.3%, p = 0.054). There was no difference in indication, etiology of heart failure, or body size. This analysis demonstrates low HMII thrombus events. Minimization of risk factors by uniform implant techniques and consistent post-op management may reduce device thrombosis. A larger scale multicenter evaluation may better elucidate the difference in thrombus events between centers. doi: 10.1111/jocs.12607 (J Card Surg 2015;30:775–780)

The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the “pearls and pitfalls” of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR.

Bleeding is the most common complication of HeartMate II and is partially attributable to platelet dysfunction; however, antiplatelet therapy is arbitrary in most centres. We investigated how antiplatelet therapy adjustment with thrombelastography affects late-onset bleeding. Thrombelastography was used to adjust antiplatelet therapy in 57 HeartMate II recipients. Kaplan–Meier survival curves and Cox proportional hazard ratio model were used to identify predictors of late-onset bleeding in univariate and multivariate analysis. Finally, late-onset bleeding rate in our study was compared with the reported rates in other studies in the literature, all of which did not use any test to monitor or adjust antiplatelet therapy. Mean follow-up was 347 days. Eighteen late-onset bleeding events occurred in 12 patients, a late-onset bleeding rate of 12/57 (21%) or 0.21 events/patient-year. The Kaplan–Meier survival curves demonstrated that late-onset bleeding was more common in the destination therapy cohort (P = 0.02), in patients older than 60 years (P = 0.04) and in females (P = 0.01), none of which was significant in multivariate analysis at a significance level of 0.05. To further investigate the higher bleeding rate in elderly patients, thrombelastography parameters were compared between younger and older patients at the age cut-off of 60 years which demonstrated a prothrombotic change the day after device implantation in younger patients that was absent in the elderly. There was also a trend towards higher requirement for antiplatelet therapy in younger patients while on device support, but the difference did not reach statistical significance. The average late-onset or gastrointestinal bleeding rate among seven comparable studies in the literature that did not use any monitoring test to adjust antiplatelet therapy was 0.49 events/patient-year. Our study implicates that antiplatelet therapy adjustment with thrombelastography may reduce late-onset bleeding rate in HeartMate II recipients. Bleeding was more common in the elderly recipients and analysis of thrombelastography data suggests that a less aggressive antiplatelet therapy regimen could potentially lower bleeding rate in this vulnerable population.

Giant basal cell carcinoma (BCC) of the chest wall is rare and poses challenges related to resection and reconstruction. A 69-year old man presented with giant BCC invading sternum. Wide resection and reconstruction with polymethylmethacrylate and mesh was performed. The soft tissue defect was covered with a pedicled omental flap and skin graft. He developed an infection requiring removal of the mesh construct; however, debridement and antibiotics cleared the infection. This case illustrates the locally aggressive nature of this disease and the need for tertiary-level care.