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Ann Thorac Surg 2001;71:S82-S85
© 2001 The Society of Thoracic Surgeons

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Session 1: acute heart failure

Discussion of acute heart failure

Presented at the Fifth International Conference on Circulatory Support Devices for Severe Cardiac Failure, New York, NY, Sept 15–17, 2000.

DR D. GLENN PENNINGTON (Johnson City, TN):

The first case is a 55-year-old woman undergoing mitral valve replacement who develops severe heart failure in spite of vasodilators, inotropic drugs, and balloon pump.

Dr. Nick Smedira, just tell us how you’d deal with this lady.

DR NICHOLAS J. SMEDIRA (Cleveland, OH):

When I asked my colleagues what they would do, their first response was: why do you have biventricular failure after a mitral valve replacement? I think that is a good question. When you start out, you have to step back and ask: What is the problem? What I would recommend initially is a transesophageal echocardiogram to assess the valve. Is the valve functioning? Do I have any regional wall motion abnormalities?

Now, here is an example of a patient who is having trouble. One view of the echocardiogram looked like the valve was working normally. But you can see here that only one leaflet is moving; in addition, there is thrombus forming on the frozen leaflet of the prosthesis. So in this situation, part of the reason you’re having biventricular failure is the fact that you have valve malfunction.

Now, the question is, what device would you use? The real issue here is trying to avoid valve and chamber thrombosis. This is a case in which we used extracarporeal membrane oxygenation (ECMO) in this setting, and you can see the large amount of thrombus that then developed within the left atrium, around the valve, and in the left ventricle, after support. So I think that is the key concern.

As Mike just mentioned, I think the ideal approach in this patient would be to use an ABIOMED device. Usually these rheumatic ladies are tiny. A 32F inflow cannula could easily be inserted in the left ventricular (LV) apex. You may . . . [Full Text of this Article]

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