Emergency Heart Transplantation Research Articles

Uso de un sistema extracorpóreo de asistencia circulatoria de flujo continuo, corta duración e inserción quirúrgica como puente a trasplante

Introduction and objectivesWe aimed to describe the clinical outcomes of the use of the CentriMag acute circulatory support system as a bridge to emergency heart transplantation (HTx). MethodsWe conducted a descriptive analysis of the clinical outcomes of consecutive HTx candidates included in a multicenter retrospective registry who were treated with the CentriMag device, configured either for left ventricular support (LVS) or biventricular support (BVS). All patients were listed for high-priority HTx. The study assessed the period 2010 to 2020 and involved 16 transplant centers around Spain. We excluded patients treated with isolated right ventricular support or venoarterial extracorporeal membrane oxygenation without LVS. The primary endpoint was 1-year post-HTx survival. ResultsThe study population comprised 213 emergency HTx candidates bridged on CentriMag LVS and 145 on CentriMag BVS. Overall, 303 (84.6%) patients received a transplant and 53 (14.8%) died without having an organ donor during the index hospitalization. Median time on the device was 15 days, with 66 (18.6%) patients being supported for> 30 days. One-year posttransplant survival was 77.6%. Univariable and multivariable analyses showed no statistically significant differences in pre- or post-HTx survival in patients managed with BVS vs LVS. Patients managed with BVS had higher rates of bleeding, need for transfusion, hemolysis and renal failure than patients managed with LVS, while the latter group showed a higher incidence of ischemic stroke. ConclusionsIn a setting of candidate prioritization with short waiting list times, bridging to HTx with the CentriMag system was feasible and resulted in acceptable on-support and posttransplant outcomes.

Use of a surgically implanted, nondischargeable, extracorporeal continuous flow circulatory support system as a bridge to heart transplant

Introduction and objectivesWe aimed to describe the clinical outcomes of the use of the CentriMag acute circulatory support system as a bridge to emergency heart transplantation (HTx). MethodsWe conducted a descriptive analysis of the clinical outcomes of consecutive HTx candidates included in a multicenter retrospective registry who were treated with the CentriMag device, configured either for left ventricular support (LVS) or biventricular support (BVS). All patients were listed for high-priority HTx. The study assessed the period 2010 to 2020 and involved 16 transplant centers around Spain. We excluded patients treated with isolated right ventricular support or venoarterial extracorporeal membrane oxygenation without LVS. The primary endpoint was 1-year post-HTx survival. ResultsThe study population comprised 213 emergency HTx candidates bridged on CentriMag LVS and 145 on CentriMag BVS. Overall, 303 (84.6%) patients received a transplant and 53 (14.8%) died without having an organ donor during the index hospitalization. Median time on the device was 15 days, with 66 (18.6%) patients being supported for> 30 days. One-year posttransplant survival was 77.6%. Univariable and multivariable analyses showed no statistically significant differences in pre- or post-HTx survival in patients managed with BVS vs LVS. Patients managed with BVS had higher rates of bleeding, need for transfusion, hemolysis and renal failure than patients managed with LVS, while the latter group showed a higher incidence of ischemic stroke. ConclusionsIn a setting of candidate prioritization with short waiting list times, bridging to HTx with the CentriMag system was feasible and resulted in acceptable on-support and posttransplant outcomes.

Application of Myocardial Contrast-Enhanced Ultrasound in Heart Transplantation in Patients with Acute Myocardial Infarction：A Case Report

Background: MCE is a safe and effective myocardial perfusion assessment technique; it is used for the assessment of post MI viability. Case Presentation: A 52-year-old male with cardiogenic shock caused by secondary acute myocardial infarction and successful coronary stent implantation with ECMO, IABP and ventilator assistance and with no significant recovery of postoperative cardiac function. The result of MCE was also reported. The allograft was successfully performed 8 days after ECMO-assisted support. The patient was successfully transferred to the general ward 8 days after surgery and successfully discharged on day 86 of admission. Conclusions: ECMO provides effective mechanical assistance support for patients with end-stage heart failure, buys time for heart transplantation surgery, and was an effective cardiopulmonary support treatment. An evaluation of myocardial perfusion and survival quantity was an important reference for emergency heart transplantation.

Prognosis of Advanced Heart Failure Patients according to Their Hemodynamic Profile Based on the Modified Forrester Classification.

Introduction: Heart transplantation (HT) remains the gold-standard treatment but is conditioned by organ shortage. This study aimed to evaluate the value of Forrester classification and determine which congestion criteria had the best prognostic value to predict cardiorenal events on heart transplant waiting list. Methods and results: One hundred consecutive patients (54 years old, 72% men) with available right heart catheterization (RHC) listed in our center for HT between 2014 and 2019 were included. Cardiac catheterization measurements were obtained at the time of HT listing evaluation. Patients were classified according to perfusion and congestion status in four groups: “warm and dry”, “warm and wet”, “cold and dry”, and “cold and wet”. pWet was used to classify patients with pulmonary congestion and sWet for systemic congestion. The primary endpoint was the rate of a composite criteria of cardiogenic shock, acute kidney injury, and acute heart failure. Secondary endpoint was the incidence of waitlist death, emergency HT, or left ventricular assist device (LVAD) implantation at 12 months evaluated by Kaplan–Meier curves and log-rank test. Only Forrester classification according to systemic congestion was associated with the primary composite endpoint (p = 0.011), while patients’ profile according to pulmonary congestion was not (p = 0.331). Similarly, only the Forrester classification according to systemic congestion predicted waitlist death, emergency HT, or LVAD implantation at 12 months, with p = 0.010 and p = 0.189 for systemic and pulmonary congestion, respectively. Moreover, systemic congestion was the main driver of cardiorenal events on waitlist. Conclusions: Forrester classification according to systemic congestion is associated with cardiorenal outcomes in patients listed for heart transplant and the risk of waitlist death, emergency HT, or LVAD implantation at 12 months.

Development and Validation of a Prediction Model for Irreversible Worsened Cardiac Function in Patients With Acute Decompensated Heart Failure.

Background: Irreversible worsening of cardiac function is an adverse event associated with significant morbidity among patients with acute decompensated heart failure (ADHF). We aimed to develop a parsimonious model which is simple to use in clinical settings for the prediction of the risk of irreversible worsening of cardiac function.Methods: A total of 871 ADHF patients were enrolled in this study. Data for each patient were collected from the medical records. Irreversible worsening of cardiac function included cardiac death within 30-days of patient hospitalization, implantation of a left ventricular assistance device, or emergency heart transplantation. We performed LASSO regression for variable selection to derive a multivariable logistic regression model. Five candidate predictors were selected to derive the final prediction model. The prediction model was verified using C-statistics, calibration curve, and decision curve.Results: Irreversible worsening of cardiac function occurred in 7.8% of the patients. Advanced age, NYHA class, high blood urea nitrogen, hypoalbuminemia, and vasopressor use were its strongest predictors. The prediction model showed good discrimination C-statistic value, 0.866 (95% CI, 0.817–0.907), which indicated good identical calibration and clinical efficacy.Conclusion: In this study, we developed a prediction model and nomogram to estimate the risk of irreversible worsening of cardiac function among ADHF patients. The findings may provide a reference for clinical physicians for detection of irreversible worsening of cardiac function and enable its prompt management.

Driveline damage and repair in continuous-flow left ventricular assist devices: A systematic review.

With mounting time on continuous-flow left ventricular assist device (CF-LVAD) support, patients occasionally sustain damage to the device driveline. Outcomes associated with external and internal driveline damage and repair are currently not well documented. We sought to evaluate the outcomes of driveline damage and its repair. Electronic search was performed to identify all relevant studies published over the past 20years. Fifteen studies were selected for analysis comprising of 55 patients with CF-LVAD dysfunction due to driveline damage. Demographic and perioperative variables along with outcomes including survival rates were extracted and pooled for the systematic review. Most patients (53/55) were supported on HeartMate II LVAD (Abbott Laboratories, Abbott Park, IL). Internal damage was more commonly reported than external damage [69.1% (38/55) vs. 30.9% (17/55), P=.01]. Median time to driveline damage was 1.9years [IQR 1.0, 2.5]. Most patients presented with a CF-LVAD alarm [94.5% (52/55)] and patients with internal driveline damage had a significantly higher rate of alarm activation compared to that observed for those with external damage [38/38 (100%) vs. 14/17 (82.4%), P=.04]. Patients with internal driveline dysfunction were more likely to experience component wear compared to those with external driveline dysfunction [10/38 (26.3%) vs. 0/17 (0%), P=.05]; 14.5% of patients (8/55) underwent external repair of the driveline, 5.5% (3/55) were treated with rescue tape, and 5.5% (3/55) were placed on an ungrounded cable, indicating a short-to-shield event had occurred. A total of 49.1% of patients (27/55) underwent CF-LVAD exchange, 5.5% (3/55) were weaned off the CF-LVAD to explant, and 5.5% (3/55) underwent emergent heart transplantation. The median length of hospital stay was 12days [IQR 7, 12] and 30-day mortality rate was 14.5% (8/55). Driveline damage was more commonly reported at an internal location and despite being a well-recognized complication, mortality still appears high.

Incidence of vasoplegic syndrome after cardiac transplantation in patients treated with sacubitril/valsartan.

Vasoplegic syndrome (VS) is associated with poor outcomes after heart transplantation (HT). Our aim was to determine whether SAC/VALS is associated with VS after HT. We retrospectively analyzed all consecutive HT performed in three centers between January 2017 and August 2018. VS was defined as vasopressor need (norepinephrine or epinephrine >.5mcg/kg/min or vasopressin) for more than 24hours to maintain a mean arterial pressure >70mmHg. Ninety-six recipients underwent HT in the study period: 60 elective HT with no LVAD, 5 elective HT on long term LVAD, and 31 emergent HT: 3 on long-term LVAD and 28 on temporary mechanical circulatory support. Fourteen patients were on SAC/VALS treatment at the time of transplant, and 82 were not. The global incidence of VS was 15.6%, with no significant differences between the groups (7.14% in with SAC/VALS vs 17.07% in no-SAC/VALS). In conclusion, in our small cohort SAC/VALS was not associated with VS development.

Impact of Preoperative Pulmonary Hypertension on Survival in Patients Undergoing Elective Heart Transplant

BackgroundPulmonary arterial hypertension (PAH) represents a marker of bad prognosis in left heart disease. Nonetheless, the effect on survival after heart transplant remains controversial. The objective was to study the impact of preoperative PAH on survival in patients undergoing elective heart transplant. MethodsA retrospective study of 173 transplant recipients was conducted at a single hospital from January 2009 to December 2018. Congenital etiology and emergent heart transplant were exclusion criteria as well as those patients without enough data in the hemodynamic study. Two groups were considered: A (without PAH) and B (with HTP). PAH was classified as mild (mean pulmonary arterial pressure [mPAP] 25-34 mm Hg, pulmonary vascular resistance [PVR] 2.5-3.4 Wood units and/or transpulmonary gradient [TPG] 13-16 mm Hg), moderate (mPAP 35-44 mm Hg, PVR 3.5-4.9 Wood units and/or TPG 17-19 mm Hg), and severe (mPAP > 44 mm Hg, PVR > 4.9 Wood units and/or TPG > 19 mm Hg). ResultsA total of 102 patients were enrolled; 71.6% were male and average age was 52.3 (SD, 10.02) years. The main etiology was ischemic cardiomyopathy; 13.7% underwent previous heart operations. A total of 61 patients (59.8%) had PAH prior to heart transplant: 25 mild, 34 moderate, and 2 severe. Mean overall survival after transplant was 79.9 (SD, 5.68) months, without differences between the 2 groups (P = .82). One-month survival was 89% (the main cause of mortality was primary graft dysfunction), and 1-year survival was 78%. Four patients required mechanical circulatory support during early post-transplant period. ConclusionsPreoperative PAH does not have a significant impact on survival in elective heart transplant.

332.9: Decision making in an adolescent requiring emergent heart transplant – Is HLA matching relevant?

Background: A 17-year old boy with Ebstein’s anomaly of tricuspid valve, severe biventricular dysfunction and class IV heart failure was admitted for pre-heart transplant evaluation (HT). Three days later, he had sudden cardiac arrest and revived with CPR and placed on VA ECMO. Attempts at ECMO wean were unsuccessful due to RV dysfunction. Pre-transplant work up showed acute kidney injury (AKI) and otherwise he was deemed an eligible recipient for emergent heart transplantation. Luminex® single antigen bead test was negative for Class I and Class II HLA antibodies. On ECMO day 5, a suitable donor was available. HLA typing of donor and recipient revealed 4 out 6 mismatch. Luminex DSA cross match was negative. Two doses of intravenous Basliximab (20 mg each) were used for induction therapy. Post operative graft function was excellent, and surveillance endomyocardial biopsies done on day 7 and day 21 were negative (ISHLT Grade 0 ACR; pAMR0; C4d and CD68 negative on IHC). He was discharged home on post-operative day 29 with oral Tacrolimus, Mycophenolate Mofetil and low dose prednisolone. He continues to do very well on follow up at 1 year. Luminex DSA continues to be negative for Class I and Class II antibodies. Discussion: Children with heart failure bridged to mechanical circulatory support are at high risk for early graft rejection after HT. Emerging crossmatch methods and HLA typing are crucial to improve organ allocation and achieve better match to recipients of HT. Extensive HLA antigen polymorphism, donor shortage and logistics and ischemia time are some of the limiting factors to derive better HLA compatability. HLA matching increases graft survival and reduce the incidence of graft rejection. HLA-DR mismatch is independently associated with ACR at 1 year and predicts long term survival in HT. Graft survival increased with fewer HLA-DR mismatches [0–1 vs. 2 mismatches: risk ratio (RR) = 1.09 (95% confidence interval (CI): 1.01–1.19; P = 0.04)]. Although our patient has several risk factors (pre-transplant ECMO, emergent listing, complicated hospital course) for successful outcome, having fewer HLA DR mismatch and negative DSA at 1 year follow up is encouraging.

P6317Recipient or donor age in heart transplantation:which one fits more?

Abstract Increasing recipient (RA) and donor age (DA) are independently associated with mortality after Heart Transplantation (HT). The aim of this study was to analyse the impact of age-matching on HT survival. 485 recipients who underwent HT between 1990 and 2018 in our Institution were divided into four groups: RA<60-DA<50 (Group 1), RA<60-DA>50 (Group 2), RA>60-DA<50 (Group 3), RA>60-DA>50 (Group 4), and their outcomes were compared. Emergency HT, bridge with MCS and re-HT were excluded. Mean follow-up was 109±84 months. The survival of Group 1 patients was significantly higher than that of patients in other groups (p=0.001). The outcome of young recipients who received older donor grafts did not significantly differ from that of older recipients. At multivariate analysis, donor age, recipient age, Diabetes Mellitus and hypercholesterolemia correlated with long-term mortality. Demographic variables 1 (d/r) 2 (r/D) 3 (R/d) 4 (D/R) P Value Recipients data No. of patients 241 61 107 76 – Female, n (%) 50 (21) 16 (26) 17 (16) 11 (14) 0.25 Age (years), mean ± sd 49±10 54±7 64±3 65±3 <0.001* Creatinine (mg/dl), mean ± sd 1.3±0.8 1.5±0.5 1.4±0.4 1.5±0.5 0.49 Diabetes Mellitus, n (%) 33 (14) 17 (28) 38 (36) 30 (39) <0.001* Hb (g/dl), mean ± sd 12.9±2.4 11.5±2 13±1.7 12±2 0.08 Tot. Bilirubin (mg/dl), mean ± sd 1.3±1 1±0.6 1.2±0.8 1.1±0.7 0.63 sPAP (mmHg), mean ± sd 42.4±14.2 47.5±15.9 44.6±14.8 49.6±16.2 0.07 Etiology 0.003* Ischemic, n (%) 74 (30) 25 (41) 55 (51) 40 (53) Dilative, n (%) 110 (46) 24 (39) 40 (37) 29 (38) Valvular, n (%) 19 (8) 5 (8) 5 (5) 5 (6) Donors and Surgical data Age, (years) mean ± sd 31±10.5 56.5±4 36±10.5 57.5±4.5 <0.001* Female sex, n (%) 73 (30) 30 (49) 38 (35) 33 (43) 0.02* LVEF, mean ± sd 58±4 56±5 60±9 63±9 0.73 Graft ischemia time (min), mean ± sd 198±63 205±62 209±64 193±69 0.75 ECC time (min), mean ± sd 218±72 213±64 214±70 192±53 0.45 In this study, the use of hearts from older donors did not affect survival of older recipients; conversely, in young recipients it increased the risk of mortality.

Prognosis and Risk Stratification of Patients With Advanced Heart Failure (from PROBE)

In recent years, many prognostic scores have been developed for advanced chronic heart failure (CHF), but none of them is comprised of first- and second level echocardiographic indexes. The aim was to create a new prognostic echocardiographic score for patients with advanced CHF. Patients with advanced CHF were analyzed by standard, 3D, and speckle tracking echocardiography and followed prospectively for 2 ± 0.7 years recording major adverse cardiac events (MACE): cardiovascular death, hospitalization for HF, emergency heart transplantation, and left ventricular assist device or intra-aortic balloon pump implantation. A total of 110 patients were enrolled. The best predictors of MACE were selected on the basis of area under the curve by receiver operating characteristic analysis >0.70: left atrial volume index (no MACE vs MACE groups, 51.3 ± 20 ml/m2 vs 67 ± 20 ml/m2, p = 0.0003), right ventricular sphericity index (0.53 ± 0.09 vs 0.61 ± 0.10, p = 0.0002), right ventricular fractional area change (41 ± 9% vs 33 ± 9.5, p <0.0001), free-wall right ventricular longitudinal strain (-20 ± 4.5% vs -16 ± 6%, p = 0.0013). A prognostic score formula was calculated as: PROBE score = 1(if left atrial volume index >65 ml/m2) + 1(if right ventricular sphericity index >0.53) + 0.5(if right ventricular fractional area change <36.5%) + 1(if free-wall right ventricular longitudinal strain >-14%). It presented an area under the curve by receiver operating characteristic analysis of 0.90 and classified patients at low (PROBE ≤1), intermediate (PROBE = 1 to 2), or high (PROBE >2) risk of MACE. The Kaplan-Meier analysis revealed a strong correlation between the event-free survival rate and the 3 groups. In conclusion, the PROBE score, with first- and second level echocardiographic parameters, demonstrated a good predictive value for MACE. It represents a useful tool for a noninvasive, individualized, and accurate evaluation and stratification of prognosis in patients with advanced CHF.

Rejection in heart transplantation for cardiac sarcoidosis mimicking idiopathic giant cell myocarditis: long-term follow-up

: Heart transplantation is a life-saving therapy for some patients admitted for acute myocarditis. However, controversial exists about the major risk of rejection following heart transplantation in specific types of myocarditis. Because of relatively few data on the post heart transplant outcomes, we report the long-term follow-up of a 39-year-old patient with a previous history of ulcerative colitis, which rapidly worsened heart failure until an emergency heart transplant in 2004.The clinical course was complicated by many episodes of rejection; lastly, after the development of severe cardiac allograft vasculopathy, re-heart transplantation was needed. The main findings of this case are: 1) inflammatory aetiology should always be suspected in patients with concomitant autoimmune disease that developing rapidly progressing heart failure; 2) patients with inflammatory myocardial disease undergoing heart transplantation should also undergo strict immunological surveillance; 3) the option of performing the re-heart transplant in a patient with a so complex management in the first one could be uncertain, but in this case the young age and lack of noncardiac comorbidities were effective to favour the survivor after two immunologically so challenging heart transplantation.

Incidence of Vasoplegic Syndrome after Cardiac Transplant in Patients Treated with Sacubitril/Valsartan

Purpose Vasoplegic syndrome (VS) is associated with high morbidity and mortality after heart transplant (HT). ACE-inhibitors have shown to increase the risk of VS after heart surgery, but little is known about the effect of Sacubitril/Valsartan (SAC/ VALS), a more potent vasodilator used in heart failure. Profound vasoplegia was reported after HT in a patient receiving SAC/VALS. We aim to assess whether SAC/VALS is associated with a higher incidence of VS in patients undergoing a HT. Methods We retrospectively analyzed all consecutive HT performed in 2 centers and two SAC/VALS HT performed in a 3rd center in the same city, between January 2017 and August 2018. VS was defined as the need of vasopressors for more than 24 hours to maintain a mean arterial pressure > 70 mm Hg, which included vasopressin or high-dose norepinephrine or epinephrine (> 0,5 mcg/kg/min). Emergent HT and recipients with primary graft failure in the first 48h post HT, defined as ejection fraction Results Among a cohort of 60 HT recipients, 9 were excluded for primary graft dysfunction and 15 for emergent transplantation. Our final cohort was 36 HT recipients (63.89% male, mean age 51± 12). 10 patients were on SAC / VALS treatment at the time of HT and were compared to 26 recipients who were not receiving SAC/VALS. Baseline characteristics were not different between the two groups. The global incidence of VS was 11.11%, with no significant differences between the groups: 10% in the SAC/VALS group vs 11.54% in the no-SAC/VALS group, p = NS. No significant differences were found in vasopressor doses 4 h post HT, 24 h post HT and maximal dose, post-operative laboratory parameters, and adverse events (Table 1). Conclusion In our study, SAC / VALS was not associated with a higher incidence of VS. More studies are needed to determine the effect of SAC/VALS in post-HT incidence of vasoplegia. Table 1 . Between-group differences in outcomes. Whit SAC/VALS Whitout SAC/VALS P value Total - n (%) 10 (27,78) 26 (72,22) Vasopressor/Inotrope (mcg/kg/min) - median (IQR) Norepinephrine at 4 hs 0 (0-0,13) 0,06 (0-0,36) NS Norepinephrine at 24 hs 0,06 (0-0,26) 0 (0-0,27) NS Highest dose of norepinephrine. 0,08 (0-0,26) 0,22 (0-0,45) NS Highest dose of dobutamine. 10 (7,66-10) 10 (8,75-11,63) NS Adverse Events - n (%) Vasoplegic Syndrome 1 (10) 3 (11,54) NS In-hospital Death 1 (10) 0 NS Mechanical Circulatory Support 1 (10) 0 NS Urgent Restransplant 0 0 NS

Long-Term Survival after Heart Transplantation: Interaction between Donor and Recipient Age

Purpose Increasing recipient (RA) and donor age (DA) are independently associated with mortality after Heart Transplantation (HT). The aim of this study was to analyse the impact of age-matching on HT survival. Methods 485 recipients who underwent HT between 1990 and 2018 in our Institution were divided into 4 groups: RA 50 (Group 2), RA>60-DA 60-DA>50 (Group 4), and their outcomes were compared. Emergency HT, bridge with MCS and re-HT were excluded. Mean follow-up was 109 ± 84 months. Results Preoperative data reported in Table 1. 30-day mortality across the groups was 4.9%, 9.8%, 8.1%, 9.2% from Group 1 to 4 (p=0,4). The survival of Group 1 was significantly higher than that of other groups (p=0,001), figure 1. The outcome of young recipients receiving older donor grafts did not significantly differ from that of older recipients. At multivariate analysis , donor age (HR 1,02; 95%CI:1,007-1,04) and recipient age (HR 1,05;95%CI:1,02-1,09) correlated with long-term mortality. Conclusion In this study, the use of hearts from older donors did not affect survival of older recipients; conversely, in young recipients it increased the risk of mortality. Older donor organs employment is advisable to expand the donor pool, but donor-recipient age matching should be taken into account to improve long-term outcomes.

Predictors of renal replacement therapy after heart transplantation and its impact on long-term survival.

Renal replacement therapy (RRT) after heart transplant (HT) is associated with worse prognosis. We aimed to identify predictors of RRT and the impact of this complication on long-term survival. Cohort study of HT patients. Univariate and multivariate competing-risk regression was performed to identify independent predictors of RRT. The cumulative incidence function was plotted for RRT. The Kaplan-Meier method was used to compare long-term survival. We included 103 patients. At multivariate analysis, only the emergency status of HT (short-term mechanical circulatory support as a bridge to transplant), chronic kidney disease, and low oxygen delivery were independent predictors of RRT (subhazard ratio [SHR] 4.11, 95% CI 1.84-9.14; SHR 3.17, 95% CI 1.29-7.77; SHR 2.86, 95% CI 1.14-7.19, respectively). Elective HT patients that required RRT showed a significantly reduced survival comparable to patients with emergency HT and RRT (75%±13% vs. 67%±16%). The absence of RRT implied an excellent survival in patients with an emergency status of HT and elective HT (100% vs. 93%±4%). The emergency status of HT, chronic kidney disease, and low oxygen delivery were independent predictors of RRT. The occurrence of RRT increases the risk of death in elective HT as much as in patients with an emergency status.

Elective and Emergency Heart Transplantation: Costs Comparison in a Single Center

Elective and Emergency Heart Transplantation: Costs Comparison in a Single Center

Ten thousand kilometre transfer of cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation for emergency heart transplantation: Cooperation between Reunion Island and Metropolitan France.

There is no heart transplantation centre on the French overseas territory of Reunion Island (distance of 10,000 km). The aim of this study was to describe the characteristics of cardiogenic shock adult patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) who were transferred from Reunion Island to mainland France for emergency heart transplantation. This retrospective observational study was conducted between 2005 and 2015. The characteristics and outcome of cardiogenic shock patients on VA-ECMO were compared with those of cardiogenic shock patients not on VA-ECMO. Thirty-three cardiogenic shock adult patients were transferred from Reunion Island to Paris for emergency heart transplantation. Among them, 19 (57.6%) needed mechanical circulatory support in the form of VA-ECMO. Median age was 51 (33-57) years and 46% of the patients had ischaemic heart disease. Patients on VA-ECMO presented higher Sequential Organ Failure Assessment score ( p = 0.03). No death occurred during the medical transfer by long flight, while severe complications occurred in 10 patients (30.3%). Incidence of thromboembolic events, severe infectious complications and major haemorrhages was higher in the group of patients on VA-ECMO than in the group of patients not on VA-ECMO ( p <0.01). Seven patients from the VA-ECMO group (36.8%) and six patients from the non-VA-ECMO group (42.9%, p=0.7) underwent heart transplantation after a median delay of 10 (4-29) days on the emergency waiting list. After heart transplantation, one-year survival rates were 85.7% for patients on VA-ECMO and 83.3% for patients not on VA-ECMO ( p=0.91). This study suggests the feasibility of very long-distance medical evacuation of cardiogenic shock patients on VA-ECMO for emergency heart transplantation, with acceptable long-term results.

Perioperative Venoarterial Extracorporeal Membrane Oxygenation Support During Heart Transplant.

Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. This technique may be used after heart transplant for conditions refractory to medical treatment like primary graft failure. Previously, we reported our experience with patients who received extracorporeal support as a bridge to emergency heart transplant. In this study, we present our perioperative experience with heart transplants in which extracorporeal support was used. We retrospectively screened the data of 31 patients who were seen at our center between January 2014 and June 2016. We screened for patients who were admitted tothe intensive care unit before transplant and who required venoarterial extracorporeal membrane oxygenation for circulatory support and postoperative patients who required extracorporeal support. Patient demographics and characteristics, clinical data, and extracorporeal support data were collected from our electronic database and patient medical records. There were 14 patients who required perioperative extracorporeal support. Preoperative support was performed in 3 patients before transplant, and postoperative support was performed in 11 patients after transplant. The mean age was 37.7 years in patients within the preoperative group and 29.7 years in patients within the postoperative group. One patient with preoperative support and 5 with postoperative support were pediatric patients. The main indication for transplant was dilated cardiomyopathy in both groups (100% and 63.7%). Overall mortality rates were 33% in the preoperative group and 63.7% in the postoperative group. For patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort. In addition, extracorporeal support can be used during the posttransplant period as salvage therapy in heart recipients with hemodynamic deterioration. In our experience, preoperative extracorporeal support had lower mortality rates compared with postoperative support.

Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation.

We report the experience in a cohort of consecutive patients receiving extracorporeal membrane oxygenation during catheter ablation of unstable ventricular tachycardia (VT) at our center. From 2010 to 2015, extracorporeal membrane oxygenation was initiated in 64 patients (average age: 63±15 years; left ventricular ejection fraction in 27±9%; cardiogenic shock in 23%, and electrical storm in 62% of patients) undergoing 74 unstable VT catheter ablation procedures. At least one VT was terminated in 81% of procedures with baseline inducible VT, and VT noninducibility was achieved in 69%. Acute heart failure occurred in 5 patients: 3 underwent emergency heart transplantation, 1 had left ventricular assist device (LVAD) implantation, and 1 patient eventually died because of subsequent mesenteric ischemia. All other patients were discharged alive. After a median follow-up of 21 months (13-28 months), VT recurrence was 33%; overall survival was 56 out of 64 patients (88%). Extracorporeal membrane oxygenation-supported ablation was the bridge to LVAD in 6.9% and to heart transplantation in 3.5% of patients. VT recurrence was related to ablation success (after 180 days of follow up: 19% when VT was noninducible, 42% if nonclinical VT was inducible, 75% when clinical VT was inducible, and 75% in untested patients, P<0.001). Incidence of all-cause death, heart transplantation, and LVAD was independently related to ablation outcome (at 180 days of follow-up: 9% when noninducibility was achieved, 50% in case of inducible VT, and 75% in untested patients, P<0.001). At multivariable analyses, noninducibility (hazard ratio 0.198; P=0.001) and left ventricular ejection fraction (hazard ratio 0.916; P=0.008) correlated with all-cause death, LVAD, and heart transplantation. Ablation of unstable VTs can be safely supported by extracorporeal membrane oxygenation, which allows rhythm stabilization with low procedure mortality, bridging decompensated patients to permanent LVAD or heart transplantation. Successful ablation is associated with better outcomes than unsuccessful ablation.

Adriamycin cardiomyopathy with congestive heart failure, cardiogenic shock and emergency heart transplant: 30-year follow up

Doxorubicin chemotherapeutic agent is widely utilized for many types of cancers since the late 1960s. Cardiomyopathy is a well-known side effect of doxorubicin often limiting its use. In many cases doxorubicin cardiomyopathy can lead to end stage cardiac failure requiring heart transplantation. The quality of life of heart transplant patients is exceptional with most patients being able to continue normal activities following recovery. There has been significant advancement in cardiac transplantation since it was first attempted in 1967 in Cape Town, South Africa. Drugs such as cyclosporine played an important role in preventing graft failure and prolonging patient survival. Cardiac transplant can extend a patients’ life by over a decade. The patient in this case, Mr. Glen Frank Spurling, has survived 30 years following his cardiac transplant surgery. In this article an overview of doxorubicin cardiotoxicity, cardiac transplantation, and an interview with Mr. Glen Frank Spurling is presented.