Emergency Heart Transplantation Research Articles

Cellular Microparticles As Predictive Markers for Thrombosis and Other Clinical Events in Patients with Implanted Lvads

▪Introduction: Since the implantation of left ventricular assist devices (LVAD) in heart failure patients has become more frequent, the need to prevent, predict, and treat the associated pathologies has become paramount. The most common complications, which include thrombosis, gastrointestinal bleeds, anemia, and hemolysis, are also the adverse events that carry a less than favorable prognosis. Current methods for predicting these conditions, i.e. elevated LDH or low hemoglobin levels, typically provide an alert, at most, days in advance. This can result in inadequate time to prevent the event, forcing emergency device exchange or heart transplant. Cellular microparticles (MPs) are formed from numerous cell types as a result of activation or damage, and may play a role in mediating hemostatic or inflammatory alterations. The altered shear stress on blood induced by an implanted LVAD may be a further source of MP generation. Our study sought to determine whether alterations in blood MP levels are observed prior to the occurrence of common adverse events in patients with implanted LVADs to determine their potential clinical usefulness.Methods: Blood samples were collected peri-operatively and long-term post-operatively (until transplant or expiration) during normal clinic visits from consented patients who were implanted with a HeartMate II LVAD (Thoratec Inc, Pleasanton, CA). Fresh whole blood specimens collected in 3.2% sodium citrate were centrifuged for platelet poor plasma then ultracentrifuged (20,000 x g for 90 minutes) to pellet the MPs. Aliquots of the MP rich samples were stained with the membrane dye PKH67 (to differentiate MPs from biological membranes vs waste) then separated into five tubes containing either: Tyrode’s buffer (control), CD41-PE (platelets), CD45-PE (leukocytes), CD146-PE (endothelium), or CD235-PE [erythrocytes (RBCs)]. Samples were analyzed on an EPICS XL flow cytometer (Beckman-Coulter, Miami, FL) to determine the presence and quantity of cellular MPs using an in-house established and validated assay (modified to enhance sensitivity to MPs). Blood samples collected from six healthy individuals were processed and analyzed in the same manner to establish normal MP levels. A database of clinical events in the consented patients was created from medical chart reviews by the Heart Failure Clinic.Results: In healthy individuals, MPs derived from platelets and RBCs were most common and MPs derived from endothelium were least prevalent. Sixteen LVAD patients, with a mean follow-up of 291±91 days (range: 52-330 days), were evaluated. Thrombosis and elevated LDH each occurred once in the study patients. With both of these events, sustained elevations in MP quantities were observed. Preceding the diagnosis of thrombus, the patient had elevated CD41+ MP [2-6 standard deviations (SD) above normal], CD45+ MP (3-5 SD above normal), and CD+146 (5-8 SD above normal). These MPs, which were within 1 SD of the normal for the first two months following implant, remained at an elevated state for more than seven months. In the patient with the elevated LDH, a clinical sign of potential thrombus formation, levels for CD41+ (3-6 SD above normal), CD45+ (2-5 SD above normal), CD146+ (1-8 SD above normal), and C235+ (2-5 SD above normal) MPs were increased for two months prior to LDH elevation. Regarding hemolytic events, extreme elevations in MP levels (all four MP types were greater than 6 SD above their respective normal values) were noted in one patient 3 days before diagnosis, but elevated levels were not observed in a separate patient’s sample that was collected 43 days prior to hemolysis.Discussion: Based on the results of this ongoing study, the sustained elevations in CD41+, CD45+, and CD146+ MP quantities were an indication of an imminent thrombotic event in LVAD patients. Because these heightened quantities occurred months prior to the diagnosis, their levels may be useful to identify and prevent thrombosis in LVAD patients. With regard to hemolysis, since elevated MP levels were only observed a few days prior to diagnosis, it is unlikely that MP levels would be an effective method to identify and prevent hemolysis in LVAD patients. We are evaluating seven additional patients enrolled in this study, will consent new patients as they emerge, and continue to follow all patients long-term. The physiological/pathological function of these blood MPs will be investigated. DisclosuresNo relevant conflicts of interest to declare.

Impact of short-term mechanical circulatory support with extracorporeal devices on postoperative outcomes after emergency heart transplantation: Data from a multi-institutional Spanish cohort

ObjectivesWe sought to investigate the potential impact of preoperative short-term mechanical circulatory support (MCS) with extracorporeal devices on postoperative outcomes after emergency heart transplantation (HT). MethodsWe conducted an observational study of 669 patients who underwent emergency HT in 15 Spanish hospitals between 2000 and 2009. Postoperative outcomes of patients bridged to HT on short-term MCS (n=101) were compared with those of the rest of the cohort (n=568). Short-term MCS included veno-arterial extracorporeal membrane oxygenators (VA-ECMOs, n=23), and both pulsatile-flow (n=53) and continuous-flow (n=25) extracorporeal ventricular assist devices (VADs). No patient underwent HT on intracorporeal VADs. ResultsPreoperative short-term MCS was independently associated with increased in-hospital postoperative mortality (adjusted odds-ratio 1.75, 95% CI 1.05–2.91) and overall post-transplant mortality (adjusted hazard-ratio 1.60, 95% CI 1.15–2.23). Rates of major surgical bleeding, cardiac reoperation, postoperative infection and primary graft failure were also significantly higher among MCS patients. Causes of death and survival after hospital discharge were similar in MCS and non-MCS candidates. Increased risk of post-transplant mortality affected patients bridged on pulsatile-flow extracorporeal VADs (adjusted hazard-ratio 2.21, 95% CI 1.48–3.30) and continuous-flow extracorporeal VADs (adjusted hazard-ratio 2.24, 95% CI 1.20–4.19), but not those bridged on VA-ECMO (adjusted hazard-ratio 0.51, 95% CI 0.21–1.25). ConclusionsPatients bridged to emergency HT on short-term MCS are exposed to an increased risk of postoperative complications and mortality. In our series, preoperative bridging with VA-ECMO resulted in comparable post-transplant outcomes to those of patients transplanted on conventional support.

Implantable Cardioverter Defibrillator for Primary Prevention in Patients with Severe Ventricular Dysfunction Awaiting Heart Transplantation

BackgroundDespite an increase in patients with end-stage heart failure, the acceptance rate has been going down in recent years owing to a change in donor demographics. Furthermore, the rate of emergency heart transplantation has progressively increased. The result is an increase in the time awaiting heart transplantation in elective patients and therefore in the risk of sudden death in this population. Implantable cardioverter defibrillators (ICDs) could be a preventive option in these cases. However, indications for the implantation in this population are not well established. ObjectiveWe sought to evaluate the effectiveness of ICDs for primary prevention in patients with left ventricular ejection fraction (LVEF) ≤30% included on the heart transplantation list. MethodsRecords from patients accepted for heart transplantation in our institution from January 1, 2006, to July 30, 2012, and whose LVEF was <31% were reviewed. Patients who received ICDs for primary prevention (n = 28) were compared with patients without ICDs (n = 51). Descriptive and univariate (χ2 and t tests) statistics and Kaplan-Meier survival curves were used for analyses. ResultsWith a median follow-up of 77 days (range 1–1,231), the overall mortality in the ICD group was 7.1% (2/28) and in the non-ICD group was 17.6% (9/51; P = .062). The main cause of death in patients without ICDs was sudden death (5/9, 55.6%), followed by heart failure (4/9, 44.4%). In patients with ICDs, heart failure was the only reported cause of death. Appropriate ICD therapies were recorded in 42.9% (12/28) in this population. ConclusionsThis study suggests that ICD could reduce the risk of sudden death in patients with LVEF ≤30% while awaiting heart transplantation. However, more studies are needed to confirm these results.

The use of eptifibatide for suspected pump thrombus or thrombosis in patients with left ventricular assist devices

Pump thrombosis in patients with left ventricular assist devices (LVADs) continues to present treatment challenges. Anti-coagulation strategies used to treat this complication are empiric and without firm data for guidance. The addition of a platelet glycoprotein IIb/IIIa inhibitor to intravenous anti-coagulation has been suggested by several case series and recent guidelines. The aim of this study was to evaluate our use of eptifibatide for the treatment of suspected pump thrombus/thrombosis. This retrospective, single-center cohort study was performed at Barnes-Jewish Hospital. The medical informatics system was queried to identify all LVAD patients who received eptifibatide for suspected pump thrombus/thrombosis from January 1, 2011, through April 30, 2013. A total of 17 patients (16 HeartMate II [Thoratec, Pleasanton, CA], 1 HeartWare [HeartWare International Inc, Framingham, MA]) with 22 separate administration attempts received eptifibatide (dose range, 0.1-2 μg/kg/min) for suspected pump thrombus/thrombosis presenting as one or more of the following findings: elevated lactate dehydrogenase, decreased haptoglobin, elevated plasma free hemoglobin, LVAD dysfunction, or new, persistently high LVAD power. The mean time from device implantation to eptifibatide therapy was 47.34 days (range, 3.88-397.67 days). Of the 22 attempts, 5 (22.7%) resulted in resolution of 1 or more patient-specific indicators of LVAD thrombus/thrombosis. Three patients (17.6%) had resolution of an indicator while also remaining free from continued hemolysis, death, pump exchange, or emergent heart transplant. Bleeding events were common, with 11 patients (64.7%) experiencing bleeding during the infusion. Seven patients (41.2%) died, with intraparenchymal hemorrhage as the cause of death in 2 patients. Pump exchange was performed in 3 patients. Our limited experience indicates the risk of using eptifibatide outweighs the proposed benefit of salvaging the existing LVAD in the setting of suspected pump thrombus/thrombosis at our institution.

Transapical Left Ventricular Vent (TLVV) during veno-arterial ECMO support: a bridge to solution in acute cardiogenic shock

Introduction: One of the main limitations of Veno-Arterial ECMO (VA-ECMO) support is the inappropriate unloading of the Left Ventricule (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of a recovery or the feasibility of other definitive treatments such as permanent LVAD implantation or emergency heart transplantation. The solution proposed by our center is the surgical implantation of a transapical LV vent (TLVV) through a minimal invasive approach. TLVV reduces significantly the pulmonary edema and it gave the chance to convert VA- ECMO circuit to a short-term LVAD as a bridge to solution. Methods: From January 2010 to June 2012, 16 consecutive pediatric and adult patients supported by pheripheral AV ECMO for acute profound cardiogenic shock underwent TLVV implantation. Cannulation was done in the ICU through a mini-torachotomy with the seldinger technique using an arterial high-flow multiperforated cannula. TLVV was subsequently connected to the venous inflow line of the AV ECMO. The switch from AV ECMO to short term LVAD has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A ECMO) and the subsequent weaning from the oxygenator. Results: In-hospital mortality was%. In 12 patients (75,0%) pulmonary function significantly improved after implanting TLVV and the VA ECMO circuit was simplified to a short term LVAD through an intermediate stage of A-A ECMO in order to evaluate the right ventricular and the pulmonary function in two different times. Ten pts were successfully bridged to a definitive treatment: heart transplantation in 3 patients, permanent LVAD implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%). Conclusions: In our series the double drenaige both of the right and the left side of the heart improved pulmonary function and it gave the possibility to switch from the VA ECMO to a short-term LVAD in the majority of cases. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an VA ECMO, TLVV implantation is useful in order to identify the best candidate for permanent LVAD, heart transplantation or recovery reducing significantly the risk of unsuccess.

Preoperative INTERMACS Profiles Determine Postoperative Outcomes in Critically Ill Patients Undergoing Emergency Heart Transplantation

Background— Postoperative outcomes of patients with advanced heart failure undergoing ventricular assist device implantation are strongly influenced by their preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles. We sought to investigate whether a similar association exists in patients undergoing emergency heart transplantation. Methods and Results— By means of the Spanish National Heart Transplant Registry database, we identified 704 adult patients treated with emergency heart transplantation in 15 Spanish centers between 2000 and 2009. Post-transplant outcomes were analyzed pertaining to patient preoperative INTERMACS profiles, which were retrospectively assigned by 2 blinded cardiologists. Before transplantation, INTERMACS profile 1 (critical cardiogenic shock) was present in 207 patients, INTERMACS profile 2 (progressive decline) in 291, INTERMACS profile 3 (inotropic dependence) in 176, and INTERMACS profile 4 (resting symptoms) was present in 30 patients. In-hospital postoperative mortality rates were, respectively, 43%, 26.8%, and 18% in patients with profiles 1, 2, and 3 to 4 ( P &lt;0.001). INTERMACS 1 patients also presented the highest incidence of primary graft failure (1: 31.3%, 2: 22.3%, 3–4: 21.8%; P =0.03) and postoperative need for dialysis (1: 33.2%, 2: 18.9%, 3–4: 21.5%; P &lt;0.001). Adjusted odds-ratios for in-hospital postoperative mortality were 4.38 (95% confidence interval, 2.51–7.66) for profile 1 versus 3 to 4, 2.49 (95% confidence interval, 1.56–3.97) for profile 1 versus 2, and 1.76 (95% confidence interval, 1.02–3.03) for profile 2 versus 3 to 4. Long-term survival after hospital discharge was not influenced by preoperative INTERMACS profiles. Conclusions— Preoperative INTERMACS profiles determine outcomes after emergency heart transplantation. Results call for a change in policies related to the management of heart transplant candidates presenting with INTERMACS profiles 1 and 2.

Heart transplantation in a patient with recurrent early extensive endocarditis

Active valvular endocarditis could be considered a contraindication to heart transplantation. Nevertheless, there have been some reports of success with this form of treatment, despite the characteristics of the infection and its aggressive nature. Here, we describe the case of a patient with acute bicuspid aortic valvular endocarditis caused by Staphylococcus aureus and with a periannular abscess. Cryopreserved aortic homograft replacement of the aortic root was initially carried out, in addition to debridement and reconstruction of the interventricular septum with a pericardial patch. Early recurrence occurred, however, with extensive tissue destruction, a periaortic abscess and involvement of multiple valves, associated with severe sepsis. In view of the failure of 'conventional' surgery, an emergency heart transplantation was decided on after discussing the case with the Spanish National Transplant Organization (ONT), because of the theoretical contraindication of transplantation in this case. Transplantation was finally carried out after a waiting period of 3 days, in emergency code conditions, and the postoperative course proved uneventful, with no reinfection during the follow-up period. The present case suggests that heart transplantation may be an alternative option in patients suffering aggressive endocarditis with extensive involvement of the heart structures.

Use of the model for end-stage liver disease score for guiding clinical decision-making in the selection of patients for emergency cardiac transplantation

The outcomes of emergency cardiac transplantation remain controversial, but recipient selection is essential for success. With a shortage of organs, it is essential to determine an objective method, such as a risk score, for choosing patients who are at too great a risk to undergo cardiac transplantation. In this study, we analysed the model for end-stage liver disease in terms of predicting operative mortality after emergency cardiac transplantation. We analysed the Nancy University database of heart transplantation and selected all patients who underwent emergency heart transplantation between January 2005 and January 2012. The calibration and discriminatory power were evaluated to determine the model for end-stage liver disease (MELD) score. Preoperative and peri-operative variables regarding the prediction of operative mortality were analysed by univariate and multivariate logistic regression models. Forty-three patients underwent emergency cardiac transplantation. The operative mortality was 20.9% (n = 9). The Hosmer-Lemeshow test demonstrated a calibrated model for predicting operative mortality (P = 0.15), and the MELD score presented an excellent discrimination between survivors and non-survivors (AUC: 0.89 ± 0.05; 95% CI: 0.79-0.99). In the univariate analysis, an MELD score of ≥ 16 and bilirubin concentration were predictive markers of operative mortality. Multivariate logistic regression tested the contribution of the univariate risk predictors (P < 0.15) and confirmed that an MELD score of ≥ 16 was predictive of operative mortality. The MELD score appears to be adequate for predicting operative mortality among patients who undergo heart transplantation. The MELD score could therefore be used to guide clinical decision-making for emergency transplantation.

Associations between Endothelin-1 and Adiponectin in Chronic Heart Failure

Objectives: Endothelin-1 (ET-1) induces cardiac hypertrophy, whereas adiponectin may elicit protective effects in the vasculature and myocardium. We therefore evaluated the relationship between plasma ET-1 and adiponectin levels in heart failure (HF) patients, and the association between adiponectin expression and ET-1-induced hypertrophy of human cardiomyocytes (HCM) in vitro. Methods: One hundred seventeen patients with chronic HF were enrolled into this study. A group of 7 patients with end-stage HF undergoing heart transplantation was included in the histopathological study. Baseline clinical evaluations and laboratory measurements were performed. HCM cultures were studied to investigate the effect of ET-1 on cell size and adiponectin expression. Results: Plasma ET-1, adiponectin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) increased with the severity of HF. Higher New York Heart Association functional class, plasma ET-1, adiponectin, and NT-proBNP levels were significant predictors of adverse outcomes in these patients. The myocardial expression of adiponectin was significantly higher in the recipient hearts of patients undergoing emergency or urgent heart transplantation. In cell culture, ET-1 significantly increased cell size and adiponectin expression in HCM. Conclusions: Adiponectin was significantly elevated in HF and was significantly associated with ET-1. The study provides a basis for further investigation of ET-1 and adiponectin modulation as a therapeutic strategy for ventricular remodeling in HF.

597 Impact of Infected Donors on Emergency Heart Transplantation

597 Impact of Infected Donors on Emergency Heart Transplantation

Emergency Heart Transplantation Outcome: The Italian Experience

The National Program for Emergency Heart Transplantation (NP) was implemented in 2005 is managed at the national level by the Italian National Transplant Center. Patients admitted to the NP must be undergoing one of the following treatments: short-term Ventricular Assist Device (VAD); complicated medium or long-term VAD; complicated Total Artificial Heart; or mechanical ventilation associated with an Intra-Aortic Balloon Pump and Continuous Inotrope Therapy (intravenously). The aim of this study was to evaluate the NP experience from January 1, 2008, to December 31, 2009. We analyzed the number of requests (both fulfilled and not fulfilled), the timeliness of organ availability as well as graft and recipient survivals at 1 year. During the study period, 108 patients were admitted to the NP. The most frequent causes of admission were dilated cardiomyopathies (42.7%) and congenital cardiomyopathies (28.7%). Overall, whereas 12 subjects improved 65 patients underwent heart transplantation (60.2%) and 43 did not undergo surgery (39.8%) because of 31 succumbing before a heart became available. The median waiting time for heart transplantation was 3 days (range = 0.1–22), compared with median waiting time for elective heart transplantation (EHT) of 2.47 years. Graft and recipient survivals were 76.0 ± 1.06 compared with superior graft and recipient survivals for EHT during the same period (87.1 ± 2.0). However, implementation of NP has guaranteed heart availability at a short median time, thus allowing equitable management of this procedure.

Management of acute left ventricular dysfunction after primary percutaneous coronary intervention for ST elevation acute myocardial infarction

Primary percutaneous coronary intervention (PCI) decreases myocardial damage and reduces the occurrence of mechanical complications and acute heart failure in patients with ST elevation myocardial infarction (STEMI). Nevertheless, left ventricular (LV) dysfunction remains the leading cause of in-hospital mortality in all subsets of patients and particularly for those in whom primary PCI fails to reopen the infarct-related artery. The clinical scenarios of acute LV failure are heart failure and cardiogenic shock, both conditions being associated with extremely poor outcomes. It has been estimated that LV failure accounts for >75% of the cases of shock complicating acute STEMI. As compared to similar situations, the decision-making process in these patients can potentially benefit from the known coronary anatomy and, in many instances, from the immediate implantation of an intraaortic balloon pump at the time of PCI in selected groups of patients. A thorough clinical and instrumental evaluation is mandatory to discriminate patients who will likely recover (either spontaneously or with further conventional procedures) from those who have irreversible myocardial injury and should be screened for LV assist devices and/or emergent heart transplantation. In this review, we provide a practical diagnostic and therapeutic algorithm that may be helpful for the clinical management of patients with acute LV failure after primary PCI.

Prognosis in patients with severe heart failure referred for heart transplantation—POLKARD-HF 2003–2007

POLKARD-HF study was a prospective registry of patients, referred for the heart transplantation. The registry collected data on factors influencing the prognosis of patients. The death or the emergency heart transplantation (UNOS status 1) was assumed as the endpoint in the distant observation. 983 patients (88% men, mean age <50) with severe heart failure (HF), referred to 4 centers were analyzed. The average period of observation was 601 days (1 to 1462 days). The Kaplan-Meier probability of surviving 1 year without urgent heart transplantation was 80%, 2 years 70%, and 3 years 67%. HF etiology was dilated cardiomyopathy in 49.4% and ischemic cardiomyopathy in 43.2%. There was only a trend in favor of survival of patients with dilated cardiomyopathy (p=0.1). Prognosis in patients with NYHA classes II and III did not differ but in NYHA IV, was significantly worse. The probability of 6-month survival was 60%, 1-year--50%, and 3-year--40%. In Kaplan-Meier analysis survival was worse for pts with pulmonary artery systolic pressure ≥50 mmHg, pulmonary capillary pressure ≥25 mmHg, left ventricular ejection fraction ≤17%, functional NYHA class IV, systemic systolic arterial pressure ≤90 mmHg, hsCRP≥6.5 mg/L, NTpro-BNP≥4302, Na serum level≤135 mEq/L, BMI≤23.8, and HFSS≤7.19. When only biochemistry parameters were analyzed using ROC, sodium plasma levels ≤135 mEq/L alone gave ROC 58.3% and inclusion of NTpro-BNP≥4302 pg/mL into the model, increased the predictive value up to 61.2%.

A Rare Cause of Heart Failure Treated by Heart Transplantation: Noncompaction of the Ventricular Myocardium

Noncompaction of the ventricular myocardium is a rare cardiomyopathy due to an arrest of myocardial morphogenesis. The characteristic echocardiographic findings are prominent myocardial trabeculations and deep intertrabecular spaces communicating with the left ventricular cavity. The clinical manifestations include heart failure (HF) signs, ventricular arrhythmias, and cardioembolic events. We describe an illustrative case of noncompaction of the ventricular myocardium associated with bicuspid aortic valve, a 42-year-old male presenting a refractory acute heart failure successfully treated by emergency heart transplantation.

Differences in Early Postoperative Complications in Elective and Emergency Heart Transplantation

Introduction and Objectives The immediate postoperative period is a critical phase in heart transplantation. Severe complications occur that may influence short-term and medium-term morbidity and mortality in these patients. The aim of this study was to analyze the incidence of severe complications in emergency and nonemergency transplantations. Materials and Methods We studied 152 patients who underwent heart transplantation between 2001 and 2007. Combined transplantations and retransplantations were excluded. Two groups were considered: emergency transplantations (36 patients, 24%) and elective transplantations. We compared survival and occurrence of infection, primary graft failure (PGF), renal and hepatic failure, respiratory complications, cardiac tamponade, arrhythmias, reoperation, and intensive care unit (ICU) stay. Results The emergency transplantation group had a greater number of ischemic patients, with a more prolonged cardiopulmonary bypass time, and a larger proportion of donors were women. Overall mortality in the intensive care unit was 2.6%, with no differences between groups. However, emergency procedures were significantly associated with a higher incidence of PGF, need for intraaortic balloon pump, and a more prolonged mechanical ventilation time, as well as a greater number of bacterial infections and a significantly longer ICU stay. Conclusions In our series, emergency transplantation showed no greater perioperative mortality. We observed a greater number of severe complications, such as PGF, bacterial infection, and more prolonged mechanical ventilation time.

Is an Emergency Heart Transplantation Justified?

Introduction Emergency heart transplantation remains an important controversy due to the shortage of donors and the previously demonstrated results inferior to other patients. These recipients display a worse clinical status and their donors are more often considered suboptimal. Nevertheless, it is the only therapeutic option for patients with advanced cardiomyopathy and acute decompensation with no response to other therapies. We compared results among the emergency indication with those of elective transplants. Methods We analyzed the 213 patients who underwent cardiac transplantation in our center up to December 2004 to compare emergency with elective heart transplantations for preoperative and surgical variables as well as outcomes. Results A higher percentage of emergency patients were New York Heart Association class IV, displayed renal dysfunction, and were women. Regarding donors, a higher percentage were over 40 years of age. No differences were observed in the early and first-year mortality or morbidity rates, although we noted a greater 5-year mortality rate among emergency cases. Conclusions In our center emergency heart transplantation was associated with only slightly worse results compared with elective transplantations. Both donors and recipients should be carefully selected to improve results.

Postoperative circulatory support in adult cardiac surgery: recent experience from one center

Between December 1998 and December 2001, circulatory support (CS) was used in seven patients submitted to cardiac surgery in our institution. The sample was composed of seven patients whose age varied from 32 to 78 years old (mean 51.85 years), and there were five male and two female patients. Coronary artery bypass grafting was performed in six patients and mitral valve replacement in one. Four patients presented failure of one ventricle and three had failure of both ventricles in the immediate postoperative period. The system most commonly used was the Bio-pump® centrifugal pump, used in all cases; in one case biventricular support with the Bio-pump was changed after 48 hours to a biventricular DAV-InCor® system (temporary pulsatile ventricular assist device). Intra-aortic balloon pumping was used as secondary support in four cases with the aim of delivering a pulsatile flow. The mean support time was 51 hours and 38 min/patient, the shortest time was 4 hours and 6 min, and the longest was 151 hours and 20 min. There were five deaths during CS and the cause of them all was multiple organ failure. Two patients were discharged from CS (28% removal), one was bridged to emergency heart transplant and the other recovered ventricle function (bridge to recovery). The patient bridged to recovery is now in 12 months of followup, and in New York Heart Association class II. Although the mortality index is still high (86%), we were able to bridge 28% of the patients to a more definitive treatment or status (transplant or recovery). The overall survival was 14%, but long-term survival of bridged patients is 50% and we expect to increase it in the near future. Table 1

Use of aspirin in conjunction with angiotensin-converting enzyme inhibitors does not worsen long-term survival in heart failure

Background: A negative interaction has been shown to exist between aspirin and angiotensin-converting enzyme inhibitors (ACE-I) in subjects with heart failure. We explored the effect of combined ACE-I and aspirin therapy compared to ACE-I without aspirin on clinical outcomes in patients with heart failure. Methods: 430 consecutive subjects (70±14 years, 55% male, 41% with coronary artery disease) released from the hospital with a primary diagnosis of heart failure were classified into three groups based on the use of aspirin and ACE-I at discharge: ACE-I without aspirin (group I, n=134), ACE-I with aspirin (group II, n=138) and no ACE-I (group III, n=158). Follow-up (all-cause mortality and the composite end-point of mortality or emergent heart transplant) was available in 406 (94%) patients at a median duration of 28 months. Differences in outcomes between patient groups were compared using contingency tables, Kaplan–Meier survival, and Cox regression analyses. Similar analyses were conducted in four predefined subsets (patients with and without coronary artery disease, and those with left ventricular ejection fraction ≤45%, and >45%). Results: Death and the composite end-point occurred in 155 (38%) and 165 (41%) patients, respectively. In the total cohort as well as in the four subsets, the treatment group showed no association with clinical outcomes in univariate or multivariate analyses. Conclusions: In patients with a principal discharge diagnosis of heart failure, the use of aspirin, in combination with ACE-I, does not worsen long-term survival compared to the use of ACE-I without aspirin.

The Tei index: A new prognostic index for patients with symptomatic heart failure

Background: The Tei index (TI) is a new echocardiographic/Doppler index of combined systolic and diastolic function, calculated as isovolumic relaxation time plus isovolumic contraction time divided by ejection time. This purpose of this study was to explore the prognostic value of TI in patients with heart failure from left ventricular (LV) systolic dysfunction. Methods: Of 105 randomly selected participants with LV ejection fraction less than 30% and at least 1 hospitalization for heart failure, we included 60 patients in whom assessment of the TI was technically feasible. Using the patients' medical records, we collected information on several clinical and echocardiographic variables. We monitored patients for a mean duration of 24 ± 19 months from the time of the echocardiogram. The study outcome was the composite of death from any cause or emergency heart transplant. Results: The median value (interquartile range) of TI was 0.79 (0.54, 1.14). Of 57 patients (95%) with complete follow-up, 28 (49%) died, and 2 (3.5%) underwent emergency heart transplant at a mean duration of 17 ± 14 months. Kaplan-Meier survival curves showed a higher cumulative incidence of the study end point among patients in the highest quartile of TI, compared with the other 3 quartiles (log rank P =.002). After adjustment for potential clinical confounders, TI in the highest quartile (TI > 1.14) was a significant independent predictor of the composite end point (odds ratio 5.3, 95% confidence interval 1.9 to 14.9, P =.0018). Conclusion: Prolonged TI (>1.14) is a powerful and independent predictor of poor clinical outcome in patients with symptomatic heart failure and severe LV systolic dysfunction. (J Am Soc Echocardiogr 2002;15:864-8.)

Intra-aortic balloon counterpulsation in the emergency department: a 7-year review and analysis of predictors of survival

Background: Intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS) is suggested as bridging therapy to definite emergency revascularization, heart transplantation and acute valvular repair. Data concerning the use of IABP counterpulsation in an emergency department (ED) are rare. Patients and Methods: We reviewed retrospectively the charts of patients who had been treated by IABP counterpulsation in the ED of a tertiary care university hospital during a 7-year period. We analyzed indications for IABP treatment, complications of IABP use and studied various predictors for 30-day survival. Results: Overall 88 (68 male) patients, median age 60 years (IQR 53–69 years) were treated with IABP counterpulsation. CS was caused by acute coronary syndrome (ACS), acute cardiomyopathy decompensation of (CMP) and aortic stenosis (AS) in 77 (87%), ten (12%) and one (1%) patients, respectively. Complications attributed to the insertion or maintenance of IABP were observed in nine (10%) patients. Thirty four patients (38%; 24 male) survived. Compared to non-survivors, these patients were younger (56 vs. 63 years; P<0.023) and had significant lower serum lactate levels before IABP insertion (3 vs. 5.5 mmol/l; P<0.002). Logistic regression analysis identified age ( P<0.04) and serum lactate serum level before IABP ( P<0.01) as independent predictors for survival. In the 77 patients with ACS PTCA tended to be associated with a higher rate of survival ( P<0.09). Conclusion: Initiation of IABP counterpulsation in patients with CS in an ED appears safe. Low levels of serum lactate and younger age were independent predictors of survival. In patients with ACS PTCA may contribute to improved outcome.