Mechanical Ventricular Assistance Research Articles

Morbidity and mortality of long-term mechanical ventricular assistance: Feedback from a center

Morbidity and mortality of long-term mechanical ventricular assistance: Feedback from a center

Electronic Health Record-Based Deep Learning Prediction of Death or Severe Decompensation in Heart Failure Patients

BackgroundSurgical mechanical ventricular assistance and cardiac replacement therapies, although life-saving in many heart failure (HF) patients, remain high-risk. Despite this, the difficulty in timely identification of medical therapy nonresponders and the dire consequences of nonresponse have fueled early, less selective surgical referral. Patients who would have ultimately responded to medical therapy are therefore subjected to the risk and life disruption of surgical therapy. ObjectivesThe purpose of this study was to develop deep learning models based upon commonly-available electronic health record (EHR) variables to assist clinicians in the timely and accurate identification of HF medical therapy nonresponders. MethodsThe study cohort consisted of all patients (age 18 to 90 years) admitted to a single tertiary care institution from January 2009 through December 2018, with International Classification of Disease HF diagnostic coding. Ensemble deep learning models employing time-series and densely-connected networks were developed from standard EHR data. The positive class included all observations resulting in severe progression (death from any cause or referral for HF surgical intervention) within 1 year. ResultsA total of 79,850 distinct admissions from 52,265 HF patients met observation criteria and contributed >350 million EHR datapoints for model training, validation, and testing. A total of 20% of model observations fit positive class criteria. The model C-statistic was 0.91. ConclusionsThe demonstrated accuracy of EHR-based deep learning model prediction of 1-year all-cause death or referral for HF surgical therapy supports clinical relevance. EHR-based deep learning models have considerable potential to assist HF clinicians in improving the application of advanced HF surgical therapy in medical therapy nonresponders.

Early reduction of pulmonary arterial hypertension in patients using a long-term mechanical ventricular assistance device: a cross-sectional study.

Severe pulmonary arterial hypertension (PAH) is a contraindication for heart transplantation (HT). It has been correlated with increased early and late mortality, mainly associated with right ventricular failure. Ventricular assistance devices (VADs) can promote reduction of intracardiac pressures and consequent reduction of PAH over the medium and long terms, thus enabling future candidature for HT. The diminution of early pulmonary pressure within this scenario remains unclear. To evaluate the reduction of PAH and correlate data from right catheterization with the earliness of this reduction. Cross-sectional study in a general hospital in São Paulo, Brazil. This was a retrospective analysis on the medical records of patients undergoing VAD implantation in a single hospital. Patients for whom VAD had been indicated as a bridge to candidature for HT due to their condition of constant PAH were selected. Four patients with VADs had constantly severe PAH. Their mean pulmonary artery systolic pressure (PASP) before VAD implantation was 66 mmHg. Over the 30-day period after the procedure, all the patients evolved with a drop in PASP to below 60 mmHg. Their new average was 36 mmHg, which was a drop of close to 50% from baseline values. The one-year survival of this sample was 100%. VAD implantation can reduce PAH levels. Early reduction occurred in all patients. Thus, use of VAD is an important bridge tool for enabling candidature for HT among patients with constantly severe PAH.

Withdrawal of active treatments in terminally ill heart failure patients

IntroductionHeart failure (HF) constitutes a growing public health problem in aging societies: when pharmacological therapies fail, HF can be sustained intensively if patients are eligible for either orthotopic heart transplantation (OHT) or mechanical ventricular assistance, otherwise additional treatments could be inappropriate.In December 2017 Italian Legislator brought in the provisions regarding the end-of-life choices, including indications for withdrawing and withholding life-sustaining therapies.The aim of our study was to provide an overview of the daily practice of our center with regard to terminally ill HF patients. Methods and resultsIn April 2019 the 7 intensivist cardiologists and 21 nurses of a tertiary ICCU were asked in, to complete a questionnaire relating to a hypothetical terminally ill HF patient for whom the decision to withdraw active treatment had been made. To assess current practice, we also identified patients who died in the previous 12 months. Out of 29 deceased patients, 18 were identified as terminally ill HF, with no indications for therapy upgrading.We observed a striking disparity between belief and practice. ConclusionsOur survey showed that the care of terminally ill HF patients in our ICCU was characterized by aggressive use of medical therapy and invasive technology.The wide disparity between belief and practice could be in part a consequence of lack of professional training, with regard to law, ethics and communication techniques.

Heart Transplantation in an Aging Society: Impact of Recipient Age on Postoperative Outcome

Purpose Heart transplantation (HTx) represents the preferred therapy for end-stage heart failure patients. In an aging society, a rising number of older patients suffers from heart failure today. Simultaneously, the number of performed HTx is limited by the lack of suitable donor organs. Therefore, the questions arise whether older patients should be transplanted or not. In contrast to donor age, which definitely impacts the outcome after HTx, the impact of recipient age is less well analyzed. Methods Between 2010 and mid 2020 a total of 178 patients underwent HTx in our department. Mean recipient age at transplantation was 54.18±11.61 years (minimum 21.71 years, maximum 72.63 years). Patients were retrospectively divided into three groups according to their age (Group 1: age 60 years, n=65. Results Donor age significantly differed between the three groups (Group 1: 40.63±10.74 years; Group 2: 41.40±13.61 years; Group 3: 46.57±12.54 years, p=0.02). In addition, patients of group 1 were significantly more often listed high urgency listing status (p=0.03). However, preoperative mechanical ventricular assistance, cardiac graft function and allograft ischemia were comparable between all groups. We did not find significant differences for the incidence of severe primary graft dysfunction necessitating mechanical circulatory support (p=0.44) as well as common postoperative major morbidity such as haemodialysis (p=0.10), neurological events (p=0.60), bleeding complications (p=0.79), infections (p=0.40) and early graft rejection (>1R) (p=0.32). Postoperative hospitalization and mechanical ventilation times did not differ either. Furthermore, Fisher-Freeman-Halton test revealed no significant differences concerning the 30-day survival (Group 1: 96.6%; Group 2: 87.5%; Group 3: 87.7%, p=0.44) as well as one-year survival of the three groups (Group 1: 79.2%; Group 2: 82.1%; Group 3: 69.8%, p=0.29). Conclusion In our single-center analysis recipient age did not significantly impact the outcome after HTx. Both postoperative morbidity and mortality were comparable for patients of different age groups. We did not observe any significant disadvantages for recipients older than 60 years compared with their younger counterparts. Thus, after careful and individual selection we support HTx in elderly patients.

Outcomes of Abdominal Surgery in Patients With Mechanical Ventricular Assist Devices: A Multi-institutional Study.

The aim of this study was to examine the outcomes of elective and emergent abdominal operations performed in end-stage heart failure patients supported with ventricular assist devices (VADs). With the growing volume of end-stage heart failure patients receiving VADs, an increasing number of these patients require surgery for noncardiac pathology. There is a paucity of studies on the safety of abdominal operations in this population. We performed a retrospective chart review across 3 hospitals of patients with VADs who underwent abdominal surgeries between 2003 and 2015. We used Chi-square, Fisher exact, and Mann-Whitney U tests for comparison of elective and emergent cases. Fifty-seven patients underwent 63 operations, of which 23 operations were elective, 24 were emergent, and 16 were emergently performed in the same admission as VAD placement and analyzed separately. Patients undergoing elective versus emergent procedures had similar comorbidities (Charlson score 2.9 vs 3.0). 43% versus 32% of patients had VADs as a destination therapy. Although perioperative anticoagulation approach was variable, holding warfarin and starting heparin/enoxaparin/bivalirudin bridge was most common (65% vs 54%). Although 2-fold higher in the emergent group (50 vs 100 mL, P = 0.06), median estimated blood loss was low. Postoperative bleeding requiring transfusion was not very common (13% vs 8%), whereas rate of ischemic cerebrovascular accident (4% each) and venous thromboembolism was low (0% vs 13%, P = 0.23). Thirty-day mortality rate was 4% versus 17%, P = 0.19. VAD patients have an acceptable risk profile for abdominal surgery.

Pediatric Heart Transplantation in a National Pediatric Hospital J.P. Garrahan (Argentina)

Purpose This abstract review all patients who underwent orthotopic heart transplantation (OHT) at our program (63 transplants) to describe their diagnostic characteristics and the surgical options for terminal heart failure like heart transplant and mechanical assistance. Methods This is a prospective, retrospective, transversal and observational paper. From July 2000, 129 patients have been listed for heart transplantation. Age from 1 to 230 months, female 52%, male:48 %. Range time in waiting list 1 to 3351 days. Diagnosis Dilated Cardiomiopathy: 93, Congenital heart disease 18, Restrictive 14, pulmonary hypertension:2, retransplant:2. Results Three Patients (16, 32, 7 months old) were transplanted with an ABO INCOMPATIBLE HEART DONOR using the “West Protocol”. (Table 2). Due to the lack of suitable donors and its consequence of high mortality on waiting list, in 2006 we have started to use mechanical assistance to let survive patients in terminal condition, and have a chance for transplantation. Sixty three heart transplants where done in sixty one patients. Fourty nine were assisted with Mechanical Ventricular Assistance (MVA) before transplantation. Berlin Heart® device in: 48 patients and Heart Ware® device: 1 patient. Age: 13 to 198 months; weight: 6 to 90,0 kg.; univentricular (54%) and biventricular (46%). No surgical deaths and no REDO because surgical bleeding in the MVA series. Seven patients where assisted with ECMO after transplantation, due to primary heart failure, with good results in 6 patients after ECMO weaning. One retransplantation dead. The triple scheme used for immunosuppression therapy was: azathioprine, cyclosporine and steroids. (Graph 7). The actuarial survival rate showed a huge survival level with good quality of life. Conclusion A Cardiac Transplant Program in a Pediatric Public Hospital; in Argentina; provides the opportunity for heart transplantation to infants and pediatric population with terminal heart failure. Survival rate and quality of life are satisfactory.

Spanish Heart Transplant Registry. 29th Official Report of the Spanish Society of Cardiology Working Group on Heart Failure

Introduction and objectivesThe present report updates the characteristics and results of heart transplantation in Spain, mainly focused in the 2008-2017 period. MethodsWe describe the recipient and donor characteristics, surgical procedures, and outcomes of heart transplants performed in 2017. The 2017 data were compared with those obtained from 2008 to 2016. ResultsA total of 304 cardiac transplants were performed in 2017. Between 1984 and 2017, 8173 procedures were performed, 2689 of them after 2008. Significant temporal trends were observed in recipient characteristics (lower pulmonary vascular resistance, lower use of mechanical ventilation, and a higher percentage of diabetic patients and those with previous cardiac surgery), donor characteristics (older donor age and a higher percentage of female donors and those with a prior cardiac arrest) and procedures (lower ischemia time). In 2017, 27% of patients were transplanted after undergoing mechanical ventricular assistance (P <.001 for trend). In the last decade, there was a trend to better survival. ConclusionsAround 300 transplants per year were performed in Spain in the last decade. There was a significant increase in the use of pretransplant mechanical circulatory support and a trend to improved survival.

Registro Español de Trasplante Cardiaco. XXIX Informe Oficial de la Sección de Insuficiencia Cardiaca de la Sociedad Española de Cardiología (1984-2017)

Introducción y objetivosThe present report updates the characteristics and results of heart transplantation in Spain, mainly focused in the 2008-2017 period. MethodsWe describe the recipient and donor characteristics, surgical procedures, and outcomes of heart transplants performed in 2017. The 2017 data were compared with those obtained from 2008 to 2016. ResultsA total of 304 cardiac transplants were performed in 2017. Between 1984 and 2017, 8173 procedures were performed, 2689 of them after 2008. Significant temporal trends were observed in recipient characteristics (lower pulmonary vascular resistance, lower use of mechanical ventilation, and a higher percentage of diabetic patients and those with previous cardiac surgery), donor characteristics (older donor age and a higher percentage of female donors and those with a prior cardiac arrest) and procedures (lower ischemia time). In 2017, 27% of patients were transplanted after undergoing mechanical ventricular assistance (P <.001 for trend). In the last decade, there was a trend to better survival. ConclusionsAround 300 transplants per year were performed in Spain in the last decade. There was a significant increase in the use of pretransplant mechanical circulatory support and a trend to improved survival.

Postoperative Right Ventricular Failure in Cardiac Surgery.

Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum’s contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.

Experience With Levosimendan as an Alternative to Catecholamines in Children

SESSION TITLE: Cardiovascular Disease Posters II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: The objective of this study was to report experience with levosimendan in hemodynamically compromised children. METHODS: all patients aged < 18years with severe myocardial dysfunction and dependent on inotrope support, who received levosimendan infusion, were reviewed for clinical, biological and echocardiographic (LV diameters, shortening fraction, sub-aortic Velocity Time Integral) data. Levosimendan was administered as a continuous intravenous infusion over 24 hours, starting 0.1 micrograms per kg per mn and increased up to 0.2micrograms per kg per mn. Blood pressure and heart rate were continuously monitored, ECG and Echocardiography recorded before, 3 and 5 days after starting levosimendan. RESULTS: From 2007 to 2011, 8 patients aged 3.5 months to 13years (mean 41months) received 10 courses of levosimendan. All were on milrinone support (mean dose 0.63 mcg/kg/mn) and 3 on associated dobutamine. All achieved the 24-hour course of levosimendan without any complication. Catecholamines were successfully discontinued in 5 cases (3 weaned off at 24th hour and 2 at 5th day). Average milrinone dose dropped to 0.3 mcg/kg/mn at day-5, p=0.028). mean shortening fraction increased from 10.8%±1.8 before to 12.7± 2.3 at day-3 (p= 0.67), mean Velocity Time Integral from 6±0.6 to 8.7±1.2 cm at day-3 (p= 0.04). Five patients (62.5%) were successfully discharged from CICU: 2 are doing well at 1 and 4.5 years follow-up, 1 died from metabolic disease and 2 were readmitted at 1.5 - and 2-month interval and received a second course of levosimendan. The latter 2 patients did not improve and needed mechanical ventricular assistance (1 died and 1 underwent successful heart transplantation). For the remaining 3 patients, first course levosimendan failed and heart transplantation was performed in an emergency setting (pretransplant mechanical ventricular support in 2). CONCLUSIONS: This small size sample study shows encouraging results of levosimendan in children with uncontrolled myocardial dysfunction. Further studies are needed to assess monitoring, timing and indications for repeated dose infusion during follow-up. CLINICAL IMPLICATIONS: The role of Levosimendant in treating patients who are inotropes dependents should be widely investigated DISCLOSURE: The following authors have nothing to disclose: Fahad Alsohime No Product/Research Disclosure Information

Mechanical Ventricular Assistance as Destination Therapy for End-Stage Heart Failure: Has it Become a First Line Therapy?

Patients with end-stage heart failure have poor quality of life and prognosis. Therapeutic options are scarce and are not available for all. Only few patients can be transplanted every year. Several medical and surgical strategies have shown limited ability to influence prognosis and quality of life. In the past years, technological progress has realized devices capable of providing appropriate hemodynamic stabilization and recovery of secondary organ failure. Recently, these devices have been assessed as definitive treatment for patients who do not qualify for transplantation or/and instead to transplantation ("destination therapy"). This indication is increasingly considered following the results of newest clinical study reporting long-term survival without device correlated adverse events using last generation devices, and acceptable quality of life. The current knowledge about destination therapy and some original data from the DAVID Study (an Italian multicenter prospective study designed to evaluate the patient's survival rate and quality of life of patients implanted with these new devices as long-term support or destination therapy) are summarized herein. -End-stage heart failure (NYHA class IV or stage D) is a vastly growing problem, with a poor prognosis and limited therapeutic options.-Heart Transplantation is nowadays the "gold standard" treatment albeit its inability to serve to the current demand let alone the future one.-The REMATCH study has demonstrated that first generation implantable devices, even with their high number of complications (infectious and thromboembolic events), allowed an improvement of quality and duration of life compared to medical therapy. Further studies have shown that the evolution of VAD technology has reduced device-related complications and consequently improved survival and quality of life of patients with results, according to some authors, similar to cardiac transplantation at least at 2 years from the implantation.-Biotechnology advancements have led to the creation of a new generation of implantable mechanical assist devices: the continuous-flow rotary pumps. Recently entered into clinical use, they seem to represent a promising solution to end -stage-heart failure allowing long-term assistance and an adequate standard of living (Destination Therapy/Bridge to Life).-The DAVID Study, an Italian multicenter prospective study, reports encouraging results in terms of late outcome and quality of life in patients implanted with newest continuous-flow devices as destination therapy. More and more numerous studies are needed to confirm our initial data and for laying the foundations for this new therapeutic frontier face to cardiac transplantation.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: Diagnoses and Surgical Results in 12 Pediatric Patients.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital condition. It responds well to early diagnosis and treatment, but otherwise the prognosis is poor. We present our case series of 12 patients (mean age, 2 ± 2.58 yr; age range, 2 mo-8 yr), emphasizing the diagnostic process and discussing our surgical results. The diagnosis of ALCAPA should be suspected in infants who have dilated cardiomyopathy with electrocardiographic changes that suggest ischemia, and in older children who have isolated mitral regurgitation. When clinical suspicion is high, the results of 2-dimensional echocardiography combined with color-flow Doppler studies in expert hands can establish the diagnosis, thus avoiding angiography in critically ill infants. The treatment of choice in our patients was transfer and reimplantation of the left coronary artery onto the ascending aorta. There were 2 deaths: both were infants in extremis who underwent emergency surgery. An older child with severe ventricular dysfunction was given mechanical ventricular assistance and then heart transplantation. As of this report, all 10 survivors remained well and asymptomatic.

(141) - Predicting Peri-operative Right Heart Failure, Post-implant Survival and Timing of Mechanical Ventricular Assistance

(141) - Predicting Peri-operative Right Heart Failure, Post-implant Survival and Timing of Mechanical Ventricular Assistance

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2013

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

Prognostic value of left atrial volume in patients with dilated cardiomyopathy

BackgroundIncreased left atrial (LA) size is a prognostic marker of mortality in the general population. LA size varies considerably in patients with dilated cardiomyopathy (DCM), but its clinical significance has not been widely studied. ObjectiveTo evaluate the long-term prognostic value of LA volume (LAV) in patients with DCM. MethodsWe prospectively studied patients admitted between January and December 2004 with a diagnosis of DCM, in sinus rhythm. Complete echocardiographic study at rest and after pharmacological stress was performed in all patients.The composite endpoint of mechanical ventricular assistance (MVA), heart transplantation or death during follow-up was assessed by univariate and multivariate analysis using a Cox regression model. ResultsThe study population consisted of 35 patients (68.6% male, mean age 52.0) with DCM, 82.9% of non-ischemic etiology. Ejection fraction (EF) at rest was 31.1±9.4%.During follow-up, eight patients died, one was placed on MVA and one underwent transplantation. Univariate Cox analysis showed various potential echocardiographic markers of prognosis in our population, including LA size in M-mode (HR 1.12, CI: 0.99–1.26, p=0.067), LAV (HR 1.03, CI: 1.00–1.07, p=0.046), LAV adjusted for body surface area (HR 1.03, CI: 0.99–1.26, p=0.049), E/A ratio (HR 0.99; CI: 0.99–1.81; p=0.060); E/A >2 (HR 7.00, CI: 1.48–32.43, p=0.014) and mitral E/E’ ratio (HR 1.04, CI: 1.00–1.09, p=0.074).The only variable that remained in the multivariate model was LAV, with a cut-off value of 63 ml (HR 7.7, CI: 0.97–60.61, p=0.05). ConclusionsLAV was the only echocardiographic determinant of MVA, heart transplantation or death in our population with DCM. The echocardiographic parameters commonly used for risk stratification such as EF, left ventricular end-diastolic diameter and contractile reserve did not show prognostic significance in our study.

O volume da aurícula esquerda como marcador ecocardiográfico de prognóstico em doentes com miocardiopatia dilatada

BackgroundIncreased left atrial (LA) size is a prognostic marker of mortality in the general population. LA size varies considerably in patients with dilated cardiomyopathy (DCM), but its clinical significance has not been widely studied. ObjectiveTo evaluate the long-term prognostic value of LA volume (LAV) in patients with DCM. MethodsWe prospectively studied patients admitted from January to December 2004 with a diagnosis of DCM, in sinus rhythm. Complete echocardiographic study at rest and after pharmacological stress was performed in all patients.The composite endpoint of mechanical ventricular assistance (MVA), heart transplantation or death during follow-up was assessed by univariate and multivariate analysis using a Cox regression model. ResultsThe study population consisted of 35 patients (68.6% male, mean age 52.0) with DCM, 82.9% of non-ischemic etiology. Ejection fraction (EF) at rest was 31.1±9.4%.During follow-up, eight patients died, one was placed on MVA and one underwent transplantation. Univariate Cox analysis showed various potential echocardiographic markers of prognosis in our population, including LA size in M-mode (HR 1.12, CI: 0.99-1.26, p=0.067), LAV (HR 1.03, CI: 1.00-1.07, p=0.046), LAV adjusted for body surface area (HR 1.03, CI: 0.99-1.26, p=0.049), E/A ratio (HR 0.99; CI: 0.99-1.81; p=0.060); E/A >2 (HR 7.00, CI: 1.48-32.43, p=0.014) and mitral E/E’ ratio (HR 1.04, CI: 1.00-1.09, p=0.074).The only variable that remained in the multivariate model was LAV, with a cut-off value of 63 ml (HR 7.7, CI: 0.97-60.61, p=0.05). ConclusionsLAV was the only echocardiographic determinant of MVA, heart transplantation or death in our population with DCM. The echocardiographic parameters commonly used for risk stratification such as EF, left ventricular end-diastolic diameter and contractile reserve did not show prognostic significance in our study.

290: Experience with levosimendan as an alternative to catecholamines in children

The objective of this study was to report experience with levosimendan in hemodynamically compromised children. all patients aged < 18years with severe myocardial dysfunction and dependent on inotrope support, who received levosimendan infusion, were reviewed for clinical, biological and echocardiographic (LV diameters, shortening fraction, sub-aortic Velocity Time Integral) data. Levosimendan was administered as a continuous intravenous infusion over 24 hours, starting 0.1 micrograms per kg per mn and increased up to 0.2micrograms per kg per mn. Blood pressure and heart rate were continuously monitored, ECG and Echocardiography recorded before, 3 and 5 days after starting levosimendan. From 2007 to 2011, 8 patients aged 3.5 months to 13years (mean 41months) received 10 courses of levosimendan. All were on milrinone support (mean dose 0.63 mcg/kg/mn) and 3 on associated dobutamine. All achieved the 24-hour course of levosimendan without any complication. Catecholamines were successfully discontinued in 5 cases (3 weaned off at 24th hour and 2 at 5th day). Average milrinone dose dropped to 0.3 mcg/kg/mn at day-5, p=0.028). mean shortening fraction increased from 10.8%±1.8 before to 12.7± 2.3 at day-3 (p=0.67), mean Velocity Time Integral from 6±0.6 to 8.7±1.2 cm at day-3 (p=0.04). Five patients (62.5%) were successfully discharged from CICU: 2 are doing well at 1 and 4.5 years follow-up, 1 died from metabolic disease and 2 were readmitted at 1.5 - and 2-month interval and received a second course of levosimendan. The latter 2 patients did not improve and needed mechanical ventricular assistance (1 died and 1 underwent successful heart transplantation). For the remaining 3 patients, first course levosimendan failed and heart transplantation was performed in an emergency setting (pretransplant mechanical ventricular support in 2). This small size sample study shows encouraging results of levosimendan in children with uncontrolled myocardial dysfunction. Further studies are needed to assess monitoring, timing and indications for repeated dose infusion during follow-up.

Invited Commentary

Invited Commentary

Listing and Transplanting Adults With Congenital Heart Disease

An increasing number of patients with congenital heart disease (CHD) are reaching adulthood and may require heart transplantation. The survival of these patients after listing and transplantation has not been evaluated. A total of 41 849 patients (aged >18 years) were listed for primary transplantation during 1995-2009. Patients with a history of CHD (n=1035; 2.5%) were compared with those with other causes (non-CHD group) (n=40 814; 97.5%); 26 055 (62.3%) reached transplantation and were subdivided into those with (reoperation group; n=10 484; 40.2%) and without (nonreoperation group; n=15 571; 59.8%) a previous sternotomy. Survival on the waiting list was similar between groups, but mechanical ventricular assistance was not associated with superior survival to transplantation among CHD patients. CHD patients were more likely to have body mass index <18.5 at transplantation (P<0.0001), were younger, and had fewer comorbidities. Early mortality among patients with CHD was high (reoperation, 18.9% versus 9.6%; P<0.0001; nonreoperation, 16.6% versus 6.3%; P<0.0001), but by 10 years, overall survival was equivalent (53.8% versus 53.6%). Analysis was limited by the lack of specific information regarding the CHD diagnosis in most patients. Adults with CHD have high 30-day mortality but better late survival after heart transplantation. Mechanical circulatory assistance does not improve waiting list survival in these patients. This may be due to a combination of highly complex reoperative surgery and often poor preoperative systemic health.