Orthotopic Heart Transplantation Research Articles

Animal models for partial heart transplantation.

Partial heart transplantation delivers growing heart valve implants by transplanting the part of the heart containing the necessary heart valve only. In contrast to heart transplantation, partial heart transplantation spares the native ventricles. This has important implications for partial heart transplant biology, including the allowable ischemia time, optimal graft preservation, primary graft dysfunction, immune rejection, and optimal immunosuppression. Exploration of partial heart transplant biology will depend on suitable animal models. Here we review our experience with partial heart transplantation in rodents, piglets, and non-human primates. This review is based on our experience with partial heart transplantation using over 100 rodents, over 50 piglets and one baboon. Suitable animal models for partial heart transplantation include rodent heterotopic partial heart transplantation, piglet orthotopic partial heart transplantation, and non-human primate partial heart xenotransplantation. Rodent models are relatively cheap and offer extensive availability of research tools. However, rodent open-heart surgery is technically not feasible. This limits rodents to heterotopic partial heart transplant models. Piglets are comparable in size to children. This allows for open-heart surgery using clinical grade equipment for orthoptic partial heart transplantation. Piglets also grow rapidly, which is useful for studying partial heart transplant growth. Finally, nonhuman primates are immunologically most closely related to humans. Therefore, nonhuman primates are most suitable for studying partial heart transplant immunobiology and xenotransplantation. Animal research is a privilege that is contingent on utilitarian ethics and the 3R principles of replacement, reduction and refinement. This privilege allows the research community to seek fundamental knowledge about partial heart transplantation, and to apply this knowledge to enhance the health of children who require partial heart transplants.

Cardiac implantable electronic devices following orthotopic heart transplantation: insights on indications and outcomes from a single centre experience

Abstract Background Need for cardiac implantable electronic devices (CIED) after orthotopic heart transplantation (OHT) ranges from 7 to 24% of cases depending on several patient and procedural related factors. Purpose The aims of this study were to investigate the frequency, indications and the predictors of CIED implantation (especially permanent pacemaker [PPM]) following biatrial anastomosis OHT. Methods A retrospective, single centre, observational study was conducted, including all the patients who underwent OHT between May 1990 and October 2023 at our Institution. For each patient clinical and procedural information were collected and a long-term active follow-up was performed. The primary endpoint of the study was PPM or implantable cardioverter defibrillator (ICD) implantation while all-cause mortality or de novo OHT was a secondary endpoint. Uni- and multivariable logistic regression analyses were performed to identify factors associated with PPM implantation. Results Overall, 546 patients were included and followed-up for a median of 8 years [IQR 1.2-14.3]. During this time frame, 89 (16.3%) patients required PPM implantation (only one patient [0.2%] underwent ICD implantation) at median time of 110 days [IQR 25-2230] after OHT. The main indication for PPM implantation was the development of sinus node dysfunction in 60 patients (67.4%) whereas 29 (32.6%) patients with atrioventricular block required PPM implantation. During follow-up, 265 deaths (48.5%) occurred but no significant differences in long-term prognosis were observed between patients requiring CIED implantation and those who did not (45.5% vs. 49.1%, p-value=0.53, figure). At multivariable analysis, impaired renal function (i.e. low eGFR), cardiac allograft vasculopathy, the occurrence of severe heart transplant rejection and a higher BMI were factors associated with PPM implantation (table). Conclusions Among patients undergoing OHT with biatrial anastomosis technique, PPM implantation is not uncommon but it does not negatively impact on prognosis. Several factors, especially severe heart transplant rejection, cardiac allograft vasculopathy and impaired renal function can help identifying patients at higher risk of PPM.TableFigure

Post–COVID-19 Era In Heart Transplantation and Its Impact on the Early Postoperative Period After Surgery

End-stage heart failure patients were at increased risk for acquiring COVID-19 infection and progression to severe disease, given multiple health care contacts and underlying health conditions. Understanding the outcomes of such patients will help risk-stratify and guide optimization before heart transplant surgery. The aim of this study was to evaluate the impact of the COVID-19 pandemic on heart transplantation activity and outcomes in the early postoperative period. Retrospective data analysis of patients undergoing orthotopic heart transplantation in our institution from March 2020 to July 2023. The patient population (N = 208) included 176 (84.6%) men and 32 (15.4%) women. The perioperative data of the pandemic group, March 2020 to February 2022 (N = 151), and the post-pandemic group, March 2022 to July 2023 (N = 57), were compared. The number of patients requiring inotropic support increased during the post-COVID-19 era (N = 48 [84.2%], vs N = 72 [47.7%], P < .001). There were no differences in renal complications. Duration of mechanical ventilation was longer in the post-pandemic group (19 hours [14-24] vs 14 hours [9-28], P < .05). The extended duration of mechanical ventilation in the post-pandemic group may be related to the patient's preoperative condition. The number of heart transplant recipients with end-stage heart failure requiring inotropic support increased in the post-COVID-19 era. Although some efforts have been made to reduce the impact of the pandemic, more research is required.

NAVIGATING THE UNCHARTED WATERS: MANAGING CONCURRENT CYTOMEGALOVIRUS MYOCARDITIS AND ALLOGRAFT REJECTION IN A PATIENT WITH HEART TRANSPLANTATION

Abstract A 49–year–old female with hypertrophic cardiomyopathy underwent orthotopic heart transplantation. She was cytomegalovirus(CMV)–positive and received a heart from a CMV–negative donor, so prophylaptic therapy was not administered. Initial immunosuppression included cyclosporine and induction with Basiliximab in a steroid–free regimen. The first routine biopsy (EMB) showed mild focal cellular rejection (grade 1A) and C4d positivity with granular aspect. Mycophenolate mofetil (MMF) was added. The second EMB, 7 days later, showed mild diffuse cellular rejection (grade 1B) and diffuse C4d positivity. Anti–HLA donor–specific antibodies (DSA) had increased anti–B13 levels (MFI=21298) compared to pre–transplantation tests. Echocardiography showed a normal ejection fraction (LVEF) and mild concentric hypertrophy (LVH). Treatment included pulse methylprednisolone therapy (1 g/day for three days) followed by oral prednisone with a slow tapering regimen, and increased MMF. CMV count weekly monitored was negative. The next two EMBs performed one week apart from each other described a grade 1A mild focal pattern while the 5th EMB (1 month and 2 weeks post–transplant) showed a grade 1A rejection together with focal mild fibrosis and eosinophils, so we replaced cyclosporine with tacrolimus, increased MMF and prednisone. At this time, the patient had no overt clinical signs of CMV infection but a CMV–PCR of 100847 IU/mL so ganciclovir 5 mg/Kg bid was started and CMV–PCR decreased to 42308 IU/mL after 1 week. Subsequently, she developed sinus tachycardia, mildly reduced LVEF, moderate LVH and diastolic dysfunction. Troponin was elevated. A new EMB revealed interstitial edema, diffuse ischemic injury, and eosinophilic inclusions suggesting CMV myocarditis. Treatment involved down–titrating MMF and Prednisone, administering standard intravenous immunoglobulin (IVIG), and high–dose Ganciclovir (7.5 mg/Kg bid). Leukopenia subsequently led to Ganciclovir down–titration. In the next days, the patient improved, CMV cleared, and leukocyte count normalized. She was discharged on Tacrolimus, MMF, Prednisone and Valganciclovir. Subsequent tests showed no cellular or antibody–mediated rejection (AMR), no CMV inclusions, recovered cardiac function, and markedly reduced anti–B13 DSA (MFI 3000). This case raises some concerns: in this context, the use of IVIG in the treatment of CMV infection and AMR appears reasonable, in support of antiviral and immunosuppressive therapy.

In vivo mitral valve repair for the transplanted donor heart in orthotopic heart transplantation

A 53-year-old woman with the dilated phase of hypertrophic cardiomyopathy underwent orthotopic heart transplantation. The donor heart was evaluated as normal preoperatively without mitral regurgitation or the left atrium dilation, transplanted using the modified bicaval technique. Although the heart beat satisfactorily after aortic declamping, massive mitral regurgitation was observed without any prolapse or annular dilation. Because of the difficulty in weaning from cardiopulmonary bypass, a second aortic cross-clamp was applied, and we detached the inferior vena cava and the right side of the left atrial anastomosis to approach the mitral valve, obtaining a satisfactory exposure. No abnormalities were observed in the mitral valve leaflets, annulus or subvalvular apparatus. Subsequent in vivo mitral annuloplasty using prosthetic full ring successfully controlled the regurgitation, and the patient was easily weaned from cardiopulmonary bypass. She discharged to home with good mitral valve and cardiac functions. And the patient has been doing well without any recurrence of MR or heart failure for over a year after surgery.

A case report of ATTR-amyloidosis following cardiac transplantation: thick ventricles that look alike

Abstract Background Transthyretin (ATTR-) amyloidosis is more prevalent than initially thought. As much as 13% of patients hospitalized with HFpEF may have ATTR-cardiomyopathy (CM). Conversely, heart transplant patients may manifest left ventricular hypertrophy or diastolic dysfunction, especially late after transplantation. Case Summary We present a case of a 82-year old male heart transplant patient, 31 years following orthotopic heart transplantation. While he was satisfied with his exercise capacity as an octogenarian, several years before he required pacemaker implantation due to 3rd degree AV block, had bilateral carpal tunnel syndrome treated with carpal tunnel release surgery and experienced idiopathic sudden deafness. Based on increasing left ventricular wall thickness during routine follow-up, a diagnosis of ATTR-amyloidosis was suspected. Ultimately, the diagnosis was confirmed non-invasively with a specific scintigraphic exam, while an additional physicochemical stain on an endomyocardial biopsy taken several years before provided pathological proof. We initiated tafamidis, yet stopped this treatment after one month because of gastro-intestinal intolerance. Ultimately, our patient died two years later due to heart failure. Discussion Our case shows the long delay between the onset of transthyretin deposition, the presence of clinical signs and the final diagnosis. Echocardiographic findings suggestive for ATTR-CM include left ventricular hypertrophy and diastolic dysfunction, which are both common in heart transplant patients. Yet, ATTR-CM should be considered in the differential diagnosis, especially late after transplantation, in this closely monitored population.

The Perioperative Period of Heart Transplantation Is Affected by Thyroid Hormone Status.

Background: Orthotopic heart transplantation (HTx) is a long-term surgical therapeutic approach for patients with end-stage heart failure. The objective of the present study was to uncover associations between altered thyroid hormone (TH) status and adverse outcomes after HTx. Methods: In this prospective, single-center cohort study, 283 patients underwent HTx between 2013 and 2020 at the Heart and Vascular Center of Semmelweis University in Hungary. We measured serum free triiodothyronine (fT3), free thyroxine (fT4), and thyrotropin (TSH) pre- and postoperatively. TaqMan qPCR was used to measure type 2 deiodinase and type 3 deiodinase mRNA (Dio2 and Dio3, respectively) levels from the diseased heart bioptates. To assess the local TH action of the heart, mRNA levels of Hcn2 and Myh7 were measured in a subgroup of patients receiving extracorporeal membrane oxygenation (ECMO) postoperatively. Groups were compared using nonparametric tests. Cox regression analysis and logistic regression test were used to investigate the outcomes. The connection between serum TH parameters and cardiac gene expressions was assessed using linear regression. Results: Serum TSH (p = 0.009), fT3 (p < 0.001), and fT4 (p < 0.001) levels were lower after HTx than preoperatively. Levothyroxine (LT4) administered to donors was associated with better survival after 30 days (p = 0.049). LT4 replacement given to recipients after HTx was associated with better survival after 30 days (p = 0.018), 1 year (p = 0.002), and 2 years (p = 0.001). Dio3 mRNA level was significantly increased in patients who were treated with ECMO (p = 0.026), left ventricular assist device (LVAD) (p = 0.008), and biventricular assist device (BiVAD) (p = 0.013) preoperatively, and ECMO (p = 0.042) postoperatively, compared with those who did not require any type of mechanical circulatory support (MCS). We found no significant difference in the expression of the Hcn2 and Myh7 marker genes between patients on postoperative ECMO and those without MCS, and neither did they correlate with serum hormone levels (p = 0.519 and p = 0.056, respectively). Conclusions: We conclude that TH status plays an important role in HTx patients, and monitoring of TH status in the perioperative period may contribute to improved treatment outcomes. Our findings require independent confirmation in a randomized controlled clinical trial.

Association of suPAR, ST2, and galectin-3 with eGFR decline and mortality in patients with advanced heart failure with reduced ejection fraction.

Patients with heart failure with reduced ejection fraction (HFrEF) are at risk for chronic kidney disease (CKD). Elevated levels of circulating biomarkers soluble urokinase plasminogen activator receptor (suPAR), galectin-3, soluble suppression of tumorigenicity 2 (ST2), and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) are associated with CKD progression and mortality. The predictive value of these biomarkers in a population with HFrEF and kidney disease is relatively unknown. We sought to determine whether these biomarkers were associated with longitudinal trajectory of estimated glomerular filtration rate (eGFR) in HFrEF and assess their association with mortality using a joint model to account for competing risks of ventricular assist device (VAD) implantation and heart transplantation. We included participants from the Registry Evaluation of Vital Information for Ventricular Assist Devices in Ambulatory Life with repeated eGFR measures over 2 years. Of 309 participants, mean age was 59 years, median eGFR 60 ml/min/1.73 m2, 45 participants died, 33 received VAD, and 25 received orthotopic heart transplantation. Higher baseline serum standardized suPAR (β coefficient = -0.36 √(ml/min/1.73 m2), 95% confidence interval (-0.48 to -0.24), p < 0.001), standardized galectin-3 (-0.14 √(ml/min/1.73 m2) (-0.27 to -0.02), p = 0.02), and log NT-proBNP (-0.23 √(ml/min/1.73 m2) (-0.31 to -0.15), p < 0.001) were associated with eGFR decline. ST2 and log NT-proBNP were associated with mortality. Higher baseline suPAR, galectin-3, and NT-proBNP are associated with eGFR decline in patients with HFrEF. Only ST2 and NT-proBNP are associated with greater mortality after controlling for other factors including change in eGFR. These biomarkers may provide prognostic value for kidney disease progression in HFrEF and inform candidacy for advanced heart failure therapies.

Assessment of Selected Parameters of Heart Donors and Recipients and Their Impact on the Transplantation Result

ObjectiveTo evaluate the impact of heart donors and recipients parameters on the outcomes after orthotopic heart transplantation (OHT). MethodologyTwo hundred fifteen patients who underwent OHT from 2020 to 2023 were analyzed. ResultsAverage donors age 36.3 (±13.1) years, 74 women (34.42%), BMI 25.3 (±4.99), Na+ concentration 153.7 (±11.8) mmol/L. Mean intraventricular septum thickness 10.0 (±2.2) mm, left ventricular end-diastolic diameter 44.3 (±6) mm, ejection fraction 60.3 (±7.92) %. Median procalcitonin was 0.6 ng/mL. Levonor was used in 75.8%, Empressin in 4.2%, Dopamine in 5.1%, Dobutamine in 3.7%, and Adrenaline in 3.7% of donors. The most common cause of death: intracranial injury (34.42%). Cardiopulmonary resuscitation occurred in 34%, alcoholism in 20.9%, nicotinism in 16.3%, and drug addiction in 7.4% of donors. Mean aortic cross-clamping time was 200.3 (±48.8) minutes. Intra-aortic balloon pump (IABP) after OHT required 6.1%, extra corporeal membrane oxygenation (ECMO) 6.1%, and renal dialysis 36% of recipients. The 1-year mortality rate was 19.1%. Death after OHT correlated with: longer aortic cross-clamping time (207.6 vs 198.59 minutes, P = .292), longer extracorporeal circulation time (196.3 vs 186.47 minutes, P = .335), lower Empressin dose (median 0.01 vs 0.02 j.m/min, P = .03) in donors, longer postoperative mechanical ventilation (mean 101.46 vs 23.09 hours, P = .001), more frequent dialysis, IABP or ECMO (P = .001) and older age of the recipient (51.2 vs 44.8 years, P = .014). Previous cardiac surgery or any surgical intervention after transplantation significantly influenced mortality. The remaining donor factors had no impact on the OHT result. ConclusionsIdentification of risk factors in the donor and recipient may improve treatment outcomes after OHT.

Effect of COVID-19 Pandemic on Complications and Mortality in the Early Postoperative Period After Heart Transplantation

IntroductionThe coronavirus disease 2019 (COVID-19) outbreak directly impacted heart transplantation (HT) surgery activity. Reallocating resources and converting surgical intensive care units to COVID‐19 facilities led to reduced accessibility and quality of health care facilities to heart recipient patients. AimTo study the effect of the COVID-19 pandemic on heart transplantation activity and outcomes in the early postoperative period. MethodsRetrospective data analysis of patients undergoing orthotopic heart transplantation in our institution from March 2018 to February 2022. The patient population (N = 281) included 223 (79.4%) men and 58 (20.6%) women. The perioperative data of the prepandemic group, March 2018 to February 2020 (N = 130), and the pandemic group, March 2020 to February 2022 (N = 151), were compared. ResultsWe found differences in preoperative inotropic support between the groups (N = 43 (33.1%) vs N = 72 (47.7%), P < .05), respectively). The number of urgent HTs increased during the COVID-19 pandemic (N = 51 (39.2%), vs N = 72 (47.7%), P = .155). Analyzed groups did not differ according to renal, pulmonary, or neurology complications. Intensive care unit (ICU) standing time was longer in the pandemic group (6 days [3-12] vs 11 days [5-12], P < .001). ConclusionWe found that during the COVID-19 pandemic, the number of end-stage heart failure recipients requiring cardiac support increased. Extended time of ICU standing in the pandemic group may be related to the COVID-19 pandemic. Although some efforts have been made to reduce the impact of the pandemic, more research is required.

Derivation of Stroke Volume from Pulmonary Artery Pressures.

Intermittent cardiac output (CO) studies using thermodilution are considered the gold standard. We have developed a stroke volume (SV) calculator from pulmonary pulse pressure (PP) to allow continuous monitoring of SV and CO from PP. Hemodynamic data on 169 patients following orthotopic heart transplantation were used to compare our calculator-derived SV (and SV index, or SVi) against thermodilution-derived SV on admission into intensive care unit immediately following heart transplantation (T0) and 6h after admission (T6). The calculated SV correlated with thermodilution-derived SV T0 (r = 0.920, p < 0.001, coefficient of 0.539 and the constant of 2.06). The median calculator SV, adjusted for coefficient and constant, was 48.4ml (37.7, 60.7), comparable to the median thermodilution-derived SV 47.9ml (37.5, 61.0), p = 0.737 with acceptable agreement on Bland-Altman plots. The thermodilution-derived SVi was 28.1ml (19.7, 38.7) and adjusted calculator-derived SVi 28.9ml (19.7, 39.9), p = 0.781. At T6, median thermodilution-derived SVi was 27.7ml (19.5, 35.9) compared to the calculator-derived SVi median of 26.1ml (17.7, 37.7), p = 0.203. Changes in PP can be used to track changes in SV using this calculator. Changes in PP may be used to assess response to treatment in the early post-operative period.

Recurrent infective endocarditis of the mitral valve after orthotopic heart transplantation

Introduction: Orthotopic heart transplantation is the gold standard for the treatment of advanced heart failure in the absence of contraindications. Infective endocarditis is a rare complication in patients after heart transplantation. The treatment of endocarditis after heart transplantation is challenging since there is a need for ongoing immunosuppression. Case description: We present the case of a 51-year-old orthotopic heart transplant recipient enrolled in a chronic dialysis program, in whom we diagnosed and successfully treated recurrent infective endocarditis of the mitral valve caused by Enterococcus and Enterobacter species. Despite the complicated course of the disease, the treatment was successful. Conclusions: Recurrent infective endocarditis after heart transplantation can be treated successfully with a multidisciplinary approach and robust antimicrobial therapy.

Advanced Respiratory Failure Requiring Tracheostomy-A Marker of Unfavourable Prognosis after Heart Transplantation.

Advanced respiratory failure with tracheostomy requirement is common in heart recipients. The aim of the study is to assess the tracheostomy rate after orthotopic heart transplantation and identify the subgroups of patients with the highest need for tracheostomy and these groups' association with mortality at a single centre through a retrospective analysis of 140 consecutive patients transplanted between December 2012 and July 2018. As many as 28.6% heart recipients suffered from advanced respiratory failure with a need for tracheostomy that was performed after a median time of 11.5 days post-transplant. Tracheostomy was associated with a history of stroke (OR 3.4; 95% CI) 1.32-8.86; p = 0.012), previous sternotomy (OR 2.5; 95% CI 1.18-5.32; p = 0.017), longer cardiopulmonary bypass time (OR 1.01; 95% CI 1.00-1.01; p = 0.007) as well as primary graft failure (OR 6.79; 95% CI2.93-15.71; p < 0.001), need of renal replacement therapy (OR 19.2; 95% 2.53-146; p = 0.004) and daily mean SOFA score up to 72 h (OR 1.50; 95% 1.23-1.71; p < 0.01). One-year mortality was significantly higher in patients requiring a tracheostomy vs. those not requiring one during their hospital stay (50% vs. 16%, p < 0.001). The need for tracheostomy in heart transplant recipients was 30% in our study. Advanced respiratory failure was associated with over 3-fold greater 1-year mortality. Thus, tracheostomy placement may be regarded as a marker of unfavourable prognosis.

Pediatric Heart Transplantation in the Context of Severe Pulmonary Hypertension Secondary to Restrictive Cardiomyopathy—Case Report

The aim of this study is to analyze the feasibility of performing an isolated heart transplant in patients with severe pulmonary hypertension as a result of restrictive cardiomyopathy. The results present the clinical course from the diagnosis of restrictive cardiomyopathy at the age of 2 until the heart transplant at 8 years old. Initially, the patient was considered for multiorgan transplantation, heart and lungs, due to extremely high pulmonary resistance. However, due to the prolonged waiting period for a donor and the worsening condition of the child, a decision was made to perforate the atrial septum with the implantation of an atrial flow regulator system. After conducting control hemodynamic measurements, the qualification was changed to an isolated heart transplant, accepting the high operative risk associated with the still elevated pulmonary resistance index of 4.9 Wood units. This study describes the medical problems that occurred during postoperative treatment. The patient underwent an orthotopic heart transplant in her eighth year of life. Postsurgery, complications were observed, including generalized seizures and heart transplant rejection reaction. Immunosuppressive therapies were applied, and efforts were made to combat anemia and electrolyte disorders. While the cardiovascular system and heart parameters improved, there were some difficulties in controlling heart rhythm and stabilizing electrolyte levels.

Temporary Mechanical Circulatory Support During Bariatric Surgery: A Novel Bridge to Durable Left Ventricular Assist Device and Cardiac Transplantation.

Advanced heart failure (HF) with comorbid severe obesity presents a unique surgical dilemma: bariatric surgery may help patients meet cardiac transplantation body mass index (BMI) criteria, but poor cardiac function puts them at increased intraoperative risk. Per International Society for Heart and Lung Transplantation (ISHLT) guidelines BMI > 35 is a contraindication for orthotopic heart transplantation. Temporary mechanical circulatory support (MCS) with Impella 5.5 during bariatric surgery, as presented in this report, may help solve this dilemma for some patients. We present three patients with severe obesity and advanced heart failure (HF) who underwent successful bariatric surgery while supported by Impella 5.5 (Abiomed, Inc., Danvers, MA).

Ten-Year Experience with Endomyocardial Biopsy after Orthotopic Heart Transplantation: Comparison between Trans-Jugular and Trans-Femoral Approach.

Endomyocardial biopsy (EMB) is considered the gold standard for monitoring allograft rejection after heart transplantation. EMB is an invasive procedure that may be performed via a trans-jugular or a trans-femoral approach with a complication rate reported as less than 6%. The aim of this study was to evaluate the complication rate after EMBs in heart recipients and to compare the results of EMBs performed via a trans-jugular or a trans-femoral approach. Medical records of heart recipients undergoing EMBs between January 2012 and December 2022 were retrospectively reviewed. EMB-related complications were classified as major (death, pericardial effusion, hemopericardium, cardiac tamponade requiring a pericardiocentesis or an urgent cardiac surgery, ventricular arrythmias, permanent atrio-ventricular block requiring permanent pacing, hemothorax, pneumothorax and retroperitoneal bleeding) and minor (de novo tricuspid regurgitation, arrhythmias, coronary artery fistula, vascular access site complications). A total of 1698 EMBs were performed during the study period at our institution in 212 heart recipients. There were 927 (55%) EMBs performed through a trans-jugular approach (TJ group) and 771 (45%) EMBs performed through a trans-femoral approach (TF group). A total of 60 (3.5%) complications were recorded, including nine (0.5%) major complications (six cardiac tamponades, two pneumothorax and one retroperitoneal bleeding) and 51 (3%) minor complications (seven coronary fistulae, five de novo tricuspid regurgitation, four supraventricular arrythmias and thirty-five vascular access site complications). No difference was found in total (38 [4%] vs. 22 [3%]; p = 0.16) and major (6 [1%} vs. 3 [0.4%]; p = 0.65) complications (32 [3%] vs. 19 [2%]; p = 0.23) between the TJ group and the TF group. No difference was found in male sex, age at time of EMB and time from HT between complicated and not complicated EMBs. EMBs represent a safe procedure with a low risk of complications. In our experience, EMBs performed via a trans-jugular approach are as safe as the trans-femoral approach.

Long-term outcomes of heart transplantation in adults with congenital heart disease: The impact of single-ventricle versus biventricular physiology

ObjectiveCongenital heart disease is a risk factor for mortality after orthotopic heart transplantation; however, the impact of preoperative circulation type and primary congenital heart disease diagnosis remains poorly delineated. MethodsWe retrospectively reviewed patients with adult congenital heart disease aged 16 years or more who underwent orthotopic heart transplantation at our institution between 2008 and 2022. Patients were categorized as having single-ventricle or biventricular circulation. The primary end point was 5-year post-transplant survival. ResultsSixty-one patients with adult congenital heart disease (single-ventricle: n = 26 [42.6%], biventricular: n = 35 [57.4%]) underwent orthotopic heart transplantation at 33.7 [interquartile range, 19.1-48.7] years. The most common congenital heart disease diagnosis was hypoplastic left heart syndrome (n = 11, 42.3%) in the single-ventricle group and congenitally corrected transposition of the great arteries (n = 7, 20.0%) in the biventricular group. Twenty-four patients previously underwent Fontan palliation. At transplant, patients in the single-ventricle group were younger (18.5 [interquartile range, 17.6-32.3] years vs 45.0 [interquartile range, 33.0-52.2] years, P < .001) and more likely to have biopsy-proven cirrhosis (46.2% vs 14.3%, P = .01) and protein-losing enteropathy (42.3% vs 2.9%, P < .001). Patients in the single-ventricle group also had longer bypass times (223.4 ± 65.3 minutes vs 187.4 ± 59.5 minutes, P = .03) and longer durations of mechanical ventilatory support (3.5 [interquartile range, 2.0-6.0] days vs 1.0 [interquartile range, 1.0-2.0] days, P < .001). Operative mortality was comparable (11.5% vs 8.6%, P = 1). Median follow-up was 6.0 [interquartile range, 2.4-10.0] years. Five-year survival was worse in the single-ventricle group (66.0% ± 10.0% vs 91.3% ± 4.8%, P = .03), as was freedom from major rejection (58.3% ± 10.2% vs 84.0% ± 6.6%, P = .02). In univariable analysis, hypoplastic left heart syndrome and Fontan circulation were risk factors for post-transplant mortality (hypoplastic left heart syndrome: hazard ratio, 5.0, P < .001; Fontan: hazard ratio, 3.5, P = .03). ConclusionsAdult patients with congenital heart disease undergoing heart transplant with single-ventricle physiology experienced a more complicated post-transplant course, with worse long-term survival and freedom from rejection. Multicenter studies are required to guide orthotopic heart transplantation decision-making in this complex cohort.

(876) - Impact of Goal-Directed Perfusion Management During Orthotopic Heart Transplantation on Early Clinical Outcome

(876) - Impact of Goal-Directed Perfusion Management During Orthotopic Heart Transplantation on Early Clinical Outcome

(875) - Does Cytokine Adsorption Improve Postoperative Course in Orthotopic Heart Transplantation?

(875) - Does Cytokine Adsorption Improve Postoperative Course in Orthotopic Heart Transplantation?

Successful Use of Anticoagulation-free Prolonged Extracorporeal Membrane Oxygenation for Massive Pulmonary Hemorrhage in a Child with Heart Transplant and Mechanical Mitral Valve: A Case Report with Review of Literature

Background: Pulmonary hemorrhage is a rare cause of morbidity and mortality in children. Extracorporeal membrane oxygenation (ECMO) can be used as a rescue mode of support in children with life-threatening respiratory failure. However, the dilemma arises as to how to balance anticoagulation to prevent circuit thrombosis while avoiding bleeding complications or worsening hemorrhage. Clinical Description: We present an adolescent with a history of Noonan syndrome, orthotopic heart transplant, and mechanic mitral valve that required emergent veno-venous (VV) ECMO support due to life-threatening hypoxia related to severe pulmonary hemorrhage secondary to anticoagulation for his prosthetic mitral valve. Management and Outcome: The patient remained on ECMO for 28 days with no anticoagulation and did not receive any anticoagulant or antiplatelet agents postdecannulation for 4 months despite the presence of a mechanical valve. No thrombotic complications to the mechanical valve or the ECMO circuit occurred. Conclusion: Prolonged anticoagulation-free VV-ECMO support may be used as a rescue strategy in patients with massive pulmonary hemorrhage resulting in refractory respiratory failure.