Treatment Of Terminal Heart Failure Research Articles

Pediatric heart transplantation: 23-year single-center experience

Early and late mortality have significantly improved during recent decades in pediatric patients after heart transplantation (HTx). Nevertheless early and late morbidity and mortality are influenced by acute rejection, cardiac allograft vasculopathy (CAV), malignancy, renal failure, and graft failure. We evaluated our results after HTx in children under the age of 18 years with 23 years of follow-up. Perioperative characteristics, probability of survival, and time-related morbidity were retrospectively analyzed. We included 169 pediatric HTx recipients, transplanted between 05/1986 and 05/2010. One hundred and one were males with a median age of 8.7 (0.02-23.2) years at the time of HTx. Main preoperative diagnoses were cardiomyopathy (CMP) (n = 139) with a median survival of 7.0 (0-23.2) years and congenital heart disease (CHD) (n = 30), median survival 11.3 (0-19.9) years. Overall survival at 1, 5, 10, and 15 years was 87%, 76%, 68%, and 50%, respectively. Patient survival was significantly reduced in patients with 0-1 year at the time of HTx versus 1-10 and 11-18 years: 2.3 (0-13.2) years versus 1-10 years = 8.6 (0-23.2) years; 11-18 years = 5.9 (0.003-18.5) years. Fifty-one patients were on mechanical circulatory support as a bridge-to-HTx with increased early but not late mortality. Ten patients underwent retransplant due to acute or chronic graft failure after a median posttransplant time of 12.25 (0.3-17.45) years. Late mortality was influenced by rejection, infection, posttransplant lymphoproliferative disease (PTLD) (11.8%), or CAV with an incidence of 25% at 5 years, 50% at 10 years, and approximately 75% at 15 years. Pediatric HTx is a safe and effective treatment for terminal heart failure. In our experience, there is no adverse effect of previous cardiac assist device implantation in long-term follow-up. Virtually all anatomic malformations are amenable to orthotopic HTx. Significant progress has been achieved in controlling rejection through improved immunosuppression and noninvasive rejection monitoring.

Herztransplantation

Since the first heart transplantation in 1967, the procedure has become an established therapy in the treatment of terminal heart failure. Constant advances in the development of potent immunosuppressive drugs, as well as greater clinical experience and pathological diagnostics have improved patient survival dramatically. The first grading system for rejection was published in 1990 by the International Society for Heart and Lung Transplantation (ISHLT) and revised in 2004. The 2004 grading system comprises three grades of severity (1R, 2R, 3R), whereby the former grade 2 in the 1990 system has been incorporated in the new grade 1R. Recommendations are made for the histological diagnosis of acute antibody-mediated rejection using immunohistochemical staining against C4d and macrophages. To the present day, the pathological examination of endomyocardial biopsies remains the gold standard for post-transplant diagnostic procedures. Whether or not non-invasive diagnostic approaches (e.g. gene array profile analysis on leukocytes) can replace morphological investigations needs to be clarified in randomised, prospective clinical studies.

Ultimate Test Bench for Pediatric Biventricular Assist Device Based on Artificial Muscles

Ventricular assist devices (VADs) are used in treatment for terminal heart failure or as a bridge to transplantation. We created biVAD using the artificial muscles (AMs) that supports both ventricles at the same time. We developed the test bench (TB) as the in vitro evaluating system to enable the measurement of performance. The biVAD exerts different pressure between left and right ventricle like the heart physiologically does. The heart model based on child's heart was constructed in silicone. This model was fitted with the biVAD. Two pipettes containing water with an ultrasonic sensor placed on top of each and attached to ventricles reproduced the preload and the after load of each ventricle by the real-time measurement of the fluid height variation proportionally to the exerted pressure. The LabVIEW software extrapolated the displaced volume and the pressure generated by each side of our biVAD. The development of a standardized protocol permitted the validation of the TB for in vitro evaluation, measurement of the performances of the AM biVAD herein, and reproducibility of data.

59: Scheduled Implantation of VADs for Treatment of Terminal Heart Failure in Patients with Advanced Age: Single-Center Experience

Heart failure is a leading cause of death in developed nations despite medical management. The prevalence of heart failure in Europe is 0.3 – 2%, and it affects approximately 10 million people living in nations represented by the European Society of Cardiology. Although advanced age is considered a relative contraindication to heart transplantation, there is no published consensus – on critical age in the case of mechanical circulatory support (MCS). The financial impact of destination MCS therapy in elderly heart failure patients is another important aspect for discussion with the medical community, hospital providers, insurance companies, and society at large.

Pediatric cardiac transplantation – the Innsbruck experience

Aims: Cardiac transplantation (HTX) is an accepted treatment of terminal heart failure in adults. In childhood, however, a number of congenital as well as aqcuired diseases may also lead to terminal heart failure. The aim of our study was to investigate the results of pediatric HTX at our department. Methods: We investigated on all pediatric HTX performed in Innsbruck between 1996 and 2007. Demographic aspects, cardiac disease, waiting time, bridging devices as well as outcome were evaluated. Results: From 1996 through 2007, 16 HTX were performed in 15 children at our departement.9 children were male, 6 female. Mean age was 10.3 years with a range from 0.8–18 years. Underlying cardiac disease was a dilative cardiomyopathy in 9 children, restrictive cardiomyopathy in 2. One transplantation was performed for Ebsteins' anomaly, one for virus myocarditis and one for muscular dystrophia. One girl, who was first transplanted in 1996, underwent retransplantation for TX-vasculopathy in 2007. Furthermore, one boy underwent retransplantation, who was first transplanted elsewhere. Mean waiting time was 177 days with a range from 4–652 days. One girl died on first postoperative day due to peracute rejection. No further deaths were encountered in postoperative course so far. Mechanical bridging systems were used in nine children. These include one ECMO, two LVADs and six BVADs. Conclusion: HTX is a good therapeutical option for children suffering from terminal heart failure, leading to good long-term results with acceptable perioperative risk. The waiting time for transplantation is longer in children, thus leading to more mechanical bridging-devices.

Mechanical circulatory support: state of the art and future perspectives.

Mechanical circulatory support (MCS) has been viewed, until recently, as a rescue therapy to be applied when all else fails. Not surprisingly, this has resulted in suboptimal outcomes. Fortunately, the perseverance of a few dedicated groups has produced improved outcomes and the concept of MCS as an elective therapy is now steadily gaining acceptance. This is particularly true in the postcardiotomy setting, where a large number of new options are now available. The recently completed REMATCH study has demonstrated the feasibility and efficacy of permanent MCS as a therapy for end-stage heart failure, despite a high rate of device complications. Donor availability is decreasing and biological solutions will not be available for many years. New generation implantable rotary pumps, a fully implantable left ventricular assist device and a total artificial heart are all undergoing clinical evaluation, and several new exciting designs are in preclinical evaluation. A new paradigm for the treatment of terminal heart failure is emerging, where an unpredictable and expensive medically managed death in an intensive care unit setting is being exchanged for a more predictable high-cost, front-loaded therapy with management from the outpatient clinic. The perfusionist community has much to contribute to this emerging life support field, not only in the perioperative period, but also in providing ongoing technical support to hospital staff, recipients and their families.

Heart transplantation in perspective.

Heart disease remains one of the leading causes of death in the western world. In the 35 years since the first human heart transplants, cardiac transplantation has become established as the therapeutic option of choice in the management of terminal cardiac failure. Since 1981, the introduction of cyclosporin for immunosuppression has dramatically increased cardiac transplantation. However, several obstacles limit further utilization, including limited availability of donor hearts, limited ischemic time tolerated by donor hearts, and chronic rejection. Research is underway into donor heart preservation and new immunosuppressant drugs in an effort to increase donor organ availability. Due to these constraints, alternative therapies are under development. More than 2,000 circulatory assist devices have been implanted with >25% used as a bridge to heart transplantation. The University of Ottawa Heart Institute began the first Canadian implantation of circulatory assist devices in 1986 and has implanted 23 total artificial hearts and 23 ventricular assist devices. The Heart Institute is also developing a totally implantable electrohydraulic ventricular assist device (EVAD) for long-term mechanical support outside the hospital. Another alternative being evaluated for clinical use is xenotransplantation. The major obstacle for widespread use of clinical xenotransplantation remains graft rejection, and fundamental research is ongoing to address hyperacute and delayed xenograft rejection. While cardiac transplantation is the most effective treatment of terminal heart failure, limited donor hearts compel us to rely on alternatives. In the future, the research underway on xenotransplantation and mechanical circulatory assist devices will provide new options for the clinical treatment of terminal cardiac failure.

Psychological distress in patients awaiting heart transplantation

Heart transplantation has become an established procedure for the treatment of terminal heart failure. However, due to a shortage of donor organs, the waiting period for a donor organ is increasing. Cross-sectional and retrospective studies have indicated that there is tremendous psychological distress during this waiting period. The aim of this study was to assess this phase systematically and longitudinally. At the beginning of their waiting period, 62 patients at the Heidelberg Transplantation Centre were examined with regard to their physical complaints, quality of life, and level of depression. Four months later the remaining 42 patients were re-examined. The sample showed a significant increase ( p<0.001) in subjective physical symptoms and an impairment in social activities ( p<0.05) and everyday life ( p<0.05), and a significant increase in depression ( p<0.001), despite the relatively short time period. These results show the necessity of supportive psychotherapy for patients undergoing heart transplantation.

O2 transport during exercise after cardiac transplantation.

Over the past two decades cardiac transplantation has emerged as a viable treatment of terminal heart failure and actuarial survival statistics have approached 75% for the first 5 years after operation. Though substantial differences exist between the performance of the cardiac allograft and the normal heart, the patient’s quality of life is improved considerably and many cardiac allograft recipients have returned to a normal life (3, 7).KeywordsCardiac OutputStroke VolumeDynamic ExerciseHeart Transplant RecipientStroke IndexThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Heart Transplantation in Perspective

Abstract Heart disease remains one of the leading causes of death in the western world. In the 35 years since the first human heart transplants, cardiac transplantation has become established as the therapeutic option of choice in the management of terminal cardiac failure. Since 1981, the introduction of cyclosporin for immunosuppression has dramatically increased cardiac transplantation. However, several obstacles limit further utilization, including limited availability of donor hearts, limited ischemic time tolerated by donor hearts, and chronic rejection. Research is underway into donor heart preservation and new immunosuppressant drugs in an effort to increase donor organ availability. Due to these constraints, alternative therapies are under development. More than 2,000 circulatory assist devices have been implanted with &gt; 25% used as a bridge to heart transplantation. The University of Ottawa Heart Institute began the first Canadian implantation of circulatory assist devices in 1986 and has implanted 23 total artificial hearts and 23 ventricular assist devices. The Heart Institute is also developing a totally implantable electro‐hydraulic ventricular assist device (EVAD) for long‐term mechanical support outside the hospital. Another alternative being evaluated for clinical use is xenotransplantation. The major obstacle for widespread use of clinical xenotransplantation remains graft rejection, and fundamental research is ongoing to address hyperacute and delayed xenograft rejection. While cardiac tran‐plantation is the most effective treatment of terminal heart failure, limited donor hearts compel us to rely on alternatives. In the future, the research underway on xenotransplantation and mechanical circulatory assist devices will provide new options for the clinical treatment of terminal cardiac failure.