A. Hage

Heart transplant recipients supported with extracorporeal membrane oxygenation: Outcomes from a single-center experience

BACKGROUNDnExtracorporeal membrane oxygenation (ECMO) provides hemodynamic support in refractory cardiogenic shock and may be used after heart transplantation for primary graft dysfunction or rejection. We hypothesized that survival after ECMO support is contingent upon patient selection.nnnMETHODSnWe examined consecutive adult heart transplant recipients at a single center who underwent transplantation between 1997 and 2009 and required ECMO support. Patients were divided by clinical presentation: pre-emptive therapy, escalating inotropic requirements despite support by intra-aortic balloon pump (IABP); and salvage therapy, cardiac arrest undergoing cardiopulmonary resuscitation with chest compressions.nnnRESULTSnBetween 1997 and 2009, there were 37 instances of ECMO use in 32 patients: 23 episodes (19 patients) for pre-emptive therapy and 14 episodes (14 patients) for salvage therapy; 1 patient had both pre-emptive and salvage therapy. Patients did not differ in age, gender or ischemic time. ECMO support was for a median 6 days in both groups, and the incidence of serious vascular complications was comparable (35% and 36%). In the pre-emptive therapy group, 15 episodes (79%) were associated with survival to hospital discharge and 5 patients (26%) were alive at 1 year. In the salvage therapy group, 2 episodes (14%) were associated with survival to hospital discharge and 1 patient (7%) was alive at 1 year.nnnCONCLUSIONSnECMO support is a viable option for adult heart transplant recipients with severe rejection and refractory cardiogenic shock. To maximize the benefit of this aggressive approach in heart transplant recipients requires early intervention, with a heightened awareness of this option to facilitate expedited use.

Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation.

Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end‐stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare‐metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 × 109/L, the median international normalized ratio was 1.3, and the median Model for End‐Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in‐hospital or 30‐day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1‐U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation. Liver Transpl 17:809‐813, 2011.

Pulmonary hypertension secondary to pulmonary veno-occlusive disease complicated by right heart failure, hypotension and acute kidney injury

Pulmonary veno-occlusive disease (PVOD) is rare condition which can lead to severe pulmonary hypertension, right ventricular dysfunction, and cardiopulmonary failure. The diagnosis of PVOD can be challenging due to its nonspecific symptoms and its similarity to idiopathic pulmonary arterial hypertension and interstitial lung disease in terms of diagnostic findings. This case describes a 57 year old female patient who presented with a 5-month history of progressive dyspnea on exertion and nonproductive cough. Workup at another hospital was nonspecific and the patient underwent surgical lung biopsy due to concern for interstitial lung disease. She subsequently became hemodynamically unstable and was transferred to our hospital where she presented with severe hypoxemia, hypotension, and suprasystemic pulmonary artery pressures. Preliminary lung biopsy results suggested idiopathic pulmonary arterial hypertension and the patient was started on vasodilating agents, including continuous epoprostenol infusion. Pulmonary artery pressures decreased but remained suprasystemic and the patient did not improve. Final review of the biopsy by a specialized laboratory revealed a diagnosis of PVOD after which vasodilating therapy was immediately weaned off. Evaluation for dual heart-lung transplantation was begun. The patients hospital course was complicated by hypotension requiring vasopressors, worsening right ventricular dysfunction, and acute kidney injury. During the transplantation evaluation, the patient decided that she did not want to undergo continued attempts at stabilization of her progressive multi-organ dysfunction and she was transitioned to comfort care. She expired hours after removing inotropic support.

CHANGE IN CYLEX SCORES PREDICTS RISK FOR INFECTION IN THE FIRST YEAR FOLLOWING HEART TRANSPLANTATION

The average Cylex score (CS) is lower in heart transplant (HTx) patients (pts) prior to infectious episodes, but the impact of a change in CS on the risk of subsequent infection is not known. The purpose of this study was to determine if a change in CS in HTx pts would impact the risk of subsequent