Andras C. Kollar

Peri-operative Alemtuzumab (Campath-1H) and Plasmapheresis for High-PRA Positive Lymphocyte Crossmatch Heart Transplant: A Strategy to Shorten Left Ventricular Assist Device Support

Patients on a left ventricular assist device (LVAD) often have a high level of panel-reactive antibodies (PRA). Conventional therapy is to await a heart from a negative prospective-crossmatch donor. We transplanted three high-PRA patients with non-crossmatched hearts, using intra- and post-operative plasmapheresis and long-term T-/B-/plasma-cell therapy with alemtuzumab. Three highly sensitized patients (70%, 94% and 96% T-PRA; 63%, 24% and 73% B-PRA) were transplanted after 29, 187 and 94 days LVAD support. The first patient (Case 1) had an erroneous prospective negative crossmatch (due to an outside laboratorys use of the wrong patients serum) with immediate allograft dysfunction. The correct serum showed a strongly positive crossmatch; plasmapheresis followed by alemtuzumab (20 mg intravenously) shortly after arrival in the ICU resulted in rapid hemodynamic improvement. Encouraged by this success, the next two patients (Cases 2 and 3) underwent LVAD explant and heart transplant with the next available ABO-identical, non-crossmatched donors, using plasmapheresis on bypass immediately before heart implant and alemtuzumab 20 mg intravenously upon ICU arrival, with uneventful courses. All three patients had positive retrospective T- and B-cell crossmatches. Maintenance immunosuppression consisted of cyclosporine and routine prednisone taper, with plasmapheresis as needed (Patient 1, x10; Patient 2, x5) based on diastolic dysfunction. Mycophenolate mofetil was started as a third agent several months post-transplant. Patients are presently New York Heart Association (NYHA) Class I at 26, 16 and 13 months post-transplant. In this small series with follow-up, immediate antibody removal with plasmapheresis, combined with alemtuzumab, a long-acting antibody to CD52 (expressed on T, B and some plasma cells), appears effective in allowing transplantation in sensitized, positive crossmatch recipients. Expanded use of this strategy could shorten LVAD support in many sensitized patients.

“Snake‐jaw” Graft for Aortic Valve Exposure During LVAD Implant

Abstract  We report a simple technique of LVAD outflow anastomosis as patch closure of a standard aortotomy during left ventricular assist device (LVAD) implant. Benefits are a single aortotomy, a low graft leaving ample native aorta for transplant, a wide‐open LVAD outflow, and excellent aortic valve exposure. (J Card Surg 2010;25:747‐748)

Valve-Sparing Aortic Root Reconstruction Using In Situ Three-Dimensional Measurements

BACKGROUND The truncated cone overall geometry of the native aortic root, an important factor in maintaining valvular competence, is significantly altered in cases of root aneurysms. We hypothesized that an early trial restoration of valve competence within the native aortic root followed by in situ three-dimensional measurements may lead to a more predictable functional reconstruction. METHODS The operation started with downsizing annuloplasty followed by sinotubular junction plication until full valve competence was observed and tested with the saline squirt test. Subsequent measurements (basal ring and sinotubular junction size, the depth of each sinus of Valsalva) formed the basis of graft sizing and tailoring. Reconstruction was completed with a new proximal suture line technique combining David subannular pledgeted fixation with Yacoub remodeling. RESULTS Ten patients were operated on during a 3-year period. Intraoperative (nonpressurized) competence by open testing translated into good postoperative valve function seen on transesophageal echocardiography. In situ measurements were done in the last 7 patients, and in 5 of them the restored root geometry was of a reverse cone (sinotubular junction 2 to 4 mm larger than basal ring size). CONCLUSIONS Rebuilding the aortic root based on in situ measurements with a fully competent aortic valve is a conceptually new surgical approach. Our observations suggest that postoperative valve competence, particularly with elongated valve leaflets, may not depend on the normal truncated cone geometry.

Successful treatment of aortic root abscess in a patient with pulmonary arterial hypertension

Continuous prostanoid infusion is an established treatment for pulmonary arterial hypertension that has led to improvements in symptoms, exercise tolerance, and survival. Patients with pulmonary arterial hypertension (PAH) who develop sepsis frequently experience clinical and hemodynamic deterioration associated with poor outcomes. Successful management of sepsis involves identification of the source of infection, early antimicrobial administration, judicious fluid resuscitation, and continuation of specific PAH therapies. We describe successful management of a patient with idiopathic PAH receiving chronic intravenous prostacyclin therapy who developed an aortic root abscess due to Clostridium perfringens requiring emergent aortic root repair. Management involved imaging studies, removal of potential sources with administration of intravenous antibiotics, and cautious fluid administration with hemodynamic monitoring. A multidisciplinary group led by a PAH specialist worked cohesively before, during, and after surgical intervention and achieved a successful outcome.