David A. D’Alessandro

Redesigning Care for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock: The "Shock Team".

Redesigning Care for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock: The “Shock Team” To the Editor The Viewpoint by Tchantchaleishvili et al1 calling for organized statewide networks for the management of acute myocardial infarction–related cardiogenic shock brings to attention the critical need for multidisciplinary, multicenter, coordinated efforts to treat and manage patients presenting with cardiogenic shock. This is a timely message because the mortality rate for these patients remains nearly 50%, despite improving technologies and access to mechanical circulatory support. Recognizing the complexity and time-sensitive nature of treating a patient with cardiogenic shock, our center, the Massachusetts General Hospital, created the “Shock Team” in 2011. This team, formally composed of the Departments of Cardiothoracic Surgery, Cardiology, Pulmonology, Interventional Cardiology, Critical Care, and Nursing; Perfusion Services; and Respiratory Therapists is available not only within the confines of our hospital but also to regional centers 24 hours a day, 7 days a week. In the acute setting, the mode of mechanical circulatory support most commonly used is extracorporeal membrane oxygenation. When a patient is considered for extracorporeal membrane oxygenation, a Shock Team activation page is delivered, and a multidisciplinary meeting is held to determine the best management strategy. Candidacy is evaluated based on predetermined indications and contraindications. If a patient receives extracorporeal membrane oxygenation, the entirety of the Shock Team is dedicated to daily rounds and optimizing care throughout the patient’s hospitalization. One of the major barriers to maximal utilization of mechanical circulatory support for the treatment of patients with cardiogenic shock is the lack of education and outreach programs to disseminate this information. Our center has created a Shock Team pocket card that succinctly defines patient criteria, contraindications, general guidelines, and absolute trigger notifications for a Shock Team consultation or referral. These informational cards have been distributed throughout Massachusetts General Hospital, as well as throughout our surrounding regional centers, via outreach education, to increase awareness of the Shock Team’s availability and the crucial importance of early activation and rapidity of care. In addition, through a collaborative effort by the members of the Shock Team, a comprehensive training program has been developed and is being offered to other centers. It is our hope that this will assist other programs in developing Shock Teams and avoiding “learning curve” catastrophes. As discussed by Tchantchaleishvili et al,1 formalized networks for the treatment of patients presenting with cardiogenic shock and for the streamlining of their care are of utmost importance. The education and outreach programs used to facilitate program development and expedite time to mechanical circulatory support can only improve outcomes. We applaud the authors’ efforts in bringing this important concept to our attention.

Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep (MINDDS): protocol for a randomised, double-blind, parallel-arm, placebo-controlled trial

Introduction Delirium, which is prevalent in postcardiac surgical patients, is an acute brain dysfunction characterised by disturbances in attention, awareness and cognition not explained by a pre-existing neurocognitive disorder. The pathophysiology of delirium remains poorly understood. However, basic science and clinical studies suggest that sleep disturbance may be a modifiable risk factor for the development of delirium. Dexmedetomidine is a α-2A adrenergic receptor agonist medication that patterns the activity of various arousal nuclei similar to sleep. A single night-time loading dose of dexmedetomidine promotes non-rapid eye movement sleep stages N2 and N3 sleep. This trial hypothesises dexmedetomidine-induced sleep as pre-emptive therapy for postoperative delirium. Methods and analysis The MINDDS (Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep) trial is a 370-patient block-randomised, placebo-controlled, double-blinded, single-site, parallel-arm superiority trial. Patients over 60 years old, undergoing cardiac surgery with planned cardiopulmonary bypass, will be randomised to receive a sleep-inducing dose of dexmedetomidine or placebo. The primary outcome is the incidence of delirium on postoperative day 1, assessed with the Confusion Assessment Method by staff blinded to the treatment assignment. To ensure that the study is appropriately powered for the primary outcome measure, patients will be recruited and randomised into the study until 370 patients receive the study intervention on postoperative day 0. Secondary outcomes will be evaluated by in-person assessments and medical record review for in-hospital end points, and by telephone interview for 30-day, 90-day and 180-day end points. All trial outcomes will be evaluated using an intention-to-treat analysis plan. Hypothesis testing will be performed using a two-sided significance level (type I error) of α=0.05. Sensitivity analyses using the actual treatment received will be performed and compared with the intention-to-treat analysis results. Additional sensitivity analyses will assess the potential impact of missing data due to loss of follow-up. Ethics and dissemination The Partners Human Research Committee approved the MINDDS trial. Recruitment began in March 2017. Dissemination plans include presentations at scientific conferences, scientific publications and popular media. Trial registration number NCT02856594.

Lung Transplantation from Donors after Circulatory Death: United States and Single Center Experience

BACKGROUNDnLung transplants from donation after circulatory death (DCD) have been scarcely used in the United States. Concerns about the warm ischemic injury, resource mal-utilization due to the uncertain timing of death, and public scrutiny may be some factors involved.nnnMETHODSnSurvival for recipients of a donation after brain death (DBD) versus DCD was analyzed by using the United Network for Organ Sharing and our institutional database. A propensity-matching and Cox regression analysis was performed for 25 characteristics. Primary graft dysfunction metrics were compared.nnnRESULTSnA total of 389 of 20,905 lung transplantations (2%) were performed by using DCDs in the United States, and 15 of 128 (12%) at our institution. Five and 10-year survival for DBDs was 55% and 30% and 59% and 33% for DCDs, respectively. Propensity-matched analysis of 311 DBD/DCD pairs did not demonstrate any difference in survival. On Cox regression, DCD was not associated with impaired survival. Male sex, Karnofsky class greater than 50, double lung transplantation, and transplantation year were predictors of improved survival. Age, creatinine, pulmonary fibrosis, retransplantation, extracorporeal membrane oxygenation, allocation score, and donor age were predictors of worse survival. Primary graft dysfunction at time 0 was worse for recipients of DCDs (pxa0= 0.005) but equivalent at 24, 48, and 72 hours.nnnCONCLUSIONSnDCD lung transplants remain underused in the United States. Nevertheless, survival is similar to DBD. Primary graft dysfunction metrics for DCDs are worse than DBDs on intensive care arrival but improved subsequently.

Single- Versus Double-Lung Transplantation in Pulmonary Fibrosis: Impact of Age and Pulmonary Hypertension

BACKGROUNDnDouble-lung transplantation (DLT) has better long-term outcomes compared with single-lung transplantation (SLT) in pulmonary fibrosis. However, controversy persists about whether older patients or patients with high lung allocation scores would benefit from DLT. Moreover, the degree of pulmonary hypertension in which SLT should be avoided is unknown.nnnMETHODSnA retrospective analysis using the United Network for Organ Sharing database was performed in all recipients of lung transplants for pulmonary fibrosis. Kaplan-Meier survival for SLT versus DLT was compared and stratified by age, allocation score, and mean pulmonary artery pressure. Cox regression and propensity-matching analyses were performed.nnnRESULTSnBetween 1987 and 2015; 9,191 of 29,779 lung transplants were performed in pulmonary fibrosis. Ten-year survival rates were 55% for DLT and 32% for SLT (p < 0.001). When stratified by age, DLT recipients had improved survival at all age cutoffs, except age ≥70 years. In addition, DLT recipients had improved survival across all lung allocation scores (<45, ≥45, ≥60, ≥75) and all pulmonary artery pressure categories (<25, ≥25, ≥30, ≥40 mm Hg). Among DLT recipients, pulmonary artery pressure and allocation score did not affect survival. Among SLT recipients, a pressure ≥25 mm Hg did not influence survival. Conversely, patients with a pressure ≥30 mm Hg and an allocation score ≥45 had decreased survival. On Cox regression and on propensity matching, DLT had improved survival compared with SLT.nnnCONCLUSIONSnIn pulmonary fibrosis, DLT has improved survival compared with SLT and should be considered the procedure of choice in patients younger than 70 years of age. SLT in patients with mean pulmonary artery pressure ≥30 mm Hg and an allocation score ≥45 should be discouraged.

Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVEnAt the authors institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting.nnnDESIGNnRetrospective, chart based review study.nnnSETTINGnSingle center, university-based hospital.nnnPARTICIPANTSnAll adult patients at the authors institution who required VA-ECMO between January 2015 and May 2017.nnnINTERVENTIONnAn Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart.nnnMEASUREMENTS AND MAIN RESULTSnManual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone.nnnCONCLUSIONSnPatients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.

The effect of donor age on posttransplant mortality in a cohort of adult cardiac transplant recipients aged 18-45

Hearts from older donors are increasingly utilized for transplantation due to unmet demand. Conflicting evidence exists regarding the prognosis of recipients of advanced age donor hearts, especially in young recipients. A retrospective analysis was performed on 11 433 patients aged 18 to 45 who received a cardiac transplant from 2000 to 2017. Overall, 10 279 patients received hearts from donors less than 45 and 1145 from donors greater than 45. Recipients of older donors were older (37 vs. 34 years, P < .01) and had higher rates of inotropic dependence (48% vs. 42%, P < .01). However, groups were similar in terms of comorbidities and dependence on mechanical circulatory support. Median survival for recipients of older donors was reduced by 2.6 years (12.6 vs. 15.2, P < .01). Multivariable analysis demonstrated donor age greater than 45 to be a predictor of mortality (HR 1.18 [1.05‐1.33], P = .01). However, when restricting the analysis to patients who received a donor with a negative preprocurement angiogram, donor age only had a borderline association with mortality (HR 1.20 [0.98‐1.46], P = .06). Older donor hearts in young recipients are associated with decreased long‐term survival, however this risk is reduced in donors without atherosclerosis. The long‐term hazard of this practice should be carefully weighed against the risk of waitlist mortality.

Traumatic Brains and Broken Hearts: Mending the Donor Shortage in Cardiac Transplantation∗

SEE PAGE 1248 C ardiac transplantation remains the gold standard for heart replacement therapy for patients with end-stage heart disease. Although the absolute numbers of heart transplant procedures performed in the United States has grown in recent years, this modest increase has little epidemiological impact on the increasing prevalence of heart failure in a growing and aging population. Despite a record number of >3,000 transplants in 2016, >20,000 patients of the 3 million with advanced heart failure could potentially be eligible for heart replacement therapy (1,2). The donor organ shortage continues to limit cardiac transplantation’s therapeutic impact. Consequently, tremendous attention has been paid to finding ways to expand the donor pool. Efforts have included public awareness campaigns to increase the absolute number of potential donors, increased use of marginal donors, and, most recently, use of donor hearts following circulatory death. New industries are emerging focused on donor organ assessment and resuscitation. Ultimately, the greatest opportunity may lie in improving our selection criteria among the available donors deemed marginal. Consensus guidelines have been introduced to help guide clinicians, although supporting evidence is limited. Donor organs are commonly rejected for coronary atherosclerosis, ventricular hypertrophy, valvular disease, or the presence of prognostically unfavorable risk factors

Predicting Success: Left Ventricular Assist Device Explantation Evaluation Protocol Using Comprehensive Cardiopulmonary Exercise Testing.

Left ventricular assist devices (LVADs) provide decongestion of the left ventricle (LV) with associated reversal of cardiomyocyte hypertrophy, restoration of adrenergic receptor density, and improvement in calcium handling. Unfortunately, translation of these changes into definitive functional recovery at the organ level is infrequent. Reports of LVAD explantation rates because of cardiac recovery are highly variable depending on heart failure (HF) pathogenesis and weaning criteria used, with reported rates ranging from 4.5% to 45%.1 Institution-specific LVAD explantation evaluation protocols exist that use various hemodynamic, imaging, and gas exchange measurements in any combination. However, protocols that provide comprehensive assessment of myocardial performance under dynamic loading conditions and in response to the highly relevant physiological stress of exercise are lacking. The high reported rates of HF recurrence after LVAD explantation provide further motivation to carefully assess cardiac reserve capacity before explantation. This case series describes the use of a novel protocol in 2 patients, which integrates assessments of hemodynamic, imaging, and gas exchange measures during the state of rest, LVAD speed reduction, and exercise to uniquely characterize cardiac reserve capacity and guide LVAD explantation decision making.nn### Patient 1nnA 44-year-old man underwent coronary bypass graft surgery in the setting of severe LV systolic dysfunction related to anabolic steroid use and coronary artery disease. Despite prolonged, postoperative mechanical support, there was no evidence of LV function recovery, and the patient underwent insertion of a Heartware LVAD (HVAD). Six months later, a transthoracic echo on full LVAD support revealed a low normal LV ejection fraction (LVEF), normal LV end-diastolic dimension, and aortic valve opening with each beat. These data prompted a LVAD explantation …