David O. Taylor

Registry of the International Society for Heart and Lung Transplantation: Twelfth Official Pediatric Heart Transplantation Report-2009

he ISHLT Registry data are provided by individual enters or a data-sharing arrangement with a national or egional organ procurement or exchange organization. pproximately 450 pediatric heart transplants are reorted to the Registry each year. Most the data are rovided from North American centers, but significant ontributions come from centers in Europe and the rest f the world (Figure 1). The Registry Committee is ctively seeking participation from all centers performng pediatric heart transplants. The tables and figures in this report and additional lides are all available from the ISHLT Web site. ontributing centers are recognized in the Introduction o the 2009 Annual Reports. Survival rates were calculated using the Kaplan-Meier ethod and compared using the log-rank test. Multivaiable analyses were performed using Cox proportional azard regression analysis. Results of the multivariable nalyses are reported as relative risks (RR) with a orresponding p-value or 95% confidence interval, or oth. A RR significantly 1 indicate that the factor is

Registry of the International Society for Heart and Lung Transplantation: Twenty-fifth Official Adult Heart Transplant Report—2008

e a t d t n this twenty-fifth official report of the International ociety for Heart and Lung Transplant (ISHLT) Registry, e present information regarding 80,000 heart translants performed worldwide. As in prior years’ reorts, we focus our principal analysis on recently ransplanted patients—rather than the entire cohort of eart recipients—to provide a contemporary represenation of the state of heart transplantation.

Prompt Reduction in Intra-Abdominal Pressure Following Large-Volume Mechanical Fluid Removal Improves Renal Insufficiency in Refractory Decompensated Heart Failure

BACKGROUNDnOur group recently reported that elevated intra-abdominal pressure (IAP, defined as > or = 8 mm Hg) can be associated with renal dysfunction in patients with advanced decompensated heart failure (ADHF). We hypothesize that in the setting of persistently elevated IAP and progressive renal insufficiency refractory to intensive medical therapy, mechanical fluid removal can be associated with improvements in IAP and renal function.nnnMETHODS AND RESULTSnThe renal and hemodynamic profiles of 9 consecutive, volume-overloaded subjects with ADHF and elevated IAP, refractory to intensive medical therapy, were prospectively collected. All subjects experienced progressive elevation of serum creatinine and IAP in response to intravenous loop diuretics. Within 12 hours after mechanical fluid removal via paracentesis (n = 5, mean volume removed 3187 +/- 1772 mL) or ultrafiltration (n = 4, mean volume removed 1800 +/- 690 mL), there was a significant reduction in IAP (from 13 +/- 4 mm Hg to 7 +/- 2 mm Hg, P = .001), with corresponding improvement in renal function (serum creatinine from 3.4 +/- 1.4 mg/dL to 2.4 +/- 1.1 mg/dL, P = .01) without significantly altering any hemodynamic measurement.nnnCONCLUSIONnIn volume-overloaded patients admitted with ADHF refractory to intensive medical therapy, we observed a reduction of otherwise persistently elevated IAP with corresponding improvement in renal function after mechanical fluid removal.

Registry of the International Society for Heart and Lung Transplantation: A Quarter Century of Thoracic Transplantation

ide the an b he rt r p f the I ep n of c ith t stry. C wn i tted t tively p ata v affiliorts f ort r be o est a lung t dies r of s w ete a d app ed a s stical s ing R req to d the s gory o ulty A SHLT R c of r ties. T e: to o rom t ning o in e art a ulty A MD, M evelo a P v e are pleased to present the 2008 annual repor he Scientific Registry of the International Society eart and Lung Transplantation (the Registry). This arks the 25th anniversary of the Registry; since 1 he Registry has collected and reported data regard ore than 80,000 heart transplants and more t 9,000 lung and heart–lung transplants ( Table 1). The ast year has also been our most active to date, ,276 transplants added to the Registry from more 00 centers worldwide. Much gratitude is owed the m eart and lung transplant surgeons and physicians, clin oordinators, data coordinators and organ-exchange or izations (OEOs) throughout the world, whose timely ccurate submission of data has made attaining th ilestones possible (see Appendix). We also report some transitions in Registry re uthorship. This year Dr Richard Kirk authored ediatric Heart Transplant report; we thank Dr M oucek, author of the first 10 Pediatric Heart Transp eports, for his singular contribution to the Regis uccess. We also welcome Anna Kucheryavaya to egistry data analysis team. There are many ways to access the the ISHLT Re ata. As in past years, all of the data figures and ncluded in the Registry reports are also available iewing and downloading from the ISHLT web www.ishlt.org/registries) in MS P OWERPOINT format. he website also contains many additional data sl hat are not included in the published reports. Fur hose wishing to view the published heart, lung eart–lung and pediatric reports online may do so ontacting www.cardiosource.com. In addition to t nformation available in the published Registry repo nd slide sets, continentand center-specific data

Thymoglobulin induction and steroid avoidance in cardiac transplantation: results of a prospective, randomized, controlled study.

Abstract:u2002 Background:u2002 Chronic use of corticosteroids (CS) following transplantation is associated with significant long‐term morbidities. Minimizing exposure to CS to improve long‐term outcomes, without compromising allograft function, remains an important goal in transplantation.

Extracorporeal Ultrafiltration vs Conventional Diuretic Therapy in Advanced Decompensated Heart Failure

Compared with conventional diuretic (CD) therapy, ultrafiltration (UF) is associated with greater weight loss and fewer re-hospitalizations in patients admitted with decompensated heart failure (HF). Concerns have been raised regarding its safety and efficacy in patients with more advanced heart failure. The authors conducted a single-center, prospective, randomized controlled trial in patients with advanced HF admitted to an intensive care unit for hemodynamically guided therapy, comparing UF (n=17) with CD (n=19) at admission. The primary end point was the time required for pulmonary capillary wedge pressure (PCWP) to be maintained at a value of ≤18u2003mmu2003Hg for at least 4 consecutive hours. Secondary end points included levels of cytokines and neurohormones, as well as several clinical outcomes. In our study cohort, the time to achieve the primary end point was lower in the UF group but did not reach statistical significance (P = .08). UF resulted in greater weight reduction, higher total volume removed, and shorter hospital length of stay. There were no differences in kidney function, biomarkers, or adverse events. In patients with advanced HF under hemodynamically tailored therapy, UF can be safely performed to achieve higher average volume removed than CD therapy without leading to adverse outcomes.

Regional referral system for patients with acute mechanical support: experience at the Cleveland Clinic Foundation.

Regional referral networks (“hub and spoke”) have been created to facilitate the transfer of patients on mechanical circulatory support. Although individual centers report good success, overall outcomes have remained poor. We investigated whether preoperative variables influenced survival and could be used to help select patients best served by referral. A retrospective chart review was conducted on all patients transferred to our institution supported on cardiac assist devices. Between January 1995 and September 2003, 39 patients were received in transfer for continued care after the implantation of a cardiac assist device. Eighty-five percent of patients had the ABIOMED BVS 5000 implanted. The most common indication was postcardiotomy shock. Sixty-four percent of patients were not candidates for heart transplantation due to medical or social contraindications. The 30-day mortality of this group was 62%. Survivors had less comorbidity and were less likely to have complex surgeries, neurologic impairment, and multisystem organ failure when presenting to our center. Devices were weaned in 30% of cases. Only six patients (15%) were successfully transplanted, and five of these patients have done well at follow-up. Based on our experience, we believe that cardiogenic shock patients benefit from a regional referral system if they have not had complex cardiac surgical procedures or developed multisystem organ failure. Furthermore, there is a survival advantage when using long-term devices because this allows possible recovery or transplantation.

Direct in vivo evaluation of pulmonary arterial pathology in chronic congestive heart failure with catheter-based intravascular ultrasound imaging

Abstract Patients with chronic congestive heart failure (CHF) frequently develop secondary pulmonary hypertension. This development is a poor prognostic indicator.1 In addition, secondary pulmonary hypertension that does not improve in response to vasodilators identifies a group of patients who will have a poor outcome after orthotopic heart transplantation.2,3 The structural abnormalities of the pulmonary artery that occur in CHF have been described in autopsy specimens,4 and human studies have demonstrated indirectly that there are alterations in pulmonary vascular impedance and stiffness.5,6 Intravascular ultrasound using high-frequency catheter-based imaging has been performed to quantify pulmonary artery area and diameter in humans.7 It also has been validated as a method of detecting plaque in both elastic and muscular arteries.8 We hypothesized that intravascular ultrasound could be used to characterize the changes in pulmonary vascular morphology and elasticity in CHF.

Impaired Systolic Function in Loeys-Dietz Syndrome A Novel Cardiomyopathy?

Loeys-Dietz syndrome (LDS) is a recently described autosomal dominant genetic syndrome caused by mutations in the gene encoding transforming growth factor-β receptor 1 or 21 with no known cardiac involvement. Common characteristics include aortic and arterial aneurysms or dissections, orbital hypertelorism, and cleft palate or bifid uvula. We report the first case of a cardiomyopathy associated with LDS in a patient with a novel transforming growth factor-β receptor mutation and pathological evidence of microvascular coronary artery dysplasia.nnA 44-year-old tall, thin, white man with “borderline” hypertension and sleep apnea developed a severe, painful stabbing sensation in his throat while walking. He presented to a local hospital and was found to have an acute thoracoabdominal aortic dissection (Stanford type A) without involvement of the coronary …

Impact of donor high-risk social behaviors on recipient survival in cardiac transplantation.

Objective. To investigate the impact of cardiac donor participation in high-risk social behaviors (HRSBs) on recipient survival. Methods. Retrospective chart review queried cardiac transplantations performed at our institution from August 1994 to November 2007 involving donors known to have engaged in HRSBs. Kaplan-Meier methodology was used to analyze survival rates, and a Cox proportional hazards regression was performed to determine the impact of donor HRSBs on survival. Results. We identified 143 donors with social histories containing the following HRSBs: incarceration (n=69), unprofessional tattoos or piercings (n=44), alternative lifestyle practice (n=11), cocaine use (n=60), heroin smoking (n=6), marijuana use (n=79), oral narcotic abuse (n=20), and intravenous drug use (n=21). At the time of donation, viral screens detected 10 donors who were hepatitis B virus (HBV) positive, 11 donors who were hepatitis C virus (HCV) positive, and no donors who were positive for the HIV. One-year and 5-year survival were 92.2% and 84.4%, respectively. Cox regression analysis found only donor HCV infection to be associated with poorer recipient survival (P=0.14). Conclusion. Using cardiac allografts from high-risk donors who are serologically negative for viruses does not seem to impact recipient survival. There is a considerable risk for transmission of HBV and HCV when these are detected by pretransplant screens. However, if pretransplant screening does not discover donor HBV, HCV, or HIV infection, it is unlikely that subclinical disease transmission will occur.