Kensuke Kuroda

Donor-transmitted Atherosclerosis Associated with Worsening Cardiac Allograft Vasculopathy After Heart Transplantation: Serial Volumetric Intravascular Ultrasound Analysis.

Background The influence of preexisting donor-transmitted atherosclerosis (DA) on cardiac allograft vasculopathy (CAV) development remains unclear. Methods We performed 3-dimensional intravascular ultrasound (3D-IVUS) analysis in 42 heart transplantation (HTx) recipients at 2.1 ± 0.9 months (baseline) and 12.2 ± 0.4 months post-HTx, as well as consecutive 3D-IVUS analyses up to 3 years post-HTx in 35 of the 42 recipients. Donor-transmitted atherosclerosis was defined as a maximal intimal thickness of 0.5 mm or greater at baseline. Changes in volumetric IVUS parameters were compared in recipients with (DA group) and without DA (DA-free group) at baseline, 1 year, and 3 years post-HTx. Results Donor-transmitted atherosclerosis was observed in 57.1% of 42 recipients. The DA group exhibited a significantly greater increase in plaque volume at 1 year post-HTx (P < 0.001), leading to increased percent plaque volume (plaque volume/vessel volume, [%]) (P < 0.001) and decreased luminal volume (P = 0.021). Donor-transmitted atherosclerosis was independently associated with a greater increase in percent plaque volume during the first post-HTx year (P = 0.011). From 1 to 3 years post-HTx, the DA group underwent continuous reduction in luminal volume (P = 0.022). These changes resulted in a higher incidence of angiographic CAV at 3 years post-HTx in the DA group (58.8% vs 5.6%, P = 0.002). Conclusions This volumetric IVUS study suggests that DA correlates with the worsening change in CAV several years post-HTx. Donor-transmitted atherosclerosis recipients may require more aggressive treatment to prevent subsequent CAV progression.

Advanced heart failure secondary to muscular dystrophy: Clinical outcomes after left ventricular assist device implantation

Advanced heart failure secondary to muscular dystrophy: Clinical outcomes after left ventricular assist device implantation Osamu Seguchi, MD, PhD, Kensuke Kuroda, MD, Tomoyuki Fujita, MD, PhD, Norihide Fukushima, MD, PhD, and Takeshi Nakatani, MD, PhD From the Department of Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan; and the Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan

Incidence, etiology, and outcome of primary graft dysfunction in adult heart transplant recipients: a single-center experience in Japan

Donor and recipient characteristics, as well as donor–recipient matching, affect clinical outcomes after heart transplantation (HTx). This study aimed to clarify how donor and recipient characteristics affect the clinical course after HTx. The medical records of all the patients who underwent HTx at the National Cerebral and Cardiovascular Center from 1999 to 2014 were retrospectively reviewed. Sixty-one patients (48 males) underwent HTx. Six recipients (9.8xa0%) developed primary graft dysfunction (PGD) determined by criteria recently established at a consensus conference. Development of PGD was associated with high-dose inotropic support for the donor heart and a history of stroke in the recipient (pxa0=xa00.04 and pxa0=xa00.002, respectively). Recipients with PGD had higher right atrial pressure (RAP) and lower cardiac output (CO) compared with those without PGD at 6xa0months after HTx (RAP, 6.8xa0±xa03.6 vs. 2.8xa0±xa02.2xa0mmHg, pxa0<xa00.001; CO, 4.6xa0±xa00.8xa0l vs. 5.8xa0±xa01.2xa0l/min, pxa0=xa00.02). With respect to survival, patients with PGD had a 5-year survival rate equivalent to those without PGD (83.3 vs. 93.3xa0%, pxa0=xa00.23). High-dose inotropic support for the donor heart and a history of stroke in the recipient are significant predictive factors for the development of PGD. However, recipients with PGD demonstrate mid-term survival comparable to those without PGD.

Risk Stratification for Cardiac Allograft Vasculopathy in Heart Transplant Recipients – Annual Intravascular Ultrasound Evaluation –

BACKGROUNDnCardiac allograft vasculopathy (CAV) limits long-term success after heart transplant. We assessed the post-transplant risk factors for CAV development.nnnMETHODSANDRESULTSnPatients who underwent heart transplant between May 1999 and December 2013 were included in this study. Patients (n=54) were divided into 2 groups according to the presence or absence of CAV progression after transplant. Coronary angiogram and intravascular ultrasound were conducted within 5-11 weeks after transplant, at 12 months, and annually thereafter. Scheduled endomyocardial biopsies were performed after transplant or whenever acute cellular rejection (ACR) or antibody-mediated rejection was suspected. Twenty-five of 54 patients (46.2%) had CAV progression. ACR ≥ International Society for Heart and Lung Transplantation grade 2 (ACR ≥ 2) and donor age >50 years were significantly associated with CAV development compared with ACR <2 and donor age <50 years. Patients with no history of ACR ≥ 2 and donor age ≤50 years had a significantly low risk of developing CAV compared with the other groups.nnnCONCLUSIONSnDonor age and history of ACR ≥ 2 are independent risk factors for CAV development. Identifying patients at risk of developing CAV is important for appropriate direction of resources and intensity of follow-up.

Suppressive effects of conversion from mycophenolate mofetil to everolimus for the development of cardiac allograft vasculopathy in maintenance of heart transplant recipients

BACKGROUNDnWhether converting to everolimus (EVL) from mycophenolate mofetil (MMF) during the maintenance period after heart transplantation (HTx) reduces cardiac allograft vasculopathy (CAV) progression remains unclear. We sought to determine the effect of converting from MMF with standard-dose calcineurin inhibitors (CNIs) to EVL with low-dose CNIs on CAV progression.nnnMETHODSnWe retrospectively reviewed the medical records of 63 HTx recipients who survived at least at 1 year after HTx. Twenty-four recipients were converted from MMF to EVL (EVL group, 2.2 ± 2.3 years after HTx), while 39 recipients were maintained on MMF (MMF group, 2.4 ± 2.2 years after HTx). The EVL group underwent three-dimensional intravascular ultrasound (3D-IVUS) analysis before and 1 year after conversion to EVL, and these data were compared with data from 2 consecutive IVUS in the MMF group.nnnRESULTSnIVUS indices in the EVL group at 1 year after conversion did not show increased CAV development, whereas a significant increase in %plaque volume (p=0.006) and decrease in lumen volume (p<0.001) were observed in the MMF group. EVL conversion was significantly associated with smaller increases in %plaque volume (p=0.004) and smaller decreases in lumen volume (p=0.017). IVUS indices in the late EVL conversion group (≥ 2 years) also did not exhibit increased CAV development, while those in the MMF group did.nnnCONCLUSIONSnConversion to EVL from MMF in maintenance periods after HTx may decrease the rate of CAV progression based on IVUS indices.

Comparison of Hemodynamic Performance and Clinical Results with EVAHEART versus HeartMate II

This study aimed to compare the hemodynamic performance and clinical results of the EVAHEART and HeartMate II left ventricular assist devices (LVADs). From 2007 to 2016, fourteen patients received EVAHEART and 28 received HeartMate II at our center. Early survival, driveline infection, and neurologic events were evaluated. Hemodynamic performance was evaluated with transthoracic echocardiography and right heart catheterization. Mean follow-up was 35.5u2009±u200914.8 months for EVAHEART and 29.8u2009±u20096.5 months for HeartMate II. Survival rates were comparable between the two groups. After 24 months, freedom from driveline infection was 28% with EVAHEART, and 85% with HeartMate II; freedom from neurologic events was 21% with EVAHEART, and 89% with HeartMate II. Serum lactate dehydrogenase was significantly lower with EVAHEART. There was a significantly greater decrease in left ventricular size with HeartMate II. In catheter examination performed 1 month postoperatively, HeartMate II recipients had significantly lower pulmonary capillary wedge pressure and mean pulmonary pressure, despite a comparable cardiac index. Both devices provided excellent clinical results and hemodynamic performance. HeartMate II could be a better choice to avoid driveline infection and neurologic events. Our results suggest that HeartMate II reduced right ventricular afterload. However, further analysis of more cases is required.

Temporary biventricular support with extracorporeal membrane oxygenation: a feasible therapeutic approach for cardiogenic shock with multiple organ failure

Various strategies using a ventricular assist device (VAD) are applied to rescue Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (Profile-1) patients. However, the optimal use of VAD in Profile-1 patients has not been completely elucidated. We retrospectively reviewed 23 Profile-1 patients [mean age 36.9xa0±xa016.6xa0years, 14 males; 11 with non-ischemic cardiomyopathy (NICM), 9 with fulminant myocarditis (FM), 2 with ischemic cardiomyopathy (ICM), and 1 with peripartum cardiomyopathy (PPCM); 18 with pre-operative percutaneous extracorporeal membrane oxygenation (p-ECMO) support] who underwent VAD implantation from 2011 to 2015 at our institution. Nine initially received left VAD (LVAD) alone (NICM in 9, ICM in 2 with ICM, and FM in 1), one with NICM received biventricular VAD (BiVAD; nxa0=xa01), and 10 received LVAD combined with right ventricular support using an ECMO circuit (BiVAD-ECMO) (FM in 8, NICM in 1, and PPCM in 1). Paracorporeal VAD was used in all patients. ECMO was used for the patients with severe pulmonary edema, inflammation, anemia, and thrombopenia. The BiVAD patient died 1.4xa0months after VAD implantation. The overall survival was comparable between patients with BiVAD-ECMO and LVAD (2-year survival, 80.0 and 75.0%, respectively). Three VAD strategies were initially applied in Profile-1 patients. Among them, the BiVAD-ECMO strategy is a promising therapeutic option to rescue Profile-1 patients with multiple organ failure.

889 days of support on hydrodynamic bearing rotation mode of the DuraHeart™ for bridge-to-heart transplantation

A 49-year-old man with ischemic cardiomyopathy and tricuspid regurgitation underwent a DuraHeart implantation and tricuspid annuloplasty for bridge-to-heart transplantation. On postoperative day 393, the magnetic levitation system suddenly broke down, and the pump system went into hydrodynamic bearing rotation (HD) mode without causing relevant symptoms. The controller was exchanged with one that adapted to the HD mode. No significant hemodynamic changes or indications of hemolysis were observed. On postoperative day 982, the pump temporarily stopped nine times. The patient refused pump exchange despite our strong recommendation for it. After 1283xa0days of DuraHeart support (889xa0days in HD mode) without hemolysis or neurologic events, he underwent heart transplantation. The DuraHeart manufacturer’s analysis revealed much damage to the insulation and fatigue fractures of the conductors, which had resulted in temporary cessation of function and failure of the magnetic levitation system. This was a rare case of long-term support under the DuraHeart HD mode.

Clinical Outcomes of Patients with Heartmate II Left Ventricular Assist Device: A Single Center Experience from Japan

BACKGROUNDnLeft ventricular assist device (LVAD) therapy is the gold standard alternative therapy for patients with advanced heart failure. However, LVAD therapy is still uncommon in the Asia-Pacific region. Therefore, we aimed to elucidate the clinical outcomes of patients from Japan supported with the HeartMate II (HM-II) LVAD at our institution.nnnMETHODSnNinety-two patients (mean 44.3 ± 12.1 years, 68 men, average body mass index 1.65 ± 0.28 m2; 81 with nonischemic cardiomyopathy) who underwent HM-II implantation for bridge to transplantation (nxa0= 91) or for destination therapy in a clinical study (nxa0= 1) at the National Cerebral and Cardiovascular Center between April 2013 and October 2017 were enrolled in this analysis. Preoperatively, most patients (nxa0= 73, 79%) had an INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of between level 2 and 4. Postoperatively, the average pump speed was 8602 ± 258 rpm and the hemodynamics were well compensated.nnnRESULTSnAdverse events consisted of 38 (41.3%) hemolysis, 30 (32.6%) major infection, 27 (29.3%) major bleeding (6 [6.5%] with gastrointestinal bleeding), and 18 (19.6%) neurologic dysfunction events. Eighteen patients underwent heart transplantation (HTx) after an average of 32.9 ± 8.9 months of VAD support, and overall survival at both 6 months and 3 years was 96.3%.nnnCONCLUSIONnClinical outcome among patients with HM-II at our institution is satisfactory for both survival and adverse events. The HM-II can provide effective hemodynamic support during the extremely long waiting period for HTx in Japan.

High Cardiac Output Immediately after Heart Transplantation is an Independent Risk Factor of Seizure early Posttransplant

Introduction Neurological complications are common complications after heart transplantation (HTx) and present with seizures, which are associated with significant morbidity. These neurologic complications occur predominantly in the early posttransplant period, especially in the first 3 months, owing to the accumulation of triggering factors, such as introduction of immunosuppressive drug. HTx for heart failure patients brings substantial hemodynamic changes early posttransplant. However, the relationship between hemodynamic changes and seizures remains to be investigated. Materials and Methods To investigate relationships between hemodynamic changes and seizures after HTx, we retrospectively reviewed consecutive 105 patients (mean age 39.2 ± 14.1 years, 82 males) who underwent HTx at our institution between May 1999 and October 2017. Data on patient characteristics and clinical outcomes were extracted from our transplant database and medical record review. Hemodynamic parameters were obtained before and 1 week after HTx. The diagnosis of seizure was based on direct observation by medical staff. Patient demographic characteristics, type of implanted left ventricular assist device, hemodynamic parameters, immunosuppressive regimen and clinical outcomes were compared between the seizure and non-seizure groups. Results and Discussion Over median follow-up of 1532 days [Interquartile range (IQR) 544-2703 days], 14 patients experienced seizures after HTx. In univariate analysis, there were significant differences between the two groups in history of cerebrovascular accidents before HTx (79% vs. 44% respectively: p = 0.02) and cardiac index after HTx (3.25 ± 0.62 vs. 2.69 ± 0.59: p = 0.02). The optimal cut-off of cardiac index was 2.8 L/min/m2 on ROC curve (AUC 0.74; Sensitivity 85.7%; Specificity 58.5%). Multivariate logistic regression analysis revealed that cardiac index is an independent risk factor of seizure after heart transplantation (Odds ratio: 1.18; 95% confidence interval: 1.02 to 1.39 per 0.1 L/min/m2; p = 0.02). There was no significant difference in survival between patients with seizures and without (at 5 years, 90% vs. 96.6% respectively: p = 0.40), but there was significant difference in hospital stay [106 (55-147) days vs. 54 (42-69) days: p = 0.02]. Table. No title available. Table. No title available. Table. No title available. Figure. No caption available. Conclusions These data suggested that high cardiac index immediately after HTx be an independent risk factor of seizure after HTx. Controlling immediate postoperative cardiac output might be important to reduce seizure and hospital stay after HTx.