Lars Wiklund

Does pretransplant left ventricular assist device therapy improve results after heart transplantation in patients with elevated pulmonary vascular resistance

OBJECTIVE Pulmonary hypertension (PH), defined as a pulmonary vascular resistance (PVR) >2.5 Wood units (WU) and (or) a transpulmonary gradient (TPG) >12 mmHg, is an established risk factor for mortality in heart transplantation. Elevated PVR in heart transplant candidates can be reduced using a left ventricular assist device (LVAD), and LVAD is proposed to be the treatment of choice for candidates with PH. We analyzed the effect on PVR of pretransplant LVAD therapy in patients with PH and compared posttransplant outcome with matched controls. Long-term survival was compared between heart transplant recipients with mild, moderate or severe PH and patients with no PH. METHODS Heart transplant recipients 1988-2007 (n=405) were reviewed and divided into two groups with respect to pretransplant PVR: <2.5 WU (n=148) and >2.5 WU (n=158). From the group with PH, patients subjected to pretransplant LVAD therapy (n=11) were analyzed with respect to PVR at implant and at transplant and, with respect to outcome, compared to matched historical controls (n=22). Patients with PH without LVAD treatment (n=147) were stratified into three subgroups: mild, moderate and severe PH and survival according to Kaplan-Meier was analyzed and compared to patients with no PH. RESULTS LVAD therapy reduced PVR from 4.3+/-1.6 to 2.0+/-0.6 WU, p<0.05. Three cases of perioperative heart failure required mechanical support whereas one control patient developed perioperative right heart failure requiring mechanical support. The incidence of other perioperative complications was comparable between groups. There was no difference in survival between LVAD patients and controls, 30-day survival was 82% and 91%, respectively and 4-year survival was 64% and 82%, respectively. CONCLUSIONS Pretransplant LVAD therapy reduces an elevated PVR in heart transplant recipients, but there was no statistically significant difference in posttransplant survival in patients with PH with, or without LVAD therapy. The study revealed no differences in survival in patients regardless of the severity of the PH.

The feasibility of left ventricular mechanical support as a bridge to cardiac recovery

To study the achievability of device weaning in patients receiving left ventricular assist devices (LVADs) as a bridge to transplantation.

Angiographic results after the use of a sutureless aortic connector for proximal vein graft anastomoses

The sutureless aortic connector system was recently developed to create anastomoses between the aorta and saphenous vein grafts for coronary artery bypass grafting. Ten consecutive patients scheduled for coronary artery bypass grafting were studied; in each patient one proximal anastomosis was performed using the aortic connector and another was sutured in the conventional manner to serve as the patients own control. One graft in the sutured group had a significant stenosis and one of the grafts in which the aortic connector was used, was occluded. In this limited study the use of the sutureless connector system for proximal anastomosis shows satisfactory early graft patency (90%).

Difficulties in the interpretation of coronary angiogram early after coronary artery bypass surgery on the beating heart

OBJECTIVE The major objective of this study was to evaluate the findings in early postoperative coronary angiography in patients who underwent coronary revascularization on the beating heart without cardiopulmonary bypass. METHODS Eighty-four consecutive patients receiving 113 grafts were studied. A coronary angiography was performed 0 to 5 days postoperatively. All the grafts were reviewed and classified in the following way: grade A (unimpaired run-off); grade B1 (<50 stenosis); grade B2 (>50% stenosis); grade O (occlusion). A second coronary angiography was performed in patients with a stenosis grade B2, 4 to 30 months postoperatively. An exercise test was performed by patients with B1 stenosis. RESULTS Overall graft patency was 96% in the 113 grafts. None of the 14 patients with B1 stenosis in the early coronary angiography had any clinical signs of ischemia. Eight of the 12 patients who exhibited B2 stenosis either at the anastomotic site, in the graft or in the distal coronary artery at the first coronary angiography had a normal angiogram at the re-angiography. CONCLUSION A majority of stenoses visualized at the early coronary angiography could not be seen at a later coronary angiography, which makes the interpretation of the angiogram unreliable as a tool for the decision as to redo-procedure in the early postoperative period.

Inflammatory response and platelet activation after off-pump coronary artery bypass surgery

Background. Cardiac surgery induces a systemic inflammatory activation and alterations in the hemostatic cascade. The responses contribute to postoperative complications but may also have protective effects. We investigated the relationship between inflammation, hemostasis and bleeding after off-pump coronary artery bypass surgery (OPCAB). Methods. Ten OPCAB patients were included in a prospective descriptive study. Selected markers of inflammation (IL-6, IL-8, PMN-elastase, C3a, and SC5b-9), and hemostasis (platelet count, β-thromboglobulin, anti-thrombin, D-dimer and fibrinogen) were measured before and immediately after surgery. Postoperative bleeding was registered. Results. Inflammatory variables did not alter significantly during surgery while β-thromboglobulin concentrations increased and anti-thrombin and fibrinogen decreased. There were significant postoperative correlations between PMN-elastase and β-thromboglobulin (r = 0.82, p = 0.004), between PMN-elastase and fibrinogen (r = 0.69, p = 0.03) and between C3a and β-thromboglobulin (r = 0.71, p = 0.02). In addition, there were significant inverse correlations between postoperative bleeding and pre- and postoperative fibrinogen levels (r = − 0.76, p = 0.011 and r = − 0.84, p = 0.002 respectively), between bleeding and postoperative β-thromboglobulin levels (r = − 0.66, p = 0.04) and between bleeding and postoperative PMN-elastase (r = − 0.75, p = 0.01). Conclusions. The results give further evidence for an association between the inflammatory response and hemostasis after cardiac surgery.

Implantation of a left ventricular assist device, back-to-front, in an adolescent with a failing mustard procedure

easier. The aorta was crossclamped and blood cardioplegic solution was administered antegradely. The optimal positioning of the HeartMate vented electric device was back-tofront, with the inflow directed toward the diaphragmatic wall of the right ventricle and the outflow toward the apex region. Two incisions were made in the diaphragm corresponding to the inflow and outflow tracts. To avoid damage to the liver, from the front of the pump, we made a “pillow” from polytetrafluoroethylene (Preclude pericardial membrane*) stuffed with Dacron felt. When the device was in place, the inflow was on the right side and the outflow on the left side (Fig 2). An expected pulmonary hypertension was prevented with inhaled aerosolized epoprostenol (prostacyclin).4 The early postoperative course in the intensive care unit was uneventful, and after 2 weeks the patient was transferred to the ward. Five weeks after the operation the patient was discharged from the hospital to his home, located 1500 km from our hospital, to await a donor heart. Comment. The need for assist devices in patients with complex congenital heart conditions, as after atrial correction for transposition of the great arteries, could be a surgical technical challenge. Because the right ventricle is the systemic ventricle in transposition, several points must be considered. To place the device on the right side in the abdomen Implantation of mechanical assist devices has saved the lives of patients awaiting heart transplantation.1 The HeartMate left ventricular assist device (Thermo Cardiosystems, Inc, Woburn, Mass) is made to connect the inflow cannula to the apex of the left ventricle.2 We describe a successful case in which the device was placed back-to-front with the inflow cannula inserted into the diaphragmatic wall of the right ventricle and the outflow graft through the left side of the diaphragm and in the left pleura to the ascending aorta (Fig 1). Medical history. A 15-year-old boy who was born with transposition of the great arteries underwent several balloon septostomies at birth because of desaturation. Despite this treatment, the desaturation was persistent. He therefore underwent an operation on an emergency basis at 3 months of age with an atrial switch as described by Mustard (pericardial baffle). At 4 years of age he required a reoperation because of residual atrial shunt and stenosis of the superior vena cava. Ten days after this operation a VVI pacemaker system was implanted because of atrioventricular dissociation. He then had an active life for almost 9 years, after which he gradually noted progressive fatigue and dyspnea. He had a cough, nausea, and cyanosis. Cardiac assessment revealed severe biventricular failure, gross atrioventricular valve regurgitation, and pulmonary hypertension (although reversible), and he was listed for heart transplantation. Despite “optimal” inotropic support, his condition continued to deteriorate with signs of multiorgan failure. Because no donor was available, we decided to implant a HeartMate left ventricular assist system, even though we expected major technical difficulties since the right ventricle, where the inflow cannula had to be placed, was the systemic ventricle. Surgical procedure. A median sternotomy was performed, and the heart, which was heavily adherent, was carefully dissected. Because the patient was thin, we decided to place the pump intraperitoneally.3 The aorta was cannulated. The systemic atrium was cannulated, and a left-sided bypass was instituted. This made the subsequent cannulation of the cavae

Plasmapheresis as a rescue therapy to resolve cardiac rejection with vasculitis and severe heart failure. A report of five cases

The predominant causes of late graft loss and death after cardiac transplantation are graft rejection and infection. The histopathological classification of acute rejection is based on cellular phenomena such as lymphocytic infiltration and myocyte damage. The adverse prognostic importance of vascular or humoral rejection has been reported, but there is no well-documented treatment available. In our experience, comprising 151 orthotopic transplants, five patients presented with graft rejection characterized by a lymphocytic vasculitis that did not respond to conventional therapy. Because of a deteriorating condition, in spite of vigorous antirejection treatment that included inotropic drugs and circulatory support, plasmapheresis was tried as a last, desperate means to stop the process from developing further. The clinical symptoms rapidly subsided in all five patients after the first couple of plasma exchanges. All of the patients are alive and well after 2–3.5 years of follow-up. Although the mechanism of action is unclear, plasmapheresis was beneficial in these critically ill patients.

Temporary circulatory support with extra corporeal membrane oxygenation in adults with refractory cardiogenic shock

Objective. Early and long-term survival in patients suffering from cardiogenic shock is poor. Treatment with mechanical assist devices is complicated and expensive but claim to improve survival. We reviewed our experience of venoarterial extracorporeal membrane oxygenation (ECMO) in patients with acute cardiogenic shock. Design. ECMO was used in 52 patients with cardiogenic shock. They were divided into those not operated upon previously (n=19) and those having had cardiac surgery prior to circulatory collapse (n=33). Results. Twenty-six patients were weaned from ECMO. Early mortality for all patients was 48%. Mortality beyond 30 days was 5.8%, with no mortality in the non-cardiotomy group. Long-term survival for patients in the non-cardiotomy group was 63%, as compared to 33% in post-cardiotomy patients (p=0.07). Age over 55 years, female gender or cannulation site did not appear to influence survival. Conclusion. Mortality for patients in cardiogenic shock is very high. Treatment with ECMO in patients with refractory cardiogenic shock can be performed with good survival especially in non-surgical patients.

Tricuspid valve insufficiency as a complication of endomyocardial biopsy

The purpose of this study was to investigate the occurrence of major tricuspid insufficiency caused by endomyocardial biopsy in heart transplant recipients. Endomyocardial biopsy was used for the detection of rejection and Doppler echocardiography was performed at regular intervals. Six of 96 heart transplant patients (6.3%) had sudden appearance of large tricuspid regurgitation, all of which were directly related to a preceding biopsy. Chordal tissue was identified histologically in biopsy samples of all six patients. All patients developed symptoms of right ventricular failure which was confirmed by right heart catheterization. Three patients subsequently underwent valvuloplasty for ruptured chordae tendineae of either of the three leaflets. Two of these three patients were free from symptoms during follow-up, but the third patient developed moderate tricuspid regurgitation and clinical symptoms. It is concluded that endomyocardial biopsy, although it is the most useful tool for detection of rejection, should be used with caution with regard to anatomical structures and the risk of damage to the tricuspid valve must not be neglected. It is also concluded that valvuloplasty of the tricuspid valve can be successfully performed in a transplanted heart.

Early Outcome and Graft Patency in Mammary Artery Grafting of Left Anterior Descending Artery With Sternotomy or Anterior Minithoracotomy

BACKGROUND The main objective of this study was to retrospectively compare early outcome and graft patency in patients who underwent coronary artery bypass grafting with the internal thoracic artery to the left anterior descending artery via an anterior minithoracotomy or median sternotomy and without the use of extracorporeal circulation. METHODS One hundred thirty consecutive patients were studied. Median sternotomy was performed in 77 patients and anterior minithoracotomy in 53 patients. RESULTS There were no differences in early clinical data or persistent postoperative pain between the groups. Early graft patency was 88% in the thoracotomy group and 96% in the sternotomy group (p = 0.3). Five of 7 patients who presented with a significant stenosis at the first coronary angiography had a normal angiogram at the reangiography. None of the patients with nonsignificant stenosis at the early coronary angiography had any clinical signs of ischemia or chest pain. CONCLUSIONS In our experience, anterior minithoracotomy and median sternotomy are different and distinguishable regarding early outcome and early graft patency. Most of the stenoses visualized at the early coronary angiography had vanished at a later coronary angiography, which makes the interpretation of the angiogram hazardous as a tool for the decision for redo procedure in the early postoperative period.