Michael B. Stokes

Successful Bridge to Orthotopic Cardiac Transplantation with Implantation of a HeartWare HVAD in Management of Systemic Right Ventricular Failure in a Patient with Transposition of the Great Arteries and Previous Atrial Switch Procedure

A clinical case is described of a patient with a history of dextro-transposition of the great arteries (d-TGA) and prior atrial switch procedure who developed significant pulmonary hypertension whilst awaiting orthotopic cardiac transplantation. The increase in his pulmonary pressures necessitated de-listing for cardiac transplantation. A strategy of ventricular assist device (VAD) placement was then employed which provided improvement in his systemic cardiac output with left atrial off-loading to provide pulmonary vascular remodelling and consequently reduction in pulmonary vascular resistance (PVR). He was supported for a period of 408 days prior to successful orthotopic cardiac transplantation. A small number of cases with this abnormality undergoing VAD implantation have been described. Mechanical circulatory support has an important role in some patients with congenital heart disease.

Role of long-term mechanical circulatory support in patients with advanced heart failure.

Advanced heart failure represents a small proportion of patients with heart failure that possess high‐risk features associated with high hospital readmission rates, significant functional impairment and mortality. Identification of those who have progressed to, or are near a state of advanced heart failure should prompt referral to a service that offers therapies in mechanical circulatory support (MCS) and cardiac transplantation. MCS has grown as a management strategy in the care of these patients, most commonly as a bridge to cardiac transplantation. The predominant utilisation of MCS is implantation of left ventricular assist devices (LVAD), which have evolved significantly in their technology and application over the past 15–20 years. The technology has evolved to such an extent that Destination Therapy is now being utilised as a strategy in management of advanced heart failure in appropriately selected patients. Complication rates have decreased with VAD implantation, but remain a significant consideration in the decision to implant a device, and in the follow up of these patients.

Role of Long‐Term Mechanical Circulatory Support (MCS) in Management of Advanced Heart Failure

Advanced heart failure represents a small proportion of patients with heart failure that possess high‐risk features associated with high hospital readmission rates, significant functional impairment and mortality. Identification of those who have progressed to, or are near a state of advanced heart failure should prompt referral to a service that offers therapies in mechanical circulatory support (MCS) and cardiac transplantation. MCS has grown as a management strategy in the care of these patients, most commonly as a bridge to cardiac transplantation. The predominant utilisation of MCS is implantation of left ventricular assist devices (LVAD), which have evolved significantly in their technology and application over the past 15–20 years. The technology has evolved to such an extent that Destination Therapy is now being utilised as a strategy in management of advanced heart failure in appropriately selected patients. Complication rates have decreased with VAD implantation, but remain a significant consideration in the decision to implant a device, and in the follow up of these patients.

Successful percutaneous closure of an extremely large secundum atrial septal defect during pregnancy

Atrial septal defects (ASDs) are one of the most of the most common acyanotic congenital heart lesions. Awareness of potential clinical presentations and complications during pregnancy is essential for those managing these patients. We report successful percutaneous closure of an extremely large secundum ASD, using the largest available percutaneous ASD closure device in a 27-year-old pregnant female. Large ASDs may have their initial clinical presentation and diagnosis during pregnancy. If indicated, percutaneous closure can be performed safely. Only a very small number of cases have previously reported this being performed safely during pregnancy.

Severe left ventricular hypertrophy and marked cardiac fibrosis in Danon disease

a Department of Cardiovascular Medicine, Heart Centre, Alfred Hospital, Commercial Road, Prahan, Victoria 3181, Australia b Alfred Hospital and BakerIDI Heart and Diabetes Institute, Department of Cardiovascular Medicine, Australia c Alfred Hospital, Department of Anatomical Pathology, Australia d Monash University Faculty of Medicine Nursing and Health Sciences, Alfred Hospital, Australia e Florey Institute of Neuroscience and Mental Health, Australia

Percutaneous closure of three atrial septal defects with three interleaved atrial septal occluders in an adult patient

A 28-year-old previously well female underwent transthoracic echocardiogram for evaluation of worsening dyspnoea. She had significant right-sided chamber enlargement with left to right inter-atrial shunting noted on colour Doppler. Follow up transoesophageal echocardiogram (TEE) demonstrated three separate secundum type atrial septal defects (ASDs) spanning the entire atrial septum: A large central ASD (18 mm), a smaller superior ASD (10 mm) and a third inferoposterior ASD (13 mm) (Panel A). Given the extensive nature of the defects, her symptoms and right heart dysfunction, surgical ASD closure was recommended. The patient strongly opposed surgical closure and due to persisting dyspnoea and worsening right ventricular function, it was decided to attempt percutaneous closure. (See Fig. 1.) The procedure was performed under general anaesthesia with TEE guidance. Venous access was obtained with three right-sided 8-French venous sheaths. Each ASD was sized with balloon inflation to observe for residual leak. Due to the separate locations of the ASDs with significant residual shunting after balloon sizing, it was felt that three devices would be required to adequately seal the septum. As previously recommended [1] the smallest defects were attempted for closure first with the aim of sandwiching the device within the larger defect sequentially. However, this manoeuvre resulted in an altered profile that would not allow interleaving of the discs as the septal tissue was too flimsy. Therefore the largest central defect was crossed instead with an 18 mm Occlutech device (Occlutech, Helsingbord, Sweden) and partially deployed. This essentially created a firm ‘pseudo-septum’ for

Left Ventricular Assist Device (LVAD) as a Bridge to Recovery for Tachycardia-Mediated Cardiomyopathy.

A case is described of cardiogenic shock that occurred following use of sotalol in a patient with severe left ventricular dysfunction. The patient required left ventricular assist device (LVAD) placement with subsequent myocardial recovery to a degree that allowed eventual device removal following 140 days of support.

Transplantation of a Donor Heart Following a Lightning Strike: MRI Identification of Myocardial Injury

Cardiac donation for transplantation following a lightning strike has the potential to provide satisfactory clinical outcomes. Magnetic resonance imaging (MRI) provides an excellent diagnostic modality for follow-up of cardiac injury in this clinical setting. A 22 year-old woman underwent prolonged cardiopulmonary resuscitation following a lightning strike (resuscitation time 115 minutes). An electrocardiogram demonstrated changes consistent with acute inferior myocardial injury (1 mm of ST elevation in the inferolateral leads with associated T wave inversion in anterior leads) and peak troponin I was 188,000 ng/L, however, an echocardiogram reported normal left ventricular systolic function. The patient was declared brain dead and was accepted for cardiac donation. The donor was haemodynamically stable without any cardiac abnormality during organ procurement. The recipient was a 52 year-old woman with an ischaemic cardiomyopathy. At the time of orthotopic cardiac transplantation, the implanting surgeon noted a circumscribed area of inferior wall oedema on the donor heart consistent with a recent acute myocardial injury (not identified at the time of procurement). The total ischaemic time was 368 minutes due to long distance transportation of the donor heart. The patient was weaned off cardiopulmonary bypass on moderate inotropic support with persisting inferior wall hypokinesis seen