Mosaad Alhussein

Percutaneous left atrial decompression in adults with refractory cardiogenic shock supported with veno-arterial extracorporeal membrane oxygenation

Left ventricular (LV) distention, a recognized complication in patients supported with veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) for refractory cardiogenic shock, can lead to pulmonary edema, increased myocardial oxygen consumption, and LV thrombus formation. Atrial septostomy was examined as a management strategy for LV distension.

Outflow Graft Occlusion of the HeartMate 3 Left Ventricular Assist Device

Continuous-flow ventricular assist devices have demonstrated clinical superiority compared with the first-generation pulsatile devices; however, complications continue to affect patients on left ventricular assist device (LVAD) support.1 The recently published MOMENTUM 3 trial (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate3) reported that the HeartMate 3 (HM3) was associated with better outcomes after 6 months when compared with the HM2. None of the patients randomized to the HM3 device had suspected or confirmed thrombosis.2 In this brief report, we describe 2 patients who developed extrinsic occlusion of the outflow graft after HM3 implantation. A 65-year-old man with ischemic cardiomyopathy underwent implantation of an HM3 LVAD as bridge to transplantation. Because of significant epistaxis, acetylsalicylic acid was reduced from 325 to 81 mg daily, whereas international normalized ratio was maintained between 2 and 3. One-year post-LVAD, the patient presented with congestive symptoms and deteriorating renal function. His LVAD had logged multiple low-flow alarms, as low as 1.9 L/min (previously 4–4.5 L/min; Figure [C]). Serum lactate dehydrogenase was 290 U/L (125–220 U/L) and international normalized ratio maintained within therapeutic range. A noncontrast computed tomographic scan of the chest showed no …

Implantable cardiac defibrillator and mortality in non-ischaemic cardiomyopathy: an updated meta-analysis

Objectives The benefit of implantable cardiac defibrillator (ICD) in symptomatic patients with systolic dysfunction and non-ischaemic cardiomyopathy remains controversial. We conducted a systematic review and meta-analysis to determine the effect of ICD in patients with non-ischaemic cardiomyopathy on (1) all-cause mortality, (2) cardiovascular mortality and (3) sudden cardiac death. Methods We searched citations in meta-analyses published until 2012, and in MEDLINE, Embase, PubMed and Cochrane databases from 2012 to October 2016. We included randomised controlled trials (RCTs) evaluating the effect of ICD therapy on all-cause and cardiovascular mortality and sudden cardiac death in patients with non-ischaemic cardiomyopathy. Independent reviewers evaluated study eligibility, abstracted data and assessed risk of bias in duplicate. We used random-effect models to meta-analyse relative risks (RR) and hazard ratios (HR) across studies, the Grades of Recommendation, Assessment, Development, and Evaluation system to quantify absolute effects and quality of evidence, and I2 to evaluate heterogeneity. Results We identified six RCTs including 1715 patients experiencing 421 deaths. ICD therapy was associated with reduced overall mortality (HR 0.78, 95% CI 0.66 to 0.92, I2 = 0%, risk difference 4.7%, high quality), cardiovascular mortality (RR 0.77, 95% CI 0.60 to 0.98, I2 = 39%, risk difference 3.3%, high quality) and sudden cardiac death (RR 0.45, 95% CI 0.29 to 0.70, I2 = 0%, risk difference 4.1%, high quality). The benefit of ICD was not influenced by the use of amiodarone in the comparison group, the duration of follow-up, by use of β-blockers and ACE inhibitors/angiotensin receptor blocker or cardiac resynchronisation therapy. Conclusion Primary prevention ICD therapy reduces all-cause and cardiovascular mortality and sudden cardiac death in patients with non-ischaemic cardiomyopathy.

Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the support of critically ill patients with cardiogenic shock is rapidly increasing. Intracardiac thrombus formation is a well-recognized complication. We present 3 cases of dramatic intracardiac thrombosis after the initiation of VA-ECMO. A 64-year-old man presented to a community hospital 3 days after the onset of chest pain with ECG evidence of anterior ST-elevation–myocardial infarction and clinical findings of cardiogenic shock. Physical examination was notable for a pansystolic murmur suggestive of a ventricular septal defect. Coronary angiography showed an occluded left anterior descending artery. Echocardiography confirmed an ischemic ventricular septal defect. He was taken urgently to the operating room for aortocoronary bypass and ventricular septal defect patch repair. Attempts to wean off cardiopulmonary bypass were unsuccessful, and the patient was placed on central VA-ECMO as a bridge to decision, with the chest left open. Forty-eight hours after the initiation of ECMO, the circuit was converted to a peripheral set-up to facilitate chest closure. Transesophageal echocardiogram performed 24 hours after chest closure showed complete thrombosis of the right ventricle despite full anticoagulation (Figure [A]; Movie I in the Data Supplement). He was taken back …

Early pneumopericardium after heart transplantation

A 60‐year‐old woman with a history of dilated cardiomyopathy underwent heart transplantation. One month post discharge, she presented to clinic with low‐grade fever and productive cough. Her chest radiograph showed air‐fluid levels in the pericardial silhouette. Transthoracic echocardiogram showed a large complex pericardial collection with no evidence of cardiac tamponade. The patient was urgently taken to the operating room for exploration. A large “egg‐shaped” mass in the pericardium measuring 10 × 12 cm with gaseous material was aspirated. As the posterior wall of the mass was firmly adhered to the right atrium, the capsule was incompletely excised. We present the case of a potentially life‐threatening complication post transplantation that required surgical debridement and life‐long antibiotic suppressive therapy. To our knowledge, this is the first report of purulent pericardial collection caused by Enterobacter cancerogenous. Further research is required to better understand the biology of this microorganism and the role it may play as a pathogen in immunocompromised patients following solid organ transplantation.

Risk evaluation using gene expression screening to monitor for acute cellular rejection in heart transplant recipients

BACKGROUND Gene expression profiling (GEP) was developed for non-invasive surveillance of acute cellular rejection. Despite its widespread use, there has been a paucity in outcome data for patients managed with GEP outside of clinical trials. METHODS The Outcomes AlloMap Registry (OAR) is an observational, prospective, multicenter study including patients aged ≥ 15 years and ≥ 55 days post-cardiac transplant. Primary outcome was death and a composite outcome of hemodynamically significant rejection, graft dysfunction, retransplantation, or death. Secondary outcomes included readmission rates and development of coronary allograft vasculopathy and malignancies. RESULTS The study included 1,504 patients, who were predominantly Caucasian (69%), male (74%), and aged 54.1 ± 12.9 years. The prevalence of moderate to severe acute cellular rejection (≥2R) was 2.0% from 2 to 6 months and 2.2% after 6 months. In the OAR there was no association between higher GEP scores and coronary allograft vasculopathy (p = 0.25), cancer (p = 0.16), or non-cytomegalovirus infection (p = 0.10). Survival at 1, 2, and 5 years post-transplant was 99%, 98%, and 94%, respectively. The composite outcome occurred in 103 patients during the follow-up period. GEP scores in dual-organ recipients (heart-kidney and heart-liver) were comparable to heart-alone recipients. CONCLUSIONS This registry comprises the largest contemporary cohort of patients undergoing GEP for surveillance. Among patients selected for GEP surveillance, survival is excellent, and rates of acute rejection, graft dysfunction, readmission, and death are low.

New Horizons on the 50th Anniversary of Heart Transplantation in Canada: “Where There Is Death, There Is Hope”

Journal News and Commentary New Horizons on the 50th Anniversary of Heart Transplantation in Canada: “Where There Is Death, There Is Hope” Yasbanoo Moayedi, MD, Mosaad Alhussein, MD, Juan G. Duero Posada, MD, Stella Kozuszko, RN(EC), MN, NP-Adult, Kiran K. Khush, MD, MAS, Jeffrey J. Teuteberg, MD, Mitesh V. Badiwala, MD, PhD, and Heather J. Ross, MD, MHSc Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada Department of Cardiovascular Medicine, Heart Transplant Program, Stanford University, Stanford, California, USA Department of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada

Letter by Moayedi et al Regarding Article, “Gene Expression Profiling for the Identification and Classification of Antibody-Mediated Heart Rejection”

We commend the authors of “Gene Expression Profiling for the Identification and Classification of Antibody-Mediated Heart Rejection” in a recent issue of Circulation. 1 The authors have begun the remarkable task of addressing the knowledge gap related to antibody mediated rejection (AMR), moving away from educated guesswork to precision medicine. We have come …