Octavio E. Pajaro

Safety of percutaneous dilatational tracheostomy with direct bronchoscopic guidance for solid organ allograft recipients.

OBJECTIVE To determine the safety of percutaneous dilatational tracheostomy (PDT) for solid organ allograft recipients, who have increased risks of bleeding and infection. PARTICIPANTS AND METHODS We reviewed the records of patients who underwent solid organ transplant between January 1, 2001, and September 30, 2005, followed by PDT (using the Ciaglia technique) with direct bronchoscopic guidance. We recorded comorbid conditions, number of days from intubation and transplant, positive end-expiratory pressures, ratios of PaO2 to fraction of inspired oxygen, coagulation study findings, complications, and procedure-related mortality rates. RESULTS Of the 51 patients in our study, 17 had undergone lung transplant; 32, liver transplant; and 2, kidney transplant. The median age was 55 years (range, 27-73), and 53% of patients were men. The median time from intubation to PDT was 10 days and from transplant to PDT, 22 days. The median ratio of PaO2 to fraction of inspired oxygen was 293, and the median positive end-expiratory pressure was 5 cm H2O. Twenty-one patients were receiving dialysis, and 11 were recovering from sepsis (of these, 8 were receiving vasopressors). Ten had coagulopathies (none of which were associated with bleeding complications). Complications were infrequent (7 periprocedural, 4 postprocedural) and included bleeding, bradycardia, hypotension, tracheal ring fracture, and cannula malfunction. Of the bleeding complications, only 2 were clinically remarkable and required removal of the tracheostomy or surgical revision. No infectious complications or procedure-related deaths were noted. CONCLUSION Percutaneous dilatational tracheostomy was tolerated well in recipients of solid organ allografts and had a relatively low risk of major complications and a low procedure-related mortality rate. This method should be considered an acceptable alternative to surgical tracheostomy.

The role of the total artificial heart in the treatment of post–myocardial infarction ventricular septal defect

improved durability and performance relative to previous VADs. Our major rationale for choosing the HeartWare HVAD was its relatively small size and ability to be contained within the pericardium, thus eliminating the potential need to create a pocket or rotate the pump configuration. In addition, the device’s integrated inflow cannula could decrease the chance of inflow obstruction related to the abnormal position of the ventricles in CC-TGA. TEE guidance ensured successful selection of the optimal insertion site for the VAD inflow cannula. In summary, we report a case of successful HeartWare HVAD implantation in a patient with CC-TGA to support the function of the RV (systemic ventricle).

Role of total artificial heart in the management of heart transplant rejection and retransplantation: case report and review

Cardiac allograft rejection and failure may require mechanical circulatory support as bridge‐to‐retransplantation. Prognosis in this patient group is poor and implantable ventricular assist devices have had limited success due to organ failure associated with the high dose immunosuppression required to treat ongoing rejection. We present a case from our institution and the world‐wide experience utilizing the SynCardia CardioWest Total Artificial Heart (TAH‐t; SynCardia Systems, Inc., Tucson, AZ, USA) for replacement of the failing graft, recovery of patient and end‐organ failure with ultimate bridge to retransplantation. We present our experience and review of world‐wide experience for use of TAH‐t in this type patient.

Mechanical circulatory assist devices: a primer for critical care and emergency physicians

Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and “decision-making”. These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices. To care for patients with these devices, health care providers in emergency departments (EDs) and intensive care units (ICUs) need to understand the physiology of the devices, the vocabulary of mechanical support, the types of complications patients may have, diagnostic techniques, and decision-making regarding treatment. Patients with LVADs who come to the ED or are admitted to the ICU usually have nonspecific clinical symptoms, most commonly shortness of breath, hypotension, anemia, chest pain, syncope, hemoptysis, gastrointestinal bleeding, jaundice, fever, oliguria and hematuria, altered mental status, headache, seizure, and back pain. Other patients are seen for cardiac arrest, psychiatric issues, sequelae of noncardiac surgery, and trauma. Although most patients have LVADs, some may have biventricular support devices or total artificial hearts. Involving a team of cardiac surgeons, perfusion experts, and heart-failure physicians, as well as ED and ICU physicians and nurses, is critical for managing treatment for these patients and for successful outcomes. This review is designed for critical care providers who may be the first to see these patients in the ED or ICU.

Anesthetic pharmacology and perioperative considerations for heart transplantation.

From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.

Antibody-mediated rejection in heart transplantation: case presentation with a review of current international guidelines.

Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limitations and the need for future research and innovation.

Ethical Analysis of Withdrawing Total Artificial Heart Support

Objectives: To describe the characteristics of patients who undergo withdrawal of total artificial heart support and to explore the ethical aspects of withdrawing this life‐sustaining treatment. Patients and Methods: We retrospectively reviewed the medical records of all adult recipients of a total artificial heart at Mayo Clinic from the programs inception in 2007 through June 30, 2015. Management of other life‐sustaining therapies, approach to end‐of‐life decision making, engagement of ethics and palliative care consultation, and causes of death were analyzed. Results: Of 47 total artificial heart recipients, 14 patients or their surrogates (30%) requested withdrawal of total artificial heart support. No request was denied by treatment teams. All 14 patients were supported with at least 1 other life‐sustaining therapy. Only 1 patient was able to participate in decision making. Conclusion: It is widely held to be ethically permissible to withdraw a life‐sustaining treatment when the treatment no longer meets the patients health care–related goals (ie, the burdens outweigh the benefits). These data suggest that some patients, surrogates, physicians, and other care providers believe that this principle extends to the withdrawal of total artificial heart support.

Lung Transplantation: Perioperative Pharmacology and Anesthetic Considerations

In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U.S. has been increasing steadily since 1988, when UNOS (United Network for Organ Sharing) started recording statistical data. In that year, 33 cases of lung transplantation were performed. As of today, a total of 23,815 lung transplants have been performed, and the largest number of yearly lung transplants (n=1,822) was performed in 2009. From appropriate patient selection, to optimal organ selection, surgical procedure, and immediate and long-term postoperative care, the medical process involves multiple healthcare providers and requires a very well-organized and committed healthcare system to achieve optimal surgical results. Understanding the pharmacology involved in the care of the lung transplant patient is of utmost importance to achieve appropriate organ preservation, immunosuppression, hemodynamic stability, and adequate anesthetic depth, while avoiding drug toxicity and side effects. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the medications most commonly administered to this patient population, throughout the perioperative period.

Monster Lung Cavity in a Heart Transplant Recipient

Invasive mucormycosis infections occur in less than 1% of recipients of orthotopic heart transplants. Given the angioinvasive nature of these infections, the mortality rate is high. Little literature exists regarding the presentation and management of these infections. We present a case of a patient who developed an infection after orthotopic heart transplant, describe the successful multidisciplinary management surrounding his care, and review the available literature regarding mucormycosis infections in heart transplant recipients.

Can we risk transplantation across positive complement-dependent cytotoxicity crossmatches in pediatric patients?

Should we continue to let complement-dependent cytotoxicity (CDC) crossmatches deny organs for sensitized patients? Or can we safely manage or prevent the potential complications associated with transplanting across a positive crossmatch? In the adult population, there are numerous studies showing poor clinical outcomes so that doing so, for the moment, is not standard of care. This article is protected by copyright. All rights reserved.