Olivier Van Caenegem

Outcome of cardiac surgery patients with complicated intensive care unit stay.

Risk stratification has become an essential element in the practice of cardiac surgery. Several studies have identified preoperative risk factors for adverse outcome. However, outcome is mostly defined by 30-day mortality and morbidity. These data reflect poorly the benefit for the patient. Long-term survival, quality of life, and functional status should be included in a more global analysis of the outcome, particularly in patients with complicated ICU stay. By reviewing the recent data reported in the literature, we can identify a number of preoperative predictive factors for complicated ICU stay, including advanced age, chronic obstructive pulmonary disease, preoperative low ejection fraction, previous myocardial infarction, reoperation, renal failure, combined surgery (coronary artery bypass grafting plus valve surgery), low hematocrit, and neurologic impairment. Short- and long-term outcomes are dependent on the type of postoperative complication. Unfortunately, data regarding the long-term outcome in these situations are very scarce.

Allosensitization in bridge to transplant Novacor left ventricular assist device patients: analysis of long-term outcomes with regard to acute rejection and chronic allograft vasculopathy §

BACKGROUND The true relevance of allosensitization in patients benefiting from left ventricular assist device (LVAD) as bridge to transplant (BTT) is still debated. Available registry data referred to numerous devices precluding LVAD-specific analysis. Therefore, we studied all patients with Novacor LVAD prior to transplantation. METHODS From 1985 to 2006, 37 Novacor LVADs were implanted as BTT, with 30 patients surviving to transplantation (81%). Post-LVAD sensitization was determined for anti-HLA-class I and class II IgGs. Study endpoints were overall survival and/or graft loss, > or =3A cellular rejection and chronic allograft vasculopathy (CAV). The results from LVAD patients were compared to non-LVAD primary heart transplant recipients (n=318). RESULTS After LVAD insertion, 5 out of 27 patients available for analysis developed anti-HLA antibodies (18.5%). The mean anti-HLA titer after Novacor LVAD implantation was 14% [SD 31]. Actuarial 5- and 10-year patient/graft survival for LVAD and non-LVAD transplant recipients were 73% and 55%, and 70% and 55%, respectively (p=NS). Overall prevalence of rejection > or =3A was 23.3 % (LVAD group) and 18.9% (non-LVAD group) (p=NS). At follow-up, the respective incidence of CAV was 8% (LVAD group) and 32.4% (non-LVAD group) (p<0.01). However, mean follow-up was significantly different for LVAD and non-LVAD patients, 46 vs 90 months (p<0.001). CONCLUSION In this study, allosensitization occurred infrequently after Novacor LVAD implantation. Secondly, analysis of outcome variables shows that Novacor-LVAD BTT patients can anticipate similar survival to non-LVAD patients, thus minimizing the impact of allosensitization after LVAD implantation.

Aortic regurgitation after left ventricular assist device placement.

A 1 60-YEAR-OLD man with a history of recent heart failure caused by both primitive and ischemic dilated cardiomypathy underwent the successful implantation of a left ventriclar assist device (Novacor LVAS; WorldHeart, Ottawa, ON, anada) under cardiopulmonary bypass. Intraoperative transsophageal echocardiography (TEE) performed immediately fter implantation showed the correct placement of both the nflow and the outflow grafts (Fig 1) and the absence of any ortic regurgitation or aortic valve pathology. His immediate postoperative course was uneventful, and no ight ventricular assistance was needed. A routine follow-up ransthoracic echocardiogram performed in the intensive care nit on postimplantation day 9 disclosed mild central aortic egurgitation along with a mild pericardial effusion. Another ransthoracic echocardiogram performed on postimplantation ay 15 showed an aggravation of both the aortic regurgitation nd the pericardial effusion. Clinically, the patient was asymptomatic and had no fever or igns of peripheral hypoperfusion. Because the magnitude of he aortic insufficiency could preclude the correct functioning t

Hypothermic continuous machine perfusion improves metabolic preservation and functional recovery in heart grafts

The number of heart transplants is decreasing due to organ shortage, yet the donor pool could be enlarged by improving graft preservation. Hypothermic machine perfusion (MP) has been shown to improve kidney, liver, or lung graft preservation. Sixteen pig hearts were recovered following cardioplegia and randomized to two different groups of 4‐hour preservation using either static cold storage (CS) or MP (Modified LifePort© System, Organ Recovery Systems©, Itasca, Il). The grafts then underwent reperfusion on a Langendorff for 60 min. Energetic metabolism was quantified at baseline, postpreservation, and postreperfusion by measuring lactate and high‐energy phosphates. The contractility index (CI) was assessed both in vivo prior to cardioplegia and during reperfusion. Following reperfusion, the hearts preserved using CS exhibited higher lactate levels (56.63 ± 23.57 vs. 11.25 ± 3.92 μmol/g; P < 0.001), increased adenosine monophosphate/adenosine triphosphate (AMP/ATP) ratio (0.4 ± 0.23 vs. 0.04 ± 0.04; P < 0.001), and lower phosphocreatine/creatine (PCr/Cr) ratio (33.5 ± 12.6 vs. 55.3 ± 5.8; P <0.001). Coronary flow was similar in both groups during reperfusion (107 ± 9 vs. 125 + /‐9 ml/100 g/min heart; P = ns). CI decreased in the CS group, yet being well‐preserved in the MP group. Compared with CS, MP resulted in improved preservation of the energy state and more successful functional recovery of heart graft.

Hypothermic continuous machine perfusion enables preservation of energy charge and functional recovery of heart grafts in an ex vivo model of donation following circulatory death.

OBJECTIVES Cardiac transplantation using hearts from donors after circulatory death (DCD) is critically limited by the unavoidable warm ischaemia and its related unpredictable graft function. Inasmuch as hypothermic machine perfusion (MP) has been shown to improve heart preservation, we hypothesized that MP could enable the use of DCD hearts for transplantation. METHODS We recovered 16 pig hearts following anoxia-induced cardiac arrest and cardioplegia. Grafts were randomly assigned to two different groups of 4-h preservation using either static cold storage (CS) or MP (Modified LifePort© System, Organ Recovery Systems©, Itasca, Il). After preservation, the grafts were reperfused ex vivo using the Langendorff method for 60 min. Energetic charge was quantified at baseline, post-preservation and post-reperfusion by measuring lactate and high-energy phosphate levels. Left ventricular contractility parameters were assessed both in vivo prior to ischaemia and ex vivo during reperfusion. RESULTS Following preservation, the hearts that were preserved using CS exhibited higher lactate levels (57.1 ± 23.7 vs 21.4 ± 12.2 µmol/g; P < 0.001), increased adenosine monophosphate/adenosine triphosphate ratio (0.53 ± 0.25 vs 0.11 ± 0.11; P < 0.001) and lower phosphocreatine/creatine ratio (9.7 ± 5.3 vs 25.2 ± 11; P < 0.001) in comparison with the MP hearts. Coronary flow was similar in both groups during reperfusion (107 ± 9 vs 125 ± 9 ml/100 g/min heart; P = ns). Contractility decreased in the CS group, yet remained well preserved in the MP group. CONCLUSION MP preservation of DCD hearts results in improved preservation of the energy and improved functional recovery of heart grafts compared with CS.

The CECARI Study: Everolimus (Certican®) Initiation and Calcineurin Inhibitor Withdrawal in Maintenance Heart Transplant Recipients with Renal Insufficiency: A Multicenter, Randomized Trial

In this 3-year, open-label, multicenter study, 57 maintenance heart transplant recipients (>1 year after transplant) with renal insufficiency (eGFR 30–60 mL/min/1.73 m2) were randomized to start everolimus with CNI withdrawal (N = 29) or continue their current CNI-based immunosuppression (N = 28). The primary endpoint, change in measured glomerular filtration rate (mGFR) from baseline to year 3, did not differ significantly between both groups (+7.0 mL/min in the everolimus group versus +1.9 mL/min in the CNI group, p = 0.18). In the on-treatment analysis, the difference did reach statistical significance (+9.4 mL/min in the everolimus group versus +1.9 mL/min in the CNI group, p = 0.047). The composite safety endpoint of all-cause mortality, major adverse cardiovascular events, or treated acute rejection was not different between groups. Nonfatal adverse events occurred in 96.6% of patients in the everolimus group and 57.1% in the CNI group (p < 0.001). Ten patients (34.5%) in the everolimus group discontinued the study drug during follow-up due to adverse events. The poor adherence to the everolimus therapy might have masked a potential benefit of CNI withdrawal on renal function.

Giant venous aneurysm jeopardising internal mammary arterial graft patency

The authors report a 79-year old man with a history of coronary bypass surgery, presenting with acute heart failure and elevated troponin. Coronarography revealed a giant saphenous vein graft aneurysm, which was compressing the left internal mammary artery bypass graft. This was confirmed by a multislice enhanced-ECG gated cardiac CT, showing the venous aneurysm responsible for external compression of the arterial graft and its functional occlusion. Myocardial ischaemia, the mechanism leading to cardiac failure, was confirmed by hypoperfusion of the sub-endocardial area shown by the CT. The aneurysm was surgically removed without complications. The patient recovered and his cardiac function improved. This is the first recorded case of compression of the left internal mammary artery by an giant saphenous vein graft aneurysm having triggered severe myocardial ischaemia and heart failure. The authors review the incidence and complications of giant venous bypass graft aneurysms reported in the literature.

Bronchogenic cyst infection presenting as pleuropericarditis

A 17-year-old woman was admitted to the emergency department with a 3-day history of dyspnoea (New York Heart Association Class II) and typical pleuritic pain following a 1-week history of cough and fever. Pneumonia was diagnosed based on a chest X-ray (figure 1A), and amoxicillin–clavulanate treatment was initiated. After 48 hours, the patient developed hypotension and tachycardia. Given hypotension, ongoing fever and rising C reactive protein despite antibiotic treatment, she was referred to the intensive care unit. On admission, an echocardiography was performed. A circumferential pericardial effusion with 14 mm maximum diameter adjacent to the right ventricle was detected, without haemodynamic compromise at the time. Besides, left pleural effusion was evidenced. An ultrasound-guided thoracentesis was conducted. Pleural …

Ventricular septal defect without tamponade after penetrating trauma

A 46-year-old man presented after having stabbed himself with a knife in the upper abdomen a day earlier. Thoraco-abdominal computed tomography and a transthoracic echocardiography were performed and showed a small pericardial effusion without other abnormality. As the patient was asymptomatic, conservative management was decided. Two days after admission, he developed a loud systolic cardiac murmur, and a repeat echocardiography showed a basal ventricular septal defect (VSD) with a significant left-to-right shunt. Surgical repair was performed, confirming the trajectory of the knife through the pericardium, the right ventricle free wall and the interventricular septum. VSD after penetrating cardiac injury is often diagnosed late as initial attention is distracted by the frequently associated tamponade or hemorrhagic shock. In this case, muscular spasm or

Artificial Heart Support.

This chapter describes the history of mechanical circulatory, available paracorporeal or implantable systems, indications for mechanical circulatory support, patient selection and management, complications and future perspectives.