P. Catarino

Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension

OBJECTIVES Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy. METHODS Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed. RESULTS Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05). CONCLUSIONS In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.

Comparison of Outcomes From Smoking and Nonsmoking Donors: Thirteen-Year Experience

BACKGROUND Lung transplantation remains the best treatment option for a variety of end-stage lung diseases. Pressure on the limited donor pool has led to the use of extended criteria donors. One aspect of this has been the liberalization of the use of smoking donors (SmD). METHODS This study is a retrospective review of lung transplants performed between April 1995 and August 2008 at a single institute. We examined the impact of donor smoking on short-term and long-term survival in relationship to recipient and donor demographics such as ischemic time, cytomegalovirus status, rates of rejection and infection, ventilation, and intensive care stay. Endpoints were survival, infection, and rejection. RESULTS During this 13-year period, 454 lung transplants were performed. Smoking history was available on 424 (93.4%) of these (SmD, n = 184; NSmD, n = 240). Seventy-one patients died within 3 months of transplant leaving 353 alive at 3 months posttransplant. Fatalities within the first 3 months were significantly higher in the SmD group (21% vs 13%, odds ratio 1.9, hazard ratio 3.3, p = 0.04). No significant difference in rejection and infection rates between recipients of lungs from SmD and NSmD at 3 months and at 1 year posttransplantation (p = 0.51 and 0.09) was found. Although recipients of lungs from SmD had higher odds of ventilation for more than 10 hours, the odds were only increased by 20%, which was not statistically significant. Recipients from SmD had significantly longer stays in the intensive care (odds ratio 1.9, p = 0.002). There was little evidence for an effect of SmD on the development of bronchiolitis obliterans. CONCLUSIONS In this large cohort of patients, donor smoking history has an effect on early survival but no effect on long-term survival. The cause of this early mortality is independent of infection and rejection. However, these data suggest that overall outcomes from the use of donor lungs from smokers are acceptable, particularly in the current era with limited donor organs.

Size matching in lung transplantation: an evidence-based review.

The evidence base for size matching between donors and recipients in lung transplantation has not recently been reviewed in a comprehensive manner. Our aim in this study was to assimilate published studies that have addressed size matching of donors to recipients and to establish a pragmatic understanding of the range of lung sizes that may be used for lung transplantation. A comprehensive literature search was performed using Medline and PubMed up to and including September 2012, to identify scientific articles that relate to size matching between donors and lung transplant recipients. Seventy-two articles were identified, of which 21 had addressed the question of the impact of size mismatching on outcomes in lung transplantation. No study has specifically tested the consequences of intentionally mismatching above or below the hypothetical limits for double lung transplantation of a predicted total lung capacity for the donor of between 75% and 125% of the recipient predicted total lung capacity as set out in the ISHLT consensus report on lung donor acceptability criteria. Research is lacking that has robustly defined limits for size mismatch for single lung transplantation and for recipients with restrictive lung pathologies such as pulmonary fibrosis. Published research on the impact of size mismatching between lung transplant donors and recipients is limited by study design and size. It is centered on addressing the issue of mismatch in double lung transplantation in cohorts with a diagnostically heterogeneous make-up and in single lung transplant patients with chronic obstructive pulmonary disease.

A moribund athlete.

In December, 2011, a 39-year-old woman presented to the local emergency department complaining of a 1-day history of vomiting and abdominal pain. She had had three or four episodes, with no infective prodrome. She was a physiotherapist and a competent long-distance runner; 2 days earlier she had run a 5 km race, and that morning had done her daily exercise workout. On examination there were no physical signs other than sinus tachycardia. Within 2 h, she collapsed and was moribund in acute cardiogenic shock. She was trans ferred to intensive care for mechanical ventilation and escalating inotropic support. Chest radiography showed pulmonary congestion. Trans thoracic echocardiography excluded valvular and con genital abnormalities and showed a slightly dilated, poorly functioning heart with no pericardial eff usion. Cardiac catheterisation was done to exclude coronary artery disease, and an intra-aortic balloon pump was placed for circulatory support. She had no arrhythmias. She was not pregnant and took no prescribed or recreational drugs; all infection screens were negative. She continued to deterior ate and needed two periods of chest compressions for loss of cardiac output. Acute myocarditis was suspected and she was transferred to our cardiothoracic centre for consideration of escalation of mechanical circu latory support. A consultant cardiologist and an intensivist accompanied her for the 70-mile journey, during which boluses of epinephrine were needed to maintain her circulation. She arrived 8 h after fi rst presentation, was found to be in extremis, with fi xed mottling of her trunk and limbs and hypotension despite epinephrine infusing at >1 μg/kg per min. She was anuric, profoundly acidaemic, and hypoxic on 100% oxygen (PaO2 6·1 kPa, pH 6·9, lactate 16 mmol/L, base excess –13). She was taken directly to theatre for median sternotomy. The heart was tense and dilated and a myocardial biopsy sample was taken from the left ventricle. Central veno-arterial extracorporeal membrane oxygenation (ECMO) was established; a cannula was inserted via the abdominal wall into the right atrium to drain systemic venous blood into the ECMO pump, which returned oxygenated blood via a separate cannula into the ascending aorta (fi gure). This procedure restored systemic cardiac output, and the sternum was closed. Her condition rapidly improved and the inotropes were stopped. During the next 24 h, signifi cant hypertension developed. The biopsy sample showed no evidence of myocarditis but did suggest catecholamine-induced myocyte damage. Continuing resistant hypertension raised the possibility of a catecholamine-secreting tumour. CT of the abdomen showed a large left adrenal mass (5×6 cm). Left adrenal ectomy was done (day 3) with concurrent ECMO support. Subsequent echo cardiography showed recovering biven tricular function (day 5) and ECMO was discontinued. She recovered fully, and was discharged in February, 2012. Histology confi rmed a benign phaeochromocytoma. Phaeochromocytomas are rare catecholamine-secreting tumours of the chromaffi n cells of the adrenal gland. They have diverse presentations including vomiting and abdominal pain, hypertension, as well as sweating, headache, and palpitations, which are typically episodic. Most cases are insidious, and although catecholamine-induced cardiomyopathy is well recognised, such a fulminant presen tation is rare. In our patient’s case, timely referral, and escalation of mechanical circulatory support were essential for resuscitation and diagnosis. Without special ised anaesthetic work-up before the adren alectomy, ECMO enabled control of the circulation during this operation. There were several support options for our patient but central ECMO could be established exped itiously and allowed examination and biopsy of the heart. Physicians should consider central ECMO in such cases as the mech an ical circulatory support of choice for “bridge to diagnosis”.

The ETTAA study protocol: a UK-wide observational study of 'Effective Treatments for Thoracic Aortic Aneurysm'.

Introduction Chronic thoracic aortic aneurysm (CTAA) affecting the arch or descending aorta is an indolent but life-threatening condition with a rising prevalence as the UK population ages. Treatment may be in the form of open surgical repair (OSR) surgery, endovascular stent grafting (ESG) or best medical therapy (BMT). Currently, there is no consensus on the best management strategy, and no UK-specific economic studies that assess outcomes beyond the chosen procedure, but this is required in the context of greater demand for treatment and limited National Health Service (NHS) resources. Methods and analysis This is a prospective, multicentre observational study with statistical and economic modelling of patients with CTAA affecting the arch or descending aorta. We aim to gain an understanding of how treatments are currently chosen, and to determine the clinical effectiveness and cost-effectiveness of the three available treatment strategies (BMT, ESG and OSR). This will be achieved by: (1) following consecutive patients who are referred to the teams collaborating in this proposal and collecting data regarding quality of life (QoL), medical events and hospital stays over a maximum of 5 years; (2) statistical analysis of the comparative effectiveness of the three treatments; and (3) economic modelling of the comparative cost-effectiveness of the three treatments. Primary study outcomes are: aneurysm growth, QoL, freedom from reintervention, freedom from death or permanent neurological injury, incremental cost per quality-adjusted life year gained. Ethics and dissemination The study will generate an evidence base to guide patients and clinicians to determine the indications and timing of treatment, as well as informing healthcare decision-makers about which treatments the NHS should provide. The study has achieved ethical approval and will be disseminated primarily in the form of a Health Technology Assessment monograph at its completion. Trial registration number ISRCTN04044627.

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement

Objective: Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini‐sternotomy (MS). The Mini‐Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first‐time isolated AVR. Methods: This pragmatic, open‐label, parallel randomized controlled trial (RCT) compared MS with FS for first‐time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent‐to‐treat population. Results: In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR, 0.874; 95% confidence interval [CI], 0.668–1.143; P = .3246) or time to fitness for discharge (HR, 0.907; 95% CI, 0.688–1.197; P value = .4914). During a mean follow‐up of 760 days (745 days for the MS group and 777 days for the FS group), 12 patients (10%) in the MS group and 7 patients (7%) in the FS group died (HR, 1.871; 95% CI, 0.723–4.844; P = .1966). Average extra cost for MS was £1714 during the first 12 months after AVR. Conclusions: Compared with FS for AVR, MS did not result in shorter hospital stay, faster recovery, or improved survival and was not cost‐effective. The MS approach is not superior to FS for performing AVR.

Branched Thoraco-Abdominal Aortic Aneurysm Repair with Branch Access Through a Transapical Left Ventricular Approach

Branched thoracic aortic aneurysm repair requires arterial access from above the diaphragm in order to insert the visceral branches. This is routinely performed from the subclavian, axillary or carotid arteries and less commonly direct thoracic aorta puncture. The left ventricular apex is an alternative access route which is commonly used for percutaneous aortic valve replacement and rarely used for EVAR, FEVAR and TEVAR access. Here we describe two patients for which the left ventricular apex was the most suitable available access to the visceral branches during a branched thoracic aortic aneurysm repair. This access should be considered as an alternative approach if conventional arterial access is not available.

Use of Intraaortic Balloon Pumps in Acute Type A Aortic Dissection

Cardiac failure may occur after repair of type A aortic dissections and contributes significantly to mortality. The use of an intraaortic balloon pump (IABP) for circulatory support in these patients is traditionally considered contraindicated because of concerns over extension of the residual dissection flap or aortic rupture. We propose that the use of an IABP may be appropriate and safe to improve cardiac function in patients after type A dissection repair. The two cases presented here contribute to increasing the body of evidence to support the appropriate use of IABP in these patients.

Stenting of the ascending aorta: a stent too far?

A 45-year old woman with then unknown Loeys-Dietz syndrome (LDS) presented in 2007 with aneurysms involving the entire thoraco-abdominal aorta, but sparing the aortic root and valve. She underwent debranching of the aortic arch, followed by stenting of entire distal ascending aorta, arch and descending aorta. Two years later, a diagnosis of LDS was established. Five years later, she re-presented with severe aortic regurgitation in a dilated aortic root, requiring aortic root replacement. We present the challenges involved in performing aortic root replacement in the presence of stents within the ascending aorta.