S. Tsui

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

Chronic thromboembolic disease is characterised by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment with pulmonary endarterectomy may improve symptoms and prevent disease progression. We sought to assess the outcome of pulmonary endarterectomy in symptomatic patients with chronic thromboembolic disease. Patients with symptomatic chronic thromboembolic disease and a mean pulmonary artery pressure <25 mmHg at baseline with right heart catheterisation and treated with pulmonary endarterectomy between January 2000 and July 2013 were identified. Patients were reassessed at 6 months and at 1 year following surgery. A total of 42 patients underwent surgery and the median length of stay in hospital was 11 days. There was no in-hospital mortality but complications occurred in 40% of patients. At 1 year, following surgery, 95% of the patients remained alive. There was a significant symptomatic improvement with 95% of patients in the New York Heart Association functional classes I or II at 6 months. There was a significant improvement in quality of life assessed by the Cambridge pulmonary hypertension outcome review questionnaire. In this carefully selected cohort of chronic thromboembolic disease patients, pulmonary endarterectomy resulted in significant improvement in symptoms and quality of life. Appropriate patient selection is paramount given the known surgical morbidity and mortality, and surgery should only be performed in expert centres. Pulmonary endarterectomy improves symptoms and quality of life in patients with chronic thromboembolic disease http://ow.ly/AeECt

Heart-lung transplantation for Eisenmenger syndrome: early and long-term results.

BACKGROUNDnHeart-lung transplantation (HLT) for Eisenmenger syndrome (ES) provides superior early and intermediate survival when compared with other forms of transplantation. The early risk factors and long-term outcome of HLT for ES are less well defined.nnnMETHODSnWe analyzed 263 patients who had undergone HLT at our institution during more than 15 years. Fifty-one consecutive patients with ES who underwent HLT, 33 (65%) of which had simple anatomy, were compared with 212 cases having HLT for other indications (non-ES).nnnRESULTSnFemale sex and previous thoracotomy were more prevalent in the ES group. Patients with ES had greater postoperative blood loss and returned more frequently to the operating room for control of bleeding. There were 8 (16%) early deaths in the ES group compared with 27 (13%) in non-ES (p = 0.65). One-, 5-, and 10-year survival rates for ES were 72.6%, 51.3%, and 27.6%, respectively, compared with non-ES of 74.1%, 48.1%, and 26.0%, respectively, and there was no difference in survival overall (p = 0.54). Among ES patients, previous thoracotomy was a risk factor for hospital death. A subgroup analysis based on simple versus complex type of ES did not show statistically significant differences in terms of postoperative course or early or late survival.nnnCONCLUSIONSnHeart-lung transplantation is a successful procedure for ES. Despite a greater frequency of risk factors and a more difficult operative course, early and late outcome with HLT is comparable to non-ES recipients.

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

OBJECTIVESnRaised 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.nnnMETHODSnPulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed.nnnRESULTSnTwenty-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).nnnCONCLUSIONSnIn 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.

Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics

BACKGROUNDnHigh-dosage inotrope use or periods of hypotension may cause rejection of donor hearts for transplantation. At our institution, we do not refuse potential donor organs based on these criteria alone before Swan-Ganz catheter (SGC) assessment. In this study, we evaluate the role of the SGC in donor heart resuscitation and selection and assess the outcome of using borderline organs.nnnMETHODSnWe retrospectively analyzed 129 donors assessed between 1996 and 1999, all with complete hemodynamic data. Two sets of SGC measurements were analyzed: one set from the initial assessments, and one set from assessments made just before organ harvesting. The physiologic targets were mean blood pressure >60 mm Hg, central venous pressure <12 mm Hg, pulmonary capillary wedge pressure <12 mm Hg, left ventricular stroke work index >15 x g.m/m(2), and use of only one inotrope. A poorly functioning heart was defined as an organ failing on 2 or more of these criteria. Hemodynamic categories were defined as A, good function throughout assessment; B, sub-optimal function and then improvement; and C, decreasing or poor function throughout. We have a policy to avoid allocating sub-optimal organs to high-risk recipients.nnnRESULTSnOne hundred fourteen donor hearts went on to be transplanted: 75 as orthotopic hearts and 39 as heart-lungs (5 of these were heart, lung, and liver transplantations, not reported further here). Of the 75 donor hearts used for heart transplantations, 53 were from Category A, 9 were from Category B, and 13 were from Category C. Of the donor hearts used for the 34 heart-lung transplantations 16 were from Category A, 10 were from Category B, and 8 were from Category C. Three patients died of donor organ failure: 1 of the corresponding hearts was from Category B, and 2 were from Category C. When comparing separately the outcome of the 2 procedures, we found no significant difference in duration of stay in the intensive care unit, requirement for mechanical support, 30-day mortality, or 1-year survival among patients with hearts from Categories A, B, and C. Ischemic time was the only significant risk factor for death (p = 0.006).nnnCONCLUSIONSnUse of organs from Categories B and C permitted expansion of the donor pool without compromising short-term outcome. However, these organs should be used with caution in combination with other risk factors, in particular long ischemic time.

Transcatheter aortic valve insertion: anaesthetic implications of emerging new technology

Transcatheter aortic valve insertion is a new development that potentially offers a number of advantages to patients and healthcare providers. These include the avoidance of sternotomy and cardiopulmonary bypass, and much faster discharge from hospital and return to functional status. The procedure itself however is quite complex, and presents significant demands in planning and implementation to the multidisciplinary team. Anaesthetic input is essential, and patient care in the perioperative period can be challenging. Early results have shown a significant mortality and morbidity rate, but the majority of procedures to date have been carried out in elderly patients with multiple comorbidities, making comparison with surgical aortic valve replacement inappropriate. Long-term outcomes are not yet known, but randomized controlled trials should allow this procedure and its application to be properly assessed.

Improved outcome with organs from carbon monoxide poisoned donors for intrathoracic transplantation

BACKGROUNDnThe success of intrathoracic organ transplantation has lead to a growing imbalance between the demand and supply of donor organs. Accordingly, there has been an expansion in the use of organs from nonconventional donors such as those who died from carbon monoxide poisoning. We describe our experience with 7 patients who were transplanted using organs after fatal carbon monoxide poisoning.nnnMETHODSnA retrospective study of the 1,312 intrathoracic organ transplants between January 1979 and February 2000 was completed. Seven of these transplants (0.5%) were fulfilled with organs retrieved from donors after fatal carbon monoxide poisoning. There were six heart transplants and one single lung transplant. The history of carbon monoxide inhalation was obtained in all of these donors.nnnRESULTSnFive of 6 patients with heart transplant are alive and well with survival ranging from 68 to 1,879 days (mean, 969 +/- 823 days). One patient (a 29-year-old male) died 12 hours posttransplant caused by donor organ failure. The patient who had a right single lung transplant did well initially after the transplant, but died after 8 months caused by Pneumocystis carinii pneumonia. All those recipients who were transplanted from carbon monoxide poisoned donors and ventilated for more than 36 hours, survived for more than 30 days. Moreover, these donors were assessed and optimized by the Papworth donor management protocol.nnnCONCLUSIONSnCarbon monoxide poisoned organs can be considered for intrathoracic transplantation. In view of the significant risk of donor organ failure, a cautious approach is still warranted. Ideally, the donor should be hemodynamically stable for at least 36 hours from the time of poisoning and on minimal support. A formal approach of invasive monitoring and active management further improves the chances of successful outcome.

Leg ischaemia following bilateral internal thoracic artery and inferior epigastric artery harvesting.

There is increasing evidence that the use of arterial conduits for coronary artery bypass grafting provides superior long-term results when compared to using saphenous veins alone. Major complications of using internal thoracic arteries (ITAs) and inferior epigastric arteries (IEAs) are uncommon. We report the case of a 42-year-old man who underwent coronary revascularisation in which harvesting of these arteries resulted in critical ischaemia of the lower limbs requiring aortobifemoral grafting. This patient had a long-standing occluded abdominal aorta which was asymptomatic and relied on the ITAs and IEAs as important collateral blood supply to the legs. The enormous size of these conduits found at operation suggested their role. Management strategies to avoid such a serious complication are discussed.

Are non–brain stem-dead cardiac donors acceptable donors?

BACKGROUNDnThe deleterious effects of brainstem death (BSD) on donor cardiac function and endothelial integrity have been documented previously. Domino cardiac donation (heart of a heart-lung recipient transplanted into another recipient) is a way to avoid the effects of brainstem death and may confer both short- and long-term benefits to allograft recipients.nnnMETHODSnThis study evaluates short- and long-term outcome in heart recipients of BSD donors (cadaveric) as compared with domino hearts explanted from patients who underwent heart-lung transplantation.nnnRESULTSnPatients having undergone cardiac transplantation between April 1989 and August 2001 at Papworth Hospital were included (n = 571). Domino donor hearts were used in 81 (14%) of these cases. The pre-operative transpulmonary gradient was not significantly different between the two groups (p = 0.7). There was no significant difference in 30-day mortality (4.9% for domino vs 8.6% for BSD, p = 0.38) or in actuarial survival (p = 0.72). Ischemic time was significantly longer in the BSD group (p < 0.001). Acute rejection and infection episodes were not significantly different (p = 0.24 vs: 0.08). Relative to the BSD group, the risk (95% confidence interval) of acute rejection in the domino group was 0.89 (0.73 to 1.08). Similarly, the relative risk of infection was 0.78 (0.59 to 1.03). The 5-year actuarial survival rates (95% confidence interval) were 78% (69% to 87%) and 69% (65% to 73%) in the domino and BSD groups respectively. Angiography data at 2 years were available in 50 (62%) and 254 (52%) patients in the domino and BSD groups, respectively. The rates for 2-year freedom from cardiac allograft vasculopathy (CAV) were 96% (91% to 100%) and 93% (90% to 96%), respectively.nnnCONCLUSIONnDespite the lack of endothelial cell activation after brainstem death and a shorter ischemic time, the performance of domino donor hearts was similar to that of BSD donor hearts. This may indicate a similar pathology (i.e., endothelial cell activation) in the domino donors.

Ventricular assist surprise: giant cell myocarditis or sarcoidosis?

Idiopathic giant cell myocarditis (GCM) is a rapidly fatal disease with a worse natural history than lymphocytic myocarditis. Transplantation is the best available therapy, despite the risk of disease recurrence in the allograft. However, patients with GCM often die before a donor heart becomes available. Mechanical assist for acute myocarditis dramatically improves the natural history of the underlying disease. Particularly when the picture is of lymphocytic myocarditis, there is a good chance of successful bridge to recovery. There are no reported cases of bridge to recovery for GCM, and the world experience of bridge to transplant totals 9 cases. Furthermore, the outcome of these patients was poorer than that of other patients with GCM who underwent transplantation without prior requirement of a ventricular assist device (VAD). Secondary GCM is associated with other systemic illnesses (eg, sarcoidosis). From a clinical and pathologic standpoint, idiopathic GCM and cardiac sarcoidosis (CS) are considered different entities. We present a case that challenges this traditional view.

1 Heart function replacement: the current state and a look into the future

There is an epidemic of advanced heart failure across developed countries. For those who are refractory to medical and/or device therapies, cardiac replacement can improve quality of life and life expectancy. Fifty years on from the first successful human case, heart transplantation remains the most effective treatment for advanced heart failure with <5% 30u2009day post-transplant mortality and median survival approaching 14 years. However, there is a severe shortage of suitable donor hearts. Conventionally, only hearts from donation after brain dead (DBD) are considered for transplantation. After careful assessment, 25% to 30% of DBD hearts go on to be retrieved and transplanted. The rest are declined due to donor medical history, poor function, coronary artery disease, hypertrophy etc. The challenge over the last decade has been to increase DBD heart utilisation and to identify other donor pools. In recent years, targeted early donor management of DBD donors by a member of the cardiothoracic retrieval team at the donor ICU, or ‘scouting’, has been shown to increase the percentage of DBD hearts retrieved and transplanted.1 The other major development has been the use of reconditioned asystolic hearts from donation after circulatory death (DCD). Here, withdrawal of life supporting therapy results in hypoventilation, hypoxia and systemic hypotension. Eventually, profound cardiac ischaemia results in cardiac arrest. After a mandatory observation period of five or more minutes, death is legally confirmed. A combination of in-situ and ex-situ perfusion techniques have been successfully used to re-animate asystolic DCD hearts for consideration of transplantation.2 3 References . Retrieval team initiated early donor management (scouting) increases donor heart acceptance rate for transplantation. J Heart Lung Transplant2016;35:S220. http://dx.doi.org/10.1016/j.healun.2016.01.620 . Functional assessment and transplantation of the donor heart after circulatory death. J Heart Lung Transplant2016;35:1443–1452. . Outcome following heart transplantation from donation after circulatory determined death (DCD) donors. http://dx.doi.org/10.1016/j.healun.2017.10.021