W. Jakobleff

Position paper for the organization of ECMO programs for cardiac failure in adults

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.

Outcomes After Transplantation of Donor Hearts With Improving Left Ventricular Systolic Dysfunction

BACKGROUNDnLeft ventricular systolic dysfunction (LVSD) accounts for almost 25% of nonacceptance of potential donor hearts. Previous smaller, single-center studies showed that LVSD following brain death may be transient, and such hearts can be successfully resuscitated with resolution of LVSD, then transplanted.nnnOBJECTIVESnThis study evaluated outcomes of donor hearts with LVSD on initial transthoracic echocardiogram (TTE) that resolved during donor management.nnnMETHODSnWe reviewed echocardiograms of all cardiac donors in the United Network of Organ Sharing database thatxa0were transplanted from January 1, 2007, to September 30, 2015, and identified 472 donor hearts with LVSD (left ventricular ejection fraction [LVEF]xa0≤40%) on initial TTE that resolved (LVEFxa0≥50%) during donor management on a subsequent TTE. These patients comprised the improved donor LVEF group. These were compared with donor hearts withxa0normal LVEF (LVEFxa0≥55%) on the initial TTE for recipient mortality, cardiac allograft vasculopathy (CAV), and primary graft failure (PGF).nnnRESULTSnThere was no significant difference in recipient mortality at 30xa0days, 1 year, 3 years, and 5 years of follow-up, nor any difference in rates of PGF at 90xa0days and CAV at 5 years between recipients of donor hearts with improved LVEFxa0and recipients of donor hearts with initially normal LVEF. Post-transplant length of stay was also similar between the 2 groups. Using propensity scores, 461 transplants in the improved-donor LVEF group were matched to 461 transplants in the normal-donor LVEF group. There was no significant difference in PGF at 90xa0days or recipient mortality after up to 5 years of follow-up.nnnCONCLUSIONSnIn the largest analysis of donor hearts with transient LVSD, we found that such hearts can be successfully resuscitated and transplanted without increasing recipient mortality, CAV, or PGF. These results underscore the importance of appropriate donor management and should help to increase utilization of donor hearts with transientxa0LVSD.

Outcomes of Early Adolescent Donor Hearts in Adult Transplant Recipients

OBJECTIVESnThis study sought to determine outcomes of adult recipients of early adolescent (EA) (10xa0toxa014xa0years) donor hearts.nnnBACKGROUNDnDespite a shortage of donor organs, EA donor hearts (not used for pediatric patients) are seldom usedxa0for adults because of theoretical concerns for lack of hormonal activation and changes in left ventricular mass. Nonetheless, the outcomes of adult transplantation using EA donor hearts are not clearly established.nnnMETHODSnAll adult (≥18 years of age) heart transplant recipients in the United Network for Organ Sharing database between April 1994 and September 2015 were eligible for this analysis. Recipients of EA donor hearts were compared with recipients of donor hearts from the usual adult age group (ages 18 to 55 years). Main outcomes were all-cause mortalityxa0and cardiac allograft vasculopathy up to 5 years, and primary graft failure up to 90 days post-transplant. Propensity score analysis was used to identify a cohort of recipients with similar baseline characteristics.nnnRESULTSnOf the 35,054 eligible adult recipients, 1,123 received hearts from EA donors and 33,931 from usual-age adultxa0donors. With the use of propensity score matching, 944 recipients of EA donor hearts were matched to 944 recipients ofxa0usual-age adult donor hearts. There was no difference in 30-day, 1-year, 3-year, and 5-year recipient survival or primary graft failure rates in the 2 groups using both Cox hazards ratio and Kaplan-Meier analysis. Of note, adult patients who received EA donor hearts had a trend toward less cardiac allograft vasculopathy (Cox hazard ratio, 0.80; 95% confidence interval: 0.62 to 1.01; pxa0= 0.07).nnnCONCLUSIONSnIn this largest analysis to date, we found strong evidence that EA donor hearts, not used for pediatric patients, can be safely transplanted in appropriate adult patients and have good outcomes. This finding should help increase the use of EA donor hearts.

The hybrid repair of a penetrating ulcer in a patient with a bovine arch; debranching followed by endovascular stent placement.

Aortic arch disease has conventionally been a subject for open surgical repair, which may require circulatory arrest, accompanied by a long perfusion and extended cross-clamp time. A 2-stage approach utilizing an elephant trunk procedure followed by a descending aortic replacement, or utilizing a frozen elephant trunk with endovascular extension is not well tolerated by multimorbid patients. On the other hand, the endovascular repair of an aortic arch disease is limited by aortic branching. Hybrid repair consists of revascularization of arch vessels followed by endovascular stenting.

Cardiac transplantation from non-viremic hepatitis C donors

BACKGROUNDnHepatitis C (HCV) donors are rarely used for cardiac transplantation due to historically poor outcomes. In 2015, nucleic acid testing (NAT) for viral load was added to the routine work-up of organ donors, allowing for the distinction between subjects who remain viremic (HCV Ab+/NAT+) and those who have cleared HCV and are no longer viremic (HCV Ab+/NAT-). The American Society of Transplantation recently recommended that HCV Ab+/NAT- donors be considered non-infectious and safe for transplantation. We present our initial experience with such donors.nnnMETHODSnAll patients were counseled regarding donor HCV antibody (Ab) and NAT. Transplant recipients were tested post-transplant at 1 week and at 1, 3, and 6 months for HCV seropositivity and viremia. We also analyzed the UNOS database to determine the potential impact of widespread acceptance of HCV Ab+/NAT- organs.nnnRESULTSnFourteen HCV Ab‒ subjects received hearts from HCV Ab+/NAT- donors in 2017. Over a median follow-up of 256 (192 to 377) days, 3 patients developed a reactive HCV Ab, yet none had a detectable HCV viral load during prospective monitoring at any time. Analysis of the UNOS database for the calendar year 2016 revealed that only 7 (3%) of 220 HCV Ab+/NAT- donors were accepted for heart transplantation.nnnCONCLUSIONSnWe have demonstrated the feasibility of utilizing HCV Ab+/NAT- donors for cardiac transplantation without recipient infection. A small percentage of recipients developed HCV Ab without evidence of viremia, possibly consistent with a biological false reactive test, as has been seen in other settings. Large-scale validation of our data may have a significant impact on transplantation rates.

The “Double-Valve” Sign in Acute Type A Aortic Dissection

61-year-old man with a complex cardiac history Apresented with severe “tearing” chest pain. On the physical examination there were no signs of malperfusion. Computed tomographic angiography of the chest confirmed the diagnosis of aortic dissection with dilatation of the ascending aorta up to 7 cm in size. There was no pericardial effusion, and the aortic root was not involved (Figs 1, 2). On the preoperative transthoracic echocardiogram (Video) a dissection flap was identified involving the ascending aorta circumferentially above the level of the sinotubular junction, acting like a “second valve,” opening in systole and closing in diastole (Fig 3). Upon initiation of cardiopulmonary bypass, the heart arrested, and retrograde cardiologic protection was immediately initiated. A 30-mm Gelweave graft was used

Severity of Hemolysis Is Associated with Death and Ischemic Stroke during Veno-Arterial Extracorporeal Membrane Support

Purpose: Acquired Von Willebrand Factor (vWF) deficiency due to the loss of high molecular weight multimers (HMWM) has been well documented during CF LVAD support. It has been proposed that lowering pump speed in response to clinical gastrointestinal bleeding (GIB) may decrease shear stress allowing for the return of HMWMs. In-vivo data supporting this practice is lacking. Methods: Subjects at least 30 days post implantation of a Heart Mate (HM) II were prospectively recruited from the LVAD clinic. After confirming INR was > 2.0, pump speed was decreased to 8000 rpm and maintained for 6 hours. Blood samples obtained at baseline and 6 hours were compared for 2 measures of acquired vWF deficiency: 1) the ristocetin cofactor activity to vWF antigen ratio (Rco:Ag) and 2) gel electrophoresis for vWF multimer distribution. Results: Four patients agreed to participation. They were 57±15 years old, all were male and had been on HM II support for 401±199 days. All patients tolerated speed reduction without any adverse events. At baseline speed, HMWMs were reduced in all 4 patients. After 6 hours at 8000 rpm, there was no change in the HMWM profile (Figure 1). Similarly, the Rco:Ag ratio was reduced (nl > 0.65) in 3 of 4 patients at baseline and did not significantly change after speed reduction (0.56 → 0.56, 0.74 → 0.67, 0.58 → 0.65, 0.47 → 0.45; p = 0.437). Conclusion: Decreasing pump speed during HM II support does not lead to restoration of HMW Von Willebrand multimers. These findings suggest there may be no benefit to speed reduction in response to GIB. ( 662)