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Based on the changes in the field of heart transplantation and the treatment and prognosis of patients with heart failure, these updated guidelines were composed by a committee under the supervision of both the Netherlands Society of Cardiology and the Netherlands Association for Cardiothoracic surgery (NVVC and NVT).
The indication for heart trans...
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Patient: Male, 37
Final Diagnosis: Acute myocardial infarction
Symptoms: Retrosternal chest pain
Medication: —
Clinical Procedure: —
Specialty: Cardiology
Objective
Unusual setting of medical care
Background
Acute myocardial infarction (AMI) complicated by cardiogenic shock has a high mortality rate, despite prompt revascularization, advanced med...
Citations
... Orthotopic heart transplantation (OHT) is considered the gold standard therapy for end-stage heart failure when all other pharmacological and nonpharmacological treatment options have been exhausted [1,2]. The assessment of potential OHT recipients is a comprehensive, multistep process. ...
Background: Frailty has been proven to be associated with mortality after orthotopic heart transplantation (OHT). The aim of our study was to determine the impact of frailty on mortality in the current era using pretransplant mechanical cardiac support (MCS). Methods: We retrospectively calculated the frailty scores of 471 patients undergoing OHT in a single institution between January 2012 and August 2022. The outcome was all-cause mortality. Results: The median survival time was 1987 days (IQR: 1487 days) for all patients. In total, 266 (56.5%) patients were categorized as nonfrail, 179 (38.0%) as prefrail, and 26 (5.5%) as frail. The survival rates were 0.73, 0.54, and 0.28 for nonfrail, prefrail, and frail patients, respectively. The frailty score was associated with mortality [HR: 1.34 (95% CI: 1.22–1.47, p < 0.001)]. Among the components of the frailty score, age above 50 years, creatinine ≥ 3.0 mg/dL or prior dialysis, and hospitalization before OHT were independently associated with mortality. Continuous-flow left ventricular assist devices (CF-LVAD) were associated with an increased risk for all-cause mortality [AHR: 1.80 (95% CI: 1.01–3.24, p = 0.047)]. Conclusions: The components of the frailty score were not equally associated with mortality. Frailty and pretransplant MCS should be included in the risk estimation.
... Er bestaat een uitgebreide richtlijn harttransplantatie waarvan een vernieuwing van deze richtlijn voor de Nederlandse praktijk in wording is. 6 De overleving van patiënten na harttransplantatie is redelijk tot goed (zeker in perspectief van de prognose van eindstadium hartfalen), met een mediane overleving van 15 jaar. [7][8][9] Het aantal harttransplantaties in de afgelopen jaren in Nederland blijft echter zeer laag (< 40/jaar) met een groeiende wachtlijst als gevolg (~120 eind 2018). ...
... 1) Inflow-canule, 2) LVAD electrische motor/rotor, 3) Driveline, 4) Controller, 5) Externe Batterijen, 6) outflow-graft naar aorta LVAD-therapie als lange termijn ondersteuning in eindstadium hartfalen LVAD-therapie als BTT is sterk gerelateerd aan de zorg rondom harttransplantatie waar een aparte richtlijn voor bestaat. 6 Echter, met de toelating van LVAD als DT in Nederland is het verschil in de dagelijkse praktijk tussen BTT en DT-therapie minder absoluut. Patiënten die in eerste instantie ongeschikt lijken voor harttransplantatie kunnen later geschikt worden bevonden en vice versa. ...
... Harttransplantatie en LVAD-therapie moeten worden overwogen in patiënten met eindstadium hartfalen die ondanks optimale (medicamenteuze/device) therapie, (sterk) symptomatisch blijven en gemotiveerd zijn om een dergelijk traject te willen ondergaan. 1,6 Dit betekent echter zeker niet dat patiënten pas in het eindstadium verwezen kunnen/moeten worden naar centra die deze therapieën aanbieden. Gezien de prognose, ernst van symptomen en complexiteit van zorg rondom deze patiëntengroep is vroege verwijzing, en/of multidisciplinaire bespreking in LVAD/HTx implanterend centrum, essentieel. ...
... Ma et al. (34) and Hollander et al. (54) reported heart transplantation in these patients, and the postoperative survival time was more than 2 years. Generally, heart transplantation is considered to be contraindicated in BD due to the risk of performing the needed vascular and atrial anastomoses in the presence of severe inflammation (53). Moreover, patients may develop other severe systemic diseases after surgery, such as kidney failure and lung infections. ...
Behcet's disease (BD) is a multisystem inflammatory disease that is characterized by oral aphthosis, genital aphthosis, ocular lesions, and cutaneous lesions. Although BD rarely affects the cardiovascular system, its symptoms can be shown as aortic regurgitation (AR), which requires surgical intervention. Due to the special pathogenesis of BD, a low preoperative diagnosis rate and a high incidence of serious complications, such as perivalvular leakage, valve detachment, and pseudoaneurysm after prosthetic valve replacement, surgical treatment of BD with severe AR has a poor prognosis. In recent years, new surgical strategies have been developed to improve treatment efficacy for this disease. This article reviews and summarizes the evolution of surgical techniques for BD with AR and aims to provide a reference for optimizing surgical strategies, improving perioperative management, and assisting prognosis in patients suffering from BD with severe AR.
... Patients with insignificant cardiac function but good neurological status may eventually undergo heart transplantation by transitioning from BTD to bridge-to-transplant. Very few patients undergo heart transplant while being supported by a short-term VAD because of the lengthy wait time for a suitable donor, therefore one outcome of BTD is the transition to a long-term LVAD to wait for a transplant in an outpatient setting [5]. Our patient was suitable for heart transplant according to general criteria, including having an end-stage heart disease not remediable by other conservative measures and not having major contraindications (irreversible pulmonary hypertension, active systemic infections, active malignancy, cerebrovascular disease, irreversible dysfunction to other organs or inability to comply with medical treatment) [6]. September 26, 2023 ...
Background:
Veno-arterial extra corporeal membrane oxygenation (VA-ECMO) support is commonly complicated with left ventricle (LV) distension in patients with cardiogenic shock. We resolved this problem by transeptally converting VA-ECMO to left atrium veno-arterial (LAVA)-ECMO that functioned as a temporary paracorporeal left ventricular assist device to resolve LV distension. In our case LAVA-ECMO was also functioning as a bridge-to-transplant device, a technique that has been scarcely reported in the literature.
Case summary:
A 65 year-old man suffered from acute myocardial injury that required percutaneous stents. Less than two weeks later, noncompliance to antiplatelet therapy led to stent thrombosis, cardiogenic shock, and cardiac arrest. Femoro-femoral VA-ECMO support was started, and the patient underwent a second coronary angiography with re-stenting and intra-aortic balloon pump placement. The VA-ECMO support was complicated by left ventricular distension which we resolved via LAVA-ECMO. Unfortunately, episodes of bleeding and sepsis complicated the clinical picture and the patient passed away 27 d after initiating VA-ECMO.
Conclusion:
This clinical case demonstrates that LAVA-ECMO is a viable strategy to unload the LV without another invasive percutaneous or surgical procedure. We also demonstrate that LAVA-ECMO can also be weaned to a left ventricular assist device system. A benefit of this technique is that the procedure is potentially reversible, should the patient require VA-ECMO support again. A transeptal LV venting approach like LAVA-ECMO may be indicated over ImpellaTM in cases where less LV unloading is required and where a restrictive myocardium could cause LV suctioning. Left ventricular over-distention is a well-known complication of peripheral VA-ECMO in cardiogenic shock and LAVA ECMO through transeptal cannulation offers a novel and safe approach for treating LV overloading, without the need of an additional percutaneous access.
... Other centres require only chest radiographs or chest and/or abdominal CT with or without contrast, and some opt for abdominal ultrasound. [8][9][10][11][12][13][14][15][16] Advanced imaging tests, such as contrastenhanced chest and abdominal CT and FDG-PET/CT have already proven useful in cancer screening in asymptomatic individuals. [17][18][19] In HTx/VAD candidates, CT and FDG-PET/CT also can document vascular anatomy, which is of importance in surgical planning. ...
This study assesses the impact of contrast-enhanced chest and abdominal computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT in preoperative screening of heart transplantation or ventricular assist device candidates. Patients who underwent both studies within a 6-month interval at our institution between 2014 and 2021 were reviewed for significant findings, defined as possible contraindications or actionable findings. Among the 79 included patients, significant findings were found in 38 (48.1%) with CT and in 18 (22.8%) with FDG-PET/CT (P = 0.0015). FDG-PET/CT identified 10 additional significant findings, but none of these precluded patient listing for heart transplantation. Use of FDG-PET/CT may lead to unnecessary investigations when performed indiscriminately in all patients.
... Patients who should be considered for cardiac transplantation are those presenting severe symptoms of heart failure, intractable angina or rhythm disturbances, are on optimal medical therapy, and have limited alternatives for treatment. Other indications for cardiac transplantation are deteriorating renal function or the inability to clear congestion without adversely affecting renal function, and worsening right ventricular function or rising pulmonary artery pressure [7,8] As for renal transplantation, according to KDIGO, it is recommended to educate and inform all patients with chronic kidney disease (CKD) G4-G5 (glomerular filtration rate (GFR) < 30 mL/min/1.73 m 2 ) who are expected to reach ESRD, about kidney transplantation. ...
The kidney is one of most frequent transplants to be performed in multi-organ transplantation. A simultaneous heart and kidney transplant (SHKT) is the best-known treatment method in patients with severe heart failure and end-stage renal disease (ESRD). Here, the authors describe the case of a kidney re-transplantation after SHKT, which is in accordance with the majority of studies, and proves the safety of simultaneous procedures. The article highlights the complex care required after the transplant, followed by the multi-factor qualification for re-transplantation. In conclusion, the case shows that SHKT provides long-term favorable outcomes and enables a repeated kidney transplantation with satisfactory one-year follow-up results.
... destination therapy; however, they can be considered for LVAD as a bridge to heart-kidney transplantation. 19 Furthermore, most hemodialysis centers are resistant to patients with LVADs, as these patients require anticoagulation which can interfere and complicate dialysis. Overall, progression of kidney injury to renal failure can be rapid and irreversible and is associated with poor outcomes; thus, the fact that 3 out of the 4 patients on CRRT no longer required dialysis after the Impella upgrade is important. ...
The Impella CP (Abiomed Inc., Danvers, MA) is widely used in cardiac catheterization laboratories for patients presenting with cardiogenic shock, but it is also known to cause significant hemolysis. The risk of hemolysis can be reduced by properly positioning the device, ensuring an adequate volume status, and using full anticoagulation strategies; however, in some cases hemolysis persists. We present a case series of eight patients that were diagnosed with cardiogenic shock, underwent Impella CP placement, and then suffered from refractory hemolysis which was treated by upgrading the Impella device to the 5.0 or 5.5 version. Fifty percent (4/8) of the patients in this series were already receiving continuous renal replacement therapy, and the levels of plasma free hemoglobin (pFHb) and lactate dehydrogenase continued to increase after the implantation of the Impella CP. The median time between Impella CP placement and the diagnosis of refractory hemolysis was 16.5 hours (interquartile range [IQR], 8.0-26.0). The median time between the diagnosis of hemolysis to Impella upgrade was 6.0 hours (IQR, 4.0-7.0). A total of 87.5% (7/8) of patients experienced a drop in pFHb to below 40 mg/dl at 72 hours post-Impella upgrade, and they were discharged without any further need of dialysis. One patient expired due to irreversible multiple organ failure. We propose that early identification of hemolysis by close monitoring of pFHb and upgrading to the Impella 5.5 reduces hemolysis, prevents further kidney damage, and significantly improves clinical outcomes. ASAIO Journal XXX; XX;00-00
... Yet, there is a lack of data on the safety of BMS performed for patients who are at high risk due to severe heart insufficiency or previous heart transplantation, or those who have an implanted left-ventricular assist device (LVAD). According to the European guidelines for organ transplant recipients, patients with a BMI above 34 kg/m 2 are not considered for the waiting list for heart transplantation [3,4]. Because attending a weight loss program may be difficult for these patients and because physical exercise is practically impossible for heart-insufficient people, a surgical solution to pretransplantation weight loss may be the most likely option. ...
Bariatric and metabolic surgery is currently the most effective procedure of achieving and maintaining weight loss. In the case under discussion, a 48-year-old male patient with heart insufficiency and an implanted left-ventricular assist device (LVAD) wanted to reduce his high BMI (48.6 kg/m<sup>2</sup>), so as to qualify for the heart transplant waiting list. According to the guidelines, he underwent all the required preoperative testing, which included psychosomatic clarifications, determination of endocrinological causes, and a nutritional consultation. During laparoscopic sleeve gastrectomy, a cardiac technician was present to support the anesthetist. After inserting 3 trocars with no complications, the greater curvature was mobilized using Medtronic’s bipolar electrothermal vessel-sealing instrument, LigaSure™. The resection was performed with an Ethicon™ endostapler. Postoperative monitoring showed no signs of hemorrhage. The patient’s BMI on the day of surgery was 46.8 kg/m<sup>2</sup> and consecutively fell to 26.7 kg/m<sup>2</sup> 1 year after the procedure. Follow-up appointments revealed that the patient was fit and in good health. Thus, the patient’s aim of being listed on the transplant list was fulfilled, and at the time of this writing, he is ready to be matched with an organ donor. Because high-BMI patients with inserted LVADs are less likely to receive a donor graft and must remain longer on transplant waiting lists than normal-weight patients, bariatric and metabolic weight loss surgery may lead to a speedier resolution for these high-risk patients.
... Guidelines are available for transplantation of all solid organs but the pancreas and the intestine (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). Unfortunately, pancreas transplantation is a relatively low volume but high complexity procedure that has never gained widespread acceptance. ...
The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts’ recommendations for the practice of pancreas transplantation.
The main message from this consensus conference is that both simultaneous pancreas kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients.
Audience discussions and live voting are available online at the following url address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246
... Heart transplantation (HTx) is the final therapeutic option in endstage heart failure. 1 Over the last decades, survival has increased due to advances in donor selection, organ preservation and prevention, and management of rejection. 2 Nonetheless, early mortality in the first year after transplantation remains high, mainly due to primary graft dysfunction. ...
Background
Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice.
Methods
Inotrope score during the first 48 hours after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality.
Results
Mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C‐reactive protein, serum urea, congenital heart disease and donor cardiac arrest (R² = .30). Inotrope score was associated with 5‐year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00‐1.07). This association was attenuated when adjusting for female‐to‐male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno‐venous hemofiltration (OR 1.07, 95% CI 1.03‐1.12).
Conclusion
High inotrope score post‐HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.
