Pneumatic pulsatile ventricular assist device as a bridge to heart transplantation in pediatric patients

Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report on our experience in the pediatric population. A retrospective review of 17 consecutive children offered mechanical support with Berlin Heart as a bridge to heart transplant from February 2002 to April 2010 was conducted. The median patient age was 3.9 years (75 days to 13.3 years). The median patient weight was 14.1 kg (2.9–43 kg). Before VAD implantation, all children were managed by multiple intravenous inotropes and mechanical ventilation (14) or extracorporeal membrane oxygenation (3). All patients had right ventricular dysfunction. Nine patients required biventricular mechanical support (BVAD), but in all other cases a single left ventricular assist device proved sufficient (47%). The median duration of VAD support was 47 days (1–168 days). The median pre‐VAD pulmonary vascular resistance index (Rpi) was 5.7 WU/m² (3.5 to 14.4 WU/m²). Eleven patients (65%) were successfully bridged to heart transplantation after a median duration of mechanical support of 68 days (6–168 days). Six deaths occurred (35%), three for neurological complications, one for sepsis, and two others for device malfunctioning. Since 2007, the survival rate of our patients has increased from 43% to 80%, and the need for BVAD has decreased from 86% to 30%. In two patients with Rpi >10 WU/m², unresponsive to pulmonary vasodilatator therapy, Rpi dropped to 2.2 and 2 WU/m² after 40 and 23 days of BVAD support, respectively. Seven patients (41%) required at least one pump change. Of 11 patients undergoing heart transplant, four developed an extremely elevated (>60%) panel reactive antibody by enzyme‐linked immunosorbent assay, confirmed by Luminex. All of them experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow‐up of 25.4 months (6 days to 7.7 years). Mechanical support in children with end‐stage heart failure is an effective strategy as a bridge to heart transplantation with a reasonable morbidity and mortality. BVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance.     

Changing face of heart failure surgery

Background

Heart failure is a serious disease ending with death if untreated. Although heart transplantation is the best therapy for end-stage heart failure, most candidates die in the waiting period due to the lack of donor organs. This condition represent a new era of heart failure surgery.

Methods

We retrospectively investigated 159 patients from 1998 to 2011 with a mean age of 40.0 years (range = 5-65), who were mostly diagnosed as dilated cardiomyopathy (n = 113). After April 2007, 67 patients underwent vascular assist device (VAD) implantation surgery for acute or chronic end-stage heart failure. We performed 69 heart transplantation with 27 on VAD systems before transplantation.

Results

Early mortality was 13.3% with 21 patients after the heart transplantation. The 67 patients supported with VAD did not experience an intraoperative death. The mean support time was 214 days (range = 3-1035). Twenty-four patients (35.8%) are still on pump support. The overall survival until transplantation or weaning was 77.6% at mean of 250.7 days survival reached 90% with Heartware (Hartware Inc, Miramar, Fla, USA) continuous flow pumps.

Conclusion

After the introduction of VAD in 2007, the overall picture has been restructured radically for heart failure surgery, reducing patient loss on the waiting list. Especially, since 2009 nearly 80% of donor hearts were used for patients on mechanical circulatory support.     

Mechanical Circulatory Support in Advanced Heart Failure: Single-Center Experience

Background

Currently, ventricular assist device (VAD) or total artificial heart (TAH) mechanical support provides an effective treatment of unstable patients with advanced heart failure. We report our single-center experience with mechanical circulatory support therapy.

Methods

From March 2002 to December 2012, 107 adult patients (mean age, 56.8 ± 9.9 y; range, 31–76 y) were primarly supported on temporary or long-term VAD or TAH support as treatment for refractory heart failure at our institution. Temporary extracorporeal radial VAD support (group A) was established in 49 patients (45.7%), and long-term paracorporeal and intracorporeal VAD or TAH (group B) in 58 patients (54.2%). Left ventricular (LVAD) support was established in 55 patients (51.4%; n = 33, Heartmate II; n = 6, Heartmate I XVE; n = 4, Heartware HVAD; and n = 12, Centrimag) and biventricular (BVAD/TAH) support (group B) in 28 patients (26.1%; n = 10, Thoratec paracorporeal; n = 2, Heartware HVAD, n = 1, Thoratec implantable; n = 1, Syncardia TAH; and n = 14, Centrimag). The temporary Centrimag was the only device adopted as isolated right ventricular (RVAD) support, and it was inserted in 24 patients (22.4%).

Results

In group A, overall mean support time was 10.2 ± 6.6 days (range, 3–43 d). In group B, LVAD mean support time was 357 ± 352.3 days (range, 1–902 d) and BVAD/TAH support time was 98 ± 82.6 days (range, 8–832 d). In group A, the overall success rate was 55.1% (27 patients). In group B, LVAD overall success rate was 74.4% (32 patients) and BVAD/TAH success rate was 50% (7 patients). Overall heart transplantation rate for both groups was 27.1% (n = 2, group A; n = 27, group B). Overall 1-year and 5-year survivals after heart transplantation were 72.4% (n = 21) and 58.6% (n = 17), respectively.

Conclusions

Mechanical circulatory support is an effective strategy even in cases of end-stage heart failure according to our experience. Further improvement of VAD and TAH technologies may support their adoption as an encouraging alternative to heart transplantation in the near future.     

Surgical therapy of end-stage heart failure in pediatric patients

Objective

We herein review our experience with ventricular assist device (VAD) implantation and heart transplantation in children with end-stage heart failure.

Methods

We performed a retrospective nonrandomized review of all patients who underwent insertion of a Berlin Heart Excor VAD or heart transplantation in our clinic. The study spans from July 2005 to July 2010. We transplanted 11 patients of mean age 11.8 ± 4.49 years, 3 of whom with critical hemodynamic situations were bridged to heart transplantation by VAD implantation. Despite the poor right ventricular systolic functions, they did not require right rVAD. In addition, 2 patients who underwent VAD implantation are still awaiting a donor heart. The mean follow-up was 825.27 ± 630.23 days (range, 21-1,888 days).

Results

There was no serious complication during VAD support. The overall heart transplantation mortality rate was 9.1% (1/11). In all patients, impaired end-organ functions were improved by VAD implantation before the heart transplantation. Cardiac biopsies revealed 4 grade 2R rejection episodes, which were successfully controlled in 3 patients.

Conclusion

Heart transplantation is highly effective therapy for pediatric patients with end-stage heart failure. Pediatric VAD implantation provided satisfactory safe circulatory support for small children in poor condition on the waiting list. This option should be considered for all pediatric candidates who show a poor hemodynamic status.     

Ventricular assist device as a bridge to heart transplantation in adults

Background

Because of the shortage of donor hearts, various ventricular asist devices (VAD) have been used in decompensated patients to prolong patient survival until a suitable heart becomes available. In this paper, we present our single-center report of adult patients in whom bridging was used with VAD.

Methods

We performed a retrospective review of 14 adult patients who underwent heart transplantation after insertion of a long-term VAD. The study spans from February 2006 until September 2010. The mean patient age was 44.28 ± 11.06 years. We used the Berlin Heart EXCOR VADs (n = 11; Berlin Heart AG Berlin, Germany), or the Berlin Heart Incor (n = 2), or the Abiomed AB500 (n = 1). Preimplantation status of the subjects were critical cardiogenic shock (n = 6), deterioration on inotropes (n = 3), or stable but inotrope-dependent (n = 5).

Results

Mean VAD support time was 153.71 days (range, 25-517). Major adverse events during VAD support included reexploration for bleeding (n = 3; 21.4%), neurologic events (n = 2; 14.3%), left VAD-related infection (n = 2; 14.3%), pneumonia (n = 1; 14.3%), or primary device failure (n = 1; 7.1%). One (7.1%) patient showed evidence of human leukocyte antigen sensitization. There were 2 deaths (14.3%) over a mean of 324 days follow-up after heart transplantation: One due to biventricular failure in the early postoperative period and the other, at 69 days from pneumonia. Rejection was observed in 2 patients who had International Society for Heart and Lung Transplantation grade 2R without hemodynamic deterioration. In our series, the 1-year mortality was 14.4% among heart transplantations without VAD implantation and 14.2% among the bridge-to-transplantation group.

Conclusion

We conclude that VAD implantation improved end-organ function before heart transplantation in critically ill patients.     

Ventricular assist device application as a bridge to pediatric heart transplantation: a single center's experience

Objectives

There are limited options for mechanical circulatory support to treat end-stage heart failure in pediatric patients. Although extracorporeal membrane oxygenation is commonly used in infants and children, ventricular assist devices (VAD) provide a longer duration of support with fewer complications before recovery or as a bridge to heart transplantation (HTx), as described herein.

Methods

This retrospective chart review of eight patients transplanted from April 2008 to December 2011, after left ventricular assist device (LVAD) implantation due to end-stage heart failure. Their mean age was 12 years (9-15 y) and mean body weight, 48 kg (20-78). All were New York Heart Association functional class IV with mean left ventricular ejection fractions less than 15%.

Results

The six patients (75%) received HTx after a mean LVAD support duration of 43.2 days; 2 (25%) died before a suitable heart became available. Their mean duration of LVAD support was 30 days. There were 4 (50%) who experienced clinically evident thromboembolic events: 3 (37.5%) cerebrovascular with 1 mortality and 1 (12.5%) as acute limb ischemia. Transient hemodialysis was performed in 4 (50%). Bloodstream infection identified in 6 (75%) was controlled with intravenous antibiotics. Driveline infection identified in 4 (50%) was treated successfully with local wound dressing changes and intravenous antibiotics. One 9-year-old boy died of rejection at 16 months after transplantation.

Conclusions

Because of the organ shortage, pediatric patients have a low chance to undergo HTx. VAD provides long-term support for children with end-stage heart failure before a suitable heart becomes available. A thromboembolic event remains a major complication influencing their survival.     

Elevated fibroblast growth factor 23 levels as a cause of early post-renal transplantation hypophosphatemia

Background

Hypophosphatemia is a common complication after renal transplantation. Hyperparathyroidism has long been thought to be the cause, but hypophosphatemia can persist after high parathyroid hormone (PTH) levels normalize. Furthermore, calcitriol levels remain inappropriately low after transplantation, suggesting that mechanisms other than PTH contribute. Fibroblast growth factor 23 (FGF-23) induces phosphaturia, inhibits calcitriol synthesis, and accumulates in chronic kidney disease. We performed prospective study to investigate if FGF-23 early after renal transplantation contributes to hypophosphatemia.

Methods

We measured FGF-23 levels before and at 1, 2, 4, and 12 weeks after transplantation in 20 renal transplant recipients. Serum creatinine, calcium (Ca), phosphate (Pi), intact PTH (PTH), and 1,25-dihydroxy vitamin D (1,25(OH)₂VitD) were measured at the same time.

Results

FGF-23 levels decreased by 97% at 4 weeks after renal transplantation (PRT) (7,471 ± 11,746 vs 225 ± 295 pg/mL; P < .05) but were still above normal. PTH and Pi levels also decreased significantly after renal transplantation, and Ca and 1,25(OH)₂VitD slightly increased. PRT hypophosphatemia of <2.5 mg/dL developed in 15 (75%) and 12 (60%) patients at 4 weeks and 12 weeks respectively. Compared with nonhypophosphatemic patients, the levels of FGF-23 of hypophosphatemic patients were higher (303 ± 311 vs 10 ± 6.9 pg/mL; P = .02) at 4 weeks PRT. FGF-23 levels were inversely correlated with Pi (r² = 0.406; P = .011); PTH was not independently associated with Pi (r² = 0.132; P = .151).

Conclusions

FGF-23 levels decrease dramatically after renal transplantation. During the early PRT period, Pi rapidly decreased, suggesting that FGF-23 is cleared by the kidney, but residual FGF-23 may contribute to the PRT hypophosphatemia. FGF-23, but not PTH levels, was independently associated with PRT hypophosphatemia.     

Valvular procedures during ventricular assist device implantation

Background

Increased experience and success with ventricular asist devices (VAD) has permitted more aggressive use in patients formerly believed to be inappropriate for mechanical circulatory support (MCS). There is no clearly proven policy to manage end-stage heart failure patients with valvular pathologies. The aim of this report was to analysis our experience with combined approach of VAD implantation and valvular procedures among patients with valvular heart disease and end-stage heart failure.

Methods

We evaluated the clinical records of 67 patients who underwent MCS from April 2007 to September 2011. We identified 12 patients (17.9%) who received concomitant valvular procedures, four of whom had significant aortic insufficiency and received a simple coaptation stitch at the center to approximate the fibrous nodules of Arantius. The mechanical aortic valve was replaced with a stentless bioprosthesis in three patients. Mitral valve commissurotomy was performed in one patient with mitral stenosis and seven patients underwent tricuspit valve repair using an annuloplasty ring.

Results

All 12 patients were males, of mean age 50.3 ± 11.5 years (range = 25-66). Eleven of them (91.6%) survived the early and late postoperative periods. Ten subjects (83.3%) continue to be supported with VAD; 1 (8.3%) was successfully bridged to transplantation. Each study participant regression of the valvular pathologies by early echocardiography demonstrated.

Conclusion

Concomitant valve surgery during VAD implantation appeared to be a reasonable option in end-stage heart failure patients with valvular heart disease.     

The outcome of heart transplantation in hepatitis C-positive recipients

Background

Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes.

Methods

Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease.

Results

Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30-63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients (P = .59).

Conclusions

There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease.     

Current Status of Heart Transplantation in Taiwan

Purpose

We reviewed the national results of heart transplantation in Taiwan.

Methods

From July 1987 to December 2012, 1354 patients underwent heart transplantation in 18 qualified heart centers in Taiwan. The transplantation volume and survival rate were reviewed.

Results

The median age of recipients was 49 years at surgery, with 37% in the International Society for Heart and Lung Transplantation (ISHLT)-1A, 30% in ISHLT-1B, and 32% in ISHLT-2. The allograft 1-, 3-, 5-, and 10-year survival rates were 78%, 68%, 61%, and 47%, respectively. Mostly difficult recipients were bridged by extracorporeal membrane oxygenation (ECMO) instead of ventricular assist device (VAD).

Conclusion

The results of heart transplantation in Taiwan are comparable with ISHLT world results. In Taiwan, we use more ECMO than VAD for mechanical circulatory support to bridge critical recipients to heart transplantation.     

Differences in Early Postoperative Complications in Elective and Emergency Heart Transplantation

Introduction and Objectives

The immediate postoperative period is a critical phase in heart transplantation. Severe complications occur that may influence short-term and medium-term morbidity and mortality in these patients. The aim of this study was to analyze the incidence of severe complications in emergency and nonemergency transplantations.

Materials and Methods

We studied 152 patients who underwent heart transplantation between 2001 and 2007. Combined transplantations and retransplantations were excluded. Two groups were considered: emergency transplantations (36 patients, 24%) and elective transplantations. We compared survival and occurrence of infection, primary graft failure (PGF), renal and hepatic failure, respiratory complications, cardiac tamponade, arrhythmias, reoperation, and intensive care unit (ICU) stay.

Results

The emergency transplantation group had a greater number of ischemic patients, with a more prolonged cardiopulmonary bypass time, and a larger proportion of donors were women. Overall mortality in the intensive care unit was 2.6%, with no differences between groups. However, emergency procedures were significantly associated with a higher incidence of PGF, need for intraaortic balloon pump, and a more prolonged mechanical ventilation time, as well as a greater number of bacterial infections and a significantly longer ICU stay.

Conclusions

In our series, emergency transplantation showed no greater perioperative mortality. We observed a greater number of severe complications, such as PGF, bacterial infection, and more prolonged mechanical ventilation time.     

The Influence of the Recipient's Body Weight on the Probability to Obtain a Heart Transplant—POLKARD HF Registry

Introduction

The aim of the study was to analyze the influence of body weight of the adult heart recipient on the chance to obtain a transplant.

Methods

We analyzed the data from all 658 patients listed for heart transplantation.

Results

During the follow-up period, 325 (49%) of listed patients underwent transplantation with 102 (15%) succumbing before heart transplantation. The mean weight of transplanted patients was 73.7 ± 13.7 kg and 81.2 ± 15.4 kg for those not transplanted (P < .00001). Patients were divided according to body weight in two groups: light = below 80 kg (n = 360) or heavy ≥ 80 kg or above (n = 297). On the transplant list, 111 heavy patients (37%) versus 213 light patients (59%) underwent the procedure, a significant difference.The waiting time among light patients was 255 versus heavy patients of 395 days (P < .005).There was a similar number of deaths before transplantation among the light (n = 56 360 patients; 15.5%) versus the heavy group (49/297; 16%).Upon multivariate Cox mode analysis independent factors related to not receiving a heart transplant were greater weight, systolic blood pressure, pulmonary vascular resistance, Heart Failure Survival Score (HFSS) score and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels.

Conclusions

Among adult heart transplant candidates, the chance to receive a heart transplant significantly decreased when the recipient's weight exceeded 80 kg. Patients with a body weight more than 110 kg had a poor chance to receive a heart transplantation.     

Intestinal transplantation for short bowel syndrome secondary to gastroschisis

Background/Purpose

Gastroschisis is the most frequent cause of pediatric intestinal transplantation. This study reviews our experience of intestinal transplantation secondary to gastroschisis to elucidate those factors affecting the outcome of children with short bowel syndrome.

Methods

A retrospective review was performed for children who underwent intestinal transplantation for gastroschisis at the University of Miami between June 2003 and August 1994.

Results

Thirty-two transplants were performed in 28 children with gastroschisis during the study period. Associated intestinal anomalies were present in 22 infants (atresia [n = 14], volvulus [n = 3], and/or ischemia [n = 16]). Spontaneous prenatal closure of gastroschisis, a rare anomaly associated with bowel atresia and ischemia because of a very small abdominal defect, was seen in 9 patients. Most of the patients had a complicated course and required multiple abdominal surgeries before transplant. Fifteen (53.6%) patients are currently alive at a median follow-up of 23.5 months. Short-term survival rate has significantly improved in recent years.

Conclusions

Patients with complex gastroschisis and intestinal anomalies have a significant risk for progression to short bowel syndrome. Intestinal transplantation can be a lifesaving option and provides a satisfactory outcome for children with short bowel syndrome secondary to gastroschisis.     

Limitations of use of the noninvasive clearance of indocyanine green as a prognostic indicator of graft function in liver transplantation

Aim

To assess the prognostic value of noninvasive indocyanine green (ICG) clearance (ICG-pulse-densitometric method [PDR]) for the outcome of liver grafts after transplantation.

Methods

ICG-PDR, hepatic artery resistance index, cardiac output, transaminases, prothrombin time, bilirubin, albumin, hematocrit at 48 to 72 hours after transplantation were analyzed with reference to outcome among 59 liver graft recipients.

Results

Two grafts were lost at 10 and 88 days during the initial hospitalization. These two patients only differed from the other recipients in the need for packing (1/2 versus 3/57) and degree of hypoproteinemia (46 ± 0 versus 51 ± 7.8 g/L), whereas they had similar ICG-PDR values (16.7%/min and 21.8%/min versus 17.3%/min ± 7.2%/min). Seven patients showed an ICG-PDR ≤ 8.8%/min, a previously identified cutoff for early postoperative complications. These patients versus the other 52 significantly differed in prothrombin index (47.9% ± 15.9% versus 64.3% ± 11.7%, P = .001) and bilirubin (8.3 ± 3.2 versus 3.3 ± 2.9 mg/dL, P = .0001). Early postoperative complications—primary graft nonfunction, hepatic artery thrombosis, or septic shock— responsible for an ICG-PDR ≤ 8.8%/min were observed in 2/7 patients. Interestingly, six cases developed an early (range: 3-15 days) rejection episode. In all the cases rejection suspected by analytical abnormalities was confirmed by liver biopsy. Among the overall series of patients, ICG-PDR significantly correlated with serum albumin (r = 0.345; P = .007), bilirubin (r = −0.514; P = .0001), and hematocrit (r = 0.462; P = .0001) but not with transaminases, prothrombin index, cardiac output, or hepatic artery resistance index. Actuarial 72-month probability of graft survival was 75%. Overall, 14 grafts were lost over a median follow-up of 78 months (range 1-99 m). There were no significant differences among early ICG-PDR values among grafts lost vs retained upon follow-up.

Conclusion

ICG-PDR measured once early after liver transplantation did not offer relevant information to predict individual patient outcomes in the immediate postoperative phase. This lack of prognostic value may have been due to the multiple confounding factors involved in ICG metabolism after liver transplantation.     

Successful Bridge‐to‐Transplant of Functionally Univentricular Patients With a Modified Continuous‐Flow Ventricular Assist Device

A continuous flow extracorporeal ventricular assist device (VAD) was modified to support functionally univentricular infants and children awaiting heart transplantation. A centrifugal VAD, designed to flow from 1.5 to 8 L/min, was used as a bridge‐to‐transplant in four patients with functionally univentricular circulation. A variable restrictive recirculation shunt permitted lower flow ranges in small patients. In hypoxic patients, an oxygenator was incorporated into the circuit. From 2012 to 2015, the modified VAD was placed in four patients with Glenn physiology. Age ranged from 0.97 to 6.98 years (median = 2.2 yrs). Body surface area ranged from 0.41 to 0.84 m² (median = 0.54 m²). One patient was on extracorporeal membrane oxygenation prior to VAD. A recirculation shunt was used in three patients. Three patients required temporary use of an oxygenator for 4, 10, and 27 days. Median time on the VAD was 32.3 days (range = 23–43 days). A decrease in the cavopulmonary pressure was noted in all patients, as was a fall in the B‐type natriuretic peptide. Three patients survived transplant and were discharged at 28–82 days post‐transplantation. One patient died after 35 days of support. Two patients experienced major bleeding events. Two patients experienced cerebrovascular accidents, one major and one minor. The centrifugal VAD successfully supported palliated functionally univentricular patients awaiting heart transplantation. The modified recirculation shunt facilitated the successful support of patients in whom optimal flows were substantially lower than that recommended by the manufacturer. The continuous‐flow VAD effectively decompressed the cavopulmonary system. The design allowed placement of an in‐line oxygenator in hypoxic patients. Further investigation is required to decrease the thromboembolic events, and associated morbidity, in patients supported with this device.     

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation

Background

Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure.

Methods

Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL).

Results

Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000).

Conclusion

The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.     

The Impact of Pretransplantation Urgency Status and the Presence of a Ventricular Assist Device on Outcome After Heart Transplantation

Introduction

There are conflicting reports on the posttransplantation morbidity and mortality of patients listed urgently and/or supported by a ventricular assist device (VAD). The aim of this study was to analyze the outcomes with regard to pretransplantation condition (elective, urgent, VAD).

Methods

All adult recipients between January 1, 2005, and October 31, 2012, were included. Demographics; preoperative, operative, and postoperative data; outpatient follow-up; and donor characteristics were collected and analyzed.

Results

Of a total of 74 patients, 19 were listed urgently, 20 had a Berlin Heart EXCOR BVAD (biventricular assist device) (Berlin Heart, Berlin, Germany) (8 urgent), 7 had a Berlin Heart INCOR left VAD (Berlin Heart, Berlin, Germany) (2 urgent), and 2 had a HeartWare left VAD (HeartWare International, Framingham, Mass, USA) (none urgent). Mean age was 52 ± 12years. The overall 30-day, 1-year, and 3-year survival was 90% ± 3%, 79% ± 5%, and 66% ± 7%. There was no difference in survival when comparing urgently listed (95% ± 5%, 84% ± 8%, 74% ± 12%) and elective patients (89% ± 4%, 77% ± 6%, 63% ± 8%; P = .4), and VAD patients (86% ± 6%, 76% ± 8%, 63% ± 11%) and those without mechanical support (93% ± 4%, 81% ± 6%, 69% ± 9%; P = .6). In-hospital outcomes and long-term complications were also comparable.

Conclusions

Our series suggests that urgent patients and patients on a VAD have a posttransplantation outcome comparable to elective patients and patients without a VAD. These data support the effectiveness of the current practice of listing for heart transplantation.     

Anemia and Erythrocytosis After Kidney Transplantation: A 5-Year Graft Function and Survival Analysis

Introduction

Both anemia and erythrocytosis frequently occur after kidney transplantation. The aim of this study was to analyze the influence of both anemia and erythrocytosis on kidney graft function and long-term patient outcomes following kidney transplantation.

Patients and Methods

Three hundred eight-five consecutive patients with at least 12 months of follow-up after successful kidney transplantation were enrolled into this study. Of the total, 88.3% of patients completed a 5-year follow-up. Anemia occurred in 30.4% of patients (with 17.7% showing a hemoglobin concentration (Hb) <11.0 g/dL), whereas erythrocytosis was observed in 19.0% of patients, including 9.6% with hematocrit (HTC) >55%. We also analyzed graft function every 6 months after transplantation for the impact of anemia or erythrocytosis on the 5-year risk of patient death or graft loss.

Results

In 57.3% of anemia patients the Hb did not reach the normal range during the observation time. The mean eGFR-Modification of Diet in Renal Disease (MDRD) at 12 months after transplantation was significantly lower among patients with anemia: 43.9 mL/min/1.73 m² (39.5-48.4) vs 55.3 mL/min/1.73 m² (53.0-57.6; P < .001). Better 12-month graft function was observed among patients with erythrocytosis, namely, 57.7 mL/min/1.73 m² (53.5-62.0). Anemia but not erythrocytosis was associated with an increased risk of graft loss (hazard ratio [HR] = 4.11 [95% confidence interval (CI) 2.02-8.37]; P < .001).

Conclusion

Anemia after transplantation was associated with worse kidney graft function and was a strong predictor of graft loss. Erythrocytosis occurs among patients with excellent allograft function; when properly treated it did not increase the risk of graft loss or death.     

Use of Ventricular Assist Device as Bridge to Simultaneous Heart and Kidney Transplantation in Patients with Cardiac and Renal Failure

Background

Ventricular assist device (VAD) implantation as a bridge to cardiac transplantation is an effective treatment option for end-stage heart failure. Renal dysfunction is not uncommon but is considered to be a poor prognostic factor. We present our experience with 6 patients who had combined heart and kidney transplantation (HKT) after VAD implantation for advanced cardiac and renal failure.

Methods

Of 74 patients who underwent VAD implantation as a bridge to transplant from May 2001 to September 2009, 28 patients developed renal failure, and of these, 6 (5 male, 1 female, ages 40–64 years) had HKT. All required hemodialysis because of renal failure before HKT. Immunosuppression consisted of anti-thymocyte globulin followed by triple drug therapy consisting of calcineurin inhibitors, mycophenolate, and corticosteroids.

Results

Of the 6 HKT patients, 5 (83%) were alive without hemodialysis at 1 and 2 years; of the 22 patients with renal failure after VAD implantation without subsequent transplant, 1- and 2-year survivals were zero. Interval from VAD implantation to HKT ranged from 36 to 366 days (133 ± 127 days). At 6 months after HKT (100% alive), left ventricular ejection fraction was 60.2 ± 5.8% and serum creatinine 1.1 ± 0.2 mg/dL. Three HKT patients required temporary hemodialysis after surgery. Endomyocardial biopsy showed absence of ISHLT grade 2R-3A or greater cellular rejection, and none showed evidence of definite antibody-mediated rejection.

Conclusions

Based on our initial experience, simultaneous HKT is a safe treatment option with excellent outcomes for patients with advanced heart failure and persistent renal dysfunction after VAD implantation.     

Long-Term Mechanical Support With the HeartMate II LVAS

Background

The use of left ventricular assist devices (LVAD) is an accepted therapy for patients with refractory heart failure. The HeartMate II is a small (350 g), implantable, axial-flow pump (nonpulsatile flow), which is designed to support the left ventricle for extended periods of time. Here we have reported our initial single-center clinical experience with this device as a bridge to heart transplantation.

Materials and Methods

Between March 2002 and December 2008, 18 transplantable adult patients were supported on long-term HeartMate II LVAS at our institution. The cohort included 15 men with an overall mean age of 52 ± 8.4 years (range, 31-64 years). Primary indications for implantation were ischemic cardiomyopathy (CMP; n = 13) and idiopathic CMP (n = 5). All heart failure patients were New York Heart Association (NYHA) functional class IV. None of them had undergone prior open heart surgery. Implantation was performed via cannulation of the left ventricular apex and ascending aorta, and in each case was an elective procedure.

Results

Mean support time was 217 ± 212.3 days (range, 1-665 days). Early (30-day) mortality was 27.7% (n = 5) due to multiple organ failure and sepsis as main causes of death. Bleeding requiring reoperation occurred in 6 cases (33.3%). Cerebral hemorrhage occurred in 1 case. There were 2 driveline infections and no device failure. Twelve subjects (66.6%) were successfully discharged home. Overall, 9 patients (50%) underwent transplantation and 3 are awaiting a suitable organ (2 were discharged home and 1 is in hospital). At latest follow-up, the survival rate after heart transplantation was 66.6% (n = 6).

Conclusions

Long-term HeartMate II LVAS can successfully bridge patients to heart transplantation. Good mid- and long-term results may support the use of this device even for a permanent solution in nontransplantable subjects.