Experience With the Levitronix CentriMag in the Pediatric Population as a Bridge to Decision and Recovery

Short‐term mechanical circulatory support in the pediatric population with acute cardiac failure has traditionally been limited to extracorporeal membrane oxygenation given the limited availability of pediatric‐sized pumps. The Levitronix CentriMag system (Thoratec Corporation, Pleasanton, CA, USA) offers expanded options for short‐term support for this population. We report our experience with the successful use of the CentriMag in the pediatric population as a bridge to decision after postcardiotomy ventricular failure and as a bridge to recovery after heart transplantation. The first patient was bridged to a long‐term HeartMate II (Thoratec Corporation) as a bridge to potential recovery. The second patient was supported after severe graft failure post heart transplantation, with a full recovery. The Levitronix CentriMag has proven to be a versatile, safe, and effective short‐term circulatory support system for our pediatric patients.     

Complications After Heart Transplantation According to the Type of Pretransplant Circulatory/Ventricular Support

BackgroundThe purpose of the study was to analyze postcardiac transplant complications in patients who received transplants with short-term mechanical ventricular assist devices and to compare complications according to the type of device.MethodsAmbispective and consecutive study of urgent heart transplants from 2015 to 2019. Pediatric transplants, retransplants, and combined transplants were excluded. A total of 45 patients were analyzed in 4 groups: (1) venoarterial extracorporeal membrane oxygenation (ECMO) implanted <10 days before heart transplant (HTx) (n = 17); (2) ECMO implanted for more than 10 days (n = 8); (3) Levitronix Centrimag implanted in INTERMACS 2 to 3 patients (n = 13); and (4) Levitronix Centrimag implanted in INTERMACS 2 patients (n = 7). ECMO assistance was in INTERMACS 2 and severe right ventricular dysfunction. Levitronix Centrimag was implanted in patients with preserved right ventricular function.ResultsPrimary graft failure associated with the need for ECMO was more frequent in patients with ECMO than with Levitronix (P < .05). When comparing the 2 groups with ECMO, an implant more than 10 days before HTx was associated, after transplant, with a longer stay in the critical care unit (P = .02), higher mortality (P = .03), and an increase in complications in general. When comparing the 2 groups with Levitronix, all the parameters studied were much better when the Levitronix was implanted in INTERMACS 2-3 (P < .05). On the other hand, all cases of deep vein thrombosis and pulmonary thromboembolism occurred in patients who were assisted with ECMO.ConclusionsHTx with mechanical assist devices is associated with significant complications. ECMO produces more complications than the Levitronix Centrimag, although they are related to the days of implantation. The best group are patients implanted with a Levitronix in INTERMACS 2-3.     

Analysis of the Intrahospital and Long-Term Survival of Heart Transplant Patients With a Short-Term Mechanical Assistance Device

BackgroundThe purpose of this study was to compare early and late survival among patients who have undergone heart transplantation (HTx) with a short-term mechanical assist device.MethodsThis was an ambispective, single-center, consecutive study of patients undergoing urgent HTx for 5 years. Pediatric transplants, retransplants, and combined transplants were excluded. Forty-five patients were included. Four groups were analyzed: those with venoarterial extracorporeal membrane oxygenation (ECMO) implanted <10 days before HTx; those with ECMO implanted for >10 days; patients classified as INTERMACS 2 to 3 with Levitronix Centrimag implanted; and those classified as INTERMACS 2 with Levitronix Centrimag implanted. Survival and the influence of orotracheal intubation (OI) at the time of transplantation were compared.ResultsThere were differences in in-hospital mortality (P = .03) and total mortality (P = .06). The groups with the highest risk for mortality were those who carried ECMO for >10 days before transplantation or those classified as INTERMACS 2 with Levitronix Centrimag implanted. In these groups, the need for posttransplant circulatory support was also greater (P = .04) as was the length of stay in critical care (P = .02). The need for OI during the days of care and until transplantation had a negative effect on survival in all groups (P < .1).ConclusionsThere are different risk subgroups among patients who are transplanted with a circulatory/ventricular assist device. The lowest mortality occurs when the days of ECMO implantation are <10 and when the implanted device is a Levitronix Centrimag in INTERMACS 2 to 3 profile, particularly when the patient reaches the HTx without requiring OI.     

Use of extracorporeal membrane oxygenation in pediatric thoracic organ transplantation.

OBJECTIVE: Mechanical cardiorespiratory support is occasionally required before or after pediatric thoracic organ transplantation. Extracorporeal membrane oxygenation is the most commonly used mechanical support technique in children. The goal of this study was to examine the indications for initiation and outcomes after peritransplant use of extracorporeal membrane oxygenation. METHODS: A retrospective study was conducted of 65 patients who received peritransplant extracorporeal membrane oxygenation between November 1994 and June 2000. The pretransplant group included 45 patients (average age, 38 months) supported with extracorporeal membrane oxygenation and listed for transplantation (31 heart, 8 lung, and 6 heart-lung), and the post-transplant group included 20 patients (average age, 83 months) who required extracorporeal membrane oxygenation after thoracic organ transplantation (12 heart, 6 lung, and 2 heart-lung transplants). Hospital course and outcomes were evaluated. RESULTS: With regard to pretransplant extracorporeal membrane oxygenation, patients listed for heart transplants were more likely to survive to transplantation than were those listed for lung or heart-lung transplants (12/31 [39%] vs 1/14 [7%], P =.03). There was no difference in long-term survival between heart transplant patients after extracorporeal membrane oxygenation and those without extracorporeal membrane oxygenation (12-month actuarial survival, 83% vs 73%; P =.68). Patients who survived for prolonged periods on extracorporeal membrane oxygenation (>250 hours) typically received heart transplants (7/8 [88%]). With regard to post-transplant extracorporeal membrane oxygenation, patients receiving lung or heart-lung transplants had better short-term outcomes than those receiving heart transplants (63% survived to discharge vs 33%). All 3 patients with early graft dysfunction receiving lung transplants survived to discharge. CONCLUSIONS: Long-term outcomes among those undergoing heart transplantation after support with an extracorporeal membrane oxygenator are comparable with those of patients not receiving extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation can be a useful post-transplant support device, particularly in patients undergoing lung transplants.     

Mechanical Circulatory Support for Bridge to Decision: Which Device and when to Decide

Abstract Despite the many advances in the management of patients with acute heart failure, the outcome for patients with refractory acute cardiogenic shock remains disproportionately poor. Clearly, there is a definitive role for wider application of temporary circulatory support in such patients. Questions remain as to the ideal device, the optimal duration of temporary support, and the ideal timing to bridge these patients to a long‐term device. There are currently several options available for circulatory support and include surgically implanted ventricular assist devices, percutaneous assist devices, and extracorporeal membrane oxygenation. This review includes a brief summary of the current assist devices available along with the University of Minnesota's experience with the Levitronix CentriMag system . (J Card Surg 2010;25:425‐433)     

Extracorporeal Membrane Oxygenation Support in Refractory Cardiogenic Shock: Treatment Strategies and Analysis of Risk Factors

Two centrifugal pumps, the RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA), used in central or peripheral veno‐arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated, in terms of double‐center experience, as treatment for patients with refractory cardiogenic shock (CS). Between January 2006 and December 2012, 228 consecutive adult patients were supported on RotaFlow (n = 213) or CentriMag (n = 15) ECMO, at our institutions (155 men; age 58.3 ± 10.5 years, range: 19–84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n = 118) and primary donor graft failure (n = 37); postacute myocardial infarction CS (n = 27); acute myocarditis (n = 6); and CS on chronic heart failure (n = 40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9 ± 9.7 days (range: 1–43 days). Eighty‐four (36.8%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n = 144), weaning from mechanical support (n = 107; 46.9%), bridge to mid‐long‐term ventricular assist device (n = 6; 2.6%), and bridge to heart transplantation (n = 31; 13.5%), was 63.1%. One hundred twenty‐two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase (CK‐MB) relative index at 72 h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality on ECMO (P = 0.010, odds ratio [OR] = 2.94; 95% confidence interval [CI] = 1.10–3.14; P = 0.010, OR = 2.82, 95% CI = 1.014–3.721; and P = 0.011, OR = 2.69; 95% CI = 1.06–4.16, respectively). Central ECMO population had significantly higher rate of continuous veno‐venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the RotaFlow and CentriMag populations in terms of device performance. At follow‐up, persistent heart failure with left ventricle ejection fraction (LVEF) ≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO. The blood lactate level, CK‐MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO.     

Levitronix CentriMag pump as perioperative left ventricular support in a patient with critical aortic stenosis, mitral regurgitation, and cardiogenic shock

Severe aortic stenosis (AS) has a poor prognosis when associated with left ventricular dysfunction and congestive heart failure. Despite a relatively high operative mortality, most patients with severe AS and a depressed left ventricular ejection fraction (LVEF) should be considered candidates for aortic valve replacement. The CentriMag left ventricular assist system (Levitronix) can be used for perioperative or postcardiotomy circulatory support for the failing heart. In this case report, we report the successful use of the Levitronix CentriMag device as perioperative support in a high-risk patient with severe AS, significant mitral insufficiency, and a poor LVEF with advanced organ failure.     

Improvements in Extracorporeal Membrane Oxygenation for Primary Graft Failure After Heart Transplant

BackgroundSevere primary graft failure is a life-threatening complication of heart transplantation that may require venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Surgical practices and management strategies regarding VA-ECMO vary between and within centers.MethodsWe performed a single-center retrospective cohort study on adult patients who received VA-ECMO for primary graft failure between 2013 and 2020. Clinical data were obtained from chart review and national databases. Patients were stratified by transplantation before or after 2017, when our center adopted additional objective criteria for VA-ECMO, adopted partial-flow support, and changed from central cannulation to chimney graft arterial cannulation of brachiocephalic, axillary, or aorta. The primary outcome was survival to device weaning. Secondary outcomes were survival to discharge, survival to 1 year, complications on support, and time to sedation weaning and extubation.ResultsFrom 276 heart transplant recipients, 39 severe primary graft failure patients requiring VA-ECMO were identified. Incidence of graft failure was 13% (n = 18 of 135) pre-2017 and 15% (n = 21 of 141) post-2017. Survival at all time points improved significantly after 2017, with greatest difference in survival to device weaning (61% pre-2017 vs 100% post-2017). After controlling for other factors in multivariable Cox regression modeling, transplantation after 2017 was a predictor of reduced mortality (hazard ratio, 0.209; 95% CI, 0.06-0.71; P = .01). Significant differences were not observed in other secondary outcomes of recovery.ConclusionsThe new VA-ECMO strategy displayed reasonable survival and a remarkable improvement from the prior system.     

Outcomes of kidney transplantation in Alport syndrome compared with other forms of renal disease

Introduction: Alport syndrome is an inherited renal disease characterized by hematuria, renal failure, hearing loss and a lamellated glomerular basement membrane. Patients with Alport syndrome who undergo renal transplantation have been shown to have patient and graft survival rates similar to or better than those of patients with other renal diseases.

Methods: In this national case series, based in Beaumont Hospital Dublin, we studied the cohort of patients who underwent renal transplantation over the past 33 years, recorded prospectively in the Irish Renal Transplant Registry, and categorized them according to the presence or absence of Alport syndrome. The main outcomes assessed were patient and renal allograft survival.

Results: Fifty-one patients diagnosed with Alport syndrome in Beaumont Hospital received 62 transplants between 1982 and 2014. The comparison group of non-Alport patients comprised 3430 patients for 3865 transplants. Twenty-year Alport patient survival rate was 70.2%, compared to 44.8% for patients with other renal diseases (p?=?.01). Factors associated with patient survival included younger age at transplantation as well as differences in recipient sex, donor age, cold ischemia time, and episodes of acute rejection. Twenty-year graft survival was 46.8% for patients with Alport syndrome compared to 30.2% for those with non-Alport disease (p?=?.11).

Conclusions: Adjusting for baseline differences between the groups, patients with end-stage kidney disease (ESKD) due to Alport syndrome have similar patient and graft survival to those with other causes of ESKD. This indicates that early diagnosis and management can lead to favorable outcomes for this patient cohort.     

Causes of late mortality in pediatric liver transplant recipients.

OBJECTIVE: This study was undertaken to review the incidence and causes of death in children who have survived long-term (more than 1 year) after liver transplantation (LT). SUMMARY BACKGROUND DATA: No studies of the causes of late mortality in pediatric LT recipients are currently available in the literature. METHODS: The study group consists of 212 pediatric patients who survived more than 1 year after LT. Twenty-three of these patients subsequently died (mean follow-up = 5.3 yr). Hospital records, office charts, and autopsy records were reviewed retrospectively to identify the causes of death. The patients who died were further evaluated by age, gender, length of survival, primary diagnosis, immunosuppression, and retransplantation. RESULTS: The most common cause of death was graft failure, followed closely by infection. In patients dying from graft failure, eight of the nine patients underwent retransplantation and no child survived more than three liver transplants. Overwhelming infections occurred suddenly in eight children who had been previously healthy. Noncompliance was the third most common cause of death, primarily in older children. One child died from a posttransplant lymphoproliferative disorder (PTLD). Actuarial survival at 10 years is 83.7% (based on 100% survival at 1 year). There was no difference in survival based on primary disease. Retransplantation was far more prevalent in the nonsurvivors (47.8%) compared with survivors (13.7%) (p < 0.05). There were no significant differences in survival based on age, gender, or immunosuppression. CONCLUSIONS: Late mortality in children continues to be directly related to complications of LT and immunosuppression, even after the first year of transplantation. This is in contrast to adult liver transplant recipients, where approximately 50% of late deaths were related to LT and the remainder were because of unrelated illnesses.     

Outcomes of Patients Undergoing Combined Heart–Kidney Transplantation With or Without Prior Ventricular Assist Device

BackgroundBoth combined heart–kidney transplantation and ventricular assist devices (VADs) pose significant challenges, including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart–kidney transplants with and without VADs would have equivalent survival. We aimed to compare the survival of heart–kidney transplant recipients with and without prior VAD placement.MethodsWe retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart–kidney transplants. We created a matched cohort of patients undergoing heart–kidney transplantation with or without prior VAD using 1:1 nearest propensity-score matching with preoperative variables.ResultsIn the propensity-matched cohort, 399 patients underwent heart–kidney transplantation with prior VAD, and 399 underwent heart–kidney transplantation without prior VAD. The estimated survival of heart-–kidney recipients with prior VAD was 84.8% at one year, 81.2% at 3 years, and 75.3% at 5 years. The estimated survival of heart–kidney recipients without prior VAD was 86.8.7% at one year, 84.0% at 3 years, and 78.8% at 5 years. There was no statistically significant difference in the survival of heart–kidney transplant recipients with or without prior VAD at one year (P = .42; Figure 2), 3 years (P = .34), or 5 years (P = .30).ConclusionDespite the increased challenge of heart–kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those who underwent heart–kidney transplantation without previous VAD placement.     

Solid Organ Transplantation in AL Amyloidosis

Vital organ failure remains common in AL amyloidosis. Solid organ transplantation is contentious because of the multisystem nature of this disease and risk of recurrence in the graft. We report outcome among all AL patients evaluated at the UK National Amyloidosis Centre who received solid organ transplants between 1984 and 2009. Renal, cardiac and liver transplants were performed in 22, 14 and 9 patients respectively, representing <2% of all AL patients assessed during the period. One and 5‐year patient survival was 95% and 67% among kidney recipients, 86% and 45% among heart recipients and 33% and 22% among liver recipients. No renal graft failed due to recurrent amyloid during median (range) follow up of 4.8 (0.2–13.3) years. Median patient survival was 9.7 years among 8/14 cardiac transplant recipients who underwent subsequent stem cell transplantation (SCT) and 3.4 years in six patients who did not undergo SCT (p = 0.01). Amyloid was widespread in all liver transplant recipients. Solid organ transplantation has rarely been performed in AL amyloidosis, but these findings demonstrate feasibility and support a role in selected patients.     

A bridge-to-bridge approach to heart transplantation using extracorporeal membrane oxygenation and total artificial heart

BackgroundThis study aims to describe the outcomes after heart transplantation using a bridge-to-bridge strategy with a sequence of extracorporeal membrane oxygenation (ECMO) support followed by temporary total artificial heart implantation (TAH-t).MethodsA retrospective, multicenter analysis of 54 patients who underwent TAH-t implantation following an ECMO for cardiogenic shock was performed (ECMO-TAH-t group). A control group of 163 patients who underwent TAH-t implantation as a direct bridge to transplantation (TAH-t group) was used to assess this strategy's impact on outcomes.ResultsFifty-four patients, averaging 47 ± 13 year old, underwent implantation of a TAH-t after 5.3 ± 3.4 days of ECMO perfusion for cardiogenic shock. In the ECMO-TAH-t group, 20 patients (20/54%; 37%) died after TAH-t implantation and 57 patients (57/163%; 35%) died in the TAH-t group (Gray test; P = .49). The top 3 causes of death of patients on TAH-t support were multisystem organ failure (40%), sepsis (20%), and neurologic events (20%). Overall, 32 patients (32/54%; 59%) underwent heart transplantation in the ECMO-TAH-t group compared with 106 patients (106/163%, 65%) in the TAH-t group (P = .44). No significant difference in survival was observed at 6 months, 1 year, and 3 years after heart transplant (ECMO-TAH-t group: 94%, 87%, and 80% vs 87%, 83%, and 76% in the TAH-t group, respectively). Deterioration of liver function (bilirubin, aspartate transaminase, and alanine aminotransferase levels on TAH-t) was associated with increased mortality before heart transplant in both groups.ConclusionsSequential bridging from ECMO to TAH-t followed by heart transplantation is a viable option for a group of highly selected patients.     

Outcomes of Heart Transplantation in Cardiac Amyloidosis Patients: A Single Center Experience

BackgroundIndications for heart transplantation are expanding to include amyloid light chain (AL) and transthyretin-related (TTR) amyloidosis. Previously, AL amyloid had been a contraindication to heart transplantation given inferior outcomes. These patients typically have biventricular failure requiring mechanical circulatory support (MCS). We report the outcomes of patients with end-stage cardiac amyloidosis who underwent cardiac transplantation, including some who were bridged to transplantation with a durable biventricular MCSMethodsThe records for patients with cardiac amyloidosis who underwent cardiac transplant between 2010 and 2018 were reviewed. Primary endpoint was post-transplant 1-year survival. Secondary endpoints included 1-year freedom from cardiac allograft vasculopathy (as defined by stenosis ≥ 30% by angiography), nonfatal major adverse cardiac events (myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and any rejection.ResultsA total of 46 patients received heart transplantation with a diagnosis of either AL or TTR amyloidosis. Of these, 7 patients were bridged to transplantation with a durable biventricular MCS device (6 AL, 1 TTR) and 39 patients were transplanted without MCS bridging. The MCS group consisted of 5 total artificial hearts and 2 biventricular assist devices. The 1-year survival was 91% for the entire cohort, 83% for those with AL amyloidosis, 94% for those with TTR amyloidosis, and 86% for those who received MCS bridging.ConclusionsCardiac transplantation can be safely performed in selected amyloidosis patients with reasonable short-term outcomes. Those bridged to transplantation with biventricular MCS appear to have short-term outcomes similar to those transplanted without MCS. Larger numbers and longer observation are required to confirm these findings.     

Antithymocyte globulin induction therapy in hepatitis c-positive liver transplant recipients

It is unclear whether antithymocyte globulin (ATG) induction therapy in hepatitis C-positive (HCVpositive) liver transplant recipients influences the risk of developing recurrent HCV disease. Multiple acute rejection episodes and high-dose steroids and/or OKT3 used to treat acute rejection increase the risk of graft loss from HCV. We studied the impact of ATG induction on graft and patient survival in HCVpositive liver transplants performed since 1990. Recipients who died or lost their grafts within 1 month of transplantation were excluded. Second, third, and fourth grafts were excluded, as were patients with stage III or IV hepatocellular carcinoma. There were 443 cadaveric liver transplants in adult recipients, of whom 142 (32%) were HCV positive. The incidence of biopsy-proven acute rejection was less in patients who received ATG induction, 34.2% (ATG induction) versus 66.6% (no ATG induction) (P = .01). ATG induction did not influence the risk of graft loss from HCV-related disease (P ≤ .75). When only HCV-related graft loss was considered, 10-year graft survival for HCV-positive recipients was 74% (ATG induction) versus 68.2% (no ATG induction). Whether ATG induction was given or not had no significant impact on either overall graft survival (P = .39) or patient survival (P = .11) in HCVpositive recipients. Presented at the Fifth Biennial Meeting of the American Hepato-Pancreato-Biliary Association, Fort Lauderdale, Florida, April 14–17, 2005     

Comprehensive management of severe intestinal bleeding in a patient supported for 94 days by the biventricular Levitronix CentriMag system

The use of short-term mechanical circulatory support during postcardiotomy acute heart failure provides an opportunity to stabilize the patient's hemodynamic state while determining the best long-term strategy. Because all of these devices require anticoagulation treatment of various intensities, management of major bleeding can be critical for the overall outcome of the therapy. In this regard, the newest generation of magnetically levitated centrifugal-flow pumps affords several potential advantages in terms of thrombogenicity and eventual discontinuation of anticoagulation treatment. We report the use of a short-term biventricular assist device (Levitronix CentriMag) for 94 days in a 55-year-old man with refractory ventricular arrhythmias after combined heart surgery. Despite serious complications while the patient was on the assist device, including severe intestinal bleeding with the necessity of discontinuing anticoagulation for 10 days and, ultimately, hemicolectomy, the circulatory support was completed with successful heart transplantation.     

An audit of a steriod withdrawal regimen in cardiac transplantation patients

Background

Heart transplantation is optimal treatment for many patients with end-stage heart failure. Current data report 1-year graft survival rates of 85% after transplantation. The success of transplantation in large part is attributable to immunosuppression, including steroids, one of the mainstay agents. Despite its efficacy to treat acute graft rejection, steroids show numerous adverse effects. With newer immunosuppressive agents, steroid withdrawal is possible.

Material and Methods

We compared cardiac transplant patients who died versus survived between 2001 and 2006. We obtained Personal, transplant, occurrence of and cause of death data as well as postoperative intervals. Steroid therapy details were gathered, particularly whether the patient had been weaned off these agents. We calculated steroid doses and steroid-free years, as well as the steroid therapy status of posttransplant patients who remained alive in 2006.

Results

Fifty cardiac transplant patients died between 2001 and 2006 excluding 6 who had graft failure and 2 who died of multiorgan failure before initial discharge. Of the 42 patient who died, 29 (69%) were on and 13 (31%) had been withdrawn from steroid therapy at time of death. There were 132 posttransplant patients currently alive in April 2006, including 43 (33%) on and 89 (67%) withdrawn from steroids. The percentages of patients who were on versus off steroids were compared for main causes of death. Thirty-eight percent of patients on steroids at the time of death died of graft vasculopathy compared with 46% of patients who had been weaned off steroids. Fifteen percent of deceased patients taking steroids at the time of death died of chronic rejection.

Discussion

The current literature focuses on early withdrawal or reduction of steroids or steroid avoidance after organ transplantation. Although steroid avoidance remains controversial, steroid withdrawal has been generally incorporated into immunosuppressive protocols. Early steroid withdrawal has a positive influence on the emergence of de novo osteoporosis and cataracts. The benefits of steroid avoidance versus withdrawal are controversial topics being currently debated.     

Mechanical circulatory support in severe heart failure: single-center experience

Ventricular assist devices (VADs) have become important therapeutic tools to treat patients with end-stage cardiac failure. VADs are an essential component of transplantation programs as they successfully bridge individuals who would otherwise die. Recently left ventricular VAD (LVAD) therapy has been proposed as alternative to heart transplantation (HTx) for patients who are not transplant candidates. Other indications have now expanded into areas such as postcardiotomy failure, acute myocarditis, and acute massive myocardial infarction. From 1988 to May 2003, 80 patients received left or biventricular mechanical circulatory support including 78 as a bridge to and two as an alternative to HT. All patients survived the operation. Mean duration of VAD support was 77 +/- 150 days. Fifty-one points (63.8%) underwent heart transplantation; 3 (3.8%) recovered and were weaned from VADs. Major bleeding episodes occurred in 11 patients (13.8%) and major neurologic events occurred in 8 (10%). Sixteen patients (20%) were discharged home while waiting for HTx. Twenty-two patients (27.5%) died on VAD. In conclusion, VAD therapy proved effective in bridging patients with end-stage heart failure to HTx. While on LVAD support patients who were assisted with implantable wearable devices could be discharged at home, improving their quality of life.     

Cardiopulmonary transplantation

More than 5260 cardiopulmonary transplants were carried out worldwide between January 2006 and June 2007 across 204 centres. Heart transplantation is a proven surgical option for selected patients who have advanced heart failure refractory to surgical or medical management. Lung transplantation is the definitive treatment for end-stage lung disease for patients who have failed medical therapy. More than 90% of adult patients presenting for heart transplantation have dilated cardiomyopathy or ischaemic cardiomyopathy. Anaesthetic principles for heart transplantation include full monitoring with transoesophageal echocardiography, cardiostable anaesthesia and cardiac support, and assessment and treatment of pulmonary vascular hypertension. Median survival after cardiac transplantation is 10 years. Lung transplantation includes single-lung, double-lung, bilateral sequential single-lung, heart–lung and lobar transplantation. The most common indication is chronic obstructive pulmonary disease, which represents more than one-third of all transplant recipients. Donor criteria are becoming more liberal. Most lung transplants involve cardiopulmonary bypass. Pre-bypass air trapping can compromise cardiac function. Postoperative ventilation management should be guided by pH, not P_aco₂. Thoracic epidural provides optimal analgesia without respiratory depression. Three year survival after lung transplantation is approximately 60% and 5 year survival is approximately 50%.     

Pancreas Graft Survival in Simultaneous Pancreas-kidney Versus Pancreas-after-kidney and Pancreas Alone Transplantations: A Single Institution Experience

BackgroundPancreas transplantation offers excellent outcomes today in patients who have type-1 diabetes mellitus (DM) with difficult control in terms of increasing patient and pancreatic graft survival. Different factors in donors, recipients, and the perioperative period have been associated with long-term graft survival. The aim of this study was to compare pancreatic graft survival in simultaneous pancreas-kidney transplantation (SPK) and the other two modalities, pancreas-alone and pancreas-after-kidney transplantation (non-SPK), at our institution.MethodsThis retrospective cohort study included 63 pancreas transplantation patients from January 2007 to May 2012 at our institution. The patients were divided into two groups: SPK and non-SPK transplantations. We excluded those patients who had transplants with vascular graft loss. The primary endpoint was 1-year and overall graft survival with consideration of multiple relevant variables. Non-parametric tests were calculated with the statistical package SPSS 20 (SPSS INC, Chicago, IL).ResultsThe 1-year and overall graft survival in this period was 87.3% and 82.5%, respectively. The median follow-up was 963 days. The causes of graft loss were vascular (64%) and immunologic (34%). Finally, we included 56 pancreas transplantations, 46 (82%) were SPK and 10 (18%) non-SPK. The donor and recipient characteristics were similar in both groups, except for the duration of DM (SPK 22 years vs. non-SPK 29 years) and recipient body mass index (SPK 23 vs. non-SPK 28); P = .042 and P = .003, respectively. The cold ischemia time was 563 minutes (standard deviation, 145). Bivariate analysis showed that long-term graft loss was only influenced by matching for gender (P = .023). Using the Kaplan-Meier method, the pancreas graft survival was better in SPK than in non-SPK transplants (log rank .038).ConclusionsPatients who receive pancreas-alone or pancreas-after-kidney grafts have shorter long-term graft survival. Multiple strategies should be applied to improve immunologic surveillance and obtain an early diagnosis of graft rejection.