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Impact of long term left ventricular assist device therapy on donor allocation in cardiac transplantation.

Tue, 01/29/2013 - 13:19
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Impact of long term left ventricular assist device therapy on donor allocation in cardiac transplantation.

J Heart Lung Transplant. 2013 Feb;32(2):188-95

Authors: Uriel N, Jorde UP, Woo Pak S, Jiang J, Clerkin K, Takayama H, Naka Y, Christian Schulze P, Mancini DM

Abstract
BACKGROUND: Left Ventricular Assist Devices (LVAD) are increasingly used as a bridge to transplant (BTT) for patients with advanced congestive heart failure (CHF) and are assigned United Network for Organ Sharing (UNOS) high priority status (1B or 1A).
METHODS: The purpose of our study was asses the effect of organ allocation in the era of continuous flow pumps. A retrospective chart review was performed of all patients transplanted between 1/2001-1/2011 at Columbia University Medical Center.
RESULTS: Seven hundred twenty six adult heart transplantations were performed. Two hundred seventy four BTT patients were implanted with LVAD; of which 227 patients were transplanted. Sixty three patients were transplanted as UNOS-1B, while 164 were transplanted as UNOS-1A (72%). Of these 164 patients, 65 were transplanted during their 30-day 1A period (43%) and 96 after upgrading to UNOS-1A for device complication (56%). For 452 non-device patients 139 (31%) were transplanted as UNOS-1A, 233 as UNOS-1B (52%), and 80 as UNOS-2 (17%). The percentage of patients bridged with LVAD increased from 19% in 2001 to 64% in 2010 while the number transplanted during their 30 day 1A grace period declined from 57% in 2005 to 16% in 2011; i.e. 84% of BTT patients in 2011 needed more than 30 days 1A time to be transplanted. Most LVAD patients are now transplanted while suffering device complication. There was no difference in post transplant survival between LVAD patients transplanted as UNOS 1B, 1A grace period or for a device complication
CONCLUSIONS: As wait time for cardiac transplantation increased the percentage of patients being bridged to transplant with an LVAD has increased with the majority of them transplanted in the setting of device complication.

PMID: 23352392 [PubMed - in process]

The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: Executive summary.

Tue, 01/29/2013 - 13:19
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The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: Executive summary.

J Heart Lung Transplant. 2013 Feb;32(2):157-87

Authors: Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA, Morgan JA, Arabia F, Bauman ME, Buchholz HW, Deng M, Dickstein ML, El-Banayosy A, Elliot T, Goldstein DJ, Grady KL, Jones K, Hryniewicz K, John R, Kaan A, Kusne S, Loebe M, Massicotte MP, Moazami N, Mohacsi P, Mooney M, Nelson T, Pagani F, Perry W, Potapov EV, Eduardo Rame J, Russell SD, Sorensen EN, Sun B, Strueber M, Mangi AA, Petty MG, Rogers J

Abstract
CO-CHAIRS: Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania TASK FORCE CHAIRS: Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan CONTRIBUTING WRITERS: Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children's Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul's Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany INDEPENDENT REVIEWERS: Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina.

PMID: 23352391 [PubMed - in process]

Local Allocation of Lung Donors Results in Transplanting Lungs in Lower Priority Transplant Recipients.

Tue, 01/29/2013 - 13:19
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Local Allocation of Lung Donors Results in Transplanting Lungs in Lower Priority Transplant Recipients.

Ann Thorac Surg. 2013 Jan 24;

Authors: Russo MJ, Meltzer D, Merlo A, Johnson E, Shariati NM, Sonett JR, Gibbons R

Abstract
BACKGROUND: Under the current lung allocation system, if organs are accepted for a candidate within the local donor service area (DSA), they are never offered to candidates at the broader regional level who are potentially more severely ill, even if the nonlocal candidate has a higher lung allocation score (LAS). The purpose of this study was to determine the frequency with which organs were allocated to a local lung recipient while a blood group-matched and size-matched candidate with a higher LAS existed in the same region. METHODS: United Network for Organ Sharing (UNOS) provided deidentified patient-level data. The study population included all locally allocated organs for double-lung transplants (DLTs) performed in 2009 in the United States (n = 580). All occurrences of an ABO blood group-matched, height-matched (± 10 cm), double-lung candidate in the same region, with a higher LAS than the local candidate who actually received the organs, were calculated; these occurrences were termed events. RESULTS: In 2009, 3,454 events occurred when a local DLT recipient candidate received a DLT while a DLT candidate in the same region had a higher LAS. With a mean of 5.96 events per transplant, this impacted 480 (82.8%) of the 580 DLTs. Further, 555 (16.1%) of these events involved 1 (or more) of the 185 regional candidates who ultimately did not receive transplants and died while on the waiting list. CONCLUSIONS: This analysis suggests that the locally based lung allocation system results in a high frequency of events whereby an organ is allocated to a lower-priority candidate while an appropriately matched higher priority candidate exists regionally.

PMID: 23352298 [PubMed - as supplied by publisher]

Off-pump anteroapical aneurysm plication following left ventricular postinfarction aneurysm: effect on cardiac function, clinical status and survival.

Tue, 01/29/2013 - 13:19
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Off-pump anteroapical aneurysm plication following left ventricular postinfarction aneurysm: effect on cardiac function, clinical status and survival.

Can J Surg. 2013 Feb 1;56(1):022111-22111

Authors: Huang XS, Gu CX, Yang JF, Wei H, Li JX, Zhou QW

Abstract
Background: In patients with coronary disease and aneurysm, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. We report our results with off-pump aneurysm plication after ventricular aneurysm with relative wall thinning. Methods:We retrospectively reviewed the records of 248 patients who had an operation for postinfarction left ventricular aneurysm. Reconstruction was accomplished by off-pump anteroapical aneurysm plication. The following variables were recorded: preoperative clinical, angiographic and echocardiographic findings and operative procedures. Outcomes were early mortality, long-term survival and poor 5-year result, defined as the need for transplantation or repeated hospitalization for congestive heart failure. Risk factors were pinpointed using the t test and survival curves. Independent risk factors were identified using Cox regression methods. Results: Hospital mortality was low (2.0%). Mean follow-up was 5.8 (standard deviation [SD] 3.8) years. Actuarial survival at 1 and 5 years was 94% and 84%. Among the 232 survivors, 200 were in functional class I or II, and the average increase in ejection fraction was 14.0% (SD 3.1%). As determined by multivariable analysis, factors predicting poor outcome were advanced age, ejection fraction less than 0.35, conicity index less than 1, end-systolic volume index greater than 80 mL/m2, advanced New York Heart Association functional class and congestive heart failure. Conclusion: Using wall thinning as a criterion for patient selection, the technique of off-pump anteroapical aneurysm plication can be performed with low operative mortality and provides good symptomatic relief and long-term survival.

PMID: 23351499 [PubMed - as supplied by publisher]

[Distant heart procurement for transplantation].

Tue, 01/29/2013 - 13:19
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[Distant heart procurement for transplantation].

Cir Cir. 2012 Sep;80(5):424-8

Authors: Careaga-Reyna G, Zetina-Tun H, Villaseñor-Colín C, Alvarez Sánchez LM, Urías-Báez R, de la Cerda-Belmont GA

Abstract
Background: the low availability of organ donors is a serious hindrance to heart transplantation. Long-distance organ procurement has been accepted as an option despite longer ischemic time for the heart. Methods: long-distance procurement from outside Mexico City in adult patients with terminal heart failure submitted to orthotopic heart transplantation between February 1st 2011, and January 31st 2012, was assessed. Ischemic time, distance from Mexico City, and perioperative and short-time mortality were determined. Results: there were 14 orthotopic heart transplants during the analyzed period. In 12 cases long-distance heart procurement was required. Mean age of recipients was 42.7 years (range between 17 and 61 years). Seven patients were male and five female. Mean ischemic time was 228.58 minutes. The longest distance of procurement for land and air travel was 2,319 km; and the lowest, 22.5 km. Perioperative mortality was 8.33% (one patient), and there were 2 short-term deaths due to non-cardiac complications. In this series we included a case of heart-kidney transplantation from same donor. Conclusion: at our hospital, long-distance procurement for heart transplantation is a useful procedure with good results.

PMID: 23351445 [PubMed - in process]

Predicting Functional Capacity in Patients with a Systemic Right Ventricle: Subjective Patient Self-assessment Is Better than B-type Natriuretic Peptide Levels and Right Ventricular Systolic Function.

Tue, 01/29/2013 - 13:19
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Predicting Functional Capacity in Patients with a Systemic Right Ventricle: Subjective Patient Self-assessment Is Better than B-type Natriuretic Peptide Levels and Right Ventricular Systolic Function.

Congenit Heart Dis. 2013 Jan 28;

Authors: Book W, McConnell M, Oster M, Lyle T, Kogon B

Abstract
BACKGROUND.: Many adults with transposition of the great arteries have an anatomic right ventricle functioning as the systemic ventricle and are known to develop congestive heart failure, premature cardiac death, and need for cardiac transplantation. Predictors of poor clinical outcome and functional status in patients with left ventricular failure do not always apply to these patients. We aimed to identify predictors of poor functional status in those patients with a systemic right ventricle. METHODS.: We performed a prospective study of 51 adults with transposition of the great arteries and systemic right ventricles. Demographic, clinical, laboratory, and imaging data were collected, and patients completed a Minnesota Living with Heart Failure Questionnaire (MLHFQ). Comparisons were made between those patients with d-type transposition of the great arteries (dTGA) who have undergone prior atrial switch and those with congenitally corrected transposition (ccTGA). A correlation analysis was performed to identify predictors of poor functional status, as determined by a 6-minute walk distance test. RESULTS.: Median age was 30 years (range 19-65). Median B-type natriuretic peptide was 48 pg/mL (range 16-406). There were 27 patients (53%) with moderate-severe right ventricular dysfunction and 10 (20%) with moderate-severe tricuspid valve regurgitation. The median MLHFQ score was 9 (range 0-78) and 6-minute walk test was 510 m (range 231-703). Forty-one patients had a diagnosis of dTGA atrial switch and 11 patients had ccTGA. Patients with ccTGA were significantly older (40 vs. 28 years, P =.004) and had more tricuspid valve regurgitation (P =.02). Despite this, their MLHFQ scores were significantly lower (2.5 vs. 17, P =.04) and they walked further (635 vs. 504 m, P =.02). Predictors of a short 6-minute walk distance included short stature (P =.009) and dTGA (P =.002). The patient's self-assessment of poor health, as measured by an increased New York Heart Association class (P =.003) and a decreased MLHFQ score (P >.0001) also correlated. B-type natriuretic peptide levels, right ventricular dysfunction, severity of tricuspid valve regurgitation, need for pacemaker, and clinical signs of heart failure did not correlate with exercise tolerance. CONCLUSIONS.: Traditional parameters used to predict outcomes in patients with left ventricular failure are not predictive in patients with a systemic right ventricle. Instead, patient's self-assessment of functional status did correlate with objective functional status.

PMID: 23350927 [PubMed - as supplied by publisher]

Stem cell-based transcatheter aortic valve implantation: first experiences in a pre-clinical model.

Tue, 01/29/2013 - 13:19
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Stem cell-based transcatheter aortic valve implantation: first experiences in a pre-clinical model.

JACC Cardiovasc Interv. 2012 Aug;5(8):874-83

Authors: Emmert MY, Weber B, Wolint P, Behr L, Sammut S, Frauenfelder T, Frese L, Scherman J, Brokopp CE, Templin C, Grünenfelder J, Zünd G, Falk V, Hoerstrup SP

Abstract
OBJECTIVES: This study sought to investigate the combination of transcatheter aortic valve implantation and a novel concept of stem cell-based, tissue-engineered heart valves (TEHV) comprising minimally invasive techniques for both cell harvest and valve delivery.
BACKGROUND: TAVI represents an emerging technology for the treatment of aortic valve disease. The used bioprostheses are inherently prone to calcific degeneration and recent evidence suggests even accelerated degeneration resulting from structural damage due to the crimping procedures. An autologous, living heart valve prosthesis with regeneration and repair capacities would overcome such limitations.
METHODS: Within a 1-step intervention, trileaflet TEHV, generated from biodegradable synthetic scaffolds, were integrated into self-expanding nitinol stents, seeded with autologous bone marrow mononuclear cells, crimped and transapically delivered into adult sheep (n = 12). Planned follow-up was 4 h (Group A, n = 4), 48 h (Group B, n = 5) or 1 and 2 weeks (Group C, n = 3). TEHV functionality was assessed by fluoroscopy, echocardiography, and computed tomography. Post-mortem analysis was performed using histology, extracellular matrix analysis, and electron microscopy.
RESULTS: Transapical implantation of TEHV was successful in all animals (n = 12). Follow-up was complete in all animals of Group A, three-fifths of Group B, and two-thirds of Group C (1 week, n = 1; 2 weeks, n = 1). Fluoroscopy and echocardiography displayed TEHV functionality demonstrating adequate leaflet mobility and coaptation. TEHV showed intact leaflet structures with well-defined cusps without signs of thrombus formation or structural damage. Histology and extracellular matrix displayed a high cellularity indicative for an early cellular remodeling and in-growth after 2 weeks.
CONCLUSIONS: We demonstrate the principal feasibility of a transcatheter, stem cell-based TEHV implantation into the aortic valve position within a 1-step intervention. Its long-term functionality proven, a stem cell-based TEHV approach may represent a next-generation heart valve concept.

PMID: 22917460 [PubMed - indexed for MEDLINE]

Assessment of organ transplants from donors with markers of hepatitis B.

Tue, 01/29/2013 - 13:19
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Assessment of organ transplants from donors with markers of hepatitis B.

Clinics (Sao Paulo). 2012;67(4):399-404

Authors: Abdala E, Azevedo LS, Avelino-Silva VI, Costa SF, Caramori ML, Strabelli TM, Pierrotti LC, Marques HH, Marques da Silva HH, Lopes MH, Varkulja GF, Santos VA, Shikanai-Yasuda MA, Comissão de Infecção em Imunodeprimidos, Hospital das Clínicas da Faculdade de Medicina da USP

PMID: 22522767 [PubMed - indexed for MEDLINE]

[Distal femoral bypass under local anaesthesia].

Tue, 01/29/2013 - 13:19
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[Distal femoral bypass under local anaesthesia].

Cir Esp. 2012 Aug-Sep;90(7):460-4

Authors: Taboada Martín R, Glenn-Ray López V, Gutiérrez García F, Cassinello Martínez N

Abstract
INTRODUCTION: The aim of this article is to present our experience in performing distal femoral bypass under local anaesthesia for high risk patients.
MATERIAL AND METHODS: Lower limb revascularisation surgery under local anaesthesia was performed on 8 patients in our centre between January and May 2010. The common characteristics of the patients were, advanced age, chronic ischaemic heart disease on antiplatelet treatment, and chronic obstructive pulmonary disease (COPD).
RESULTS: All 8 patients (100%) tolerated the procedure well without having to resort to sedation or invasive anaesthetic procedures. The receiving artery was the posterior tibial in 6 cases (75%) and the popliteal and peroneal in 1 (12%). Early patency of the graft was achieved 7 patients and 1 had early thrombosis with a supracondylar amputation. The technique used was femoral-popliteal in 1 case, femoral-posterior tibial in 6 cases, and popliteal-peroneal in 1 case. The saphenous vein was the graft used, inverted in 1 patient (12%), and in situ in 7 (88%) with a 3mm BARD™ valvotomy. There were no post-operative complications as regards haemorrhage, infections or death. A minor amputation was performed on 3 patients (37%), and after a mean of 3 months (1-4 months) follow-up, 7 cases were free of major amputation.
CONCLUSIONS: Revascularisation of the distal zone of the lower limbs can be safely and effectively performed using local anaesthesia, avoiding the risks of general anaesthesia and without the need to stop antiplatelet treatment. Anatomical problems (obesity) may limit the procedure.

PMID: 22445111 [PubMed - indexed for MEDLINE]

Variants in the 15q24/25 locus associate with lung function decline in active smokers.

Sat, 01/26/2013 - 12:56

Variants in the 15q24/25 locus associate with lung function decline in active smokers.

PLoS One. 2013;8(1):e53219

Authors: Mohamed Hoesein FA, Wauters E, Janssens W, Groen HJ, Smolonska J, Wijmenga C, Postma DS, Boezen HM, De Jong PA, Decramer M, Lammers JW, Lambrechts D, Zanen P

Abstract
Genetic variation in nicotinic acetylcholine receptor subunit genes (nAChRs) is associated with lung function level and chronic obstructive pulmonary disease (COPD). It is unknown whether these variants also predispose to an accelerated lung function decline. We investigated the association of nAChR susceptibility variants with lung function decline and COPD severity. The rs1051730 and rs8034191 variants were genotyped in a population-based cohort of 1,226 heavy smokers (COPACETIC) and in an independent cohort of 883 heavy smokers, of which 653 with COPD of varying severity (LEUVEN). Participants underwent pulmonary function tests at baseline. Lung function decline was assessed over a median follow-up of 3 years in COPACETIC. Current smokers homozygous for the rs1051730 A-allele or rs8034191 G-allele had significantly greater FEV(1)/FVC decline than homozygous carriers of wild-type alleles (3.3% and 4.3%, p = 0.026 and p = 0.009, respectively). In the LEUVEN cohort, rs1051730 AA-carriers and rs8034191 GG-carriers had a two-fold increased risk to suffer from COPD GOLD IV (OR 2.29, 95% confidence interval [CI] = 1.11-4.75; p = 0.025 and OR = 2.42, 95% [CI] = 1.18-4.95; p = 0.016, respectively). The same risk alleles conferred, respectively, a five- and four-fold increased risk to be referred for lung transplantation because of end-stage COPD (OR = 5.0, 95% [CI] = 1.68-14.89; p = 0.004 and OR = 4.06, 95% [CI] = 1.39-11.88; p = 0.010). In Europeans, variants in nAChRs associate with an accelerated lung function decline in current smokers and with clinically relevant COPD.

PMID: 23349703 [PubMed - in process]

Genetic analysis in 418 index patients with idiopathic dilated cardiomyopathy: overview of 10 years' experience.

Sat, 01/26/2013 - 12:56

Genetic analysis in 418 index patients with idiopathic dilated cardiomyopathy: overview of 10 years' experience.

Eur J Heart Fail. 2013 Jan 24;

Authors: van Spaendonck-Zwarts KY, van Rijsingen IA, van den Berg MP, Lekanne Deprez RH, Post JG, van Mil AM, Asselbergs FW, Christiaans I, van Langen IM, Wilde AA, de Boer RA, Jongbloed JD, Pinto YM, van Tintelen JP

Abstract
AIMS: With more than 40 dilated cardiomyopathy (DCM)-related genes known, genetic analysis of patients with idiopathic DCM is costly and time-consuming. We describe the yield from genetic analysis in DCM patients in a large Dutch cohort. METHODS AND RESULTS: We collected cardiological and neurological evaluations, family screenings, and genetic analyses for 418 index patients with idiopathic DCM. We identified 35 (putative) pathogenic mutations in 82 index patients (20%). The type of DCM influenced the yield, with mutations found in 25% of familial DCM cases, compared with 8% of sporadic DCM cases and 62% of cases where DCM was accompanied by neuromuscular disease. A PLN founder mutation (43 cases) and LMNA mutations (19 cases, 16 different mutations) were most prevalent and often demonstrated a specific phenotype. Other mutations were found in: MYH7, DES, TNNT2, DMD, TPM1, DMPK, SCN5A, SGCB (homozygous), and TNNI3. After a median follow-up of 40 months, the combined outcome of death from any cause, heart transplantation, or malignant ventricular arrhythmias in patients with a mutation was worse than in those without an identified mutation (hazard ratio 2.0, 95% confidence interval 1.4-3.0). This seems to be mainly attributable to a high prevalence of malignant ventricular arrhythmias and end-stage heart failure in LMNA and PLN mutation carriers. CONCLUSION: The yield of identified mutations in DCM index patients with clinical clues, such as associated neuromuscular disease or familial occurrence, is higher compared with those without these clues. For sporadic DCM, specific clinical characteristics may be used to select cases for DNA analysis.

PMID: 23349452 [PubMed - as supplied by publisher]

Racial differences in patients with left ventricular assist devices.

Sat, 01/26/2013 - 12:56
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Racial differences in patients with left ventricular assist devices.

ASAIO J. 2012 Sep-Oct;58(5):499-502

Authors: Aggarwal A, Gupta A, Pappas PS, Tatooles A, Bhat G

Abstract
We examined clinical outcomes based on ethnicity in patients undergoing left ventricular assist device (LVAD) implantation. We hypothesized that treatment in a specialized, comprehensive heart failure program results in similar survival between African Americans and whites. We retrospectively reviewed patient data implanted with HeartMate II (HM-II) LVAD over 2 years. There were 79 patients: 34 (43%) whites, 33 (42%) African Americans, and 12 (15%) patients belonging to other ethnicities there was no difference in demographics. The etiology of cardiomyopathy was more commonly ischemic in white patients compared to nonischemic in African American patients (p = 0.01). The mean left ventricular ejection fraction was 22.21 ± 10.66% in African American patients and 15.21 ± 5.54% in white patients (p = 0.008). The left ventricular end-diastolic (p = 0.06) and end-systolic (p = 0.03) diameters were greater in white patients compared to African American patients. Hypertension was seen in 79% of African American patients compared to 56% in white patients (p = 0.07). Survival by Kaplan-Meier analysis revealed an unadjusted survival advantage in African American patients (p = 0.04 by log-rank test), but this survival advantage was lost in multivariable Cox regression analysis after adjustment for other covariates. There was no difference in readmissions (p = 0.36). In patients with advanced heart failure undergoing HM-II LVAD implantation, African American patients had a similar survival and no difference in readmissions when compared with white patients despite significant differences in baseline clinical characteristics.

PMID: 22929898 [PubMed - indexed for MEDLINE]

Growing experience with extracorporeal membrane oxygenation as a bridge to lung transplantation.

Sat, 01/26/2013 - 12:56
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Growing experience with extracorporeal membrane oxygenation as a bridge to lung transplantation.

ASAIO J. 2012 Sep-Oct;58(5):526-9

Authors: Shafii AE, Mason DP, Brown CR, Vakil N, Johnston DR, McCurry KR, Pettersson GB, Murthy SC

Abstract
Extracorporeal membrane oxygenation (ECMO) is rarely used as a bridge to lung transplantation (BTT) because of its associated morbidity and mortality. However, recent advancements in perfusion technology and critical care have revived interest in this application of ECMO. We retrospectively reviewed our utilization of ECMO as BTT and evaluated our early and midterm results. Nineteen patients were placed on ECMO with the intent to transplant of which 14 (74%) were successfully transplanted. Early and midterm survival of transplanted patients was 75% (1 year) and 63% (3 years), respectively, with the most favorable results observed in interstitial lung disease patients supported in the venovenous configuration. Extracorporeal membrane oxygenation-bridged transplant survival rates were equivalent to nonbridged recipients, but early morbidity and mortality are high and the failure to bridge to transplant is significant. Overall, successfully bridged patients can derive a tangible benefit, albeit with considerable consumption of resources.

PMID: 22929896 [PubMed - indexed for MEDLINE]

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

Fri, 01/25/2013 - 13:30
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Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension.

Eur J Cardiothorac Surg. 2013 Jan 22;

Authors: Kutty RS, Parameshwar J, Lewis C, Catarino PA, Sudarshan CD, Jenkins DP, Dunning JJ, Tsui SS

Abstract
OBJECTIVES: Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy. METHODS: Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed. RESULTS: Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05). CONCLUSIONS: In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.

PMID: 23345184 [PubMed - as supplied by publisher]

Use of the model for end-stage liver disease score for guiding clinical decision-making in the selection of patients for emergency cardiac transplantation.

Fri, 01/25/2013 - 13:30
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Use of the model for end-stage liver disease score for guiding clinical decision-making in the selection of patients for emergency cardiac transplantation.

Eur J Cardiothorac Surg. 2013 Jan 22;

Authors: Vanhuyse F, Maureira P, Mattei MF, Laurent N, Folliguet T, Villemot JP

Abstract
OBJECTIVES: The outcomes of emergency cardiac transplantation remain controversial, but recipient selection is essential for success. With a shortage of organs, it is essential to determine an objective method, such as a risk score, for choosing patients who are at too great a risk to undergo cardiac transplantation. In this study, we analysed the model for end-stage liver disease in terms of predicting operative mortality after emergency cardiac transplantation. METHODS: We analysed the Nancy University database of heart transplantation and selected all patients who underwent emergency heart transplantation between January 2005 and January 2012. The calibration and discriminatory power were evaluated to determine the model for end-stage liver disease (MELD) score. Preoperative and peri-operative variables regarding the prediction of operative mortality were analysed by univariate and multivariate logistic regression models. RESULTS: Forty-three patients underwent emergency cardiac transplantation. The operative mortality was 20.9% (n = 9). The Hosmer-Lemeshow test demonstrated a calibrated model for predicting operative mortality (P = 0.15), and the MELD score presented an excellent discrimination between survivors and non-survivors (AUC: 0.89 ± 0.05; 95% CI: 0.79-0.99). In the univariate analysis, an MELD score of ≥16 and bilirubin concentration were predictive markers of operative mortality. Multivariate logistic regression tested the contribution of the univariate risk predictors (P < 0.15) and confirmed that an MELD score of ≥16 was predictive of operative mortality. CONCLUSIONS: The MELD score appears to be adequate for predicting operative mortality among patients who undergo heart transplantation. The MELD score could therefore be used to guide clinical decision-making for emergency transplantation.

PMID: 23345182 [PubMed - as supplied by publisher]

Severe Bacterial Superinfection Based on Influenza A (H1N1) Pneumonia in a Heart-Lung Transplant Recipient.

Fri, 01/25/2013 - 13:30
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Severe Bacterial Superinfection Based on Influenza A (H1N1) Pneumonia in a Heart-Lung Transplant Recipient.

Thorac Cardiovasc Surg. 2013 Jan 23;

Authors: Yildirim Y, Pecha S, Sill B, Deuse T, Reichenspurner H

Abstract
A 47-year-old heart-lung transplant recipient presented to our outpatient transplant clinic with respiratory infection. Her nose and throat swabs for influenza A (H1N1) infection were negative. Broncheoalveolar lavage showed a positive result for H1N1 infection. Antiviral therapy was initiated. Because of superinfection with Pseudomonas aeruginosa and Aspergillus terreus, her clinical condition worsened. The clinical condition of the patient improved with antibiotic and antifungal treatment. Negative nose and throat swab results cannot rule out H1N1 infection safely. We therefore advocate to routinely perform broncheoalveolar lavage.

PMID: 23344758 [PubMed - as supplied by publisher]

Early metabolic/cellular-level resuscitation following terminal brain stem herniation: implications for organ transplantation.

Fri, 01/25/2013 - 13:30
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Early metabolic/cellular-level resuscitation following terminal brain stem herniation: implications for organ transplantation.

AACN Adv Crit Care. 2013 Jan;24(1):59-78

Authors: Arbour RB

Abstract
Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor's organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.

PMID: 23343814 [PubMed - in process]

Hydrodynamic analysis of the miniaturized hemofilter for a wearable ultrafiltration device.

Fri, 01/25/2013 - 13:30
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Hydrodynamic analysis of the miniaturized hemofilter for a wearable ultrafiltration device.

Blood Purif. 2013;35(1-3):127-32

Authors: Ronco C, Kim JC, Garzotto F, Galavotti D, Bellini C, Brolgli M, Nalesso F

Abstract
Background/Aims: Using a small wearable hemofiltration device, heart failure (HF) patients may have the possibility of eliminating acute hemodynamic changes and the freedom from spending many hours attached to a large stationary treatment system. Methods: We developed a miniaturized hemofilter for a vest-type wearable ultrafiltration device for the treatment of overhydration and congestive HF. In this study, we investigated the feasibility of the newly developed hemofilter based on dynamic CT imaging and in vitro evaluation of hydrodynamic properties. Results: The dynamic CT imaging technique showed development of uniform flow distribution and effective bubble removal in the hemofilter. Hydrodynamic performance of the hemofilter was also acceptable with a stable pressure drop in the blood compartment and ultrafiltration profiles in the intended operating ranges for the treatment of congestive HF patients. Conclusions: The newly developed miniaturized hemofilter for a wearable ultrafiltration device meets the technical requirements of wearable medical devices and its structural design enables uniform blood flow distribution and stable hydrodynamics during operation.

PMID: 23343557 [PubMed - in process]

Effect of percutaneous ventricular assist devices on renal function.

Fri, 01/25/2013 - 13:30
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Effect of percutaneous ventricular assist devices on renal function.

Blood Purif. 2013;35(1-3):119-26

Authors: Mao H, Giuliani A, Blanca-Martos L, Kim JC, Nayak A, Virzi G, Brocca A, Scalzotto E, Neri M, Katz N, Ronco C

Abstract
Ventricular assist devices (VADs) are used to improve the systemic circulation and to decrease ventricular loading in patients with hemodynamic instability that is refractory to pharmacologic therapies. During an acute critical event, percutaneous devices are preferred because of their rapid deployment, since implantable devices require more extensive procedures. Implantable devices are used for patients with established end-stage heart failure as a bridge to heart transplantation, recovery or destination therapy. This report reviews mechanical principles and clinical studies regarding percutaneous VAD to address their potential renal effects. Since the focus of this study is set on devices that are dedicated to cardiac support only, extracorporeal membrane oxygenation systems are not included.

PMID: 23343556 [PubMed - in process]

[Dialysis and renal transplantation. Update 2012].

Fri, 01/25/2013 - 13:30
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[Dialysis and renal transplantation. Update 2012].

Dtsch Med Wochenschr. 2012 Dec;137(49):2567-70

Authors: Riegel W, Krüger B, Schnülle P

PMID: 23188637 [PubMed - indexed for MEDLINE]

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