Utilization of hepatitis C virus infected donors in heart transplant recipients with elevated MELD-XI score.

BACKGROUND: The advent of direct-acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end-stage liver disease excluding international normalized ratio (MELD-XI). METHODS: The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post-transplant outcomes stratified by recipient MELD-XI score (low <10.37, medium, 10.38-13.39, and high >13.4) was compared between patients with HT from HCV+ (N = 792) and patients with HT from HCV-negative donors (N = 15,266). RESULTS: The median MELD-XI score was comparable (HCV+, 12.1, vs. HCV-negative, 11.8, p = .37). In the HCV+ group, donors were older (33 vs. 31 years, p < .001). Ischemic time of donor hearts (3.48 vs. 3.28 h, p < .001) and travel distance (250 vs. 157 miles, p < .001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow-up of 750 days, survival was comparable between the two groups (2-year survival, MELD-XI Low: HCV+, 92.4 ± 3.6% vs. HCV-negative, 91.1 ±.8%, p = .83, Medium: HCV+ 89.2 ± 4.3% vs. HCV-negative, 88.2 ± 1.0%, p = .68, and High: HCV+, 84.9 ± 4.5% vs. HCV-negative, 84.6 ± 1.1%, p = .75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD-XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p = .94; Medium: aHR, .95, p = .81; and High: aHR, .93, p = .68). CONCLUSION: Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD- XI score.

Groin wound management after decannulation of veno-arterial extracorporeal membrane oxygenation in heart transplantation: Role of sartorius muscle flap.

BACKGROUND: The management of complex groin wounds following VA-ECMO after heart transplant (HT) is uncertain due to limited experience. Sartorius muscle flaps (SMF) have been used in vascular surgery for groin wound complications. However, their use in HT recipients with perioperative VA-ECMO is unclear. This study aims to describe characteristics and outcomes of HT patients with groin complications after arterial decannulation for femoral VA-ECMO. METHODS: We retrospectively reviewed HT patients who underwent peri-transplant femoral VA-ECMO at our institution from April 2011 to February 2023. Patients were categorized into two groups based on the presence of cannulation-related wound complications. RESULTS: Among the 34 patients requiring VA-ECMO peri-transplant, 17 (50%) experienced complications at the cannulation site. Baseline characteristics including duration of VA-ECMO support were comparable in both groups. Patients with complications presented mostly with open wounds (41.1%) after a median duration of 22 days post-transplant. Concurrent groin infections were observed in 52.3% of patients, all caused by gram-negative bacteria. Wound complications were managed with 12 (70.6%) undergoing SMF treatment and 5 (31.2%) receiving conventional therapy. Four SMF recipients had preemptive procedures for wound dehiscence, while eight underwent SMF for groin infections. Among the SMF group, 11 patients had favorable outcomes without recurrent complications, except for one patient who developed a groin infection with pseudoaneurysm formation. Conventional therapy with vacuum assisted closure (VAC) and antibiotics were utilized in four patients without infection and one patient with infection. Three patients required additional surgeries with favorable healing of the wound. CONCLUSION: Complications related to femoral VA-ECMO are common in HT patients, with infection being the most frequent complication. SMFs can be a useful tool to prevent progression of infection and improve local healing.

Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation.

BACKGROUND: In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS: From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS: Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS: Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.

Evolution of concomitant use of veno-arterial extracorporeal membrane oxygenation support with Impella in cardiogenic shock: From percutaneous femoral Impella to axillary Impella 5.5.

BACKGROUND: Little is known about safety and efficacy of the use of Impella 5.5 compared to previous iterations in the setting of Impella with Veno-Arterial Extracorporeal Membrane Oxygenation Support as ECPELLA. METHODS: Consecutive patients who were treated by ECPELLA with surgically implanted axillary Impella 5.5 (N = 13) were compared with patients supported by ECPELLA with percutaneous femoral Impella CP or 2.5 (Control, N = 13). RESULTS: The total ECPELLA flow was higher in ECPELLA 5.5 group (6.9 vs. 5.4 L/min, p = 0.019). Actual hospital survival was higher than predicted and comparable in both groups (ECPELLA 5.5, 61.5% vs. Control, 53.8%, p = 0.691). Both total device complications (ECPELLA 5.5, 7.7% vs. Control, 46.1%, p = 0.021) and Impella-specific complications (ECPELLA 5.5, 0% vs. Control, 30.8%, p = 0.012) were significantly lower in the ECPELLA 5.5 group. CONCLUSIONS: Utilization of Impella 5.5 in the setting of ECPELLA provides greater hemodynamic support with a lower risk of complications compared to Impella CP or 2.5.

Escalation from impella 5.5 to ECPELLA support as a bridge to mitral valve surgery in a patient with degenerative mitral regurgitation.

Severe mitral regurgitation (MR) is an important cause of acute heart failure and significant contributor to morbidity and mortality. Mechanical circulatory support (MCS) devices such as Impella are readily used to hemodynamically stabilize patients with cardiogenic shock (CS) secondary to this valvular pathology. Impella can also be combined with VA-ECMO to an "ECPELLA" configuration if further escalation of hemodynamic support is needed. We report a case of a 57-year-old female who presented with CS secondary to a perforated anterior mitral valve leaflet and non-ischemic cardiomyopathy that did not stabilize with initial choice of Impella 5.5. She required further escalation from axillary Impella 5.5 to the combined ECPELLA configuration, which allowed hemodynamic stabilization and ultimately a successful high-risk isolated mitral valve replacement. Despite adequate Impella flow, escalation to a combined MCS configuration, such as ECPELLA, may need to be considered upfront for acute valvular insufficiency in the setting of pre-existing cardiomyopathy.

Catheter thrombectomy for basilar artery stroke immediately after insertion of durable left ventricular assist device.

Background: Acute ischemic stroke (AIS) following left ventricular assist device (LVAD) implantation is a serious complication associated with device morbidity. AIS development following LVAD placement typically presents between 6- and 24-months post implantation.Case/Results: We report a case of a 67-year-old male who initially presented with reduced ejection fraction and severe coronary vessel disease. Following coronary artery bypass graft surgery, the patient remained in a low output state necessitating placement of an LVAD device. Approximately 4.5 hours following LVAD implantation, a severe acute decrease in mental status revealed new development of ischemic stroke of the basilar artery, which was successfully treated in one pass with catheter endovascular thrombectomy.Conclusion: While embolic stroke management in these cases remains difficult as patients are usually anticoagulated, our case demonstrates the utilization of endovascular thrombectomy as a viable therapeutic option in the setting of an uncommon occurrence of embolic stroke in the hours following LVAD implantation.

Practical approach to confirm femoral artery patency after percutaneous closure for veno-arterial extracorporeal membrane oxygenation decannulation.

BACKGROUND: We describe a technique to assess blood flow distal to the decannulation site after deployment of Perclose ProGlide (Abbott Vascular, Abbott Park, Ill) in patients on femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. TECHNIQUE: An antegrade distal perfusion catheter was placed in all patients, and decannulation was primarily performed at bedside (N = 11/12). With the VA-ECMO circuit switched off, a needle was inserted into the arterial tubing, passed through the femoral arterial cannula into the artery. The arterial cannula was removed over a wire and the previously placed Proglide Perclose sutures were secured. Back bleeding from the antegrade distal perfusion catheter, confirmed using a three-way connector, indicated blood flow to the superficial femoral artery. This was followed by confirmation of blood flow to the lower leg using a Doppler ultrasound. Hemostasis of the antegrade perfusion catheter was achieved through manual compression. RESULTS: We implemented this technique in 12 patients with a technical success rate of 100%. There were no ipsilateral leg ischemia, bleeding, pseudoaneurysm, or infection after decannulation. CONCLUSIONS: This technique allows prompt assessment of blood flow to the distal leg immediately following arterial decannulation.

Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support.

Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.

Does utilization of heart machine perfusion for donation after cardiac death transplantation affect outcomes of other abdominal transplanted organs?

INTRODUCTION: Machine perfusion of heart for donation after circulatory death (DCD) is being increasingly utilized. Current protocols for utilizing heart DCD's machine perfusion might prolong donor warm ischemic time for nonheart organs. The aim of this study was to analyze the effects of utilizing heart machine perfusion on liver and kidney transplants from the same donor. METHODS: We analyzed data of DCD donors from the United Network for Organ Sharing (UNOS) from January-2020 to September-2021 among two groups: donors with heart machine perfusion (HM) and without heart machine perfusion (NHM). Propensity score (PS) matching was performed to compare the short-term outcomes of liver and kidney transplants between two groups. RESULTS: Total of 102 liver and 319 kidney transplants were performed using organs from donors with HM. After PS matching, no statistically significant difference was seen in 1-year graft survival (GS) for both liver and kidney transplants between two groups (liver HM 90.6% vs. NHM 90.2%, p = .47; kidney HM 95.2% vs. NHM 92.9%, p = .40). There was no difference in the delayed graft function (DGF) rates in kidney transplantation (KT) (HM 42% vs. NHM 35%, p = .062). CONCLUSION: Utilization of heart machine perfusion in DCD donors had no significant impact on 1-year outcomes of liver and kidney transplantation.

High flow from Impella 5.5 with partial veno-arterial extracorporeal membrane oxygenation support: Case series.

Optimal flow balance between Impella 5.5 and veno-arterial extracorporeal membrane oxygenation (ECMO) support in the setting of EC-PELLA (ECMO+Impella) is unknown. Outcomes of high Impella 5.5 flow in the setting of EC-PELLA support were reviewed (N = 7). EC-PELLA was successfully explanted in 6 patients (bridge-to-transplant, N = 1; bridge-to-recovery, N = 5). The median duration of EC-PELLA support in explanted patients was 6 days. Survival at discharge was 71.4% (5 patients). In terms of device-related events, either VA-ECMO or Impella-related complications were not experienced. The median performance level of Impella 5.5 was P5 at the time of starting EC-PELLA support and then increased with time up to the median of P8 with increment of the Impella flow, and index (L/min/m2 ). The percentage of Impella flow per total EC- PELLA flow reached 50% after 48 h of support. The vasoactive-inotropic score and serum lactate level improved after institution of EC-PELLA support as well as the pulmonary artery pressures and central venous pressure. In conclusion, a high pump flow from Impella 5.5 with partial VA-ECMO support in the setting of EC-PELLA provided great support with favorable survival and device-related complications rate.

Safe Technique of Coronary Button Preparation in Redo Bentall Operation.

We introduce a technique of coronary button reconstruction in performing a redo Bentall procedure. A coronary button is prepared leaving a 3 to 4 mm rim of old Dacron graft surrounding the previous button. The Dacron rim may be sewn to the new aortic root graft directly or via an interposed 8- or 10-mm graft, using a modified Cabrol technique. If the button is comprised of good tissue and can be well-mobilized, it is removed from the Dacron rim and anastomosed directly to the new Dacron graft.

Insertion of durable left ventricular assist device with repair of ischemic ventricular septal rupture.

BACKGROUND: A 63-year-old male who presented with acute anterior wall myocardial infarction with ischemic ventricular septal defect (VSD) required veno-arterial extracorporeal membrane oxygenation support due to a profoundly reduced left ventricular function. METHOD AND RESULS: The VSD was closed with a large bovine pericardial patches. Another Dacron patch was used to close the defect on the anterior wall. The inflow cannula of the left ventricular assist device (LVAD) was sewn to the Dacron patch to secure hemostasis and to maintain the cavity in the left ventricle. The Dacron patch beneath the inflow cuff was then incised, then the LVAD was connected. CONCLUSIONS: we described a case of concomitant insertion of durable LVAD and repair of ischemic VSD utilizing multiple patches.

Heart transplantation using manubrium-sparing sternotomy for sternal re-entry.

We report a technique of heart transplantation performed by manubrium-sparing sternotomy for challenging re-entry after minimally invasive left ventricular assist device insertion. A T-shaped, manubrium-sparing sternotomy was performed using an oscillating saw up to the first intercostal space. After cardiopulmonary bypass was established via the right axillary artery and percutaneous venous cannulation of the right jugular and femoral vein, the outflow graft was ligated and divided via a left thoracotomy. All anastomoses were performed with a standard technique with an excellent exposure and outcome.

Repair of fungal pseudoaneurysm of the common brachiocephalic trunk.

BACKGROUND AND AIM: To date, little is known about the aneurysms of the bovine aortic arch, known as a "common brachiocephalic trunk (CBT)" from where the left carotid and innominate arteries bifurcate. PATIENT AND RESULTS: Here we report a case of a fungal pseudoaneurysm of the bovine aortic arch in a patient who had prior history of multiple aortic valve replacement, hepatitis C infection, and human immunodeficiency virus infection. A re-operative replacement of the aortic arch repair utilizing a bifurcated graft was successfully performed under deep hypothermia and selective antegrade cerebral perfusion. Pathological examination demonstrated a pseudoaneurysm of the CBT. Intraoperative cultures from the aneurysmal wall showed Aspergillus fumigatus DISCUSSION AND CONCLUSION: we experienced a complex surgical repair of CBT pseudoaneurysm caused by Aspergillus species.

Heart recovery from a brain-dead donor with a history of Ravitch procedure for repair of pectus excavatum.

BACKGROUND: We describe the successful heart transplantation of a brain-dead male donor with a remote history of pectus excavatum repair. METHOD AND RESULTS: On computed tomography, the ascending aorta was in close proximity to metallic struts from the donor's sternal repair. Before harvesting the heart, visual and digital inspections revealed minimal space between the sternum and ascending aorta, complicated by severe adhesions in the lower sternum. After the pericardium was opened, the subsequent recovery of the heart was performed in a standard fashion. At one-year post-transplant, the recipient continues to have normal graft function. CONCLUSIONS: Careful evaluation, intraoperative consideration, and coordination with other transplant teams were essential in the successful recovery of the heart during a time of organ shortages.

Escalation from intra-aortic balloon pump to axillary impella 5.5 support: Staged removal of the femoral access.

Background: With the growing population of advanced heart failure, the use of Impella 5.5 has been increasing. Here, we report an effective strategy of removing the intra-aortic balloon pump (IABP) in the setting of escalation of support to Impella 5.5.Results: From January 1, 2022 to June 30, 2022, a total of 6 patients have undergone IABP removal during Impella 5.5 insertion. The IABP was subsequently removed over the long wire with manual compression on the femoral artery to control bleeding. An 8 or 9 Fr short sheath is inserted over the wire. Staged hemostasis was successfully performed in 4 patients, and the remaining two patients required escalation of support to veno-arterial membrane oxygenation as EC-PELLA utilizing the femoral arterial sheath.Conclusion: This does not only achieve secured hemostasis but also enables a smooth transition to further escalate support such as extracorporeal membrane oxygenation support, if necessary.

Surgical repair of candida mycotic pseudoaneurysm with extensive vegetations of the ascending aorta and pulmonary artery after heart and kidney transplant.

We report a case of invasive candidiasis causing a mycotic pseudoaneurysm involving the ascending aorta and pulmonary artery. The patient presented two years after heart-kidney transplant with acute limb ischemia resulting from embolization of fungal vegetations. Operative findings included a pseudoaneurysm resulting from near-complete dehiscence of the aortic suture line, and large vegetations within the ascending aorta extended to the aortic arch and pulmonary artery, with localized dehiscence of the pulmonic suture line. The ascending aorta was replaced, and the pulmonary artery was repaired with bovine pericardium. The patient did well, and blood cultures were negative at 6 months follow-up.