Domino heart transplant following heart-lung transplantation: a systematic review and meta-analysis.

BACKGROUND: The domino-donor operation occurs when a "conditioned" heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure. METHODS: An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis. RESULTS: HLT indications included cystic fibrosis in 58% (95% CI: 27-84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12-24%), bronchiectasis in 5% (95% CI: 3-10%), emphysema in 5% (95% CI: 0-45%), and Eisenmenger's syndrome in 4% (95% CI: 2-8%). HT indications included ischemic heart disease in 40% (95% CI: 33-47%), non-ischemic disease in 39% (95% CI: 25-56%), and re-transplantation in 10% (95% CI: 1-59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95% CI: 18-41%) at an average follow-up of 15.68 months (95% CI: 0.82-30.54), and 35% (95% CI: 17-58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68-67.84). Freedom from rejection in HT was 94% (95% CI: 75-99%) at 1 month, 77% (95% CI: 30-96%) at 6 months, and 41% (95% CI: 33-50%) at 1 year. CONCLUSIONS: The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.

Airway complications after lung transplantation: Contemporary survival and outcomes.

BACKGROUND: Airway complications are rare and cause increased morbidity and mortality after lung transplantation (LT). We sought to examine risk factors associated with this complication and its impact on survival. METHODS: We retrospectively evaluated United Network for Organ Sharing data from 2000 to 2012. A backward stepwise logistic regression was performed on recipient-, donor-, and transplant-related variables to select independent risk factors associated with airway complications and mortality. Survival was evaluated using the Kaplan-Meier method. RESULTS: We evaluated 16,156 consecutive adult LT recipients, among whom 233 (1.4%) developed airway complications. Predictors of increased risk of airway complications included male gender (odds ratio [OR] 1.61, p = 0.001), advancing recipient age (OR 1.02, p < 0.001) and pre-transplantation admission to the intensive care unit (ICU) (OR 2.13, p < 0.001). The 30-day (89.6% vs 96.2%, p = 0.001), 90-day (69.9% vs 93.1%, p < 0.001), 1-year (54.6% vs 84.4%, p < 0.001), 3-year (38.7% vs 67.4%, p < 0.001) and 5-year (33.2% vs 54.2%, p < 0.001) survival rates were each significantly reduced in recipients with airway complications. Factors associated with an increased risk of 1-year mortality included recipient age (hazard ratio [HR] 1.01, p < 0.001), use of extracorporeal mechanical support (HR 1.5, p = 0.01), diagnosis of cystic fibrosis (HR 1.22, p = 0.01), glomerular filtration rate (GFR) 60 to 90 ml/min/1.73 m2 (HR 1.61, p < 0.001), GFR <60 ml/min/1.73 m2 (HR 1.13, p = 0.01), non-ICU hospitalization (HR 1.32, p < 0.001), pre-transplantation ICU hospitalization (HR 2.54, p < 0.001), donor with positive serology for cytomegalovirus (HR 1.16, p < 0.001) and donor with a smoking history (HR 1.19, p < 0.001). Double LT (HR 0.83, p < 0.001) was associated with a decreased risk of death. Chronic obstructive pulmonary disease/emphysema was protective compared with idiopathic pulmonary fibrosis (HR 0.85, p = 0.008). CONCLUSION: Airway complications are associated with a significant mortality burden.

The effect of acute mechanical left ventricular unloading on ovine tricuspid annular size and geometry.

OBJECTIVES: Left ventricular assist device (LVAD) implantation may alter right ventricular shape and function and lead to tricuspid regurgitation. This in turn has been reported to be a determinant of right ventricular (RV) failure after LVAD implantation, but the effect of mechanical left ventricular (LV) unloading on the tricuspid annulus is unknown. The aim of the study was to provide insight into the effect of LVAD support on tricuspid annular geometry and dynamics that may help to optimize LV unloading with the least deleterious effect on the right-sided geometry. METHODS: In seven open-chest anaesthetized sheep, nine sonomicrometry crystals were implanted on the right ventricle. Additional nine crystals were implanted around the tricuspid annulus, with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Left ventricular unloading was achieved by connecting a cannula in the left atrium and the aorta to a continuous-flow pump. The pump was used for 15 min at a full flow of 3.8 ± 0.3 l/min. Epicardial echocardiography was used to assess the degree of tricuspid insufficiency. Haemodynamic, echocardiographic and sonomicrometry data were collected before and during full unloading. Tricuspid annular area, and the regional and total perimeter were calculated from crystal coordinates, while 3D annular geometry was expressed as the orthogonal distance of each annular crystal to the least squares plane of all annular crystals. RESULTS: There was no significant tricuspid regurgitation observed either before or during LV unloading. Right ventricular free wall to septum diameter increased significantly at end-diastole during unloading from 23.6 ± 5.8 to 26.3 ± 6.5 mm (P = 0.009), but the right ventricular volume, tricuspid annular area and total perimeter did not change from baseline. However, the septal part of the annulus significantly decreased its maximal length (38.6 ± 8.1 to 37.9 ± 8.2 mm, P = 0.03). Annular contraction was not altered. The tricuspid annulus had a complex 3D saddle-shaped geometry that was unaffected during experimental conditions. CONCLUSIONS: In healthy sheep hearts, left ventricular unloading increased septal-free wall RV diameter and reduced the length of the septal annulus, without altering the motion or geometry of the tricuspid annulus. Acute left ventricular unloading alone in healthy sheep was not sufficient to significantly perturb tricuspid annular dynamics and result in tricuspid insufficiency.

Procedural volume and survival after lung transplantation in the United States: the need to look beyond volume in the establishment of quality metrics.

BACKGROUND: We sought to evaluate the effect of center volume on patient survival. METHODS: We performed a retrospective analysis on nationwide data from the Scientific Registry of Transplant Recipients provided by United Network for Organ Sharing pertaining to lung transplantation (LT) recipients transplanted between 2005 and 2013. Centers were categorized into 4 groups based on their annual volume as follows: less than 20, 20 to 29, 30 to 39, and greater than or equal to 40 LTs. Baseline characteristics were compared and Kaplan-Meier analysis was used to estimate survival. RESULTS: A total of 13,506 adult recipients underwent LT during the study period. Of these, 2,491 (18.4%) patients were transplanted in centers with volume less than 20, 2,562 (19.0%) in centers with volume 20 to 29, 2,998 (22.2%) in centers with volume 30 to 39, and 5,455(40.4%) in centers with volume greater than or equal to 40. Survival was poorest in the lowest volume centers (1-year 81.4% vs 85.5% and 5-year 49.7% vs 56.5%, respectively). CONCLUSIONS: Post-LT survival in low volume centers is significantly lower than in high volume centers but the explanatory power of volume as a predictor of survival is low.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure.

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

The effect of pulmonary hypertension on ovine tricuspid annular dynamics.

OBJECTIVES: Pulmonary hypertension (PHT) is associated with tricuspid annular dilatation, but the effect of acute increase of pulmonary pressure on three-dimensional (3D) tricuspid annular dynamics and shape is unknown. Better understanding of tricuspid annular dynamics may lead to improved and more durable surgical reparative techniques. METHODS: In nine open-chest anaesthetized sheep nine sonomicrometry crystals were implanted on the right ventricle while on cardiopulmonary bypass. Additional nine crystals were implanted around the tricuspid annulus (TA) with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Two additional equidistant crystals were implanted between each commissure, creating three segments for every region. Pressure transducers were placed in the left ventricular (LV), right ventricular (RV) and right atrium. PHT was induced by acute pulmonary artery constriction with a pneumatic occluder. Sonomicrometry and echocardiographic data were collected before and after induction of PHT. TA area, regional and total perimeter, and 3D annular geometry were calculated from 3D crystal coordinates. Regional annular contraction was defined as the percentage difference between maximal and minimal region length during the cardiac cycle. RESULTS: PHT increased RV pressure from 31 ± 9 mmHg to 46 ± 13 mmHg (P = 0.001) and decreased left ventricular (LV) pressure from 111 ± 24 mmHg to 78 ± 36 mmHg (P = 0.018). There was no significant tricuspid regurgitation observed with PHT. During PHT, the TA area increased by 12 ± 13% from 641 ± 139 mm(2) to 721 ± 177 mm(2) (P = 0.037). The total perimeter increased from 103 ± 11 mm to 109 ± 13 mm (P = 0.02). All annular regions dilated significantly with PHT with 8 ± 10, 5 ± 5 and 5 ± 5% increase in anterior, posterior and septal annular length, respectively (P < 0.05). PHT reduced regional annular contraction in the anterior region only (17 ± 7 vs 14 ± 8%; P = 0.02). The TA had a complex 3D saddle geometry and the shape of the annulus was altered during PHT only in the antero-posterior region. CONCLUSIONS: The changes in tricuspid annular conformation, contractility and its 3D geometry observed during acute ovine PHT may help in the design of new pathology-specific tricuspid annular rings.

Ventricular assist device outflow graft in congenitally corrected transposition of great arteries - a surgical challenge.

Congenitally corrected transposition of the great arteries is a complex congenital cardiac anomaly with a wide spectrum of morphologic features and clinical profiles. Most patients are diagnosed late in their life, undergoes surgical repairs, eventually leading to systemic ventricular failure needing heart transplant or mechanical circulatory assistance. As, aorta is located anterior to and left of the PA (Transposition of great arteries), the outflow graft of ventricular assist device traverse across pulmonary artery to reach aorta which poses challenge during further surgical explorations.

Long-term outcomes of patients bridged to recovery versus patients bridged to transplantation.

OBJECTIVE: The proportion of patients who can be bridged with left ventricular assist devices to myocardial recovery and the long-term outcome of these patients is unknown. METHODS: We investigated the outcomes of patients bridged to recovery compared with those bridged to transplantation. All left ventricular assist devices were implanted as a bridge to transplantation with a very proactive program of promoting myocardial recovery. A total of 40 patients were bridged to recovery and 52 to transplantation. Of the bridged to recovery (explanted) group, 33 were men (age, 32.8 ± 11.8 years), 37 had dilated cardiomyopathy (familial in 3, peripartum cardiomyopathy in 3) and 3 had myocarditis. Of the bridged to transplantation (transplanted) group, 42 were men (age, 42.3 ± 12.5 years; P < .0005 vs bridged to recovery). The diagnosis was ischemic heart disease in 24, dilated cardiomyopathy in 21 (only 13 received drug therapy), hypertrophic obstructive cardiomyopathy in 2, arrythmogenic right ventricular dysplasia in 2, myocarditis in 1, and congestive heart disease in 2. RESULTS: The survival rate was 89.9%, 73.9%, and 73.9% and 80.4%, 78.3, and 78.3% in the explanted and transplanted groups at 1, 5, and 7 years, respectively. In total, 12 (23%) patients bridged transplantation either died from, or required ventricular assist device support, for primary graft failure. Of the explanted patients, 4 (10%) subsequently required transplantation at 34, 512, 1019, and 1213 days (2 died 25 and 1867 days after transplantation and 2 were well after 1523 and 3199 days). The rate of transplant or ventricular assist device-free survival less noncardiac death for the bridged to recovery and bridged to transplantation groups, respectively, was 89.9%, 73.9%, and 73.9% and 80.4%, 78.3%, and 78.3% at 1, 3, and 7 years. At latest follow-up (1394 ± 1195 days for the bridged to recovery and 1913 ± 941 days for the bridged to transplantation group), 5 of the bridged to transplantation patients (9.6%) had malignancy, 34 (65.4%) had hypercholesterolemia, 25 (48.1%) had hypertension, and 7 (13.5%) had coronary disease. The creatinine was 125.5 ± 43.5 vs 95.2 ± 16.5 µmol/L for the bridged to transplantation and bridged to recovery groups (P < .001). CONCLUSIONS: The outcome after explantation for myocardial recovery is comparable, if not better than, after bridge to transplantation.

European results with a continuous-flow ventricular assist device for advanced heart-failure patients.

OBJECTIVE: The HeartMate II (HM II) LVAD is a small, quiet, continuous-flow, left ventricular assist device (LVAD) for circulatory support in advanced heart-failure patients, with over 2000 implants worldwide. This article reports on the European experience with this device. METHODS: The HM II was implanted in 571 patients at 64 European institutions. In 72% of cases (411 patients), implantation has taken place at least 6 months before the closing date of the study (1 August 2008). Patients (19% female, 70% ischaemic aetiology) were on maximum medical therapy, including inotropic support. Body surface area ranged from 1.30 to 2.50 m(2) and age from 14 to 75 years (mean: 51+/-14 years; n=115, 28% over age 60 years). The intention of support was to provide a bridge to transplantation (73%), destination therapy (21%) and a bridge to recovery (6%). Adverse events were documented in the first 53 patients - for obtaining the Conformité Européenne (CE) Mark (group A) - from a European multicentric study (Strüber et al. [Strüber M, Sander K, Lahpor J, Ahn H, Litzler P-Y, Drakos SG, Musumeci F, Schlensak C, Friedrich I, Gustafsson R, Oertel F, Leprince P. HeartMate II left ventricular assist device; early European experience. Eur J Cardiovasc Surg 2008;34(2):289-94.]: 101 patients) and from a single-centre study (UMCU, The Netherlands: 30 patients). RESULTS: The mean support duration ranged from 0 to 1019 days with a mean of 236+/-214 days (249 patients: >6 months, 119: 1 year, 12: >2 years; total support time: 293 years). The overall survival to transplantation, recovery or ongoing device support at the end of the study was 69% (284) with an early mortality of 17.5% and late mortality of 13.5%. Of the surviving patients, 23% have been transplanted, 4% had their device removed after recovery of the left ventricle and 42% are still ongoing. Adverse events included bleeding (ranging from 42% in group C to 59% in group A), percutaneous lead infections (A: 0.19, B: 0.61 and C: 0.18 events per patient year), pocket infections (A: 0.08, B: 0.07 and C: 0.09 events per patient year), ischaemic stroke (A: 0.06, B: 0.09 and C: 0.04 events per patient year), haemorrhagic stroke (B: 0.07, C: 0.04 events per patient year) and transient ischaemic attacks (TIAs; A: 0.08, B: 0.02 and C: 0.13 events per patient year). CONCLUSIONS: These results support the use of the HM II continuous-flow LVAD for long-term support as a bridge to transplantation and possibly for destination therapy. Future emphasis should focus on minimising adverse events such as infections, bleeding and neurological events.

Bridging patients after salvage from bridge to decision directly to transplant by means of prolonged support with the CentriMag short-term centrifugal pump.

OBJECTIVE: Optimum strategy for salvage in patients with acutely decompensated end-stage heart failure and severe multiorgan dysfunction is complex. We present our experience with prolonged CentriMag (Levitronix, Waltham, Mass) support for transitioning patients after successful salvage from bridge to decision directly to transplant. METHODS: Records of patients who underwent salvage with a CentriMag as bridge to decision and later to transplant were reviewed. Between June 2003 and June 2008, 4 patients in cardiogenic shock from acute decompensated end-stage heart failure and multiorgan dysfunction underwent salvage with biventricular CentriMag as bridge to decision. Three were male. Mean age was 39.3 years (range 24-52 years). Three had dilated cardiomyopathy; 1 had ischemic cardiomyopathy. All had preoperative mechanical ventilation, large doses of multiple inotropes, and intra-aortic balloon support. All also had acute liver and renal failure and metabolic acidosis. RESULTS: After mean postimplant period of 43 days (range 7-70 days), patients had reversal of end-organ dysfunction; after mean waiting time of 31 days (range 21-67 days), all were transplant listed. Mean mechanical circulatory support was 87.7 days (range 26-105 days). No thromboembolic or neurologic events or mechanical failures occurred. Posttransplant mean ventilation and intensive care unit stay were 2 and 4 days (ranges 1-4 and 3-7 days), respectively. All patients were discharged home and remain alive and well. CONCLUSION: CentriMag use as long as 3 months appears to be safe and cost-effective for bridging selected patients directly to transplant after salvage. Further clinical experience is still needed.

Intrathoracic organ transplantation from donors with meningitis: a single-center 20-year experience.

BACKGROUND: Availability of cadaveric organs continues to be the key factor limiting the number of transplants performed. Donor with bacterial meningitis is often considered to be controversial for organ retrieval. The purpose of this retrospective study was to review the long-term outcome of orthotopic heart and lung transplantation at our institution, from donors who died as a result of meningitis. METHODS: Between July 1986 and July 2006, 39 adult patients who underwent heart and lung transplantation performed with organs from cadaveric donors with bacterial meningitis were retrospectively studied. Donors and recipients were identified by a prospectively kept database. Bacterial meningitis was identified either with positive blood or cerebrospinal fluid culture and positive signs and symptoms. All patients had one or more of these criteria. There were 15 heart, 12 lung (4 bilateral), and 12 heart-lung transplants. RESULTS: All donors had identified pathogens: Neisseria meningitidis (n = 21; 53.8%), Streptococcus pneumoniae (n = 16; 41%), and Haemophilus influenzae (n = 2; 5.2%). Adequate antimicrobial therapy before organ retrieval and after transplant was administered. The hospital mortality was 10.2% (n = 4). There were no infectious complications caused by meningeal pathogens. Other causes of hospital mortality were rejection (n = 2), intracranial bleeding (n = 1), and staphylococcus sepsis (n = 1). The mean posttransplant follow-up was 5.35 +/- 5.54 years (range, 1 month to 18.9 years). CONCLUSIONS: Intrathoracic organ transplantation using donors with bacterial meningitis is an acceptable strategy. No organism (Neisseria meningitides, Streptococcus pneumoniae, and Haemophilus influenzae) could be identified as contraindication because no recipient died of infectious-related diseases.

Midterm experience with the Jarvik 2000 axial flow left ventricular assist device.

OBJECTIVE: Rotary axial flow pumps have several potential advantages and disadvantages over pulsatile pumps. The Jarvik 2000 is distinctive in being intracardiac. We report our experience in 22 patients. METHODS: The Jarvik 2000 was implanted in 15 men and 7 women. Mean age was 38.8 (range 23-59) years, preoperative diagnosis was dilated cardiomyopathy in 16, postpartum cardiomyopathy in 3, ischemic heart disease in 2, and chronic allograft failure in 1. Twenty-one patients were in New York Heart Association class IV, and 1 patient was in class III. Nineteen patients were on inotropic support, 6 were supported with an intra-aortic balloon pump, and 2 patients had been salvaged with a Centrimag (Levitronix) ventricular assist device. The median pulmonary vascular resistance was 3 Wood units; median pulmonary capillary wedge pressure was 26.6 mm Hg; and mean Cardiac Index was 1.5 L/min/m2. RESULTS: There were 2 early deaths and 6 late deaths. The average postoperative ventilation time and Intensive Treatment Unit stay was 2.2 and 10 days, respectively. One patient required a right ventricular assist device for short-term support and another for medium-term support. Seven patients were bridged to transplant, 3 had myocardial recovery, and 4 are ongoing. Mean and total duration of support was 280.5 and 6172 days, respectively. Driveline failures were noted in 3, but there were no pump infections or failure. CONCLUSION: The Jarvik 2000 provides satisfactory intermediate-term results as a bridge to transplant or recovery. It appears to be associated with a low rate of serious driveline or pump infections and technical failure. However, bleeding complications due to the required anticoagulation treatment frequently occurred.

Bridge to transplantation with a left ventricular assist device for systemic ventricular failure after Mustard procedure.

After Mustard or Senning procedures, transplantation remains the only option for some patients who present at late stage with severe systemic (right) ventricular failure. In some circumstances these patients may require urgent mechanical circulatory support to bridge them to transplantation. The use of mechanical support poses considerable potential and actual specific problems both in terms of insertion and management of the device. We report the case of a 17-year-old patient who had a left ventricular assist device implanted from the right ventricle to the aorta for "end-stage" heart failure 15 years after the Mustard procedure. The specific problems are discussed and a management scheme is proposed.

A calcified cardiac mass.

Cardiac fibromas are benign tumours, often diagnosed in childhood, but rarely they may be diagnosed in adults or the elderly. We present an interesting case of a middle-aged lady presenting with exertional chest pain and breathlessness, who was found to have a heavily calcified mass within the myocardium. With a previous history of chest trauma, a calcified myocardial haematoma was initially suspected. Complete surgical excision led to a total resolution of symptoms. Histological examination confirmed the diagnosis of a cardiac fibroma. Complete excision of cardiac fibromas, where possible, is advised and is associated with excellent survival.

Left ventricular assist device and drug therapy for the reversal of heart failure.

BACKGROUND: In patients with severe heart failure, prolonged unloading of the myocardium with the use of a left ventricular assist device has been reported to lead to myocardial recovery in small numbers of patients for varying periods of time. Increasing the frequency and durability of myocardial recovery could reduce or postpone the need for subsequent heart transplantation. METHODS: We enrolled 15 patients with severe heart failure due to nonischemic cardiomyopathy and with no histologic evidence of active myocarditis. All had markedly reduced cardiac output and were receiving inotropes. The patients underwent implantation of left ventricular assist devices and were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse remodeling. Once regression of left ventricular enlargement had been achieved, the beta2-adrenergic-receptor agonist clenbuterol was administered to prevent myocardial atrophy. RESULTS: Eleven of the 15 patients had sufficient myocardial recovery to undergo explantation of the left ventricular assist device a mean (+/-SD) of 320+/-186 days after implantation of the device. One patient died of intractable arrhythmias 24 hours after explantation; another died of carcinoma of the lung 27 months after explantation. The cumulative rate of freedom from recurrent heart failure among the surviving patients was 100% and 88.9% 1 and 4 years after explantation, respectively. The quality of life as assessed by the Minnesota Living with Heart Failure Questionnaire score at 3 years was nearly normal. Fifty-nine months after explantation, the mean left ventricular ejection fraction was 64+/-12%, the mean left ventricular end-diastolic diameter was 59.4+/-12.1 mm, the mean left ventricular end-systolic diameter was 42.5+/-13.2 mm, and the mean maximal oxygen uptake with exercise was 26.3+/-6.0 ml per kilogram of body weight per minute. CONCLUSIONS: In this single-center study, we found that sustained reversal of severe heart failure secondary to nonischemic cardiomyopathy could be achieved in selected patients with the use of a left ventricular assist device and a specific pharmacologic regimen.

Minimally invasive technique for explantation of right ventricular assist devices.

In an attempt to reduce some or all of the complications resulting from the use of biventricular assist devices after mechanical circulatory support, we have developed and applied a minimally invasive technique for explantation of right ventricular assist devices.

Acinetobacter mediastinitis in a heart transplant patient.

We report a 56-year-old who underwent orthotopic heart transplantation following left ventricular assist device bridge to transplantation. His postoperative course was complicated by severe sternal wound infection with Acinetobacter species requiring extensive debridement and reconstruction with a pectoralis major flap. This was followed by a total sternectomy, pectoralis flap debridement, and vacuum-assisted dressing.

Levitronix as a short-term salvage treatment for primary graft failure after heart transplantation.

BACKGROUND: Primary graft failure after heart transplantation is a well-recognized catastrophic complication with a high mortality rate. It is becoming more frequent due to the increasing use of marginal donors. In these difficult cases a ventricular assist device (VAD) as a bridge to recovery or as a bridge to re-transplantation can be used. The recently introduced Levitronix Centrimag centrifugal pump might be an ideal device for this purpose. METHODS: In this study we describe 2 patients with primary graft failure who received a Levitronix in the last 2 years, immediately after failure to wean from cardiopulmonary bypass. Biventricular support was necessary in both patients. RESULTS: One patient was successfully re-transplanted after 2 days of support, and subsequently discharged. After 16 months she has good ventricular function with no symptoms of cardiac failure. The second patient showed signs of ventricular recovery after a few days and was weaned from the device after 7 days, with good graft function. No device-related complications were recorded. After 14 days he was discharged from the intensive care unit (ICU), and a post-operative echocardiogram showed normal dimensions, good ejection fraction and no valvular regurgitation. He was discharged home 26 days after the transplant. CONCLUSIONS: In our experience, the Levitronix Centrimag seems to be safe and effective in the treatment of primary graft failure, achieving effective circulatory support and ventricular off-loading. We propose its use in isolated or biventricular graft failure either as bridge to re-transplant or as a bridge to recovery.