Ex-Vivo Preservation with the Organ Care System in High Risk Heart Transplantation.

OBJECTIVE: Ex vivo organ perfusion is an advanced preservation technique that allows graft assessment and extended ex situ intervals. We hypothesized that its properties might be especially beneficial for high-risk recipients and/or donors with extended criteria. METHODS: We reviewed the outcomes of 119 consecutive heart transplant patients, which were divided into two groups: A (OCS) vs. B (conventional). Ex vivo organ perfusion was performed using the Organ Care System (OCS). Indications for OCS-usage were expected ischemic time of >4 h or >2 h plus given extended donor criteria. RESULTS: Both groups included mostly redo cases (A: 89.7% vs. B: 78.4%; p = 0.121). Incidences of donors with previous cardiac arrest (%) (A: 32.4 vs. B: 22.2; p < 0.05) or LV-hypertrophy (%) (A: 19.1 vs. B: 8.3; p = 0.119) were also increased in Group A. Ex situ time (min) was significantly longer in Group A (A: 381 (74) vs. B: 228 (43); p < 0.05). Ventilation time (days) (A: 10.0 (19.9) vs. B: 24.3 (43.2); p = 0.057), postoperative need for ECLS (%) (A: 25.0 vs. B: 39.2; p = 0.112) and postoperative dialysis (chronic) (%) (A: 4.4 vs. B: 27.5; p < 0.001) were numerically better in the OCS group, without any difference in the occurrence of early graft rejection. The 30-d-survival (A: 92.4% vs. B: 90.2%; p = 0.745) and mid-term survival were statistically not different between both groups. CONCLUSIONS: OCS heart allowed safe transplantation of surgically complex recipients with excellent one-year outcomes, despite long preservation times and unfavourable donor characteristics. Furthermore, we observed trends towards decreased ventilation times and fewer ECLS treatments. In times of reduced organ availability and increasing recipient complexity, OCS heart is a valuable instrument that enables otherwise infeasible allocations and contributes to increase surgical safety.

Is the branched graft technique better than the en bloc technique for total aortic arch replacement?

OBJECTIVES: Total aortic arch replacement remains a surgical challenge. For the reimplantation of the supra-aortic vessels, either the en bloc (island) or branched graft technique (BGT) is used. The BGT has been proposed to have several advantages over the classical island technique. The purpose of this study was to compare the perioperative and mid-term follow-up results of these two methods. METHODS: From March 2006 to December 2010, 103 patients (74.8% male, age 59 ± 12 years) underwent total aortic arch replacement. In 45.6% of the patients (n = 47), branched grafts (Group A, 35 males, 58 ± 13 years) were used, while 54.4% of the patients (n = 56) underwent en bloc technique (Group B, 42 males, 60 ± 12 years). Concomitant procedures were performed as necessary. Twenty-nine (28.2%) patients had an aortic aneurysm [Group A: n = 12 (25.5%), Group B: n = 17 (30.4%)] and 74 (71.8%) patients had an aortic dissection [Group A: n = 35 (74.5%), Group B: n = 39 (69.6%)]. Thirty-one (30.1%) of these patients [Group A: 17 (36.2%), Group B: 14 (25%)] had undergone previous cardiac operations. RESULTS: Cardiopulmonary bypass, cross-clamp and circulatory arrest times were 243 ± 71, 140 ± 55 and 53 ± 28 min in Group A and 249 ± 76, 147 ± 54 and 57 ± 30 min in Group B, respectively (P = n.s.). The overall 30-day mortality was 10.6% in Group A and 16.1% in Group B (P = n.s.). The postoperative stroke rate was 4.3% in Group A and 3.8% in Group B, respectively (P = n.s.). Rethoracotomy due to bleeding was 27.7% in Group A and 23.2% in Group B (P = n.s.). At a mean follow-up of 4.0 years, 61.7% of the patients in Group A were alive and 29.8% had undergone operations on the downstream aorta. In Group B, 60.7% of the patients were alive at a mean follow-up of 4.4 years and 20.0% had undergone operations on the downstream aorta. None of the patients in Group B developed further pathological changes in the 'island' or the proximal supra-aortic vessels. CONCLUSIONS: The BGT is not inferior perioperatively or in the mid-term follow-up compared with the classical island technique. Thus, this technique can be used during total arch replacements in most aortic arch pathologies.

Aortic valve replacement in geriatric patients with small aortic roots: are sutureless valves the future?

OBJECTIVES: Aortic valve replacement (AVR) in geriatric patients (>75 years) with small aortic roots is a challenge. Patient-prosthesis mismatch and the long cross-clamp time necessary for stentless valves or root enlargement are matters of concern. We compared the results of AVR with sutureless valves (Sorin Perceval), against those with conventional biological valves. METHODS: Between April 2007 and December 2012, 120 isolated AVRs were performed in patients with a small annulus (<22 mm) at our centre. In 70 patients (68 females, age 77.4 ± 5.5 years), conventional valves (C group) and in 50 patients (47 females, age 79.8 ± 4.5 years), sutureless valves (P group) were implanted. The Logistic EuroSCORE of the C group was 16.7 ± 10.4 and that of the P group 20.4 ± 10.7, (P = 0.054). Minimal-access surgery was performed in 4.3% (3/70) patients in the C group and 72% (36/50) patients in the P group. RESULTS: The cardiopulmonary bypass (CPB) and cross-clamp times of the C group were 75.3 ± 23 and 50.3 ± 14.2 min vs 58.7 ± 20.9 and 30.1 ± 9 min in the P group, (P < 0.001). In the C group, two annulus enlargements were performed. Thirty-day mortality was 4.3% (n = 3) in the C group and 0 in the P group, (n.s.). At follow-up (up to 5 years), mortalities were 17.4% (n = 12) in the C group and 14% (n = 7) in the P group, (n.s.). CONCLUSIONS: This study highlights the advantages of sutureless valves for geriatric patients with small aortic roots reflected by shorter cross-clamp and CPB times, even though most of these patients were operated on via a minimally invasive access. Moreover, due to the absence of a sewing ring, these valves are also almost stentless, with greater effective orifice area (EOA) for any given size. This may potentially result in better haemodynamics even without the root enlargement. This is of advantage, as several studies have shown that aortic root enlargement can significantly increase the risks of AVR. Moreover, as seen in this series, these valves may also enable a broader application of minimally invasive AVR.

Long-term results after aortic valve-sparing operation (David I).

OBJECTIVE: Aortic valve-sparing David procedure has gained broad acceptance. However, few long-term results have been published. We present our results. METHODS: More than 450 David procedures have been performed in our institution so far. Of these, 126 patients were operated between July 1993 and December 2000. Median age was 57 (8-83) years and 46 (36.5%) were female. As many as 26 (20.6%) had Marfan syndrome, 21 (16.7%) had acute aortic dissection type A (AADA) and 67 (53.2%) had additional procedures. RESULTS: There were six (4.8%) deaths in 30 post-operative period (POD), four of whom had AADA. In the follow-up, there were 32 (25.4%) late deaths, 11 (34.4%) of these were caused by cardiac or underlying disease or op-related. As many as 15 (11.9%) patients were re-operated; six (40%) were Marfan patients and two (13.3%) had early endocarditis. Follow-up echocardiography of 76 (60.3%) event-free patients showed valve insufficiency (AI)≤AI I° in 68 (89.5%) and grade II in 7 (9.2%) patients. Leaflet degeneration due to proposed leaflet contact with the straight Dacron graft was not observed. A total of 36 (47.4%) patients were in New York Heart Association (NYHA) class I, 33 (43.4%) in NYHA II, and five (6.6%) were in class III. During the entire follow-up of 790 patient-years, there was no stroke or major bleeding. Survival at 1, 5 and 10 years was 93%, 85% and 70%, respectively. Freedom from valve replacement at 1, 5 and 10 years was 96%, 91% and 87%, respectively. CONCLUSIONS: Regardless of the underlying pathology, valve-sparing David I procedure has acceptable long-term results. Valve-related complications such as stroke or major bleeding is exceedingly low.

Non-adherence in patients on chronic hemodialysis: an international comparison study.

BACKGROUND: Adherence to diet and fluid restrictions by adults on hemodialysis treatment is challenging. This study compared non-adherence (NA) to diet and fluid restrictions between adult US and German hemodialysis patients, and assessed potential predictors for NA. METHODS: A cross-sectional multicenter comparative study of 456 adult hemodialysis patients was conducted in 12 outpatient-based hemodialysis centers in the United States and Germany. NA was based on self-report using the Dialysis Diet and Fluid Non-adherence Questionnaire (DDFQ). Laboratory marker, interdialytic weight gain (IDWG) and dialysis adequacy (Kt/V) information were obtained from medical records. Mean time on dialysis was 50 months (range 3-336); mean age was 62 years (range 19-91), with the majority of patients (89.7%) being white. RESULTS: Self-reported frequency of NA to diet was 80.4% and to fluid 75.3% in the total sample. The degree of NA to diet and fluid differed significantly, with the US patients (68.1% vs. 61.1%) reporting less NA when compared with German (81.6% vs. 79.0%) patients (p<0.0001). Phosphorus, albumin, IDWG and Kt/V levels were higher in the US compared with the German subsample (all p<0.0001; IDWG p<0.003). Generalized regression models revealed that education (p<0.01) and smoking (p<0.01) predicted NA to diet, whereas single marital status (p<0.008) and male sex (p<0.04) were independent predictors for NA to fluid. CONCLUSIONS: NA persists as one of the most challenging tasks in health care of patients with chronic conditions, including hemodialysis patients. Our findings suggest that patient, condition-related, socioeconomic and health care system-related factors may contribute to NA to diet and fluid restrictions.