Pectoral muscle mass is not a robust prognostic factor for survival after left ventricular assist device (LVAD) implantation.

BACKGROUND: Left ventricular assist devices (LVAD) are an established treatment for end-stage left ventricular heart failure. Parameters are needed to identify the most appropriate patients for LVADs. This study aimed to evaluate pectoral muscle mass and density as prognostic parameters. METHODS: This single-center study included all patients with LVAD implantation between January 2010 and October 2017 and a preoperative chest CT scan. Pectoral muscle mass was assessed using the Pectoralis Muscle Index (PMI, surface area indexed to height, cm2/m2) and pectoral muscle density by Hounsfield Units (HU). Overall mortality was analyzed with Kaplan-Meier survival analysis and 1-year and 3-year mortality with receiver operating characteristic (ROC) curves and Cox regression models. RESULTS: 57 patients (89.5% male, mean age 57.8 years) were included. 64.9% of patients had end-stage left ventricular failure due to ischemic heart disease and 35.1% due to dilated cardiomyopathy. 49.2% of patients had preoperative INTERMACS profile of 1 or 2 and 33.3% received mechanical circulatory support prior to LVAD implantation. Total mean PMI was 4.7 cm2/m2 (± 1.6), overall HU of the major pectoral muscle was 39.0 (± 14.9) and of the minor pectoral muscle 37.1 (± 16.6). Mean follow-up was 2.8 years (± 0.2). Mortality rates were 37.5% at 1 year and 48.0% at 3 years. Neither PMI nor HU were significantly associated with overall mortality at 1-year or 3-year. CONCLUSIONS: The results of our study do not confirm the association between higher pectoral muscle mass and better survival after LVAD implantation previously described in the literature.

Evaluation of risk factors for cytomegalovirus DNAemia after end of regular prophylaxis after heart transplantation.

BACKGROUND: Cytomegalovirus (CMV) infections after heart transplantation (HTx) can cause cardiac allograft vasculopathy. Consequently, monitoring and prophylaxis for cytomegalovirus deoxyribonucleic acid (CMV-DNAemia) within the first weeks after HTx is recommended. METHODS: All patients who underwent HTx between September 2010 and 2021 surviving the first 90 days (n = 196) were retrospectively reviewed. The patients were divided on the prevalence of CMV-DNAemia during the first postoperative year after the end of the prophylaxis. A total of n = 35 (20.1%) developed CMV-DNAemia (CMV group) and were compared to patients without CMV-DNAemia (controls, n = 139). The remaining patients (n = 22) were excluded due to incomplete data. RESULTS: Positive donors and negative recipients (D+/R-) and negative donors and positive recipients (D-/R+) serology was significantly increased and D-/R- decreased in the CMV group (p < .01). Furthermore, the mean age was 57.7 ± 8.7 years but only 53.6 ± 10.0 years for controls (p = .03). Additionally, the intensive care unit (p = .02) and total hospital stay (p = .03) after HTx were approximately 50% longer. Interestingly, the incidence of CMV-DNAemia during prophylaxis was only numerically increased in the CMV group (5.7%, respectively, 0.7%, p = .10), the same effect was also observed for postoperative infections. Multivariate analyses confirmed that D+/R- and D-/R+ CMV immunoglobulin G match were independent risk factors for postprophylaxis CMV-DNAemia. CONCLUSION: Our data should raise awareness of CMV-DNAemia after the termination of regular prophylaxis, as this affects one in five HTx patients. Especially old recipients as well as D+/R- and D-/R+ serology share an elevated risk of late CMV-DNAemia. For these patients, prolongation, or repetition of CMV prophylaxis, including antiviral drugs and CMV immunoglobulins, may be considered.

Changes in Therapy and Outcome of Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation (vv-ECMO) is related with poor outcome, especially in Germany. We aimed to analyze whether changes in vv-ECMO therapy during the pandemic were observed and lead to changes in the outcome of vv-ECMO patients. METHODS: All patients undergoing vv-ECMO support for COVID-19 between 2020 and 2021 in a single center (n = 75) were retrospectively analyzed. Weaning from vv-ECMO and in-hospital mortality were defined as primary and peri-interventional adverse events as secondary endpoints of the study. RESULTS: During the study period, four infective waves were observed in Germany. Patients were assigned correspondingly to four study groups: ECMO implantation between March 2020 and September 2020: first wave (n = 11); October 2020 to February 2021: second wave (n = 23); March 2021 to July 2021: third wave (n = 25); and August 2021 to December 2021: fourth wave (n = 20). Preferred cannulation technique changed within the second wave from femoro-femoral to femoro-jugular access (p < 0.01) and awake ECMO was implemented. Mean ECMO run time increased by more than 300% from 10.9 ± 9.6 (first wave) to 44.9 ± 47.0 days (fourth wave). Weaning of patients was achieved in less than 20% in the first wave but increased to approximately 40% since the second one. Furthermore, we observed a continuous numerically decrease of in-hospital mortality from 81.8 to 57.9% (p = 0.61). CONCLUSION: Preference for femoro-jugular cannulation and awake ECMO combined with preexisting expertise and patient selection are considered to be associated with increased duration of ECMO support and numerically improved ECMO weaning and in-hospital mortality.

Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation.

OBJECTIVES: Perioperative mortality and complications still remain high after left ventricular assist device (LVAD) implantation, especially in highly compromised patient cohorts. Here, we evaluate the effects of preoperative Levosimendan therapy on peri- and postoperative outcomes after LVAD implantation. METHODS: We retrospectively analysed 224 consecutive patients with LVAD implantation for end-stage heart failure between November 2010 and December 2019 in our centre with regard to short- and longer-term mortality as well as incidence of postoperative right ventricular failure (RV-F). Out of these, 117 (52.2%) received preoperative i.v. Levosimendan therapy within 7 days before LVAD implantation (Levo group). RESULTS: In-hospital, 30-day and 5-year mortality was comparable (in-hospital mortality: 18.8% vs 23.4%, P = 0.40; 30-day mortality: 12.0% vs 14.0%, P = 0.65; Levo vs control group). However, in the multivariate analysis, preoperative Levosimendan therapy significantly reduced postoperative RV-F but increased postoperative vasoactive inotropic score ([RV-F: odds ratio 2.153, confidence interval 1.146-4.047, P = 0.017; vasoactive inotropic score 24 h post-surgery: odds ratio 1.023, confidence interval 1.008-1.038, P = 0.002). These results were further confirmed by 1:1 propensity score matching of 74 patients in each group. Especially in the subgroup of patients with normal preoperative RV function, the prevalence of postoperative RV-F was significantly lower in the Levo- group as compared to the control group (17.6% vs 31.1%, P = 0.03; respectively). CONCLUSIONS: Preoperative Levosimendan therapy reduces the risk of postoperative RV-F, especially in patients with normal preoperative RV function without effects on mortality up to 5 years after LVAD implantation.

Preoperative atrial fibrillation predicts worse outcomes after LVAD implantation.

Introduction: Left ventricular assist device (LVAD) implantation is a common therapy for end-stage heart failure. Heart failure patients often present with atrial fibrillation (AF). The purpose of this study was to evaluate the influence of preoperative AF as well as vascular complications on outcome in LVAD patients. Methods: Between 01/2010 and 12/2017, 168 patients (141 male) with end-stage heart failure underwent LVAD implantation at a single center. Patient outcome was retrospectively studied by using the Kaplan-Meier method for analyzing crude survival as well as Cox regression for analyzing risk factors. Results: Sixty-two patients suffered from preoperative atrial fibrillation at LVAD implantation. Mean age was 56.8±11.9 years (range: 22-79) and 141 (84%) were male. Postoperative vascular or visceral surgical management due to malperfusion was needed in 27 patients (16.1%) and did not correlate with postoperative mortality (P=0.121, HR=1.587, CI=0.885-2.845). Patients with preoperative AF had a worse outcome in the Kaplan-Meier analysis (P=0.069). In contrast, cox regression showed that postoperative AF could not to be considered to be an independent predictor of mortality in this study group. Conclusion: Our data suggest that preoperative AF may be a potential predictor of mortality and impaired long-term outcome in LVAD patients. In contrast, preoperative ECLS and vascular or visceral surgery after LVAD implantation did not represent limiting factors with regard to mortality after LVAD implantation.

Impact of psoas muscle evaluation on clinical outcomes in patients undergoing left ventricular assist device implantation.

AIMS: The measurement of muscle mass reflects the physical components of frailty, which might affect postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to investigate the relationship between preoperative skeletal muscle evaluation and clinical outcomes in patients undergoing LVAD implantation. METHODS: From January 2010 to December 2017, a total of 63 patients were enrolled in this single-centre study. A retrospective analysis of preoperative abdominal computed tomography (CT) for psoas muscle index (PSMI) and Hounsfield-Units of the Psoas Muscle (PSHU) at the level of the mid-L4 vertebra was performed. RESULTS: Sixty-three patients (male; n = 49, 78%), with a mean age of 58.0 ±â€Š11.8 years, were treated with LVAD due to dilated (32%) or ischemic cardiomyopathy (68%). Among them, 43 patients (68.3%) were categorized in the Interagency Registry for Mechanically Assisted Circulatory Support profile I. The survival rate was 73.0% at 30 days and 44.4% at 1 year. Receiver-operating characteristic (ROC) curve analyses revealed that PSMI was a significant numeric predictor of 1-year mortality (P = 0.04). In contrast, PSHU displayed a significant predictive potential for pericardial effusion (P = 0.03) and respiratory insufficiency (P = 0.01). In addition, comparative ROC curve analysis revealed no significant difference in the predictive potential of PSMI and PSHU. CONCLUSION: Preoperative PSMI might be a predictor of 1-year mortality in patients undergoing LVAD implantation. In contrast, the PSHU seemed to potentially assume postoperative adverse events in this study. Thus, the evaluation of the preoperative psoas muscle using CT appears to be promising.

[Venovenous extracorporeal membrane oxygenation for COVID-19]. / Venovenöse extrakorporale Membranoxygenierung bei COVID-19: Erkenntnisse eines Zentrums aus 96 konsekutiven Fällen.

Background: Since the beginning of the COVID-19 pandemic global health systems are confronted with a large number of unknown problems. Venovenous (vv) extracorporeal membrane oxygenation (ECMO) in cases of therapy refractive ARDS often represents a last resort treatment. To improve the health care it is necessary to identify possible influencing factors. Objective: This analysis presents the findings of an ECMO centre and aims to identify potential factors with an impact on vv-ECMO therapy in cases of COVID-19. Material and methods: Between 03/2020 and 01/2022 n = 96 patients were treated with vv-ECMO in cases of a COVID-19 infection in our center. A retrospective analysis of demographic and health-specific data took place. The patients with fatal treatment outcome (L-group, n = 62) were compared to the surviving patients (Ü-group, n = 34). Results: Overall n = 34 (35%) of the patients survived the hospital stay. The patients with a fatal treatment outcome had an average age of 56.7 ± 9.5 years compared to the average age of the surviving patients of 47.9 ± 12.9 years. There were n = 72 (75%) males and n = 24 (25%) females among the treated patients, n = 51 (82.3%) of the deceased patients were male and n = 11 (17.7%) were female. The prevalence of pre-existing illnesses like COPD, diabetes mellitus, cardiovascular diseases and chronic renal insufficiency had shown no significant difference between both groups. Also, in relation to the presence of arterial hypertension and obesity we could not prove a negative influence on the treatment outcome. A nicotine abuse in the patient history showed a negative tendency. The most common reasons for the death of patients were respiratory failure, neurological injury, multiorgan failure and sepsis. Conclusion: The use of vv-ECMO in cases of therapy resistant ARDS in COVID-19 still correlates with a high mortality and as such should only be considered as a last resort of intensive care treatment.According to our expectations we could notice better therapy results for younger patients as well as for women in our patient database. In addition, for most comorbidities we could not prove any negative influence on the therapy outcome. This knowledge could help to identify future high-risk patients.

IgM-enriched immunoglobulin as adjuvant therapy for heart transplant after infection of left ventricular assist devices.

Patients undergoing heart transplantation (HTx) with active infection of left ventricular assist devices (LVAD) are at high risk for postoperative infections. Between 2021 and 2022, five (P1-P5) of a total of n = 44 patients underwent HTx in our department while suffering from LVAD infection. Postoperatively, patients received adjuvant IgM-enriched human intravenous immunoglobulin (IGM-IVIG), consisting of 76% IgG, 12% IgM, and 12% IgA as a novel approach to prevent infective complications. While in P1, P2, and P4, LVAD driveline infection was known before HTx; in P3 and P5, abscess of device pocket was found incidentally during HTx. After a single dose of IGM-IVIG, all patients showed adequate rise in serum immunoglobulins. In the postoperative course, no patient developed infective complications. All patients were successfully discharged and in good condition at the last follow-up. Therefore, IGM-IVIG seems to be an effective adjuvant treatment for patients undergoing HTx with LVAD infections.

[ECMO cannulation for COVID-19]. / ECMO-Kanülierung bei COVID-19: Venovenöse extrakorporale Membranoxygenierung bei COVID-19: Einfluss der Kanülierungsstrategie auf das Therapieergebnis.

Background: The novel coronavirus disease 2019 (COVID-19) can cause a severe and therapy-refractory acute respiratory distress syndrome. Temporary mechanical assistance by veno-venous extracorporeal membrane oxygenation (v.v.-EMCO) is a well-established supportive therapy, but is still associated with a high mortality. Objective: This work aimed to identify potential effects of the ECMO cannulation strategy on the outcome in COVID-19 patients. Material and methods: All patients who were treated in a single center between March 2020 and November 2021 for COVID-19-related ARDS (n = 75) were prospectively entered into an institutional database. The patients were assigned into two groups with respect to the ECMO cannulation (femorofemoral: n = 20, femorojugular: n = 55) and the outcome was retrospectively analyzed. Results: We observed severe therapy-related adverse events in both groups in more than 70% of patients with sepsis being the most common (> 50% each). The outcome (successful ECMO weaning, in-hospital death, 6­month survival) was comparable in both groups. In-hospital mortality was about 70% each; however, the duration of event-free ECMO support seemed to be prolonged in the femorojugular group. Conclusion: Regardless of the support duration, v.v.-ECMO therapy for COVID-19 is associated with high mortality rates. The cannulation strategy did not impact on the outcome; however, femorojugular cannulation might prolong the event-free support duration and facilitate the mobilization of the patients during ECMO support.

Removal of Electrophysiological Devices in the Context of Heart Transplantation: Comparison of Combined and Staged Extraction Procedures.

BACKGROUND: During heart transplantation (HTx), tip of the leads of cardiac implantable electrophysiological devices (CIEPD) has to be cut when resecting the heart. Timing of the removal of the remaining device and leads is still discussed controversially. METHODS: Between 2010 and 2021, n = 201 patients underwent HTx, of those n = 124 (61.7%) carried a present CIEPD. These patients were divided on the basis of the time of complete device removal (combined procedure with HTx, n = 40 or staged procedure, n = 84). RESULTS: CIEPD was removed 11.4 ± 6.7 days after the initial HTx in staged patients. Dwelling time, number of leads as well as incidence of retained components (combined: 8.1%, staged: 7.7%, p = 1.00) were comparable between both groups. While postoperative incidence of infections (p = 0.52), neurological events (p = 0.47), and acute kidney injury (p = 0.44) did not differ, staged patients suffered more often from primary graft dysfunction with temporary mechanical assistance (combined: 20.0%, staged: 40.5%, p = 0.03). Consecutively, stay on intensive care unit (p = 0.02) was prolonged and transfusions of red blood cells (p = 0.15) and plasma (p = 0.06) as well as re-thoracotomy for thoracic bleeding complications (p = 0.10) were numerically increased in this group. However, we did not observe any differences in postoperative survival. CONCLUSION: Presence of CIEPD is common in HTx patients. However, the extraction strategy of CIEPD most likely did not affect postoperative morbidity and mortality except primary graft dysfunction. Especially, retained components, blood transfusions, and infective complications are not correlated to the timing of CIEPD removal.

Effect of preoperative erector spinae muscles mass on postoperative outcomes in patients with left ventricular assist devices.

BACKGROUND: Frailty influences the postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. Recently, erector spinae muscle (ESM) mass has been proposed as a parameter to assess frailty accurately. Thus, the purpose of the present study was to evaluate whether preoperative ESM mass is associated with short- and long-term clinical outcomes in patients with LVAD. METHODS: A total of 119 consecutive patients with LVAD were enrolled between January 2010 and October 2017 at a single heart center. The ESM area, ESM index, and Hounsfield units (HU) of the ESM were calculated by computed tomography for preoperative ESM mass evaluation. We then statistically evaluated the in-hospital mortality, major adverse cardiovascular events (MACE), duration of hospital stay, and long-term survival. RESULTS: In a multivariate Cox regression analysis, ESM mass indicated no effect on all clinical outcomes. In addition, the ESM area presented a weak but significant negative linear correlation only with the duration of hospital stay (r = -0.21, p < .05). In contrast, the Model For End-stage Liver Disease (MELD) score and preoperative venous-arterial extracorporeal membrane oxygenation (va-ECMO) were significant predictive factors for in-hospital mortality (MELD score: p < .001, hazard ratio [HR] 1.1; preoperative va-ECMO: p < .01, HR 2.72) and MACE (MELD score: p < .001, HR 1.07; preoperative va-ECMO: p < .005, HR 2.62). CONCLUSION: Preoperative ESM mass might predict the length of hospital stay in patients undergoing LVAD implantation. In contrast, it had no effect on MACE, in-hospital mortality, or long-term survival in this study.

Impact of pretransplant left ventricular assist device support duration on outcome after heart transplantation.

OBJECTIVES: Heart transplantation after left ventricular assist device (LVAD) implantation remains challenging. It is still unclear whether its support duration impacts the outcome after transplantation. METHODS: All patients undergoing heart transplantation between 2010 and 2021 at a single department after previous left ventricular assistance were retrospectively reviewed and divided into 4 different study groups with regard to the duration of LVAD support to examine the impact on the postoperative morbidity and mortality. RESULTS: A total of n = 198 patients were included and assigned to the 4 study groups (group 1: <90 days, n = 14; group 2: 90 days to 1 year, n = 31; group 3: 1-2 years, n = 29; group 4: >2 years, n = 24). Although there were no differences between the 4 groups concerning relevant mismatch between the recipients and donors, the incidence of primary graft dysfunction was numerically increased in patients with the shortest support duration, and also those patients with >1 year of support (group 1: 35.7%, group 2: 25.8%, group 3: 41.4%, group 4: 37.5%, P = 0.63). The incidence of acute graft rejection was by trend increased in patients of group 1 (group 1: 28.6%, group 2: 3.3%, group 3: 7.1%, group 4: 12.5%, P = 0.06). Duration of LVAD support did not impact on perioperative adverse events (infections, P = 0.79; acute kidney injury, P = 0.85; neurological events, P = 0.74; thoracic bleeding, P = 0.61), neither on postoperative survival (1-year survival: group 1: 78.6%, group 2: 66.7%, group 3: 80.0%, group 4: 72.7%, P = 0.74). CONCLUSION: We cannot identify a significant impact of the duration of pretransplant LVAD support on postoperative outcome; therefore, we cannot recommend a certain timeframe for transplantation of LVAD patients.

The quality of afterlife: surviving extracorporeal life support after therapy-refractory circulatory failure-a comprehensive follow-up analysis.

AIMS: Extracorporeal life support (ECLS) represents a popular treatment option for therapy-refractory circulatory failure and substantially increases survival. However, comprehensive follow-up (FU) data beyond short-term survival are mostly lacking. Here, we analyse functional recovery and quality of life of longer-term survivors. METHODS AND RESULTS: Between 2011 and 2016, a total of n = 246 consecutive patients were treated with ECLS for therapy-refractory circulatory failure in our centre. Out of those, 99 patients (40.2%) survived the first 30 days and were retrospectively analysed. Fifty-eight patients (23.6%) were still alive after a mean FU of 32.4 ± 16.8 months. All surviving patients were invited to a prospective, comprehensive clinical FU assessment, which was completed by 39 patients (67.2% of survivors). Despite high incidence of early functional impairments, FU assessment revealed a high degree of organ and functional recovery with more than 70% of patients presenting with New York Heart Association class ≤ II, 100% free of haemodialysis, 100% free of moderate or severe neurological disability, 71.8% free of moderate or severe depression, and 84.4% of patients reporting to be caring for themselves without need for assistance. CONCLUSIONS: Patients surviving the first 30 days of ECLS therapy for circulatory failure without severe adverse events have a quite favourable outcome in terms of subsequent survival as well as functional recovery, showing the potential of ECLS therapy for patients to recover. Patients can recover even after long periods of mechanically support and regain physical and mental health to participate in their former daily life and work.

Cytomegalovirus mismatch after heart transplantation: Impact of antiviral prophylaxis and intravenous hyperimmune globulin.

OBJECTIVE: Cytomegalovirus (CMV) infections are correlated with complications following heart transplantation (HTx) and impaired outcome. The impact of a serologic mismatch between donor and recipient and the necessity of prophylactic virostatic medication is still a matter of concern. METHODS: We retrospectively reviewed all patients that underwent HTx between 2010 and 2020 in our department. The recipients (n = 176) could be categorized into four risk groups depending on their serologic CMV matching (D+ /R- = donor CMV-IgG positive and recipient CMV-IgG negative, n = 32; D- /R+ , n = 51; D- /R- , n = 35; D+ /R+ , n = 58). All patients followed the same protocol of CMV prophylaxis with application of ganciclovir/valganciclovir and intravenous CMV hyperimmune globulin. RESULTS: Incidence of postoperative morbidity such as primary graft dysfunction, neurological events, infections, and graft rejection were comparable between all groups (p > .05). However, the incidence of postoperative acute kidney injury with hemodialysis was by trend increased in the D- /R+ group (72.0%) compared to the other groups. In-hospital CMV-DNAemia was observed in serologic positive recipients only (D+ /R- : 0.0%, D- /R+ : 25.0%, D- /R- : 0.0%, D+ /R+ : 13.3%, p < .01). During the first year, a total of 18 patients developed CMV-DNAemia (D+ /R- : 31.6%, D- /R+ : 31.9%, D- /R- : 3.4%, D+ /R+ : 11.1%, p = .03). CONCLUSIONS: Seropositive recipients carry an important risk for CMV-DNAemia. However, we did not observe differences in perioperative morbidity and mortality regarding CMV matching, which might be related to regularly administer prophylactic virostatics and additional CMV-IVIG for risk constellations. For high-risk constellation, long-term application of CMV-IVIG during the first year after transplant may be beneficial.

Treatment of Postoperative New Onset Atrial Fibrillation with Repolarization Delaying Agents after Heart Surgery.

PURPOSE: The aim of this study was to evaluate the efficacy of the multichannel-blocker dronedarone for postoperative new onset atrial fibrillation (POAF) as compared to amiodarone. METHODS: Out of 990 patients who underwent cardiothoracic surgery between March 2011 and March 2012, 166 patients who developed POAF and treated with amiodarone or dronedarone were enrolled in this study. RESULTS: Eighty-nine patients were treated with amiodarone and 77 patients were treated with dronedarone at discharge. Seventy-five percent of patients with dronedarone were treated initially with intravenous amiodarone but quickly converted to oral dronedarone as soon as the mechanical ventilation was weaned off. The rate of conversion in sinus rhythm was not influenced by the resulting amiodarone-to-dronedarone crossover as compared to oral dronedarone only (p <0.247 at the ICU and p <0.640 at the normal care unit). At hospital discharge sinus rhythm was documented in 44% of the amiodarone patients and 99% of the dronedarone patients (p <0.001). The maintenance of sinus rhythm was demonstrated in 82% of the amiodarone patients versus 81% of the dronedarone patients at 6-month follow-up (p <0.804). CONCLUSIONS: Our data demonstrated the higher conversion rate to sinus rhythm in the early phase in the dronedarone group despite a comparable conversion rate in the mid-term phase compared to amiodarone.

Impact of increasing levels of adaptive statistical iterative reconstruction on image quality in oil-based postmortem CT angiography in coronary arteries.

INTRODUCTION: Postmortem multi-detector computed tomography (PMCT) has become an important part in forensic imaging. Modern reconstruction techniques such as iterative reconstruction (IR) are frequently used in postmortem CT angiography (PMCTA). The image quality of PMCTA depends on the strength of IR. For this purpose, we aimed to investigate the impact of different advanced IR levels on the objective and subjective PMCTA image quality. MATERIAL AND METHODS: We retrospectively analyzed the coronary arteries of 27 human cadavers undergoing whole-body postmortem CT angiography between July 2017 and March 2018 in a single center. Iterative reconstructions of the coronary arteries were processed in five different level settings (0%; 30%; 50%; 70%; 100%) by using an adaptive statistical IR method. We evaluated the objective (contrast-to-noise ratio (CNR)) and subjective image quality in several anatomical locations. RESULTS: Our results demonstrate that the increasing levels of an IR technique have relevant impact on the image quality in PMCTA scans in forensic postmortem examinations. Higher levels of IR have led to a significant reduction of image noise and therefore to a significant improvement of objective image quality (+ 70%). However, subjective image quality is inferior at higher levels of IR due to plasticized image appearance. CONCLUSION: Objective image quality in PMCTA progressively improves with increasing level of IR with the best CNR at the highest IR level. However, subjective image quality is best at low to medium levels of IR. To obtain a "classic" image appearance with optimal image quality, PMCTAs should be reconstructed at medium levels of IR.

Effects of Donor Age and Ischemia Time on Outcome After Heart Transplant: A 10-Year Single-Center Experience.

OBJECTIVES: In heart failure patients, heart transplant still remains the gold standard of care. Controversy prevails whether organs from older donors or with expected prolonged ischemia times may be accepted for transplant. MATERIALS AND METHODS: Between 2010 and 2020, a total of 149 patients underwent heart transplant at our department. In a retrospective analysis, 4 different groups were defined according to donor age and total ischemia time. The younger group with short ischemia time consisted of 62 donors age < 50 years and total ischemia time < 240 minutes; the younger group with long ischemia time consisted of 32 donors age < 50 years and total ischemia time ≥ 240 minutes; the older group with short ischemia time consisted of 43 donors age ≥ 50 years and total ischemia time < 240 minutes; and the older group with long ischemia time consisted of 12 donors age ≥ 50 years and total ischemia time ≥ 240 minutes. RESULTS: Prolonged total ischemia time increased the risk of primary graft dysfunction (P = .02) and perioperative neurological events (P = .04). In contrast, there were no differences regarding durations of intensive care unit stay and hospital stay, perioperative bleeding, and renal failure. Although the younger donor age group showed excellent short-term survival (30-day survival rates of 97% for the younger group with short ischemia time and 91% for the younger group with long ischemia time), short-term and mid-term survival rates were impaired in patients with prolonged total ischemia time and older donor age (P = .02). CONCLUSIONS: Our results indicate that, in younger donors, prolonged ischemia times may be acceptable. However, in donors older than 50 years, the decision for acceptance as a donor should be made with great caution if the presumed ischemia time exceeds 4 hours.

Extracorporeal Membrane Oxygenation after Heart Transplantation: Impact of Type of Cannulation.

BACKGROUND: Primary graft dysfunction (PGD) is a common cause of early death after heart transplantation (htx). The use of extracorporeal life support (ECLS) after htx has increased during the last years. It is still discussed controversially whether peripheral cannulation is favorable compared to central cannulation. We aimed to compare both cannulation techniques. METHODS: Ninety patients underwent htx in our department between 2010 and 2017. Twenty-five patients were treated with ECLS due to PGD (10 central extracorporeal membrane oxygenator [cECMO] and 15 peripheral extracorporeal membrane oxygenator [pECMO] cannulation). Pre- and intraoperative parameters were comparable between both groups. RESULTS: Thirty-day mortality was comparable between the ECLS-groups (cECMO: 30%; pECMO: 40%, p = 0.691). Survival at 1 year (n = 18) was 40 and 30.8% for cECMO and pECMO, respectively. The incidence of postoperative renal failure, stroke, limb ischemia, and infection was comparable between both groups. We also did not find significant differences in duration of mechanical ventilation, intensive care unit stay, or in-hospital stay. The incidence of bleeding complications was also similar (cECMO: 60%; pECMO: 67%). Potential differences in support duration in pECMO group (10.4 ± 9.3 vs. 5.7 ± 4.7 days, p = 0.110) did not reach statistical significance. CONCLUSIONS: In patients supported for PGD, peripheral and central cannulation strategies are safe and feasible for prolonged venoarterial ECMO support. There was no increase in bleeding after central implantation. With regard to the potential complications of a pECMO, we think that aortic cannulation with tunneling of the cannula and closure of the chest could be a good option in patients with PGD after htx.

Successful Heart Transplantation after Cardiopulmonary Resuscitation of Donors.

BACKGROUND: Heart transplantation (HTx) is the best therapy for end-stage heart failure. Unfortunately, death on the waiting list remains a problem. Decreasing the number of rejected organs could increase the donor pool. METHODS: A total of 144 patients underwent HTx at our department between 2010 and 2019. Of them, 27 patients received organs of donors with cardiopulmonary resuscitation (CPR) prior to organ donation (donor CPR) and were compared with patients who received organs without CPR (control; n = 117). RESULTS: We did not observe any disadvantage in the outcome of the donor CPR group compared with the control group. Postoperative morbidity and 1-year survival (control: 72%; donor CPR: 82%; p = 0.35) did not show any differences. We found no impact of the CPR time as well as the duration between CPR and organ donation, but we found an improved survival rate for donors suffering from anoxic brain injury compared with cerebral injury (p = 0.04). CONCLUSIONS: Donor organs should not be rejected for HTx due to resuscitation prior to donation. The need for CPR does not affect the graft function after HTx in both short- and mid-term outcomes. We encourage the use of these organs to increase the donor pool and preserve good results.