Pig-to-human heart xenotransplantation in two recently deceased human recipients.

Genetically modified xenografts are one of the most promising solutions to the discrepancy between the numbers of available human organs for transplantation and potential recipients. To date, a porcine heart has been implanted into only one human recipient. Here, using 10-gene-edited pigs, we transplanted porcine hearts into two brain-dead human recipients and monitored xenograft function, hemodynamics and systemic responses over the course of 66 hours. Although both xenografts demonstrated excellent cardiac function immediately after transplantation and continued to function for the duration of the study, cardiac function declined postoperatively in one case, attributed to a size mismatch between the donor pig and the recipient. For both hearts, we confirmed transgene expression and found no evidence of cellular or antibody-mediated rejection, as assessed using histology, flow cytometry and a cytotoxic crossmatch assay. Moreover, we found no evidence of zoonotic transmission from the donor pigs to the human recipients. While substantial additional work will be needed to advance this technology to human trials, these results indicate that pig-to-human heart xenotransplantation can be performed successfully without hyperacute rejection or zoonosis.

Hemodynamic effects of COVID-19 vaccination in hospitalized patients awaiting heart transplantation.

Background: The hemodynamic effects of pre-transplant vaccination against COVID-19 among heart transplant candidates hospitalized for advanced heart failure remains unknown. Methods: A retrospective chart review was conducted at a high-volume transplant center from January through December 2021. 22 COVID-19 vaccination events occurred among patients hospitalized for decompensated heart failure while awaiting transplantation. Primary outcomes included inotrope and vasopressor dosages. Secondary outcomes included vital signs, pulmonary artery catheter measurements, diuretic dosages, and renal function. Data were extracted 24 h before through 72 h after vaccination. Results: One of 22 vaccination events was associated with hemodynamic changes requiring increased inotropic and vasopressor support post-vaccination. In all other cases, transient hemodynamic changes occurred without need for escalated therapy. Conclusions: COVID-19 vaccination can be administered safely to most critically ill patients with advanced heart failure including those awaiting transplantation. All patients should be monitored closely as some may be susceptible to significant hemodynamic changes.

Sodium-Glucose Cotransporter-2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Orthotopic Heart Transplant in a Prediabetic Patient: A Case Report.

Postoperative euglycemic diabetic ketoacidosis (euDKA) associated with sodium-glucose cotransporter-2 (SGLT2) inhibitor use has been well-documented and carries a Food and Drug Administration recommendation to hold SGLT2 inhibitors 3 to 4 days before a planned surgical procedure. Unfortunately, many surgical procedures, such as orthotopic heart transplant (OHT), are unplanned and unpredictable. With the increasing use of SGLT2 inhibitors in diabetic and non-diabetic heart failure patients, new challenges in patient management and perioperative risk have arisen. We report a case in which SGLT2 inhibitor-associated euDKA complicated the postoperative course of a prediabetic patient who had undergone OHT.

Efficacy of Manual Hemostasis for Percutaneous Axillary Artery Intra-Aortic Balloon Pump Removal.

BACKGROUND: The prevalence of peripheral vascular disease has led to the re-emergence of percutaneous axillary vascular access as a suitable alternative access site to femoral artery. We sought to investigate the efficacy and safety of manual hemostasis in the axillary artery. METHODS: Data were collected from a prospective internal registry of patients who had a Maquet® (Rastatt, Germany) Mega 50 cc intra-aortic balloon pumps (IABP) placed in the axillary artery position. They were anticoagulated with weight-based intravenous heparin to maintain an activated partial thromboplastin time (aPTT) of 50-80 seconds. Anticoagulation was discontinued 2 hours prior to the device explantation. Manual compression was used to achieve the hemostasis of the axillary artery. Vascular and bleeding complications attributable to manual hemostasis were classified based on the Valve Academic Research Consortium-2 (VARC-2) and Bleeding Academic Research Consortium-2 (BARC-2) classifications, respectively. RESULTS: 29 of 46 patients (63%) achieved axillary artery homeostasis via manual compression. The median duration of IABP implantation was 12 days (range 1-54 days). Median compression time was 20 minutes (range 5-60 minutes). There were no major vascular or bleeding complications as defined by the VARC-2 and BARC-2 criteria, respectively. CONCLUSION: Manual compression of the axillary artery appears to be an effective and safe method for achieving hemostasis. Large prospective randomized control trials may be needed to corroborate these findings.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child.

A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.

Emergent TandemHeart-ECMO for acute severe mitral regurgitation with cardiogenic shock and hypoxaemia: a case series.

BACKGROUND: Acute severe mitral regurgitation (MR) associated with cardiogenic shock is a life-threatening emergency. Traditional teaching has focused on the need for emergent coronary angiography and/or intra-aortic balloon counterpulsation in preparation for emergent open-heart surgery for repair/replacement. Unfortunately, emergent open-heart surgery in patients with acute MR complicated by cardiogenic shock is associated with 25-46% perioperative mortality. New devices have provided additional options for stabilization prior to emergent surgery which facilitate improved outcomes. CASE SUMMARY: We present two cases of acute severe MR resulting in cardiogenic shock and profound hypoxaemia. TandemHeart® mechanical circulatory support with an oxygenator spliced into the circuit, akin to veno-arterial extracorporeal membrane oxygenation (ECMO), facilitated haemodynamic stabilization and decongestion of the lungs facilitating successful bridge to mitral valve surgery. Successful discharge to home was achieved in both patients with good neurological outcomes and sustained long-term functional recovery at 18 and 14 months, respectively. DISCUSSION: Selective use of the TandemHeart®, with or without ECMO, facilitates management of the critically ill cardiogenic shock patient with acute severe MR.

Differential responses to larger volume intra-aortic balloon counterpulsation: Hemodynamic and clinical outcomes.

OBJECTIVES: Examine hemodynamic and clinical correlates of use of an intra-aortic balloon pump catheter in a single center. BACKGROUND: The intra-aortic balloon pump catheter (IABC) has been used for 50 years but the clinical benefit is still debated. We reviewed 76 patients with right heart catheter measurements prior to IABC to assess response and outcomes. METHODS: All patients who received IABC with a 50cc balloon for at least 1 hour were included in this retrospective chart review study. Demographics, comorbidities, lab values, and hemodynamic parameters were recorded at baseline and 15 h postinsertion. RESULTS: Seventy-six patients had paired measurements of cardiac output. 60 patients had a higher cardiac output with IABC treatment (responder group) and 16 did not (nonresponders). In the 60 patients in the responder group, cardiac output and index significantly increased from baseline 3.6 ± 1.3 L/min to 5.2 ± 1.8 L/min, and 1.8 ± 0.5 L/min/m2 to 2.6 ± 0.8 L/min/m2 respectively following IABC placement (P < 0.0001 for both comparisons). Various hemodynamic variables were examined and the best predictor of response to IABC was a cardiac power index of 0.3 or less. Regardless of response, in hospital survival was similar between groups. CONCLUSIONS: The majority of patients improve their cardiac output with IABC but survival was unchanged. Further work into the pathophysiology of cardiogenic shock is needed.

A single center tertiary care experience utilizing the large volume mega 50cc intra-aortic balloon counterpulsation in contemporary clinical practice.

OBJECTIVE: Clinical outcomes and adverse events utilizing the large volume 50cc intra-aortic balloon (IAB) in contemporary clinical practice. BACKGROUND: The newer large volume 50cc IAB, recently introduced into clinical practice offers improved diastolic augmentation and better left ventricular (LV) unloading compared to the older 40cc IAB. METHODS: In 150 consecutive patients who received intra-aortic balloon counterpulsation (IABC) with a 50cc balloon from 2011 to 2015, we retrospectively analyzed demographic, clinical, laboratory, and hemodynamic variables, adverse events and survival to discharge from index hospitalization. RESULTS: Median LVEF was 20%. The most common indication was cardiogenic shock (CS) in 100 patients. Median duration of IABC was 92.5 hr. 95% of patients were free of any IAB device related complications. Five patients received a transfusion for bleeding causally related to IABC. 70 of the 150 patients who received MCS with IABC with no escalation of therapy, recovered and were discharged alive. Fifteen patients were stabilized on IABC and bridged to orthotopic heart transplant. All 15 were discharged alive. Thirty-four patients were initiated on IABC and escalated to VAD and/or Impella/Tandem Heart, with 24 patients surviving to hospital discharge. Overall survival to hospital discharge for the 150 patients was 72.7%. CONCLUSION: IABC using a larger volume 50cc balloon appears effective as a first line percutaneous MCS strategy in a large fraction of critically ill cardiac patients with few adverse events. A large scale registry or randomized clinical trial utilizing the larger volume IAB is needed to validate our results. © 2017 Wiley Periodicals, Inc.

Utility of carotid duplex ultrasonography in a general inner-city hospital.

BACKGROUND: Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis. However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), before heart surgery, syncope and non-specific neurological symptoms although its value is unclear. Our study aimed to further investigate the yield of CDUS in these conditions. METHODS: A retrospective analysis was conducted on 827 consecutive carotid ultrasounds ordered between March 2013 and August 2013 at Newark Beth Israel Medical Center. Clinical characteristics such as age, sex, smoking status, systemic hypertension, diabetes mellitus, CAD, PAD, carotid bruit and indications for carotid ultrasound were included. Significant cerebrovascular disease (sCBVD) was defined as greater than or equal to 50% diameter reduction in internal carotid arteries (ICA) or any degree of occlusion in vertebrobasilar system. RESULTS: Only 88 out of 827 (10.6%) patients had sCBVD. Using logistic regression analysis we identified age greater than 65 years (OR 2.1, 95% CI 1.2 to 3.7; P=0.006), carotid bruit (OR 7.8, 95% CI 3.6 to 16.6; P <0.001) and history of prior carotid endarterectomy or carotid artery stenting (OR 5.8, 95% CI 2.3 to 14.8; P <0.001) as significant predictors of sCBVD. CONCLUSIONS: Significant carotid artery stenosis is more likely in patients 65 years and older, presence of carotid bruit and prior CEA. On the other hand, it has low diagnostic yield in less than 65-year-old individuals, syncope and non-focal neurological symptoms. This highlights the need for better risk prediction models in order to promote optimal utilization.