Isolated annuloplasty in elderly patients with secondary mitral valve regurgitation: short- and long-term outcomes with a less invasive approach.

Background: Long-term outcomes of elderly and frail patients with secondary mitral valve regurgitation (MR) are inconclusive. Especially in patients with co-morbidities such as atherosclerosis who are suffering from heart failure, optimal medical therapy (OMT) is the preferred therapy relative to surgical or percutaneous interventions. It remains challenging to identify the most successful therapy to improve symptoms and increase life expectancy. To reduce surgical trauma for these patients, minimally invasive mitral valve surgery (MIMVS) was developed; this has shown promising medium-term results, but there is still a lack of evidence regarding long-term results. The aim of this investigation was to describe the long-term outcomes of less invasive mitral valve surgery (MVS) in elderly patients. Methods: In this longitudinal retrospective analysis, 67 patients (aged ≥70 years) with secondary MR who underwent MV repair ± tricuspid valve repair (TVR) were identified. MVS was performed via minithoracotomy (MT) in most cases (n = 54); in patients with contraindications for MIMVS, partial upper sternotomy (PS) was the preferred route for surgical access (n = 13). The appropriate access route was chosen according to the patient's clinical condition and comorbidities. We analyzed reoperation-free long-term survival, combined operative success (lack of residual MR, conversion to MV replacement, or larger thoracic incisions), and perioperative safety (at 30 days: mortality, re-thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation, stroke, myocardial infarction). In a subgroup analysis, we compared long-term survival in MVS patients with and without TVR. Results: The median age of patients (62.7% female) was 74 years (interquartile range: 72-76 years), with a median EuroSCORE2 of 2.8% (1.5%-4.6%) and N-terminal pro-brain natriuretic peptide plasma levels of 1,434 ng/L (1035-2149 ng/L). The median follow-up period was 5.6 years (2.7-8.5 years). The reoperation-free long-term survival rate up to 10 years was 66.2%. Combined operative success and perioperative safety were achieved in 94% and 76% of patients, respectively. Additional TVR was performed in 56.7% of patients, without any significant difference in survival rates compared to the group without TVR (p = 0.417; HR 1.473, 95% CI 0.578-3.757). Conclusion: Less invasive MV repair for secondary MR shows excellent operative success and safety in selected patients. Freedom from significant MR and from the need for reoperation indicates long-lasting efficacy. These results should be considered in heart team discussions regarding allocation of patients to surgical mitral procedures.

Interstitial Pulmonary Fibrosis and Extensive Dendriform Ossification with Persistent Viral Load: A Rare Presentation of Post-COVID-19 Condition in Need of Lung Transplantation.

The incidence, presentation, and predisposing factors of post-acute sequelae of COVID-19 (PASC) are currently poorly understood. Lung explants may provide a rare insight into terminal SARS-CoV-2-associated lung damage and its pathophysiology. A 62-year-old man presented with progressively worsening respiratory symptoms after recovering from mild COVID-19 3 months earlier. No underlying pulmonary comorbidities were reported. A chest CT revealed bilateral extensive ground-glass and reticular opacities, suspicious of pulmonary fibrosis. Despite initial high-dose glucocorticoid therapy, the interstitial lung disease progressed, and after exhausting all viable therapeutic options, bilateral lung transplantation was successfully conducted. Histological analysis revealed extensive end-stage interstitial fibrosis with diffuse dendriform ossification and bronchiolar and transitional cell metaplasia. Signs of interstitial remodeling such as an increased interstitial collagen deposition, a pathological accumulation of CD163+/CD206+ M2-polarized macrophages with an increased expression of phosphorylated ERK, and an increased density of CD105+ newly formed capillaries were observed. qRT-PCR and immunohistochemistry for SARS-CoV-2 N-protein in the endothelium of medium-sized vessels confirmed a persistence of SARS-CoV-2. Our findings highlight a highly unusual presentation of SARS-CoV-2-associated lung fibrosis, implying that incomplete viral clearance in the vascular compartment may play a vital pathophysiological role in the development of PASC.

Upper Hemi-Sternotomy Provides Benefit for Patients with Isolated or Combined Mitral Valve Surgery.

Background and objectives: Certain clinical and anatomical conditions are absolute or relative contraindications for safe mitral valve surgery via the right mini-thoracotomy access. It is uncertain whether patients with these contraindications may benefit from the less invasive approach via upper hemi-sternotomy compared to standard full sternotomy. Materials and methods: Out of 2052 mitral valve surgery patients, operated from 6/04 through 2/19, 1535 were excluded due to the different criteria for eligibility to both approaches. Out of these, 350 received full sternotomy and 167 upper hemi-sternotomy. After propensity score matching, 164 pairs were analyzed for operative variables, postoperative complications and 30-day and one-year survival. Results: Upper hemi-sternotomy was associated with a survival benefit of 30 days (99.4% vs. 82.1%; p < 0.001) and one-year (93.9% vs. 79.9% p < 0.001, HR 0.26, 95% CI 0.14-0.49). Cardiopulmonary bypass and aortic cross-clamp times were comparable in both groups. Upper hemi-sternotomy resulted in less low cardiac output syndrome (18.9% vs. 31.1%; p = 0.011); ventilation time (8 vs. 13 h; p < 0.001), length of intensive care stay (1 vs. 2 days; p < 0.001) and total hospital stay (8 vs. 9 days; p < 0.001) were shorter in the upper hemi-sternotomy group. Conclusion: In patients undergoing mitral valve surgery, upper hemi-sternotomy is associated with short- and mid-term survival benefits as well as lower postoperative complication rates compared to full sternotomy. Hence, the less invasive upper hemi-sternotomy can be a valid approach in patients with contraindications for right mini-thoracotomy.

Predictors of safety and success in minimally invasive surgery for degenerative mitral disease.

OBJECTIVES: The aim of this study was to identify predictors of periprocedural success and safety in minimally invasive mitral valve surgery and to determine the impact of pathology localization and repair technique on reoperation-free survival. METHODS: We isolated 686 patients (mean age 60.5, standard deviation 12.3 years, 69.4% male) who underwent surgery for mitral valve prolapse between 2002 and 2020 in a single institution. Patients with concomitant disease, redo or mitral pathology other than degenerative mitral disease were excluded from the analysis. Periprocedural safety was defined as: freedom from perioperative death, myocardial infarction, stroke, use of extracorporeal membrane oxygenation or reoperation for bleeding. Operative success was defined as: successful primary mitral repair without conversion to replacement or to larger thoracic incisions, without residual mitral regurgitation > mild at discharge or reoperation within 30 days. Predictors for perioperative success and safety were identified using univariable and multivariable analyses. The impact of prolapse localization and repair technique on reoperation-free survival was assessed by Cox regression. RESULTS: The mitral repair rate and the need for concomitant tricuspid repair were 94.6% and 16.5%, respectively. Perioperative mortality occurred in 5 patients (0.7%). The criteria for perioperative safety and success were met in 646/686 (94.2%) and 648/686 (94.5%) patients, respectively. The absence of tricuspid disease requiring repair was the only independent predictor of safety in this cohort [hazard ratio (HR) 0.460 (0.225-0.941), P = 0.033]. The only independent predictor of operative success was the use of chordal replacement [0.27 (0.09-0.83), P = 0.022]. Reoperation-free survival was 98.5%, 94.5% and 86.9% at 1, 5 and 10 years, respectively. Posterior leaflet pathology demonstrated a higher reoperation-free survival as compared to other localizations (log-rank P = 0.002). The localization of leaflet pathology but not the repair method was an independent predictor for reoperation-free survival (HR 1.455, 95% confidence interval 1.098-1.930; P = 0.009). CONCLUSIONS: In minimally invasive mitral surgery for degenerative disease, chordal replacement yields higher rates of periprocedural success than leaflet resection. Posterior leaflet pathology is an independent predictor of reoperation-free survival.

Partial Upper Sternotomy is a Safe Alternative in Mitral Annulus Decalcification.

In patients with major annulus calcifications (MAC) requiring en-bloque decalcification anterolateral minithoracotomy is not suitable for safe and reproducible mitral valve surgery (MVS) procedures. In these cases, full sternotomy (FS) is still the preferred approach. Alternatively, less invasive MVS via partial upper sternotomy (PS) and transseptal access can be used in experienced centers. After reviewing the records of 1741 patients, who were treated with either isolated MVS or combined procedures, we identified 32 patients who had undergone en-bloque decalcification for MAC. The 2 techniques (PS-group n = 17, FS-cohort n = 15) were presented in terms of 1-year mortality as well as intra- and perioperative outcome. In the PS group, the age was 60.06 ± 7.56 patients, 64.7% were female and had a STS Predicted Risk of Mortality (PROM) score of 1.01 ± 1.06. In the FS group the patients (53.3% female) mean age was 58.47 ± 14.45 and had a STS PROM score 2.35 ± 2.73%. Rates of mitral repair were in the PS and FS cohort 64.7% and 46.7%, respectively. One-year mortality for PS-MVS was 5.9% (n = 1) and 20% (n = 3) for FS-MVS. The cardiopulmonary bypass (FS: 181.60 ± 49.99 minutes, PS: 192.83 ± 77.32 minutes and the cross-clamp times (FS: 119.67 ± 46.06, PS: 136.94 ± 54.37 minutes). The observed ventilation times in the PS and FS group were 5 hours (IQR 3.5-9) and 10 hours (IQR 5-15), respectively. A permanent pacemaker implantation was not necessary in any patient. In patients with MAC and en-bloque decalcification PS seems to be a safe access and might be a valid less invasive alternative to minithoracotomy.

Impact of donor lung quality on post-transplant recipient outcome in the Lung Allocation Score era in Eurotransplant - a historical prospective study.

The aim of this study was to investigate whether there is an impact of donation rates on the quality of lungs used for transplantation and whether donor lung quality affects post-transplant outcome in the current Lung Allocation Score era. All consecutive adult LTx performed in Eurotransplant (ET) between January 2012 and December 2016 were included (N = 3053). Donors used for LTx in countries with high donation rate were younger (42% vs. 33% ≤45 years, P < 0.0001), were less often smokers (35% vs. 46%, P < 0.0001), had more often clear chest X-rays (82% vs. 72%, P < 0.0001), had better donor oxygenation ratios (20% vs. 26% with PaO2 /FiO2  ≤ 300 mmHg, P < 0.0001), and had better lung donor score values (LDS; 28% vs. 17% with LDS = 6, P < 0.0001) compared with donors used for LTx in countries with low donation rate. Survival rates for the groups LDS = 6 and ≥7 at 5 years were 69.7% and 60.9% (P = 0.007). Lung donor quality significantly impacts on long-term patient survival. Countries with a low donation rate are more oriented to using donor lungs with a lesser quality compared to countries with a high donation rate. Instead of further stretching donor eligibility criteria, the full potential of the donor pool should be realized.

Mitral Valve Surgery via Partial Upper Sternotomy: Closing the Gap between Conventional Sternotomy and Right Lateral Minithoracotomy.

BACKGROUND: Minithoracotomy (MT) has gained broad acceptance for mitral valve surgery (MVS) in the last decade. In the presence of defined limitations of MT, however, full sternotomy (FS) is still widely preferred. We assume that the less investigated partial upper sternotomy (PS) will permit the gap between MT and FS in MVS to be closed. The purpose of this study is to investigate a valid less invasive alternative to MT for isolated MVS or multivalve surgery. METHODS: This retrospective analysis includes data on 1,639 patients, who underwent either isolated or combined primary MVS at our department from May 2011 to August 2017. Out of these, 663 patients were operated via MT access. One-hundred three patients had been judged as not suitable for MT but feasible for PS approach in which 53.4% (n = 55) had isolated MVS and 46.6% patients (n = 48) underwent multivalve surgery. Concomitant myocardial revascularization was performed in 2.9% of the study patients (n = 3). RESULTS: Operative, 90-day, and 1-year mortality in the PS-cohort was 0, 1.0% (n = 1), and 3.3% (n = 3), respectively. During a median follow-up time of 1,115 days (interquartile range 398-1806), all-cause mortality was 5.8% (n = 6). Operative times for cardiopulmonary-bypass and cross-clamping were 167 minutes (140-198) and 107 minutes (93-132), respectively. Median length of stay at the intensive care unit and hospital was 1 (1-2) and 7 days (7-10), respectively. CONCLUSION: The presented results demonstrate that there is a cohort of patients, who are not candidates for MT in MVS but may be operated successfully by an alternative less invasive approach.

Lung allocation score: the Eurotransplant model versus the revised US model - a cross-sectional study.

Both Eurotransplant (ET) and the US use the lung allocation score (LAS) to allocate donor lungs. In 2015, the US implemented a new algorithm for calculating the score while ET has fine-tuned the original model using business rules. A comparison of both models in a contemporary patient cohort was performed. The rank positions and the correlation between both scores were calculated for all patients on the active waiting list in ET. On February 6th 2017, 581 patients were actively listed on the lung transplant waiting list. The median LAS values were 32.56 and 32.70 in ET and the US, respectively. The overall correlation coefficient between both scores was 0.71. Forty-three per cent of the patients had a < 2 point change in their LAS. US LAS was more than two points lower for 41% and more than two points higher for 16% of the patients. Median ranks and the 90th percentiles for all diagnosis groups did not differ between both scores. Implementing the 2015 US LAS model would not significantly alter the current waiting list in ET.

Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs.

OBJECTIVES: To evaluate the nonclinical outcomes of a proactive palliative care program funded and operated by a health system for Medicare Advantage plan beneficiaries. DESIGN: Observational, retrospective study using propensity-based matching. SETTING: A health system in southern California. PARTICIPANTS: Individuals who received the intervention between 2007 and 2014 (n = 368) were matched with 1,075 comparison individuals within each of four disease groups: cancer, chronic obstructive pulmonary disease, heart failure, and dementia. All were known to be dead at the time of the retrospective study, were Medicare Advantage beneficiaries, and had 2 years of usage data before death. Median age at death for each disease group was older than 80. INTERVENTION: Home- and clinic-based palliative care (PC) services provided by a multidisciplinary team. MEASUREMENTS: Outcomes included hospital costs, other healthcare costs, readmission rates, hospital admissions and bed days, intensive care unit use in final 30 days of life, and death within 30 days of an admission. RESULTS: Intervention participants in all four disease groups had less hospital use and lower hospital costs nonintervention participants, which drove lower overall healthcare costs. In the final 6 months of life, healthcare costs for the intervention groups stayed largely the same from month to month, whereas costs for comparison participants increased dramatically. CONCLUSION: In the context of an alternative payment model in which the provider was "at risk" of bearing the costs of care, a proactive PC program helped to avoid the escalation in hospital use and costs commonly seen in the final months of life.

Clinical usefulness of gene-expression profile to rule out acute rejection after heart transplantation: CARGO II.

AIMS: A non-invasive gene-expression profiling (GEP) test for rejection surveillance of heart transplant recipients originated in the USA. A European-based study, Cardiac Allograft Rejection Gene Expression Observational II Study (CARGO II), was conducted to further clinically validate the GEP test performance. METHODS AND RESULTS: Blood samples for GEP testing (AlloMap(®), CareDx, Brisbane, CA, USA) were collected during post-transplant surveillance. The reference standard for rejection status was based on histopathology grading of tissue from endomyocardial biopsy. The area under the receiver operating characteristic curve (AUC-ROC), negative (NPVs), and positive predictive values (PPVs) for the GEP scores (range 0-39) were computed. Considering the GEP score of 34 as a cut-off (>6 months post-transplantation), 95.5% (381/399) of GEP tests were true negatives, 4.5% (18/399) were false negatives, 10.2% (6/59) were true positives, and 89.8% (53/59) were false positives. Based on 938 paired biopsies, the GEP test score AUC-ROC for distinguishing ≥3A rejection was 0.70 and 0.69 for ≥2-6 and >6 months post-transplantation, respectively. Depending on the chosen threshold score, the NPV and PPV range from 98.1 to 100% and 2.0 to 4.7%, respectively. CONCLUSION: For ≥2-6 and >6 months post-transplantation, CARGO II GEP score performance (AUC-ROC = 0.70 and 0.69) is similar to the CARGO study results (AUC-ROC = 0.71 and 0.67). The low prevalence of ACR contributes to the high NPV and limited PPV of GEP testing. The choice of threshold score for practical use of GEP testing should consider overall clinical assessment of the patient's baseline risk for rejection.

Performance of gene-expression profiling test score variability to predict future clinical events in heart transplant recipients.

BACKGROUND: A single non-invasive gene expression profiling (GEP) test (AlloMap®) is often used to discriminate if a heart transplant recipient is at a low risk of acute cellular rejection at time of testing. In a randomized trial, use of the test (a GEP score from 0-40) has been shown to be non-inferior to a routine endomyocardial biopsy for surveillance after heart transplantation in selected low-risk patients with respect to clinical outcomes. Recently, it was suggested that the within-patient variability of consecutive GEP scores may be used to independently predict future clinical events; however, future studies were recommended. Here we performed an analysis of an independent patient population to determine the prognostic utility of within-patient variability of GEP scores in predicting future clinical events. METHODS: We defined the GEP score variability as the standard deviation of four GEP scores collected ≥315 days post-transplantation. Of the 737 patients from the Cardiac Allograft Rejection Gene Expression Observational (CARGO) II trial, 36 were assigned to the composite event group (death, re-transplantation or graft failure ≥315 days post-transplantation and within 3 years of the final GEP test) and 55 were assigned to the control group (non-event patients). In this case-controlled study, the performance of GEP score variability to predict future events was evaluated by the area under the receiver operator characteristics curve (AUC ROC). The negative predictive values (NPV) and positive predictive values (PPV) including 95 % confidence intervals (CI) of GEP score variability were calculated. RESULTS: The estimated prevalence of events was 17 %. Events occurred at a median of 391 (inter-quartile range 376) days after the final GEP test. The GEP variability AUC ROC for the prediction of a composite event was 0.72 (95 % CI 0.6-0.8). The NPV for GEP score variability of 0.6 was 97 % (95 % CI 91.4-100.0); the PPV for GEP score variability of 1.5 was 35.4 % (95 % CI 13.5-75.8). CONCLUSION: In heart transplant recipients, a GEP score variability may be used to predict the probability that a composite event will occur within 3 years after the last GEP score. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT00761787.

Concordance among pathologists in the second Cardiac Allograft Rejection Gene Expression Observational Study (CARGO II).

BACKGROUND: There has been no large evaluation of the ISHLT 2004 acute cellular rejection grading scheme for heart graft endomyocardial biopsy specimens (EMBs). METHODS: We evaluated agreement within the CARGO II pathology panel and between the panel (acting by majority) and the collaborating centers (treated as a single entity), regarding the ISHLT grades of 937 EMBs (with all grades ≥2R merged because of small numbers). RESULTS: Overall all-grade agreement was almost 71% both within the panel and between the panel and the collaborating centers but, in both cases, was largely because of agreement on grade 0: for the average pair of pathologists, fewer than a third of the EMBs assigned grade ≥2R by at least one were assigned this grade by both. CONCLUSION: The 2004 revision has done little to improve agreement on the higher ISHLT grades. An EMB grade ≥2R is not by itself sufficient as a basis for clinical decisions or as a research criterion. Steps should be taken toward greater uniformity in EMB grading, and efforts should be made to replace the ISHLT classification with diagnostic criteria--EMB based or otherwise--that correspond better with the pathophysiology of the transplanted heart.

Efficacy and Safety of Low-Dose Cyclosporine with Everolimus and Steroids in de novo Heart Transplant Patients: A Multicentre, Randomized Trial.

A six-month, multicenter, randomized, open-label study was undertaken to determine whether renal function is improved using reduced-exposure cyclosporine (CsA) versus standard-exposure CsA in 199 de novo heart transplant patients receiving everolimus and steroids ± induction therapy. Mean C(2) levels were at the low end of the target range in standard-exposure patients (n = 100) and exceeded target range in reduced-exposure patients (n = 99) throughout the study. Mean serum creatinine at Month 6 (the primary endpoint) was 141.0 ± 53.1 µmol/L in standard-exposure patients versus 130.1 ± 53.7 µmol/L in reduced-exposure patients (P = 0.093). The incidence of biopsy-proven acute rejection ≥3A at Month 6 was 21.0% (21/100) in the standard-exposure group and 16.2% (16/99) in the reduced-exposure group (n.s.). Adverse events and infections were similar between treatment groups. Thus, everolimus with reduced-exposure CsA resulted in comparable efficacy compared to standard-exposure CsA. No renal function benefits were demonstrated; that is possibly related to poor adherence to reduced CsA exposure.

Donor hypo- and hypernatremia are predictors for increased 1-year mortality after cardiac transplantation.

Donor hypernatremia is known to be associated with initial graft dysfunction in liver transplantation. Controversial data exist regarding the impact of sodium dysregulation on patient survival after heart transplantation (HTX). The aim of this study was to investigate the influence of donor sodium levels on survival in a large cohort of heart transplant recipients from the Eurotransplant registry. From 1997 to 2005, all consecutive adult HTX performed in the Eurotransplant region were included into this study (n = 4641 patients). Multivariate analysis was applied to investigate possible clinical predictors for 1-year post-transplant survival after cardiac transplantation (donor sodium levels, donor age, donor cause of death, recipient age, primary disease, urgency status, cold ischemia time). In multivariate analysis, recipients receiving a donor heart with serum sodium level lower than 130 mmol/l or higher than 170 mmol/l had a 1.25-fold higher risk for 1-year post-transplant mortality than patients with normal donor sodium ranges (P = 0.007). Other independent risk factors for impaired 1-year survival were recipient age, the indication for transplantation and the urgency status of the recipient. Our study demonstrates that hyponatremia as well as hypernatremia show a strong U-shaped correlation with poor survival after cardiac transplantation. Accurate donor management to avoid electrolyte disorder seems to be crucial for ensuring good quality of donor hearts.

Thromboembolic complications during weaning from right ventricular assist device support.

We report on two patients who experienced life-threatening thromboembolic complications during prolonged weaning from Levitronix CentriMag right ventricular assist device support. Right ventricular assist device flow in both patients was reduced below 2 L/min for a period of 72 or 36 h to closely monitor patients' hemodynamics and echocardiography because the extent of right ventricular recovery was difficult to assess. Thrombus formation occurred despite adjusting the heparin dosage to achieve partial prothrombin time values between 60 and 70 s. Periods of reduced flow during Levitronix CentriMag support must be kept short, and an additional bolus dose of heparin should be considered.

The pediatric mechanical circulatory support program in Innsbruck, Austria, and the impact of such programs on lack of donor hearts in Europe.

Strategy and results of the Innsbruck Mechanical Circulatory Support Program are presented, and the impact of such programs on pediatric heart transplantation (HTX) in Europe is discussed. Venoarterial extracorporeal membrane oxygenation (vaECMO) and ventricular assist devices (VADs) were used in 21 pediatric patients (median age 3.3 years, 2 days to 17 years) for acute heart failure (AHF) following a bridge or bridge-to-bridge strategy. Twelve patients were treated with vaECMO: eight were weaned after 2-10 days, two died, and two were switched to a VAD. Of the last, one was weaned 47 days later and the other underwent HTX 168 days later. In nine patients, VAD was implanted without preceding vaECMO. One such patient died (cerebral hemorrhage) after 236 days; of the remaining eight patients three were weaned and five underwent HTX. Waiting time for HTX (high-urgency status) varied from 4 to 372 days. Fifteen patients were discharged (follow up: 2-74 months); 14 are doing very well (New York Heart Association (NYHA) Functional Classification Class I, neurologically normal), whereas one suffers from severe neurologic damage, presumably from resuscitation before vaECMO. Data from Eurotransplant on pediatric HTX in 2004, 2005, and 2006 (33, 49, and 34 transplanted hearts, respectively; recipients <16 years of age) are discussed. Mechanical circulatory support (MCS) substantially improves survival with AHF in pediatric patients. Medium-term support (up to 400 days in our patients) is possible and outcome of survivors is excellent. Wide spread use of MCS might slightly aggravate the lack of donor organs, which could result in longer support times.

Interventional and medical treatment of acute heart failure due to inflammation: four cases.

Four patients (aged 15-41 years, mean age 26.7 years) with fulminant myocarditis undergoing mechanical circulatory support are reported. All patients suffered from acute low-output syndrome refractory to inotropic support. Diagnosis was confirmed by histology and immunohistochemistry. RT-PCR (reverse transcription-polymerase chain reaction) from endomyocardial biopsy specimens revealed parvovirus B19 in two patients and a coinfection with Chlamydia pneumoniae and parvovirus B19 in one patient. Midterm support with the biventricular Thoratec system was preceded by implantation of an extracorporeal membrane oxygenation (ECMO) device in two patients. Two patients regained full cardiac function and were successfully weaned from the ventricular assist device (VAD) after 12 and 40 days. Heart transplantation was performed in another patient without evidence of myocardial recovery after 53 days. One patient died of cerebral hemorrhage on day 12 after VAD implantation. In summary, patients with life-threatening fulminant myocarditis can be successfully bridged to recovery or transplantation with mechanical circulatory support.

Outcome evaluation of the bridge-to-bridge concept in patients with cardiogenic shock.

BACKGROUND: Patients with cardiogenic shock can be stabilized by percutaneous implantation of extracorporeal membrane oxygenation (ECMO). If weaning from ECMO is impossible, the implantation of a ventricular assist device (VAD) is required. Patients either go for recovery of myocardial function (bridge to recovery) or for heart transplantation (bridge to transplant). METHODS: One hundred thirty-one patients were supported with ECMO between March 1995 and November 2005. Reasons for ECMO implantation were acute heart failure, acute or chronic heart failure, and postcardiotomy heart failure. In 28 patients, subsequent VAD implantation was necessary (bridge to bridge concept). RESULTS: Fourteen bridge to bridge patients (50%) became long-time survivors with a mean follow-up of 39 months. Risk factors for mortality were status post-cardiopulmonary resuscitation and elevated lactate and bilirubin levels before VAD implantation. Complications after ECMO and VAD implantation were bleeding and thromboembolic events. The most common cause of death was multiorgan failure. CONCLUSIONS: Bridge to bridge is a successful concept for selected patients with cardiogenic shock. During ECMO support, patients can be evaluated for comorbidities. For patients with a combination of risk factors (status post-cardiopulmonary resuscitation, elevated lactate levels, and impaired liver function), VAD implantation should be considered very carefully.