Treating rare tumors with liver transplantation.

PURPOSE OF REVIEW: The success of liver transplantation (LT) in treating unresectable hepatocellular carcinoma (HCC) has resulted in interest in LT for other oncologic conditions. Here, we discuss the role of LT for rare oncologic indications including metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs), hepatic epitheliod hemangioendothelioma (HEHE), fibrolamellar hepatocellular carcinoma (FLC), and hepatic angiosarcoma (HAS). RECENT FINDINGS: Conditions reviewed have been documented indications for LT in the available literature. We summarize the experience of LT for these indications and proposed management guidelines. SUMMARY: GEP-NETs with isolated metastases to the liver can be treated with LT with excellent long-term outcomes (10-year survival 88%) if strict selection criteria are used (low-intermediate grade, Ki-67% < 20%, complete resection of primary tumor, stable disease for 6 months, <50% hepatic involvement). HEHE is a rare hepatic tumor for which LT can be performed with reported 10-year survival around 70%. FLC is a distinct clinical entity to HCC and is optimally treated with surgical resection though experience with LT is described in observational series (5-year survival 50%, recurrence in 10%). HAS is a rapidly progressive tumor with a dismal prognosis with or without treatment, including LT.

Society for Cardiovascular Angiography and Interventions Shock Classification to Stratify Outcomes of Extracorporeal Membrane Oxygenation.

We applied the Society for Cardiovascular Angiography and Interventions (SCAI) schema to cardiogenic shock (CS) patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess performance in this high acuity group of patients. Records of adult patients receiving VA-ECMO for CS at our institution from 01/2015 to 12/2019 were reviewed. Post-cardiotomy and noncardiogenic shock patients were excluded. A total of 245 patients were included, with a median age of 59 years [IQR: 48-67]; 159 (65%) were male. There were 34 (14%) patients in Stage C, 82 (33%) in D, and 129 (53%) in E. Of E patients, 88 (68%) were undergoing cardiopulmonary resuscitation. Median ECMO duration decreased with stage (C:7, D:6, E:4 days, P < 0.001). In-hospital mortality increased (C:35%, D:56%, E:71%, P < 0.001) and myocardial recovery decreased with stage (C:65%, D:35%, E:30%, P < 0.001). Acute kidney injury (C:35%, D:45%, E:54%, P = 0.045), acute liver failure (C:32%, D:66%, E:76%, P < 0.001), and infection (C:35%, D:28%, E:16%, P = 0.004) varied among groups. Multivariable analysis revealed age (HR=1.02), male sex (HR=0.62), and E classification (HR=2.69) as independently associated with 1-year mortality. Competing-risks regression identified D (SHR=0.53) and E classification (SHR=0.45) as inversely associated with myocardial recovery. In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification.

Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock.

OBJECTIVE: Left ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO. METHODS: We conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation. RESULTS: During the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts. CONCLUSIONS: Concomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.

National outcomes of bridge to multiorgan cardiac transplantation using mechanical circulatory support.

BACKGROUND: Little is known regarding the profile of patients with multiorgan failure listed for simultaneous cardiac transplantation and secondary organ. In addition, few studies have reported how these patients are bridged with mechanical circulatory support (MCS). In this study, we examined national data of patients listed for multiorgan transplantation and their outcomes after bridging with or without MCS. METHODS: United Network for Organ Sharing data were reviewed for adult multiorgan transplantations from 1986 to 2019. Post-transplant patients and total waitlist listings were examined and stratified according to MCS status. Survival was assessed via Cox regression in the post-transplant cohort and Fine-Gray competing risk regression with transplantation as a competing risk in the waitlist cohort. RESULTS: There were 4534 waitlist patients for multiorgan transplant during the study period, of whom 2117 received multiorgan transplants. There was no significant difference in post-transplant survival between the MCS types and those without MCS in the whole cohort and heart-kidney subgroup. Fine-Gray competing risk regression showed that patients bridged with extracorporeal membrane oxygenation had significantly greater waitlist mortality compared with those without MCS when controlling for preoperative characteristics (subdistribution hazard ratio, 2.27; 95% confidence interval, 1.48-3.47; P < .001), whereas those bridged with a ventricular assist device had a decreased incidence of death compared with those without MCS (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.63-0.96; P = .017). CONCLUSIONS: MCS, as currently applied, does not appear to compromise the survival of multiorgan heart transplant patients. Waitlist data show that extracorporeal membrane oxygenation patients have profoundly worse survival irrespective of preoperative factors including organ type listed. Survival on the waitlist for multiorgan transplant has improved across device eras.

Bleeding and Thrombotic Events During Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

BACKGROUND: Anticoagulation therapy management during venoarterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation treatment on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO. METHODS: We retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who had bleeding and thrombosis were investigated, and risk factors were assessed by multilevel logistic regression. RESULTS: Of the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) had 40 thrombotic events and 64 (45%) had 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.01 to 1.09), platelet transfusion (OR 1.10; 95% CI, 1.05 to 1.16), international normalized ratio (OR 1.18; 95% CI, 1.02 to 1.37), and activated partial thromboplastin time greater than 60 seconds (OR 2.32; 95% CI, 1.14 to 4.73). Predictors of thrombosis were anticoagulant use (OR 0.39; 95% CI, 0.19 to 0.79), surgical venting (OR 3.07; 95% CI, 1.29 to 7.31), hemoglobin (OR 1.38; 95% CI, 1.06 to 1.79), and central cannulation (OR 2.06; 95% CI, 1.03 to 4.11). The daily predicted probability of thrombosis was between 0.075 and 0.038 for patients who did not receive anticoagulation and decreased to between 0.030 and 0.013 for patients who received anticoagulation treatment at activated partial thromboplastin times between 25 and 80 seconds. CONCLUSIONS: Anticoagulation therapy can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at activated partial thromboplastin times greater than 60 seconds.

Role of left atrial appendage occlusion in patients with HeartMate 3.

OBJECTIVES: Left atrial appendage occlusion (LAAO) at the time of implantation may reduce thromboembolic events (TEs) during continuous-flow left ventricular assist device support. The HeartMate 3 (HM3) reduces TEs overall, but the efficacy of LAAO in HM3 is unknown. METHODS: Adults receiving first HM3 implantation from November 2014 through December 2019 at a single, large medical centre were retrospectively reviewed. TEs included device thrombosis and ischaemic stroke. Patients were classified by whether they received LAAO or not. Incidence of TEs was compared between groups using cumulative incidence curves with competing risks (death and heart transplant) and risk factors for TEs were assessed with Fine and Gray competing risk regression. RESULTS: A total of 182 patients received HM3, of whom 99 (54%) received LAAO versus 83 (46%) who did not. There were 14 TEs, including 13 strokes (7%) and 1 pump thrombosis (0.5%). No significant difference in the incidence of TEs in each group was found (Gray's test: P = 0.35). LAAO was not associated with TEs in multivariable Fine-Gray analysis (P = 0.10) and no significant risk factors for TEs were found. There were zero disabling strokes in those who received LAAO compared to 6 (7%) in those who did not receive LAAO (P = 0.008). CONCLUSIONS: A low number of TEs was observed in HM3 recipients. LAAO did not further reduce the overall rate of TEs in this patient population, though its use may be beneficial in preventing disabling ischaemic strokes after HM3 implantation.

Development of De Novo Aortic Insufficiency in Patients With HeartMate 3.

BACKGROUND: De novo aortic insufficiency (AI) is a common adverse event after continuous-flow left ventricular assist device (LVAD) placement and is associated with morbidity and mortality. This study aims to compare the development of de novo AI between HeartMate 3 (Abbott) and HeartMate II LVAD recipients. METHODS: A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year postimplantation) of HeartMate 3 patients implanted between November 2014 and March 2019 and of HeartMate II patients implanted between April 2004 and December 2015 at Columbia University Irving Medical Center. One hundred twenty-two patients were excluded from analysis for a history of aortic valve surgery, concomitant aortic valve surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as development of more than mild AI after LVAD implant. RESULTS: Included in the study were 121 HeartMate 3 patients and 270 HeartMate II patients. After accounting for competing risks of death and transplantation, there was no significant difference in the development of de novo AI by 1 year postimplantation between HeartMate II and HeartMate 3 patients (P = .68). There was no significant difference in severity of AI developed up to 1 year post-implantation between HeartMate II and HeartMate 3 patients. CONCLUSIONS: Development of de novo AI is comparable between HeartMate 3 and HeartMate II patients. There is no significant difference in severity of AI between HeartMate II and HeartMate 3 patients.

A Standardized Approach Improves Outcomes of Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

Postcardiotomy shock (PCS) has historically been associated with substantial morbidity and mortality. Mortality at discharge is reportedly more than 60%. We investigated the outcomes of our standardized approach to veno-arterial extracorporeal membrane oxygenation (ECMO) management for PCS. We retrospectively reviewed 60 consecutive PCS patients who required ECMO following major cardiac surgery from January 2017 to September 2019. Index surgery included CABG (n = 10), valve (n = 23), valve and CABG (n = 12), root surgery (n = 10), and other (n = 5). Median lactate level, systolic blood pressure, and mean pulmonary artery pressure before ECMO were 4.0 mmol/L, 80 mm Hg, and 29 mm Hg, respectively. Fifty-nine patients (98%) were on two vasopressors, and 54 (90%) were on at least two inotropes. Vasoactive-Inotropic Score was 30 (IQR, 25-49). Eighty percent of patients received peripheral ECMO. Median ECMO flow index was 1.61 (IQR, 1.4-2.0) L/min/m2. Anticoagulation was not given in 12 (20%) patients during ECMO support. Major adverse events included chest re-exploration (15%), stroke (6.7%), renal replacement therapy (22%), and limb ischemia (5%). In-hospital mortality was 33%. This study suggests that a standardized approach with a dedicated ECMO team is feasible and may improve outcomes of PCS.

Serial assessment of HeartMate 3 pump position and inflow angle and effects on adverse events.

OBJECTIVES: This study analyses the position of the HeartMate 3 left ventricular assist device on serial radiographs to assess positional change and possible correlation with adverse events. METHODS: We retrospectively analysed 59 left ventricular assist device recipients who had serial chest radiographs at 1 month, 6 months and 12 months post-implantation between November 2014 and June 2018. We measured pump angle, pump-spine distance and pump-diaphragm depth and investigated their relationship to a composite outcome of heart failure readmission, low flow alarms, stroke or inflow/outflow occlusion requiring surgical repositioning through recurrent event survival modelling. RESULTS: Between 1 and 6 months, the absolute pump-spine distance changed by 10.00 mm (P < 0.01) and the absolute pump-diaphragm depth changed by 18.80 mm (P < 0.01). These parameters did not change significantly between 6 and 12 months post-implantation. Pump angle did not change significantly over any period. Twenty-six patients experienced the composite outcome; in these patients, the median 1-month pump angle was 66.2° (interquartile range 54.5-78.0) as compared to 59.0° (interquartile range 47.0-65.0) in the 33 patients who did not have adverse events (P = 0.04). Pump depth and pump-spine distance at 1 month were not associated with the composite outcome. Change in pump depth between 1 and 6 months [hazard ratio (HR) 1.019; 95% confidence interval (CI) 1.000-1.039] and between 6 and 12 months (HR 1.020; 95% CI 1.000-1.040) were weakly associated with the composite outcome. CONCLUSIONS: Larger pump angles are associated with the composite outcome of position-related adverse events. Pump depth movement is weakly associated with the composite outcome.

Prosthetic valve thrombosis during extracorporeal life support for postcardiotomy shock.

Postcardiotomy shock is a complication after open-heart surgery that may be alleviated with extracorporeal life support (ECLS). Postcardiotomy shock patients on ECLS with prosthetic valves are at a high risk of valve thrombosis. We retrospectively reviewed patients supported with ECLS after the development of postcardiotomy shock at our centre, 90 of which had prosthetic valves. Nine patients developed prosthetic valve thrombosis, an incidence of 10%. Patients who developed prosthetic valve thrombosis were more often supported via central cannulation (78% vs 38%, P = 0.034) and had a higher median initial flow (4.4 vs 3.2 l/min, P = 0.018). Central cannulation was associated with valve thrombosis by multivariable logistic regression (odds ratio 7.56; 95% confidence interval 1.12-149.87). Central cannulation with high flow is thought to reduce intracardiac blood flow, thereby increasing the risk of stasis and thrombus formation. Patients with prosthetic valve thrombosis were treated with anticoagulation or surgical intervention and 4 patients (44%) survived to discharge.

Use Side Branch of the Aortic Graft to Facilitate Coronary Reconstruction During Complex Aortic Surgery.

The interposition graft could be used for difficult coronary reconstruction during aortic root replacement. We introduced a new technique that utilizes side branch of an aortic graft to facilitate coronary reconstruction. The present study describes this technique and its outcomes. We retrospectively reviewed 234 patient charts of those who underwent aortic root replacement between January 2013 and November 2017. Within this group, 6 patients required coronary reconstruction with branches of aortic graft and were included in this study. All patients were reoperative cases, 3 of which were for acute type A aortic dissection. The mean cardiopulmonary and aortic cross clamp times were 317.2 ± 35.1 minutes and 153.3 ± 75.4 minutes, respectively. All patients survived to discharge with a median hospital stay of 20.5 days (interquartile range: 13.75-27.75). During a median follow-up of 221 days (interquartile range: 197.78-1208), no patients experienced major adverse cardiovascular events. Four patients underwent radiographic follow-up, which confirmed patent interposition grafts (5/5). The use of branches from the aortic graft for coronary reconstruction is feasible with satisfactory outcomes.