Salvage heart transplantation for Mycoplasma hominis prosthetic valve endocarditis: A case report and review of the literature.

Heart transplantation (HT) has been rarely performed in patients with infective endocarditis (IE) and is considered a "last resort" procedure. Orthotropic HT with bicaval technique was performed in a man with culture-negative endocarditis. Mycoplasma hominis was later detected using 16S ribosomal DNA PCR from surgically removed valve tissue. Literature review and previous results are summarized. HT may be considered as salvage treatment in selected patients with intractable IE. In cases when there is no growth in culture, 16S ribosomal DNA PCR sequencing can be used to identify the pathogen in excised valvular tissue. Mycoplasma spp. is extremely uncommon and difficult to diagnose cause of infective endocarditis (IE). There are no proposed or defined criteria for heart transplantation (HT) in patients with refractory IE, and HT has been rarely performed in this setting. We report a case of M hominis prosthetic valve endocarditis diagnosed by 16S ribosomal DNA PCR in a patient who underwent a salvage HT. We reviewed in the literature other cases of IE caused by Mycoplasma spp.

Red blood distribution width and heart transplantation: any predictive role on patient outcome?

BACKGROUND: Red blood cell distribution width (RDW) has been emerging as a strong predictor of mortality among patients with cardiovascular disease. The aim of this study was to verify if RDW is able to predict survival after heart transplantation (HTx). METHODS: Two hundred and eighteen recipients who underwent HTx between 2000 and 2013 were classified into three groups according to the pre-HTx RDW tertile values (14.6 and 16.4%), and their outcomes were compared. Mean follow-up was 6.6 ±â€Š4.2 years. RESULTS: RDW correlated with other markers of chronic pathological conditions, such as the Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score (P = 0.002) and Charlson Comorbidity Index (P < 0.001), and with creatinine levels (P = 0.007), previous cardiac surgery (P < 0.001), diabetes mellitus (P = 0.02), haemoglobin value (P = 0.004), pulmonary capillary wedge and central venous pressures (P = 0.019 and 0.01, respectively), systolic and mean pulmonary artery pressures (P = 0.002 and 0.014, respectively). The rate of 30-day mortality from the lowest to the highest RDW tertile was 1.4, 4 and 9% (P = 0.02), respectively.Long-term mortality correlated at multivariate analysis with recipient age [hazard ratio 1.06, 95% confidence interval (95% CI) 1.02-1.09], donor age (hazard ratio 1.02, 95% CI 1.0-1.04) and RDW (hazard ratio 1.13, 95% CI 1.04-1.23). The survival probability at 4, 8 and 12 years was 90, 84 and 74% for recipients with RDW less than 14.6%, while it was 72, 60 and 42% for recipients with RDW more than 16.4% (hazard ratio 3.29, 95% CI 1.74-6.24). No differences were found between causes of death. CONCLUSION: RDW correlated with survival in HTx recipients. This marker of blood cell size may represent a surrogate of disease and a helpful tool in the risk-assessment process.

Extracorporeal photochemotherapy in heart transplant rejection: A single-center experience.

BACKGROUND: The addition of extracorporeal photochemotherapy (ECP) to standard immunosuppressive therapy has been suggested to be beneficial in the treatment of recurrent/persistent heart rejection. METHODS: We reviewed medical data of heart transplant recipients who received ECP between 2010 and 2016 at our institution. RESULTS: During the study period, eight patients underwent nine ECP courses. The median time from transplant to ECP was 18 months (range 9-54). Indications for ECP were recurrent rejection in 6 patients, persistent rejection in 1 patient and mixed rejection with hemodynamic compromise in 1 patient. Additional criteria for patients' selection were represented by relevant comorbidities limiting the increase of immunosuppressive therapies. ECP was performed on an outpatient basis in 6 out of 8 patients. The median ECP duration was 12 months (range 1-18). Three out of 8 patients responded to ECP showing negative endomyocardial biopsies at the end of treatment. No additional rejection episodes were observed at their follow up (at 44, 72 and 31 months). Four of 8 patients failed to respond to ECP treatment, one patient has been judged not evaluable. Reduction of immunosuppressive therapies was obtained in all 3 responsive patients but also in 3 patients with a stable grade of rejection. The median duration of the follow up was 26 months (range 6-80). Two patients died at 6 and 21 months after beginning ECP. Survival after ECP was 78.2% at 26 months. No adverse effect or infectious complications associated with ECP were reported. CONCLUSIONS: The low response rate (37.5%) in our case series could be partially explained by patient selection, the treated patients representing a high-risk sub-set group. Further studies to provide evidence of a role for ECP in heart rejection treatment or prophylaxis are needed.

Recipient age impact on outcome after cardiac transplantation: should it still be considered in organ allocation?

OBJECTIVES: Improvement of clinical results in heart transplantation (HTx) has favoured the expansion of indication criteria towards aged population. The impact of increasing recipient age is controversial and, owing to donor shortage, the debate still remains whether HTx is justified for older patients. We analysed age as a prognostic factor at long-term after HTx and if it should be a determinant in organ allocation. METHODS: Data of 364 consecutive patients who underwent cardiac transplantation between 1999 and 2014 at the University Hospital of Udine were analysed. Patients were divided into three groups according to age (Group 1: 18-40, Group 2: 41-59, Group 3: ≥ 60 years) and survival and major complications were evaluated at long-term (mean follow-up 6.7 ± 4.5 years, range 1-15.7 years). RESULTS: Preoperatively, renal failure (2.9, 16.1, 39.5%, P < 0.01) and cardiovascular factors such as diabetes (1.2, 17.1, 36.4%, P < 0.01), systemic hypertension (5.9, 31.5, 40.8%, P < 0.01) and dyslipidaemia (5.9, 40.3, 42.9%, P < 0.01) were more common in older patients (Group 3), as well as ischaemic cardiopathy (0, 42.6, 49.7%, P < 0.01). Donor age was lower in younger recipients (Group 1) (33 ± 15, 39 ± 14, 45 ± 14 years, P < 0.01). Older patients showed a worse long-term survival (hazard ratio 1.7; 1.1-2.5), also after adjusting for major cardiovascular risk factors, renal failure and donor age. In fact, 15-year survival was 100% in Group 1, while at 1, 5, 10 and 15 years survival was 88, 78, 69 and 56% in Group 2, and 87, 68, 49 and 43% in Group 3, respectively. Even major long-term complications were less frequent in younger patients in terms of neoplasms (P < 0.01), rehospitalizations (P < 0.01) and a tendency to higher freedom from other complications such as cytomegalovirus infections, renal failure and dialysis. CONCLUSIONS: Our results showed a significantly different outcome according to recipient age, even when adjusted for major risk factors. Notably, patients younger than 40 years showed 100% long-term survival, and apparent lower rate of complications due to immunosuppression. Since 15-year survival in patients ≤40 years is twice that of patients ≥60 years, recipient age should be taken into account in organ allocation.

From bench to bedside: Can the improvements in left ventricular assist device design mitigate adverse events and increase survival?

OBJECTIVE: In vitro tests demonstrated that the new cone-bearing configuration of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device exhibits better hydraulic efficiency than the previous pin-bearing design. We investigated the long-term outcomes of patients who received the Jarvik 2000 left ventricular assist device, depending on bearing design. METHODS: A retrospective review of prospectively collected data from 18 centers included in the Italian Registry was performed. From May 2008 to September 2013, 99 patients with end-stage heart failure were enrolled. Patients were divided into 2 groups according to their Jarvik 2000 suspending mechanism: Group pin included patients with pin bearings (May 2008 to June 2010), and group cone included patients with newer cone bearings (July 2010 to September 2013). The 2 groups did not differ significantly in terms of baseline characteristics. RESULTS: A total of 30 of 39 patients (group pin) and 46 of 60 patients (group cone) were discharged. During follow-up, 6 patients underwent transplantation, and in 1 patient the left ventricular assist device was explanted. The cumulative incidence competing risk of the entire cohort for noncardiovascular-related death was 28% (20%-40%); the cumulative incidence competing risk for cardiovascular-related death was 56% (42%-73%): 71% in group pin versus 26% in group cone (P = .034). The multivariate analyses confirmed that the pin-bearing design was a risk factor for cardiovascular death, along with Interagency Registry for Mechanically Assisted Circulatory Support class. Right ventricular failures and ischemic and hemorrhagic strokes were significantly higher in group pin. CONCLUSIONS: Patients with the new pump configuration showed a better freedom from cardiovascular death and lower incidence of fatal stroke and right ventricular failure. Further studies are needed to prove the favorable impact of pump-enhanced fluid dynamics on long-term results.

Does psychosocial compliance have an impact on long-term outcome after heart transplantation?†.

OBJECTIVES: Since patient compliance following organ transplantation is considered a limiting factor for long-term outcome, psychosocial assessment is commonly employed to evaluate suitability for organ transplantation. We analysed the impact of psychosocial characteristics on long-term outcome after heart transplantation in our institution. METHODS: The outcomes of 345 patients (82% male, mean age: 56 ± 11 years) who had undergone a heart transplant since 1999 were evaluated taking into consideration major clinical and psychosocial findings. The impact on survival of the psychological habitus, substance abuse, economic status, education level, presence of caregivers and distance from the hospital (Area 1: <100 km, Area 2: ≥100 and <500 km, Area 3: ≥500 km) were considered in an univariate and multivariate analysis. RESULTS: Univariate analysis showed that only retired patients had an increased risk of mortality. In fact, survival at 1, 5 and 10 years in unemployed versus retired versus employed people was 94 ± 3% vs 91 ± 2% vs 88 ± 3%; 86 ± 5% vs 75 ± 3% vs 80 ± 5%; 72 ± 8% vs 57 ± 5% vs 76 ± 5%, respectively (P = 0.05). Unemployed and employed patients were younger than retired patients. In multivariate analysis, after correction of clinical data, no psychosocial characteristics were found to be risk factors for long-term mortality: psychological problems [hazard ratio (HR) = 0.87; 0.56-1.33]; smoking (HR = 0.96; 0.61-1.54); alcohol abuse (HR = 1.62; 0.73-3.61); absence of caregivers (HR = 0.9; 0.44-1.83); critical economical condition (HR = 1.12; 0.65-1.93); lower school degree (HR = 0.95; 0.60-1.51); unemployment (HR = 1.00; 0.58-1.73) and distance from hospital (HR = 1.12; 0.76-1.98). At the same time, no psychosocial factors were identified as risk factors for coronary allograft vasculopathy, acute rejection and infection. CONCLUSIONS: The psychosocial factors analysed in our study seem to have no impact on patient outcome, and should not preclude candidates from listing for heart transplantation; on the other hand psychosocial assessment should be utilized to identify patients requiring more specific surveillance to obtain the best outcome.

Cardiac autonomic dysfunction in the early phase after left ventricular assist device implant: Implications for surgery and follow-up.

PURPOSE: In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance.
 METHODS: HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 30 healthy subjects served as control groups. INCLUSION CRITERIA: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration.
 RESULTS: HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients.
 CONCLUSIONS: In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.

Mid-term clinical outcomes in cardiac surgery of Jehovah's witnesses.

INTRODUCTION: Surgical treatment of Jehovah's witnesses is a special challenge for cardiac surgery. The purpose of this study was to evaluate perioperative management and mid-term clinical outcome of Jehovah's witnesses who underwent cardiac surgery. METHODS: Between January 1990 and June 2009, 34 Jehovah's witnesses (22 men, mean age 66 +/- 8 years) underwent cardiac surgery. Surgical procedures included 17 coronary artery bypass grafts (CABG): 3 CABG and aortic valve replacements (AVR); 1 CABG and mitral valve plasty (MVP); 6 AVR; 1 subaortic membrane resection; 2 mitral valve replacements (MVR) and 2 MVP; 1 mitro-aortic valve replacement; and 1 cardiac foreign body removal. There were four urgent operations; 14 patients had NYHA class II-III. Sixteen patients received erythropoietin preoperatively. Preoperative haemoglobin (Hb) value was 14.2 +/- 1.4 g/dl. RESULTS: Extracorporeal circulation time was 127 +/- 66 min, aortic cross-clamping 84 +/- 45 min. Haemoglobin value 24 h after surgery was 11.2 +/- 1.7 g/dl, haematocrit 34.1 +/- 5.2%. None required surgical reoperation for bleeding.Intensive care unit stay was 2.3 +/- 4.3 days, hospital stay 12.3 +/- 10.4 days; there was no hospital mortality. Postoperatively, erythropoietin was administered to 19 patients. Follow-up was completed in 100%. Reoperation was necessary 8 years later in one patient for mitral bioprosthesis degeneration; the patient died 8 months later. All other patients are alive 59 +/- 60 months after surgery; actuarial survival is 100% and 80 +/- 2% at 5 and 10 years, respectively. CONCLUSION: In our limited experience, early and late surgical results of Jehovah's witnesses patients are satisfactory. Appropriate preoperative management, optimization of Hb values, intraoperative measures to reduce the risk of bleeding and total blood loss recovery are the goals to achieve these results.

Laparoscopic approach for urgent abdominal surgery in patients with left ventricular assist devices.

Despite the fact that the rate of surgical complications mainly related to the necessary anticoagulation has been reported to be significant in patients supported by ventricular assist devices (VADs) who underwent noncardiac surgery, we report two cases showing that adequate peri-operative management of medical therapy and utilization of mini-invasive surgical approaches (i.e. laparoscopy) may limit the risks of morbidity, especially when surgery is required on an urgent basis.

Clinical results of minimally invasive mitral valve surgery: endoaortic clamp versus external aortic clamp techniques.

OBJECTIVE: : This study was carried out with the aim of presenting our experience with minimally invasive mitral surgery and compare the endoaortic clamp with the external aortic clamp (EAC) techniques. METHODS: : Between December 2002 and May 2009, 139 patients (75 men, aged 63 ± 11 years) underwent video-assisted mitral valve surgery through right thoracotomy. Twelve (9%) patients were operated without clamping the aorta, 32 (23%) patients (group A) were operated on by using the endoaortic clamp, and 95 (68%) patients were operated on by using the EAC (group B). There was no significant difference between groups A and B regarding preoperative variables. RESULTS: : Intraoperative procedure-associated problems were experienced in three group A patients (9.3%, two aortic dissections with conversion to sternotomy; one conversion due to bad exposure) and in two group B patients (2%, one conversion to sternotomy for bleeding and one for ascending aorta hematoma). At a mean follow-up of 32 months, 121 patients (97%) were in New York Heart Association class I-II, with satisfactory echocardiographic results. There was one in-hospital and six late deaths (three noncardiac, two cardiac, and one valve related). Five-year actuarial survival was 88% ± 8%. There were three reoperations, one early (<30 days) after complex mitral valve repair, with a 5-year freedom from reoperation of 97% ± 2%. Postoperative levels of myocardial cytonecrosis enzymes as well as the extracorporeal circulation time were significantly lower in group B patients (P < 0.05). CONCLUSIONS: : Intraoperative procedure-associated complications with endoclamping combined with an apparently better myocardial protection forced us to change our practice to the more simple and economic EAC technique.

Stented bioprosthetic valve hemodynamics: is the supra-annular implant better than the intra-annular?

BACKGROUND AND AIM OF THE STUDY: The use of stented bioprostheses for aortic valve replacement (AVR) in elderly patients with a small aortic annulus may result in unsatisfactory hemodynamic performance of the prosthesis. To overcome this limitation, new bioprostheses have been designed for complete supra-annular implantation, but the actual hemodynamic advantage of the supra-annular implant over the intra-annular has not been fully investigated. Accordingly, the hemodynamic performance of the same stented bioprosthesis (except for sewing ring design) implanted in the supra-annular and conventional intra-annular seating was compared. METHODS: Twenty-two patients received an intra-annular implant, and 38 a supra-annular implant. Age (74 +/- 5 versus 76 +/- 5 years, p = 0.54), gender (55% versus 50% males, p = 0.79) and body surface area (1.74 +/- 0.2 versus 1.81 +/- 0.2 m2, p = 0.13) were similar in both subgroups, who underwent echocardiography at 8 +/- 2 and 6 +/- 2 months after surgery, respectively (p = 0.09). RESULTS: The two patient subgroups had similar preoperative left ventricular outflow tract diameters (2.06 +/- 0.2 and 2.1 +/- 0.2 cm; p = 0.62), average size of implanted prosthesis (21.0 and 21.3 mm; p = 0.44) and mean transprosthetic flow rate (246 +/- 70 and 218 +/- 58 ml/s; p = 0.12). Mean (8 +/- 3 and 19 +/- 8 mmHg, p < 0.0001), and peak (17 +/- 6 and 40 +/- 13 mmHg; p < 0.0001) transprosthetic gradients were lower, and mean effective orifice area (EOA) (1.78 +/- 0.4 and 1.45 +/- 0.5 cm2, p = 0.006) was higher in patients with supra-annular implants than in those with intraannular. The incidence of patient-prosthesis mismatch (EOA index < 0.85 cm2/m2) decreased from 50% to 34% (p < 0.0001), with no case of severe mismatch using the supra-annular implant. During follow up, a left ventricular mass reduction occurred in patients with supra-annular implants (from 225 +/- 110 to 173 +/- 59 g/m2; p < 0.03), but not in patients with intra-annular implants (173 +/- 62 and 186 +/- 64 g/m2; p = 0.87) CONCLUSION: The study results showed that, compared to intra-annular implantation, supra-annular implantation of bioprosthetic stented valves in the aortic position was associated with a significantly better hemodynamic performance of the prosthesis and significant regression of left ventricular hypertrophy.

One-year clinical experience with the Acorn CorCap cardiac support device: results of a limited market release safety study in Italy and Sweden.

BACKGROUND: The Acorn CorCap cardiac support device (CSD) is a mesh-like device intended to provide end-diastolic support and reduce ventricular wall stress. Animal studies with the CorCap CSD have demonstrated beneficial reverse remodeling, and preliminary safety studies in patients with heart failure have shown that the device is safe and associated with improved left ventricular (LV) structure and function. The objective of the current study was to further evaluate the safety and efficacy of the CorCap CSD in patients with advanced heart failure. METHODS: Twenty-four patients with dilated cardiomyopathy, severe LV dysfunction, and advanced heart failure (NYHA class II-IV) were enrolled at four centers in Italy and Sweden. All patients underwent CorCap CSD implantation either alone (n = 3) or in combination with mitral valve repair/replacement (n = 13), coronary artery bypass surgery (n = 6), combined mitral valve repair/coronary artery bypass surgery (n = 1) or aneurysmectomy (n = 1). RESULTS: The LV end-diastolic diameter decreased from 69.3 +/- 7.2 to 60.1 +/- 9.0 mm at 3 months, 60.9 +/- 9.6 mm at 6 months, and 58.9 +/- 8.0 mm at 12 months (all p < 0.05). A trend toward an improved LV ejection fraction (28.8 +/- 10.5% at baseline and 32.4 +/- 12.7, 33.1 +/- 10.8, and 33.8 +/- 13.9% at 3, 6 and 12 months respectively) was also noted. The NYHA functional class, 6-min walking distance, and quality of life as measured using Uniscale were all improved. There were no differences in response among the patients submitted to the different types of concomitant surgery. CONCLUSIONS: In agreement with earlier safety studies, even the present investigation demonstrated improvements in cardiac structure and function as well as in patient functional status after Cor Cap CSD implantation. Randomized controlled trials are in progress.

Long-term decrease in subjective perceived efficacy of immunosuppressive treatment after heart transplantation.

BACKGROUND: Mild, long-term non-compliance with immunosuppressive treatment after organ transplantation is common, and can result in early mortality. One possible source of non-compliance is the belief that the treatment is ineffective or unnecessary. This study investigates patients perception of the efficacy of their immunosuppressive treatment in a sample of heart transplant patients. METHODS: A questionnaire was given to 67 heart transplant recipients. The first part of the questionnaire addressed health-related behavior and attitude toward the immunosuppressive medication, using self-report questions. In the second part of the questionnaire, participants evaluated the perceived risk of rejection associated with non-compliant behaviors described in 8 scenarios. RESULTS: The data from the self-report questions showed a mild level of behavioral non-compliance, increasing over time, and a mild level of medication non-compliance. One third of the medication non-compliant patients chose the inefficacy or non-necessity of the treatment as a main cause of non-compliance. The second part of the questionnaire showed that subjective perceived efficacy of the immunosuppressive treatment decreased over time. CONCLUSIONS: Medication non-compliance is fostered by many factors. One of these is the belief that the treatment is ineffective or unnecessary. This belief increases over time, and could be the result of a non-clinical selective-attention bias.

Frontal cerebral blood flow is impaired in patients with heart transplantation.

Patients with cardiovascular disease have cognitive function disturbances that are still evident after heart transplantation (HT). The aim of this study was to evaluate cerebral function in transplant patients and to assess whether cyclosporine therapy was responsible for cerebral abnormalities 1 year after transplantation. Six HT patients, eight liver transplant (LT) patients, and ten age-matched healthy controls underwent regional cerebral blood flow (rCBF) assessment by the (99m)Tc-hexamethyl-propylene-amineoxime ((99m)Tc-HM-PAO) single-photon emission computed tomography (SPECT) technique. The rCBF was correlated with cyclosporine blood levels. rCBF in HT and LT patients was similar to that of controls in all regions assayed, except for the frontal inferior region of HT patients, where it was significantly lower than in controls. No correlations between rCBF and cyclosporine blood levels were found in either HT or LT patients. In conclusion, the cerebral abnormalities seen in patients after HT but not after LT may be due to long-standing cerebral hypoperfusion resulting from severe heart disease, whereas cyclosporine does not account for such functional alterations.