Rabbit Antithymocyte Globulin Induction in Heart Transplant Recipients at High Risk for Rejection.

Background: Induction with lymphocyte-depleting antibodies may improve allograft outcomes in heart transplant recipients who are at high immunologic risk for rejection. Methods: We conducted a single-center retrospective cohort study that compared outcomes between adult patients receiving rabbit antithymocyte globulin (rATG) induction vs no induction from 2011 through 2017. Key exclusion criteria were patients who did not receive tacrolimus and mycophenolate and patients who did not meet high immunologic risk criteria. Results: A total of 50 patients were included in the analysis. At 1 year, the composite primary outcome of ≥2R rejection as defined by the International Society for Heart and Lung Transplantation, any treated rejection, development of cardiac allograft vasculopathy, or graft loss was not different between groups (P=0.474). Serious infections were also similar between groups (P=0.963). In accordance with institutional guidelines, prednisone exposure was decreased in the rATG induction group at 1 month (24.04 mg ± 13.74 vs 35.18 mg ± 16.95; P=0.014). Conclusion: These results suggest that while rATG induction does not improve heart allograft outcomes, it may enable reducing early corticosteroid exposure in patients at high immunologic risk.

Laparoscopic Sleeve Gastrectomy in Patients with Obesity and Ventricular Assist Devices: a Comprehensive Outcome Analysis.

We analyzed in detail the outcomes of eight patients with ventricular assist devices (VADs) and obesity who underwent laparoscopic sleeve gastrectomy (LSG) at a single heart transplant (HT) center. This comprehensive analysis included body mass index (BMI) trends from VAD implantation to the time of LSG; BMI and percentage of excess BMI lost during follow-up; adverse outcomes; and changes in echocardiographic parameters, fasting lipids, unplanned hospitalizations, and functional status. We also identified the patients who achieved the following outcomes: listing for HT, HT, 50% excess BMI loss, and BMI < 35 kg/m2. Laparoscopic sleeve gastrectomy seems to be a reasonable and effective intervention to help patients with VADs and obesity to decrease excess BMI and become candidates for HT.

Laparoscopic sleeve gastrectomy in obese patients with ventricular assist devices: a data note.

OBJECTIVES: Patients with end-stage heart failure (ESHF) treated with ventricular assist devices (VADs) tend to gain weight after implantation, which is associated with higher complication rates and is a contraindication for heart transplantation (HT). The objective was to analyze the outcomes of obese patients with ESHF and VADs who underwent laparoscopic sleeve gastrectomy (LSG) at Ochsner Medical Center in New Orleans, which is the only program performing VADs and HT in the State of Louisiana, and also one of the largest VAD centers in the USA. DATA DESCRIPTION: This dataset contains detailed baseline, perioperative, and long-term data of patients with VADs undergoing LSG. These variables were collected retrospectively from electronic medical records. Patients who achieved ≥ 50% excess BMI loss, BMI ≤ 35 kg/m2, listing for HT, HT, or myocardial recovery were identified and the timing to each of these milestones was documented. These data can be used alone or in combination with other datasets to achieve a larger sample size with more power for further analysis of these variables, which include the most important, standard, and objective bariatric and ESHF outcomes of patients with VADs undergoing LSG. Elaboration of composite outcomes is feasible.

Use of TandemHeart as Bridge to Recovery for Antibody-Mediated Rejection in a Heart Transplant Patient.

Antibody-mediated rejection is a major cause of graft failure, mortality, and morbidity among cardiac transplant recipients. We present the first reported case of TandemHeart (LivaNova, Pittsburgh, Pennsylvania) used in the management of antibody-mediated rejection associated with cardiogenic shock. (Level of Difficulty: Advanced.).

Long-Term Cardiac Morbidity and Mortality in Patients With Aortic Valve Disease Following Liver Transplantation: A Case Matching Study.

INTRODUCTION: This retrospective study examined the role of aortic valve (AV) disease in patients who underwent orthotopic liver transplantation (OLT) to determine the incidence of postoperative cardiac morbidity and mortality when compared with a matched control group without AV disease. METHODS: Patients were included in the AV group if diagnosed with aortic stenosis (AS) or aortic regurgitation or had received AV replacement prior to OLT. The AV group (n = 53) was matched to a control group (n = 212) with the following preoperative variables: type of organ transplanted, age, gender, race, body mass index, MELD, redo-transplantation, preoperative renal replacement therapy, nonalcoholic steatohepatitis, viral hepatitis, diabetes, and coronary artery disease. A 1:4 ratio was utilized to improve the efficiency and power of the analysis. RESULTS: No significant difference in survival or posttransplant cardiac complications (acute coronary syndrome, heart failure, or dysrhythmia) was observed between groups. However, statistically significantly more patients-11% (6/53)-required coronary intervention following OLT in the AV group, whereas 3% (7/212) required coronary intervention (χ2 = 5.8; P = .0156) in the control group. Following OLT, 9% (5/53) in the AV group required surgical or nonsurgical AV intervention, whereas no valvular events were observed in the control group. Event-free survival in the AV group, with an end point defined as AV intervention (n = 5) and death (n = 10), was 92% (49/53) at 1 year, 83% (44/53) at 3 years, and 72% (38/53) at 5 years. CONCLUSIONS: Patients with pretransplant AV replacement or AS have significant cardiac complications (myocardial infarction, AV replacement, or cardiac death) in 1 to 3 years post-OLT.

Using the Minimally Invasive Impella 5.0 via the Right Subclavian Artery Cutdown for Acute on Chronic Decompensated Heart Failure as a Bridge to Decision.

BACKGROUND: Outcomes of traditional mechanical support paradigms (extracorporeal membrane oxygenation, intraaortic balloon pump [IABP], and permanent left ventricular assist device [LVAD]) in acute decompensated heart failure have generally been suboptimal. Novel approaches, such as minimally invasive LVAD therapy (Impella 5.0 device), promise less invasive but equivalent hemodynamic support. However, it is yet unknown whether the outcomes with such devices support widespread acceptance of this new technology. We recently started utilizing the right subclavian artery (RSA) for Impella 5.0 implantation and report our early experience and outcomes with this novel approach. METHODS: A single-center retrospective review was performed of 24 patients with acute on chronic decompensated heart failure who received the Impella 5.0 via the RSA from June 2011 to May 2014. The device was implanted via a cutdown through an 8-mm vascular graft sewn to the RSA. The device was positioned with fluoroscopy and transesophageal echocardiography. RESULTS: The mean age of the patients was 51.29 years, and 75% were male. At implantation, all patients were mechanically ventilated on at least 2 inotropes with persistent cardiogenic shock, and 17 (70.8%) were on IABP support. Postimplantation, 21 (87.5%) tolerated extubation, and all 17 of the patients with IABPs tolerated discontinuation of IABP support. The reduction in the Model for End-Stage Liver Disease score preimplantation vs postimplantation was statistically significant (21.17 vs 14.88, P=0.0014), suggesting improvement in end organ function. A significant decrease was also seen in creatinine levels before and after implantation (2.17 mg/dL vs 1.50 mg/dL, P=0.0043). The endpoint of support included recovery in 6 patients (25.0%), permanent LVAD in 9 (37.5%), and heart transplantation in 2 (8.3%). Death occurred in 7 patients (29.2%) as a result of multisystem organ failure, infection, or patient withdrawal of care. CONCLUSION: Minimally invasive LVAD therapy using the Impella 5.0 via the RSA cutdown is an attractive option in acute on chronic decompensated heart failure. Improvement in end organ function allows for transition to recovery or to advanced surgical therapies such as permanent LVAD and heart transplantation. Significant advantages to this approach include improved left ventricular unloading, lower anticoagulation need, and the potential for ambulation and physical therapy.

Management of Patients Admitted with Acute Decompensated Heart Failure.

BACKGROUND: Hospital admission for the treatment of acute decompensated heart failure is an unfortunate certainty in the vast majority of patients with heart failure. Regardless of the etiology, inpatient treatment for acute decompensated heart failure portends a worsening prognosis. METHODS: This review identifies patients with heart failure who need inpatient therapy and provides an overview of recommended therapies and management of these patients in the hospital setting. RESULTS: Inpatient therapy for patients with acute decompensated heart failure should be directed at decongestion and symptom improvement. Clinicians should also treat possible precipitating events, identify comorbid conditions that may exacerbate heart failure, evaluate and update current guideline-directed medical therapy, and perform risk stratification for all patients. Finally, efforts should be made to educate patients about the importance of restricting salt and fluid, monitoring daily weights, and adhering to a graded exercise program. CONCLUSION: Early discharge follow-up and continued optimization of guideline-directed medical therapy are key to preventing future heart failure readmissions.

Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients.

Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range = 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests.

Ventricular fibrillation complicating endomyocardial biopsy of transplanted heart.

Life-threatening arrhythmia is an unusual complication of endomyocardial biopsy in transplanted heart. Herein we described a case of VF during endomyocardial biopsy. The possibility of VF during a biopsy necessitates immediate access to defibrillation during endomyocardial biopsy.

Induced hypothermia prior to left ventricular assist device.

Induced hypothermia, a therapy that recently gained the attention of a broad spectrum of US and international medical authorities for its neuroprotective benefits in post-cardiac arrest patients, may represent an underexplored therapeutic option in patients with severe cardiac failure by optimizing hemodynamics and augmenting cardiac contractility. The authors present the first case report, to their knowledge, of a patient with severe congestive heart failure who underwent cooling prior to successful left ventricular assist device implantation.

Innovative application of immunologic principles in heart transplantation.

BACKGROUND: Each year, approximately 2,200 heart transplants are performed in the United States. As our understanding of the immune system grows, new tools are being developed to find compatible organ donors and to help with immune surveillance after transplantation. The purpose of this article is to review 3 of these techniques: the virtual crossmatch, the Cylex ImmuKnow assay, and the AlloMap test. METHODS: Two authors (S.A.M. and J.C.) independently performed a literature search with the PubMed database using the key words ImmuKnow, Allomap, and virtual crossmatch in conjunction with heart transplantation. Articles were selected for inclusion if they had a primary focus on the use of virtual crossmatch in heart transplantation, the Cylex ImmuKnow assay, and the AlloMap test. Articles were not excluded on the basis of sample size but were excluded if they did not include heart transplant patients. RESULTS: The virtual crossmatch is a technique that is being used successfully in heart transplant candidates to predict compatibility of donor organs by comparing the potential recipient's HLA-specific antibodies with the HLA type of the prospective donor. The ImmuKnow assay is a noninvasive blood test that measures the strength of immune activity, allowing clinicians to predict risk of infection and possible rejection in heart transplant patients. The AlloMap test is a noninvasive test that quantifies intracellular mRNA levels in mononuclear cells in peripheral blood samples using real-time polymerase chain reaction; this test has been shown to distinguish the dynamic changes in gene expression that occur in the presence or absence of acute cellular rejection. CONCLUSION: As the science of transplant immunology advances, transplant cardiologists are taking advantage of the growing fund of knowledge to help their sensitized transplant candidates increase their chances of finding a compatible donor heart and are using commercially available tests to monitor the immune system and rule out rejection after transplantation.

Posttransplant pacemaker placement: case series and review.

INTRODUCTION: Sinus node dysfunction (SND) following orthotopic heart transplantation may lead to bradycardia, atrioventricular block, sick sinus syndrome, syncope, and death, with 6%-23% of patients requiring pacemakers. METHODS: Permanent pacemakers were placed in 5% of orthotopic heart transplants conducted at our institution from January 2002 to October 2008. RESULTS: THREE DIFFERENT IMPLANT TECHNIQUES WERE USED OVER THIS TIME: (1) dual-chamber pacing in the donor atrium and ventricle (A(D)-V(D)) (62.5%); (2) single lead in the donor atrium (A(D)) (12.5%); and (3) dual leads placed in both donor and recipient atrium (A(R)-A(D)) (25%). Using the percentage of paced histograms recorded in the device, heart rate variability for the types of lead placements were 14% for A(D)-V(D), 35% for A(D), and 97% for A(R)-A(D). DISCUSSION: The transplanted heart is characterized physiologically by autonomic denervation and chronotropic incompetence. Restoration of chronotropic competence by atrial pacing increases exercise duration and peak VO(2). Rate responsiveness can be achieved in this patient population with the placement of one lead in the remnant right atrium and one lead in the transplanted donor right atrium.

Metabolic parameters derived from cardiopulmonary stress testing for prediction of prognosis in patients with heart failure: the ochsner experience.

Cardiopulmonary parameters, particularly peak oxygen consumption, have proven utility in prognostic stratification for patients with heart failure. These have been typically corrected for total body weight as opposed to lean body mass (LBM). For practical purposes, fat consumes virtually no oxygen and receives minimal perfusion. Based on this rationale and on observations from previous studies, several investigations conducted at the Ochsner Clinic Foundation have assessed the prognostic value of metabolic parameters when corrected for LBM. Three studies reviewed in this discussion consistently found greater prognostic value for LBM-corrected parameters, especially peak oxygen consumption and oxygen pulse. These findings lead to a strong recommendation for LBM correction of cardiopulmonary exercise stress test-derived parameters for more accurate prognostic stratification in patients with heart failure, especially in the obese population. Other centers have studied additional parameters such as the ventilation to carbon dioxide production slope, oxygen uptake efficiency slope, and partial pressure of end-tidal carbon dioxide during exercise and rest. In multiple studies, these ventilation-dependent parameters have shown prognostic superiority compared with the standard peak oxygen consumption even when obtained from submaximal exercise data. However, no study to our knowledge has compared these parameters with LBM-adjusted values as described herein. The prognostic validity of cardiopulmonary exercise stress test-derived parameters requires further investigation in patients treated with ß-blockers.

Pulmonary hypertension for primary care providers.

Pulmonary hypertension is a constellation of diseases that shares signs and symptoms of dyspnea, fatigue, chest pain, palpitations, and syncope. Research advances made over the past decade have significantly changed the natural history of this disease. Therapies initially designed to specifically target the molecular causes of increased pulmonary vascular resistance are now used in all types of patients with pulmonary hypertension. The challenge of the primary care physician is first, identifying pulmonary hypertension, and second, determining the modifiable substrates that contribute to the development and symptoms of this disease.