A 5-year single-center early experience of heart transplantation from donation after circulatory-determined death donors.

BACKGROUND: In an effort to address the increasing demand for heart transplantation within the United Kingdom (UK), we established a clinical program of heart transplantation from donation after circulatory-determined death (DCD) donors in 2015. After 5 years, we report the clinical early outcomes and impact of the program. METHODS: This is a single-center, retrospective, matched, observational cohort study comparing outcomes of hearts transplanted from DCD donors from March 1, 2015 to February 29, 2020 with those from matched donation after brain death (DBD) donors at Royal Papworth Hospital (RPH) (Cambridge, UK). DCD hearts were either retrieved using thoracoabdominal normothermic regional perfusion or the direct procurement and perfusion technique. All DBD hearts were procured using standard cold static storage. The primary outcomes were recipient 30-day and 1-year survival. RESULTS: During the 5-year study, DCD heart donation increased overall heart transplant activity by 48% (79 for DCD and 164 for DBD). There was no difference in survival at 30 days (97% for DCD vs 99% for DBD, p = 1.00) or 1 year (91% for DCD vs 89% for DBD, p = 0.72). There was no difference in the length of stay in the intensive care unit (7 for DCD vs 6 for DBD days, p = 0.24) or in the hospital (24 for DCD vs 25 for DBD days, p = 0.84). CONCLUSIONS: DCD heart donation increased overall heart transplant activity at RPH by 48%, with no difference in 30-day or 1-year survival in comparison with conventional DBD heart transplantations. DCD heart donation is set to make a dramatic difference in the number of patients who can benefit from heart transplantation.

Regional extracorporeal membrane oxygenation retrieval service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: an interdisciplinary team approach to maintain service provision despite increased demand.

OBJECTIVES: Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing. METHODS: The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO. RESULTS: We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport. CONCLUSIONS: Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.

Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes.

BACKGROUND: Vasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx. METHODS: Patients undergoing LVAD explant followed by HTx from 01/2013-12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 µg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database. RESULTS: During the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 vs. 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% vs. 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% vs. 100% P=0.99) and 1-year (67.7% vs. 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period. CONCLUSIONS: Vasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.

Emergency valve-in-valve transcatheter aortic valve implantation for endocarditis degeneration.

The use of transcatheter aortic valve implantation (TAVI) in the emergency setting has not been widely reported, and TAVI is generally contraindicated in the context of endocarditis. Here we describe a patient developing acute cardiogenic shock due to prosthetic aortic valve degeneration with free-flow aortic regurgitation 8 months after receiving treatment for confirmed infective endocarditis. Due to his clinical status, he was deemed unfit for redo surgery, and he underwent salvage valve-in-valve (ViV)-TAVI. The patient made an excellent recovery. Postprocedure he was treated with a 6-week course of antibiotics, and at 18-months follow-up remains very well with no evidence of reinfection. This case may demonstrate that for selected patients with degenerative prosthetic aortic valve disease, despite a history of infective endocarditis, ViV-TAVI may be considered an alternative to redo surgery in the emergency setting.

Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes. DESIGN: A retrospective case series. SETTING: A tertiary referral cardiothoracic transplantation center. PARTICIPANTS AND INTERVENTIONS: Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central). MEASUREMENTS AND MAIN RESULTS: All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%. CONCLUSIONS: The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.

An Incidental Finding at Transplant Assessment: Case Report.

A 43-year-old woman with chronic hypersensitivity pneumonitis was referred for lung transplant assessment. An echocardiogram as part of her work-up revealed a large left atrial myxoma, presenting a conundrum on how best to manage her combined pathology. Because of the level of pulmonary disease, early intervention to remove the myxoma was not thought be viable without postoperative support. Use of extracorporeal membrane oxygenation to bridge patients for lung transplant is feasible, yet risks increased perioperative mortality. We present the first reported case of simultaneous cardiac myxoma removal and lung transplant.

Bilateral versus Single Internal-Thoracic-Artery Grafts at 10 Years.

BACKGROUND: Multiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG. METHODS: We randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. RESULTS: A total of 1548 patients were randomly assigned to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intention-to-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P=0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). CONCLUSIONS: Among patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. (Funded by the British Heath Foundation and others; Current Controlled Trials number, ISRCTN46552265 .).

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement.

OBJECTIVE: Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR. METHODS: This pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population. RESULTS: In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR, 0.874; 95% confidence interval [CI], 0.668-1.143; P = .3246) or time to fitness for discharge (HR, 0.907; 95% CI, 0.688-1.197; P value = .4914). During a mean follow-up of 760 days (745 days for the MS group and 777 days for the FS group), 12 patients (10%) in the MS group and 7 patients (7%) in the FS group died (HR, 1.871; 95% CI, 0.723-4.844; P = .1966). Average extra cost for MS was £1714 during the first 12 months after AVR. CONCLUSIONS: Compared with FS for AVR, MS did not result in shorter hospital stay, faster recovery, or improved survival and was not cost-effective. The MS approach is not superior to FS for performing AVR.

Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation.

OBJECTIVES: Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness. METHODS: In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS: More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20-3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76-5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64-1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321-£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS: Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term. Study registration: ISRCTN82731440 (project number 07/01/34).

Outcome after heart transplantation from donation after circulatory-determined death donors.

BACKGROUND: The requirement for heart transplantation is increasing, vastly outgrowing the supply of hearts available from donation after brain death (DBD) donors. Transplanting hearts after donation after circulatory-determined death (DCD) may be a viable additive alternative to DBD donors. This study compared outcomes from the largest single-center experience of DCD heart transplantation against matched DBD heart transplants. METHODS: DCD hearts were retrieved using normothermic regional perfusion (NRP) or direct procurement and perfusion (DPP). During NRP, perfusion was restored to the arrested heart within the donor with the exclusion of the cerebral circulation, whereas DPP hearts were removed directly. All hearts were maintained on machine perfusion during transportation. A retrospective cohort of DBD heart transplants, matched for donor and recipient characteristics, was used as a comparison group. The primary outcome measure of this study (set by the United Kingdom regulatory body) was 90-day survival. RESULTS: There were 28 DCD heart transplants performed during the 25-month study period. Survival at 90 days was not significantly different between DCD and matched DBD transplant recipients (DCD, 92%; DBD, 96%; p = 1.0). Hospital length of stay, treated rejection episodes, allograft function, and 1-year survival (DCD, 86%; DBD, 88%; p = 0.98) were comparable between groups. The method of retrieval (NRP or DPP) was not associated with a difference in outcome. CONCLUSIONS: These results suggest that heart transplantation from DCD heart donation provides comparable short-term outcomes to traditional DBD heart transplants and can serve to increase heart transplant activity in well-selected patients.

Delayed Diagnosis of Q Fever: Finally Diagnosed After Elective Cardiac Surgery.

Q fever is a bacterial infection caused by Coxiella burnetti. It can cause both acute and chronic illness. Chronic QF can present as a variety of clinical syndromes. A common and critical manifestation is endocarditis which can present atypically and is easily missed. This case describes a man who, after extensive investigation for splenomegaly and pancytopenia by several specialties, was finally diagnosed with Q fever endocarditis after unexpected aortic valve abnormalities found during elective cardiac surgery. Several factors contributed to diagnostic delay including aspects of clinical assessment and radiologic findings. Vigilance is essential for diagnosis and prompt initiation of effective treatment.

Size matching in lung transplantation: an evidence-based review.

The evidence base for size matching between donors and recipients in lung transplantation has not recently been reviewed in a comprehensive manner. Our aim in this study was to assimilate published studies that have addressed size matching of donors to recipients and to establish a pragmatic understanding of the range of lung sizes that may be used for lung transplantation. A comprehensive literature search was performed using Medline and PubMed up to and including September 2012, to identify scientific articles that relate to size matching between donors and lung transplant recipients. Seventy-two articles were identified, of which 21 had addressed the question of the impact of size mismatching on outcomes in lung transplantation. No study has specifically tested the consequences of intentionally mismatching above or below the hypothetical limits for double lung transplantation of a predicted total lung capacity for the donor of between 75% and 125% of the recipient predicted total lung capacity as set out in the ISHLT consensus report on lung donor acceptability criteria. Research is lacking that has robustly defined limits for size mismatch for single lung transplantation and for recipients with restrictive lung pathologies such as pulmonary fibrosis. Published research on the impact of size mismatching between lung transplant donors and recipients is limited by study design and size. It is centered on addressing the issue of mismatch in double lung transplantation in cohorts with a diagnostically heterogeneous make-up and in single lung transplant patients with chronic obstructive pulmonary disease.

Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension.

OBJECTIVES: Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy. METHODS: Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed. RESULTS: Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05). CONCLUSIONS: In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.

Comparison of outcomes from smoking and nonsmoking donors: thirteen-year experience.

BACKGROUND: Lung transplantation remains the best treatment option for a variety of end-stage lung diseases. Pressure on the limited donor pool has led to the use of extended criteria donors. One aspect of this has been the liberalization of the use of smoking donors (SmD). METHODS: This study is a retrospective review of lung transplants performed between April 1995 and August 2008 at a single institute. We examined the impact of donor smoking on short-term and long-term survival in relationship to recipient and donor demographics such as ischemic time, cytomegalovirus status, rates of rejection and infection, ventilation, and intensive care stay. Endpoints were survival, infection, and rejection. RESULTS: During this 13-year period, 454 lung transplants were performed. Smoking history was available on 424 (93.4%) of these (SmD, n = 184; NSmD, n = 240). Seventy-one patients died within 3 months of transplant leaving 353 alive at 3 months posttransplant. Fatalities within the first 3 months were significantly higher in the SmD group (21% vs 13%, odds ratio 1.9, hazard ratio 3.3, p = 0.04). No significant difference in rejection and infection rates between recipients of lungs from SmD and NSmD at 3 months and at 1 year posttransplantation (p = 0.51 and 0.09) was found. Although recipients of lungs from SmD had higher odds of ventilation for more than 10 hours, the odds were only increased by 20%, which was not statistically significant. Recipients from SmD had significantly longer stays in the intensive care (odds ratio 1.9, p = 0.002). There was little evidence for an effect of SmD on the development of bronchiolitis obliterans. CONCLUSIONS: In this large cohort of patients, donor smoking history has an effect on early survival but no effect on long-term survival. The cause of this early mortality is independent of infection and rejection. However, these data suggest that overall outcomes from the use of donor lungs from smokers are acceptable, particularly in the current era with limited donor organs.

Perioperative outcomes in hybrid versus conventional surgical coronary artery revascularisation.

A best evidence topic was written on perioperative outcomes in hybrid coronary revascularisation according to a structured protocol. The question addressed was 'In patients with stable multivessel coronary artery disease, does the use of hybrid coronary revascularisation compared to conventional and off-pump coronary artery bypass grafting (CABG) reduce perioperative morbidity and mortality?' Six hundred and twenty-three papers were found in the literature search. From these results, six comparative studies and one review paper appeared to be relevant. The authors, journal, date and country of publication, patient group studied, study type, relevant results and weaknesses of these papers were compiled and tabulated. Critical appraisal ruled out three of the six comparative studies identified by the search. Therefore, the following papers constituted best evidence. de Cannière et al. reported a non-randomised retrospective comparison of staged hybrid revascularisation with conventional CABG, showing an association with shorter intensive care unit and total hospital stays, as well as shorter time to return to work. Kon et al. reported a non-randomised retrospective comparison of simultaneous hybrid revascularisation with off-pump CABG, showing that fewer blood transfusions were required in addition to shorter intensive care and hospital stays. Vassiliades et al. reported a non-randomised retrospective comparison of staged hybrid revascularisation with off-pump CABG, which failed to show a difference between 30-day major adverse cardiac events in the two patient groups. DeRose reviewed 13 published series of hybrid revascularisation cases, concluding that experienced centres should consider hybrid revascularisation as an appropriate alternative to conventional CABG for selected patients. In summary, these papers provide limited evidence of improved perioperative outcomes in both staged and simultaneous hybrid revascularisation compared to CABG. Weaknesses of the comparative studies include the lack of mid-term and long-term follow-up and the difficulty of generalising results from specialist units to general cardiac surgical practice. A large randomised control trial comparing hybrid revascularisation and coronary artery bypass with mid-term follow-up will be required to establish the clinical effectiveness of this procedure.

Thoratec implantable ventricular assist device: the Papworth experience.

OBJECTIVE: The Thoratec (Thoratec Corp, Pleasanton, Calif) implantable ventricular assist device (IVAD) can be used for univentricular or biventricular support. The objective of this study is to review the 5-year experience of bridging patients to heart transplantation with this device in a single center. Surgical aspects, including hybrid pump pocket, double tunneling of driveline, and optimal cannulae placement, are discussed. METHODS: This is a retrospective review of 24 patients treated between January 2002 and December 2007. Nineteen patients (79.1%) received a single implantable ventricular assist device as left ventricular assist devices, and 5 patients (21.9%) received 2 implantable ventricular assist devices as biventricular assist devices. The devices were implanted in pre-peritoneal/posterior rectus hybrid pump pockets. The driveline was passed through a 2-stage double-tunnel to exit onto the lateral chest wall. Patients were anticoagulated with Warfarin aiming for an international normalized ratio of 2.0 to 3.0. RESULTS: Twenty male and 4 female patients with a mean age of 39.8 years (17-57 years) and a body surface area of 1.87 m(2) (1.63-2.2 m(2)) were supported for a total of 2308 patient-days. Mean duration of support was 96 days (10-301 days). The cause of heart failure was dilated cardiomyopathy in 18 patients and ischemic cardiomyopathy in 6 patients. Preoperatively, 23 patients were receiving inotropes, 12 patients required intra-aortic balloon pump support, 5 patients were intubated and mechanically ventilated, and 3 patients required continuous venovenous hemofiltration for renal support. Eleven patients (45.8%) were discharged with ventricular assist device support (1015 home patient-days). Complications observed were a) neurologic: stroke in 3 patients, transient ischemic attacks in 4 patients; and b) infection: driveline infection in 3 patients and pump pocket infection in 1 patient. There was no mechanical device failure. Support to transplantation was achieved in 17 patients (70.8%): 3 of 5 biventricular assist devices (60%) and 14 of 19 left ventricular assist devices (73.7%). CONCLUSION: The Thoratec IVAD is a versatile and reliable ventricular assist device. It can provide univentricular or biventricular support for bridging patients to heart transplantation with acceptable complication rates. The portable Thoratec TLC-II console facilitated discharge while patients waited for a suitable donor heart.

Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation.

OBJECTIVE: Cardiac arrest in the organ donor raises concerns about the possibility of ischemic cardiac damage. We evaluated the outcome of heart transplantation in patients receiving an organ from donors who had suffered a period of cardiac arrest. METHODS: Demographics, operative details and outcome data were obtained retrospectively. Actuarial survival was reported using Kaplan-Meier analysis and compared with the log rank test. Cox proportional hazards regression was used to model risk adjusted survival. RESULTS: Between 1 January 1991 and 1 November 2004 38 patients were transplanted with hearts from multiorgan donors who were resuscitated after a cardiac arrest. The mean (standard deviation) duration of cardiac arrest was 15 (8)min. The interval between donor cardiac arrest and organ excision was 69 (5)h. The 30-day mortality was 2.6% (1/38). In the same interim 566 patients underwent cardiac transplantation with hearts from organ donors without a cardiac arrest. Median time to follow up was 61 months (IQR 15-166). One and 5-year survival comparing the arrest and non-arrest groups was 94.2% versus 83.6% and 79.8% versus 74.5%, respectively, p=0.35. Donor cardiac arrest was not an adverse predictor of mortality on multivariate analysis, the adjusted odds ratio was 0.86 (95% CI 0.60-1.25, p=0.42). CONCLUSIONS: With careful case selection, there was no evidence that survival after cardiac transplantation was worse following a period of cardiac arrest in the organ donor. A history of cardiac arrest in the organ donor should not exclude an organ from being considered for transplantation.

The impact of altitude on early outcome following the Fontan operation.

BACKGROUND: The success of a Fontan circulation depends on several factors including low pulmonary vascular resistance. Pulmonary vascular resistance rises in response to hypoxia. Hypoxia is associated with altitude. Therefore, we wondered whether altitude is a risk factor for early failure after the Fontan operation. The aim was to test this hypothesis. METHODS: Data were obtained from all published series of 'total cavopulmonary' Fontan operations since 1990. The early failure rate from each series and the altitude of the respective cities were recorded. Early failure was defined as death, takedown of Fontan, or transplantation during the same hospital admission. The association between altitude and failure rate was investigated by rank correlation and logistic regression. RESULTS: 24 series were identified from centres situated at altitudes ranging from sea level to 520 metres. The plot of failure rate versus altitude suggests that failure rate increases with altitude. Logistic regression did not fit the data adequately. This was possibly due to the influence of unmeasured and unknown factors affecting the results, as well as the fact that centres were not randomly chosen but were self-selected by virtue of publishing their results. However, Spearman's rank correlation was 0.74 (p = 0.001). CONCLUSION: The early outcome of the Fontan circulation appears to be adversely affected by altitude.

Repair of coarctation of the aorta in infants weighing less than 2 kilograms.

BACKGROUND: We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients. METHODS: Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1). RESULTS: Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair. CONCLUSIONS: Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.