Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience.

Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation. Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups. Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases). Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.

[The predictive value of DE-CMR in patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber].

OBJECTIVE: To determine whether preoperative contrast delay-enhanced cardiovascular magnetic resonance imaging (DE-CMR) could help predict long-term survival of patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber after aortic valve replacement. METHODS: Totally 37 patients enrolled between February 2008 and November 2010 with severe chronic aortic regurgitation and extremely dilated left ventricular chamber, who met the echo criteria, that was left ventricular end diastolic dimension > 70 mm or left ventricular end systolic dimension > 55 mm, and were scheduled to the surgery. The 2-dimensional echocardiographic examinations and CMR with late gadolinium-enhancement (LGE) were performed routinely preoperatively. According to the results of CMR, the patients were divided into 2 groups: the LGE positive(+) group and LGE negative(-) group. The association of LGE with event free survival, postoperative cardiac function and postoperative hospital stay time was investigated. Fifteen patients had significant LGE signals in CMR films, while the other twenty-two were silent. All of them received the operative procedures, including aortic valve replacement in 28 cases, Bentall procedure in 3 cases, aortic valve replacement and ascending aorta replacement in 6 cases, and concomitant mitral valve repair in 11 cases. RESULTS: Over a follow-up of 33.6 months, 1-year, 2-year and 3-year event free survival rates in LGE(-) group were 94.7%, 88.4%, and 72.6%, respectively, compared to 80.0%, 48.9%, and 32.6%, respectively in LGE(+) group (χ(2) = 7.244, P = 0.007). The postoperative hospital stay time of LGE(-) group was (9 ± 2) days, which of LGE(+) group was (10 ± 3) days (t = 1.175, P = 0.248). CONCLUSIONS: LGE positive signal in CMR films is a potential predictor of persistent cardiac failure after aortic valve replacement for patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber. It has intimate relationship with malignant arrhythmia and sudden death, which makes it a valuable technique in preoperative evaluation and risk stratification.

[Goal-directed renal replacement therapy for acute kidney injury after cardiac surgery].

OBJECTIVE: To compare the efficacy and safety of goal-directed renal replacement therapy(GDRRT) and daily high volume hemofiltration (dHVHF) in the treatment of acute kidney injury (AKI) after cardiac surgery. METHODS: Clinical data from 128 patients received either GDRRT (n = 64) or dHVHF (n = 64) for AKI after cardiac surgery were analyzed retrospectively. parameters examined included: urea nitrogen, serum creatinine (SCr, before and after treatment), heart rate, mean artery pressure (MAp, recorded within 72 hours after the initiation of renal replacement therapy). The hospital mortality, day-28 mortality, renal function recovery rate, and the incidence of adverse events in the two groups were also compared. RESULTS: The hospital mortality was 43.75% for both GDRRT and dHVHF treated patients (group). The day-28 mortality in GDRRT group were slightly lower, but the difference was not significant (43.75% vs. 57.81%, P = 0.055). Also no significant difference was found between the two groups in hospital stay. The patients received dHVHF had longer intensive care unit (ICU) stay (hours) and duration of mechanical ventilation (days) as compared to the patients received GDRRT [356.5 (176.3, 554.6) vs. 238.3 (119.6, 440.9), P = 0.023; 8.0 (5.0, 16.0) vs. 6.0 (3.0, 13.5), P = 0.042]. The logistic regression analyses showed that complete renal function recovery rate in GDRRT group was significantly higher (39.1% vs. 18.8%, P < 0.01). The partial renal function recovery rate in GDRRT group was slightly lower but not statistically different from dHVHF group (3.1% vs. 9.4%, P > 0.05). In dHVHF group, the maximum SCr during the treatment, and the SCr before discharge were both significantly higher than GDRRT group (µmol/L: SCr maximum 559.0 ± 236.0 vs. 440.4 ± 192.0, SCr before discharge 381.4 ± 267.0 vs. 271.2 ± 164.4, both P < 0.01). No significant difference was found between the two groups in incidence of hypotension (35.9% vs. 37.5%) and MAP (mm Hg, 1 mm Hg=0.133 kPa, 82 ± 13 vs. 81 ± 15) 72 hours into the therapy (both P > 0.05). The incidence of tachycardia, and incidence of blood coagulation were both higher in dHVHF group (78.1% vs. 59.4%, 35.9% vs. 20.3%, both P < 0.05). However, the hospitalization expense (thousand yuan) was significantly higher for dHVHF group (15.00 ± 2.80 vs. 9.85 ± 3.00, P < 0.01). CONCLUSION: For patients with post-cardiac surgery AKI, GDRRT and dHVHF are very similar in terms of short-term survival rate and safety. But GDRRT is superior for renal function recovery and cost saving.

[Orthotopic heart transplantation: clinical experience on 56 patients].

OBJECTIVE: To summarize the clinical experience on 56 patients undergoing orthotopic heart transplantation. METHODS: Between May 2000 and December 2003 56 patients, 47 with cardiomyopathy, 2 with end-stage valvular heart disease, 2 with end-stage ischemic heart disease, 2 with primary malignant cardiac tumor, 1 with complicated congenital heart disease, 1 with muscular dystrophy cardiomyopathy, and 1 with refractory malignant ventricular arrhythmias, underwent orthotopic heart transplantation in the Transplantation Center of Fudan University. The operative procedures included 19 conventional Stanford orthotopic cardiac transplantation in 19 cases and bicaval anastomotic cardiac transplantation in 37 cases. Postoperatively, the patients were prescribed with cyclosporine A + corticosteroids + MMF or FK506 + corticosteroids + MMF as anti-rejection therapy. RESULTS: One patient undergoing his fifth operation died of bleeding 3 days after operation. All survivors were followed-up for 12.4 months on average. Five patients died within 1 year postoperatively with a one-year survival rate of 91%. One patient died of allograft vasculopathy 38 months after operation. Other patients enjoyed heart function recovering to class I-II (NYHA). CONCLUSION: With proper recipient selection, excellent donor heart conservation, bicaval anastomotic technique, and efficient postoperative surveillance and treatment, heart transplantion may produce satisfying mid-term results.