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The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 04/2012; 31(6):672-3. · 3.54 Impact Factor
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The Annals of thoracic surgery 10/2011; 92(4):1529. · 3.74 Impact Factor
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The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 09/2011; 30(12):1421-2. · 3.54 Impact Factor
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ABSTRACT: Mechanical circulatory support (MCS) may be used for severe graft failure after heart transplantation, but the degree to which it is lifesaving is uncertain.
Between June 1990 and December 2009, 53 patients after 1417 heart transplants (3.7%) required post-transplant MCS for acute rejection (n=17), biventricular failure (n=16), right ventricular failure (n=16), left ventricular failure (n=1), or respiratory failure (n=3). Although support was occasionally instituted remotely post-transplant (5>1 year), in 39 (73%) instances it was required within 1 week. Initial mode of support was extracorporeal membrane oxygenation in 43 patients (81%), biventricular assist device in 4 (7.5%), and right ventricular assist device in 6 (11%).
Risk of requiring respiratory support was highest in those with restrictive cardiomyopathy as indication for transplant, women, and those with elevated pulmonary pressure or renal failure. Complications of support, which increased progressively with its duration, included stroke in two patients (3.8%), infection in two (3.8%), and reoperation for bleeding (seven instances) in four (7.0%). Nineteen patients (36%) recovered and were removed from support, five (9.4%) underwent retransplantation (four after biventricular failure and one after acute rejection), and 29 died while on support (55%). Overall survival after initiating support was 94%, 83%, 66%, and 43% at 1, 3, 7, and 30 days, respectively. Patients requiring support for biventricular failure had better survival than those having acute rejection or other indications (P=0.03). Survival after retransplantation or removal from support following recovery was 88% at 1 year and 61% at 10 years.
Severe refractory heart failure after transplantation is a rare catastrophic event for which MCS offers the possibility of recovery or bridge to retransplantation, particularly for patients with biventricular failure in the absence of rejection. Early retransplantation should be considered in patients who show no evidence of graft recovery on MCS.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 06/2011; 41(1):200-6; discussion 206. · 2.40 Impact Factor
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Randall C Starling,
Yoshifumi Naka,
Andrew J Boyle, Gonzalo Gonzalez-Stawinski,
Ranjit John,
Ulrich Jorde,
Stuart D Russell,
John V Conte,
Keith D Aaronson,
Edwin C McGee,
William G Cotts,
David DeNofrio,
Duc Thinh Pham,
David J Farrar,
Francis D Pagani
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ABSTRACT: The aim of this study was to determine whether results with the HeartMate (HM) II left ventricular assist device (LVAD) (Thoratec Corporation, Pleasanton, California) in a commercial setting are comparable to other available devices for the same indication.
After a multicenter pivotal clinical trial conducted from 2005 to 2008, the U.S. Food and Drug Administration approved the HM II LVAD for bridge to transplantation (BTT). A post-approval study was required by the U.S. Food and Drug Administration to determine whether results with the device in a commercial setting are comparable to other available devices for the same indication.
The study was a prospective evaluation of the first 169 consecutive HM II patients enrolled in the national INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) who were listed for transplant or likely to be listed. Patients were enrolled from April through August 2008 at 77 U.S. centers and followed for at least 1 year after implant. A comparison group (COMP) included all patients (n = 169 at 27 centers) enrolled in the INTERMACS registry with other types of LVADs (79% HeartMate XVE, 21% Implantable Ventricular Assist Device [Thoratec Corporation]) for the same BTT indication in the same time period. Survival rates, adverse events, and quality of life with the EuroQol EQ-5D visual analog scale were obtained in the INTERMACS registry.
Baseline characteristics were similar, but creatinine and blood urea nitrogen were lower in the HM II versus COMP groups, and there were fewer patients in the highest-risk INTERMACS patient profile Number 1 (24% for HM II vs. 39% for COMP). Adverse event rates were similar or lower for HM II versus COMP for all events. Bleeding was the most frequent adverse event for both groups (1.44 vs. 1.79 events/patient-year). Operative 30-day mortality for HM II was 4% versus 11% for COMP. The percentage of patients reaching transplant, cardiac recovery, or ongoing LVAD support by 6 months was 91% for HM II and 80% for COMP, and the Kaplan-Meier survival for patients remaining on support at 1 year was 85% for HM II versus 70% for COMP. Quality of life was significantly improved at 3 months of support and sustained through 12 months in both groups compared with baseline.
The results in a post-market approval, actual patient care setting BTT population support the original findings from the pivotal clinical trial regarding the efficacy and risk profile of the HM II LVAD. These data suggest that dissemination of this technology after approval has been associated with continued excellent results.
Journal of the American College of Cardiology 05/2011; 57(19):1890-8. · 14.16 Impact Factor
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ABSTRACT: 67-year-old female with left ventricular assist device (LVAD) presented with recurrent low-flow alarms. No clear etiology could be determined by history, or evaluation with radiograph and echocardiogram. Computed tomographic (CT) imaging with 3-D and 4-D assessment identified the abnormality as steep angulation of the inflow cannula and partial obstruction by the adjacent anterior wall, likely in part caused by recovered left ventricular function and reverse remodeling. Improved left ventricle size and function was correlated by semi-automated analysis of CT data, which also indicated mild right ventricle dilation and systolic dysfunction. LVAD explantation was performed, and has been well tolerated by the patient. Echocardiography remains the primary imaging modality to assess patients post LVAD placement, but in this instance CT provided valuable information to identify the abnormality and help direct patient management. CT assessment in patients with LVAD additionally provides valuable information prior to redo sternotomy for pump explantation, revision, or transplantation.
Journal of cardiovascular computed tomography 01/2011; 5(3):186-8.
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Journal of the American College of Cardiology 06/2010; 55(23):2607. · 14.16 Impact Factor
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ABSTRACT: The primary objective of this study was to analyze perioperative intra-aortic balloon pump (IABP) insertion in patients undergoing cardiac surgery in the authors' institution from 1995 to 2005 and to propose an explanation for changes in use over this period. A secondary objective was to assess patient variables associated with IABP use.
This is a retrospective study including patients who underwent cardiac surgery between 1995 and 2005.
The Cardiothoracic Anesthesia Patient Registry of a single teaching institution was queried to obtain the required information.
Thirty thousand two hundred sixty-nine cardiac surgery patients.
Intra-aortic balloon pump insertion before surgery, after cardiopulmonary bypass, or in the cardiovascular intensive care unit was assessed in patients who underwent isolated coronary artery bypass graft surgery, valve surgery, or both. Select patient variables were analyzed for their association with IABP insertion. Transesophageal echocardiography (TEE) examinations, milrinone use, and mortality rates also were determined.
Among 30,269 cardiac surgery patients, 1,310 (4.32%) underwent IABP insertion. Combined preoperative, intraoperative, and postoperative IABP use decreased from 7.8% in 1995 to 3.0% in 2005. Simultaneously, the intraoperative use of milrinone increased from 4.8% to 8.8% and postoperative use increased from 5.2% to 7.8%. The number of intraoperative TEE examinations more than doubled from approximately 1,700 to 3,500. The overall mortality for patients with preoperative, intraoperative, and postoperative IABP insertion was 12.6%, 17.5%, and 47.7%, respectively.
From 1995 to 2005, preoperative, intraoperative, and postoperative IABP use decreased by approximately 60% in cardiac surgery patients. Simultaneously, the use of TEE and milrinone each doubled. Although a cause-effect relationship cannot be established from the present study's observational data, the trends coincide and may be related.
Journal of cardiothoracic and vascular anesthesia 04/2009; 23(4):479-83. · 1.06 Impact Factor
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ABSTRACT: Coronary artery vasculopathy (CAV), characterized by diffuse concentric coronary artery intimal thickening with fibrosis, remains a significant complication impeding long term engraftment in heart transplantation. The pathophysiologic processes driving CAV are not well understood, however T cell mediated cellular immunity and cytokines have been implicated. The inability to prevent CAV may be related in part to a limited spectrum of inhibition that that current immunosuppressive therapies exhibit against second messenger pathways elicited by T cell receptor (TCR) activation and dose limiting toxicities. Therefore, considering that antigen specific T cell activation is initiated at the TCR, including alloresponses involving direct and indirect antigen presentation, targeting the proximal kinases involved in this process may provide novel therapeutic options for controlling rejection. Src family kinases (SFK), particularly p56(lck) (Lck) and p59(fyn) (Fyn), are intimately associated with the earliest signaling events through the TCR and could provide targets for immunomodulatory agents. Such targeted inhibition of TCR signaling may institute a novel approach for diminishing the T cell mediated response associated with CAV. In this review we discuss therapeutic agents that have been shown to inhibit SFK and the rationale for investigating the potential application of these agents in heart transplantation.
Cardiovascular & Haematological Disorders - Drug Targets(Formerly Current Drug Targets - Cardiovascular & Hematological Disorders) 04/2008; 8(1):1-6.
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Lars G Svensson,
Eugene H Blackstone,
Jeevanantham Rajeswaran,
Joseph F Sabik,
Bruce W Lytle, Gonzalo Gonzalez-Stawinski,
Poseidon Varvitsiotis,
Michael K Banbury,
Patrick M McCarthy,
Gösta B Pettersson,
Delos M Cosgrove
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ABSTRACT: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest.
Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression.
Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs).
Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.
The Annals of thoracic surgery 11/2004; 78(4):1274-84; discussion 1274-84. · 3.74 Impact Factor
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ABSTRACT: We evaluated our experience with the surgical management of aortic coarctation (ACo) in adults with concurrent cardiac and aortic disease approached via median sternotomy. Eight patients were presented using a variety of repair techniques including end-to-end anastomosis, transpericardial ascending aorta to descending aorta bypass, and stage 1 elephant trunk insertion. All patients were male and symptomatic at presentation. The average age was 41 years (range, 27-67 years). The systolic blood pressure decreased by a mean of 49 mmHg in the patients presenting with hypertension. The postoperative New York Heart Association functional class was I or II in all patients. Mean length of stay was 7.7 days. There were no perioperative complications, and overall survival was 100%. Operative repair of complex ACo can be safely accomplished through the mediastinum in patients in whom a conventional left thoracotomy may not be the preferred approach.
Journal of Cardiac Surgery 23(6):787-90. · 0.87 Impact Factor
