Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation.

Background: Cardiac transplantation can be complicated by refractory hemorrhage particularly in cases where explantation of a ventricular assist device is necessary. Recombinant activated factor VII (rFVIIa) has been used to treat refractory bleeding in cardiac surgery patients, but little information is available on its efficacy or cost in heart transplant patients. Methods: Patients who had orthotopic heart transplantation between January 2009 and December 2014 at a single center were reviewed. Postoperative bleeding and the total costs of hemostatic therapies were compared between patients who received rFVIIa and those who did not. Propensity scores were created and used to control for the likelihood of receiving rFVIIa in order to reduce bias in our risk estimates. Results: Seventy‑six patients underwent heart transplantation during the study period. Twenty‑one patients (27.6%) received rFVIIa for refractory intraoperative bleeding. There was no difference in postoperative red blood cell transfusion, chest tube output, or surgical re‑exploration between patients who received rFVIIa and those who did not, even after adjusting with the propensity score (P = 0.94, P = 0.60, and P = 0.10, respectively). The total cost for hemostatic therapies was significantly higher in the rFVIIa group (median $10,819 vs. $1,985; P < 0.0001). Subgroup analysis of patients who underwent redo‑sternotomy with left ventricular assist device explantation did not show any benefit for rFVIIa either. Conclusions: In this relatively small cohort, rFVIIa use was not associated with decreased postoperative bleeding in patients undergoing heart transplantation; however, it led to significantly higher cost.

Issues in solid-organ transplantation in children: translational research from bench to bedside

In this review, we identify important challenges facing physicians responsible for renal and cardiac transplantation in children based on a review of the contemporary medical literature. Regarding pediatric renal transplantation, we discuss the challenge of antibody-mediated rejection, focusing on both acute and chronic antibody-mediated rejection. We review new diagnostic approaches to antibody-mediated rejection, such as panel-reactive antibodies, donor-specific cross-matching, antibody assays, risk assessment and diagnosis of antibody-mediated rejection, the pathology of antibody-mediated rejection, the issue of ABO incompatibility in renal transplantation, new therapies for antibody-mediated rejection, inhibiting of residual antibodies, the suppression or depletion of B-cells, genetic approaches to treating acute antibody-mediated rejection, and identifying future translational research directions in kidney transplantation in children. Regarding pediatric cardiac transplantation, we discuss the mechanisms of cardiac transplant rejection, including the role of endomyocardial biopsy in detecting graft rejection and the role of biomarkers in detecting cardiac graft rejection, including biomarkers of inflammation, cardiomyocyte injury, or stress. We review cardiac allograft vasculopathy. We also address the role of genetic analyses, including genome-wide association studies, gene expression profiling using entities such as AlloMap®, and adenosine triphosphate release as a measure of immune function using the Cylex® ImmuKnow™ cell function assay. Finally, we identify future translational research directions in heart transplantation in children.

Estado actual del trasplante pulmonar / Lung transplantation: state of the art

Actualmente el trasplante pulmonar es considerado como tratamiento definitivo para algunas enfermedades pulmonares avanzadas. Los primeros trasplantes pulmonares experimentales en animales fueron realizados en los años 1940’s por el soviético Vladimir P. Demikhov. Sin embargo, pasaron aproximadamente dos décadas antes de que se realizara el primer trasplante pulmonar en humanos por el doctor James Hardy. Desafortunadamente los inicios clínicos del trasplante pulmonar no fueron muy exitosos debido a complicaciones quirúrgicas y efectos secundarios de los fármacos inmunosupresores. Gracias al mejoramiento de la técnica quirúrgica y al desarrollo de fármacos inmunosupresores más efectivos y menos tóxicos, la morbimortalidad ha disminuido significativamente. La selección y el cuidado del donador antes de la procuración de los órganos juegan un papel primordial en los resultados en el receptor. Debido a la escasez de donadores, algunas instituciones están utilizando criterios de selección más liberales con resultados satisfactorios. El manejo del paciente con trasplante pulmonar o del bloque cardiopulmonar requiere de un enfoque multidisciplinario que incluye al cirujano de trasplantes cardiotorácicos, al neumólogo, al anestesiólogo y al intensivista entre otros. En este artículo revisamos aspectos históricos y avances recientes en el manejo de estos pacientes incluyendo indicaciones y contraindicaciones, evaluación y cuidado del donador y del receptor, técnica quirúrgica y manejo peri- y posoperatorio.

Lung transplantation is currently considered an established treatment for some advanced lung diseases. The beginning of experimental lung transplantation dates back to the 1940's when the Soviet Vladimir P. Demikhov performed the first lung transplants in animals. Two decades later, James Hardy performed the first lung transplant in humans. Unfortunately, the beginning of clinical lung transplantation was hampered by technical complications and the excessive toxicity of immunosuppressive drugs. Improvement in the surgical technique along with the development of more effective and less toxic immunosuppressive drugs has led to a better outcome in lunt transplant recipients. Donor selection and management before organ procurement play a key role in the receptor's outcome. Due to the shortage of donors, some institutions are using more liberal selection criteria, reporting satisfactory outcomes. The approach of the lung and heart-lung transplant patient is multidisciplinary and includes the cardiothoracic transplant surgeon, pulmonologist, anesthesiologist, and intensivist, among others. Herein, we review some relevant historical aspects and recent advances in the management of lung transplant recipients, including indications and contraindications, evaluation of donors and recipients, surgical techniques and peripost-operative care.