The past, present and future of heart transplantation / 器官移植

Heart transplantation is one of the most effective strategies to treat end-stage heart failure. Multiple challenges, such as difficulty in preservation of heart allograft, rejection and postoperative complications, emerge in heart allotransplantation. After decades of research and practice, most problems have been resolved. Nevertheless, the shortage of donor organs has become increasingly prominent. To alleviate the shortage of donor organs, artificial heart and heart xenotransplantation have captivated attention, and obtained significant progress in recent years. The application of artificial heart in clinical practice has significantly enhanced the survival rate of patients with end-stage heart failure, which is expected to become the standard treatment for end-stage heart failure. Heart xenotransplantation still faces many challenges, which is still far from clinical application. In this article, the history of heart transplantation, development of heart allotransplantation, use of artificial heart and research progress on heart xenotransplantation were reviewed, and the future development direction of heart transplantation was predicted.

Effect of preoperative pulmonary artery pressure on perioperative prognosis of recipients with end-stage heart failure undergoing heart transplantation / 器官移植

Objective To evaluate the effect of preoperative pulmonary artery pressure on perioperative prognosis of the recipients with end-stage heart failure undergoing heart transplantation. Methods Clinical data of 105 recipients receiving heart transplantation were retrospectively analyzed. The mean pulmonary artery pressure (mPAP) was used as the diagnostic criterion. The optimal cut-off value of mPAP for predicting perioperative prognosis of heart transplant recipients was determined. According to the optimal cut-off value of mPAP, all recipients were divided into the low mPAP group (n=66) and high mPAP group (n=39). Intraoperative indexes (cardiopulmonary bypass time, aortic occlusion time, assisted circulation time and cold ischemia time of donor heart) and postoperative indexes [intra-aortic balloon pump (IABP) support rate, IABP support time, extracorporeal membrane oxygenation (ECMO) support rate, ECMO support time, mechanical ventilation time, length of ICU stay, incidence of moderate and severe tricuspid regurgitation and perioperative mortality rate] were compared between the low and high mPAP groups. The prognosis of the two groups was compared. Results The optimal cut-off value of mPAP in predicting clinical prognosis of heart transplant recipients was 30.5 mmHg. In the high mPAP group, the ECMO support rate and perioperative mortality rate were higher than those in the low mPAP group (both P < 0.05). No significant differences were observed in the cardiopulmonary bypass time, aortic occlusion time, assisted circulation time, cold ischemia time of donor heart, IABP support rate, IABP support time, ECMO support time, mechanical ventilation time, length of ICU stay and incidence of moderate and severe tricuspid regurgitation between two groups (all P > 0.05). No significant differences were noted in the 1-, 2-, 3- and 4- survival rates between two groups (all P > 0.05). Conclusions Preoperative mPAP in patients with end-stage heart failure is intimately correlated with perioperative prognosis of heart transplant recipients. The optimal cut-off value of mPAP in predicting perioperative prognosis of heart transplant recipients is 30.5 mmHg. In the high mPAP group, perioperative ECMO support rate and perioperative mortality rate are high, which do not affect the medium and long-term prognosis of the recipients undergoing heart transplantation.

Analysis of effect of preoperative renal insufficiency on clinical prognosis of heart transplant recipients / 器官移植

Objective To evaluate the effect of renal insufficiency before heart transplantation on perioperative death, complications and long-term survival, and to compare the differences between preoperative serum creatinine (Scr) and estimated glomerular filtration rate (eGFR) in preoperative risk assessment. Methods Clinical data of 1 095 heart transplant recipients were retrospectively analyzed. According to preoperative Scr level, all recipients were divided into the Scr < 133 μmol/L(n=980), Scr 133-176 μmol/L (n=83) and Scr≥177 μmol/L groups (n=32). According to preoperative eGFR, all recipients were divided into eGFR≥90 mL/(min·1.73m2) (n=436), eGFR 60-89 mL/(min·1.73m2) (n=418) and eGFR < 60 mL/(min·1.73m2) groups (n=241). Clinical prognosis of postoperative renal function, perioperative and long-term outcomes of recipients were compared among different groups. The effect of eGFR and Scr level on renal function injury and long-term survival after heart transplantation was assessed. Results With the increase of preoperative Scr level, the proportion of recipients undergoing postoperative continuous renal replacement therapy (CRRT) was increased, the proportion of recipients receiving postoperative mechanical circulatory support was elevated, the incidence of postoperative complications was increased, the duration of mechanical ventilation and intensive care unit(ICU) stay was prolonged, and the in-hospital fatality was increased. The differences among three groups were statistically significant (all P < 0.05). With the decrease of preoperative eGFR, the proportion of recipients receiving postoperative CRRT was increased, the proportion of recipients using postoperative intra-aortic balloon pump (IABP) was elevated, the duration of mechanical ventilation and ICU stay was prolonged, and the in-hospital fatality was increased. The differences among three groups were statistically significant (all P < 0.05). Scr≥177 μmol/L was an independent risk factor for postoperative death [adjusted hazard ratio (HR) 3.64, 95% confidence interval (CI) 1.89-6.99, P < 0.01]. Among different groups classified by Scr and eGFR, the cumulative incidence rate of postoperative renal function injury and long-term survival rate were statistically significant among three groups (all P < 0.05). In patients with preoperative Scr < 133 μmol/L, the cumulative incidence rate of postoperative long-term renal function injury was significantly increased with the decrease of preoperative eGFR (P < 0.01). There was no significant difference in postoperative long-term survival rate among patients stratified by different eGFR (P > 0.05). Conclusions Renal insufficiency before heart transplantation is associated with poor perioperative and long-term prognosis. Preoperative Scr and eGFR are the independent risk factors for postoperative renal function injury. Scr yields low sensitivity in the assessment of preoperative renal function, whereas it has high accuracy in predicting perioperative death risk. And eGFR is a more sensitive parameter to evaluate preoperative renal function, which may identify early-stage renal functional abnormality and take effective measures during early stage to reduce adverse effect on prognosis.

A prospective multicenter clinical trial study of a domestic HeartCon third-generation magnetic and hydrodynamic levitation LVAD for the treatment of 50 cases of end-stage heart failure / 中华胸心血管外科杂志

Objective:To analyze and evaluate the safety and efficacy of a Chinese domestically manufactured Heart Con-type implantable third-generation magnetic and hydrodynamic levitation left ventricular assist device(LVAD) for the treatment of end-stage heart failure(ESHF), by reporting the results of eleven-center clinical trial on 50 cases.Methods:This study was a multicenter clinical trial, designed by means of prospective, multicenter and single-group target value. 50 subjects with ESHF were competitively enrolled and treated with HeartCon as the LVAD in eleven centers. The primary efficacy measure was survival, defined as either the subjects experiencing the transition to heart transplantation(HT) or myocardial recovery assisted by the device within 90 days, or as successfully assisted by the LVAD for full 90 days after implantation. The target survival rate was 60%, other observations included implantation success rate, mortality, pump failure needing replacement or emergency heart transplantation.Results:All enrolled 50 patients received LVAD implantation successfully, 46 survived with the pump for 90 days, 1 patient transitioned to heart transplantation, and 3 patients experienced pump thrombosis, within which 2 patients underwent pump replacement and continued to live with the pump for 90 days, and the other one received emergency heart transplantation. There were no dropout subjects. The survival rate at full 90 days after HeartCon implantation was 100%. The survival rates with pump in the full set analysis and the protocol set analysis were 96.00% and 95.92% respectively, which were higher than the target value of 60%. The differences were both statistically significant( P<0.05). Conclusion:The results of the multicenter clinical trial with the largest sample size in China using domestically manufactured third-generation LVAD has demonstrated that, HeartCon is a safe and effective LVAD to treat ESHF patients.

Short-term effect of HeartCon left ventricular assist device on the treatment of 20 adult patients with end-stage heart failure / 中华危重病急救医学

Objective:To investigate and evaluate the efficacy of HeartCon left ventricular assist device (LVAD) in the treatment of adult patients with end-stage heart failure (ESHF).Methods:A prospective and observational study was conducted. Patients with ESHF who underwent LVAD implantation in the department of cardiac surgery of Teda International Cardiovascular Hospital from September 2020 to August 2021 were selected. The left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) classification, N-terminal pro-B type natriuretic peptide (NT-proBNP), and six minute walk distance (6MWD) before operation and 90 days after operation were compared. The incidence of equipment failures and major adverse events within 90 days after operation were recorded.Results:A total of 20 patients with ESHF were included, with 15 males and 5 females. Patients' age ranged from 20 to 67 years old, with an average of (50.2±13.6) years old. The range of body weight was 49.8-106.1 kg, with an average of (67.9±15.5) kg, and the body surface area (BSA) was from 1.49 to 2.32 m 2, with an average of (17.6±0.22) m 2. The operation process of all the patients were successful. The length of hospital stay ranged from 33 to 90 days, and the average was 56.0 (42.8, 75.0) days. Complications within 90 days after operation as follows, 2 cases with pericardial tamponade (10%), 1 case with cerebral hemorrhage (5%), 1 case with mediastinum infection (5%), 3 cases with acute renal injury (AKI, 15%), 5 cases with gastrointestinal bleeding (25%). There were no mechanical failure of LVAD and hemolysis events, right ventricular failure (RVF), cerebral infarction and death occurred. Compared with preoperative, the LVEDD significantly decreased (mm: 67.50±13.98 vs. 77.40±9.73), LVEF significantly increased (%: 34.80±9.76 vs. 22.70±5.62), NT-proBNP significantly decreased (ng/L: 2 028.65±1 752.05 vs. 4 796.45±4 355.40), 6MWD significantly increased (m: 385.20±144.12 vs. 85.81±63.50) at 90 days after operation, and the differences were statistically significant (all P < 0.05). 18 cases (90%) of the 20 patients reached NYHA classification Ⅰ and 2 cases (10%) reached NYHA classification Ⅱ, which were significantly improved compared with those before surgery (all patients' NYHA classification were Ⅳ before surgery). Conclusion:HeartCon LVAD can effectively improve the life quality of patients with ESHF, which has been proved safe and effective in clinical trials, but its long-term effects and complications need further observation and study.

Discussion on heart transplantation indications in patients with end-stage heart failure complicated with reversible pulmonary artery hypertension / 器官移植

Heart transplantation can save the life and improve the quality of life of patients with end-stage heart failure. Nevertheless, it is not suitable for all patients with end-stage heart failure. As a common complication of end-stage heart failure, pulmonary artery hypertension may increase the incidence of right heart failure after heart transplantation, which is associated with the short- and long-term fatality risk in the recipients after heart transplantation. In clinical practice, different transplant centers have different criteria for heart transplantation indications in patients with end-stage heart failure complicated with pulmonary artery hypertension. Accurate preoperative evaluation of surgical indications plays a critical role in determining the success of heart transplantation. In this article, the definition, pathogenesis and effects on heart transplantation, diagnostic methods and reversibility judgment of pulmonary artery hypertension, diagnostic treatment of reversible pulmonary artery hypertension and indications of heart transplantation in patients with end-stage heart failure complicated with reversible pulmonary hypertension were reviewed.

A qualitative research of true experience in patients with end-stage heart failure / 中国实用护理杂志

Objective To explore the true experience of patients living with end-stage heart failure Methods The phenomenological methodology was used in the study.Eleven inpatients with end-stage heart failure were treated with semi-structured interviews and recorded live. Colaizzi method was used for data analysis with Nvivo11.0. Results Four themes were extracted:perceivestressful heart failuresymptoms; complex psychological experience, both negative and positive response coexist;perceive insufficient medical system support;ambivalent attitude toward death. Conclusion Health care providers should pay attention to the physical and psychological feelings of patients with end-stage heart failure, take targeted interventions to alleviate their suffering, provide palliative care while providing heart failure management to patients, and attach importance to communication with patients to help them recognize death correctly. At the same time, we should promote the development of grass-roots health institutions and provide patients with more convenient and adequate medical resources.

Symptom Management and Factors Related to Nurses’ Attitudes toward Terminally Ill Patients with Congestive Heart Failure

<p>Objectives: This study examined symptom assessments and non-pharmacological interventions to relieve symptoms among heart failure patients, and factors related to nurses’ attitudes towards terminal care. Method: A cross-sectional study was conducted with 180 nurses using a questionnaire. Results: Symptom assessments were conducted about 80% of the times for all 14 symptoms of congestive heart failure. Non-pharmacological interventions, such as adjustment in daily life, consideration of positioning and movement in daily life, and environment adjustment, were frequently conducted. Nurses who attended palliative care seminars indicated more positive attitudes toward terminal care including a positive attitude toward caring for dying persons. Low points in difficulties with terminal care reflected nurses’ knowledge and skills related to high points in positive attitudes toward caring for dying persons. Conclusion: These results suggest that educational programs are required for nurses providing palliative care for patients with heart failure to enhance nurses’ attitudes towards terminal care and to promote palliative care practice. </p>

Continuous Intravenous Infusion of Oxycodone for Dyspnea from End Stage-heart Failure due to Dilated Cardiomyopathy

Introduction: Patients of end-stage heart failure often develop dyspnea. Although morphine is used for dyspnea, these patients are often inappropriate group for using morphine due to renal failure. Case: A seventy-year-old male with end-stage heart failure due to dilated cardiomyopathy developed dyspnea. We used continuous oxycodone infusion for dyspnea with small dose as an alternative to morphine due to renal failure. His dyspnea was relieved in dose-dependent without heart failure recovery. Conclusion: Oxycodone may be an alternative therapy for dyspnea with end-stage heart failure with renal failure.

Treatment of Medically Intractable End-Stage Heart Failure

Heart failure is the final pathway for myriad diseases that affect the heart. Patients with refractory symptoms of heart failure despite ultimate medical therapy have very poor prognosis. In these patients, replacement of failing heart with permanent organ transplantation or ventricular assist device, which is temporarily or permanently implanted, is often life-saving and can improve long term prognosis. Cardiac transplantation is the established standard for the treatment of end-stage cardiac disease refractory to medical therapy. The clinical success of transplantation has been streadily improving with the refinement of recipient selection, better donor management, and better immunosuppressive agents. Recent substantial evolution of mechanical circulatory assist devices improved dramatically the outcome of not only patients in decompensated heart failure but also a large proportion of acute heart failure patients in cardiogenic shock. With this evolution, implantable sophisticated devices are being used as destination therapy as a substitute for transplantation and are expected to diminish the intrinsic shortage of donor compared to the epidemic of heart failure.