The Glasgow Experience of Extended Myocardial Protection: A Novel Method of Implantation to Reduce Primary Graft Dysfunction After Heart Transplant.

OBJECTIVES: Around 2000 heart transplants are performed in Europe annually. The rates of primary graft dysfunction in Europe are among the highest in the world. With increasing demand for organs and the limited supply of donors, novel techniques such as ex vivo normothermic perfusion have garnered incre-asing interest. We present a series of patients who underwent heart transplant at our unit in which we used a novel implantation technique to reduce primary graft dysfunction. MATERIALS AND METHODS: We compared our experience with the novel method detailed in our article (Glasgow experience group) with a contemporary UK cohort (2015-2016) of patients (control group). We performed multivariable logistic regression to compare the Glasgow experience with the control group with primary graft dysfunction as the outcome measure. We adjusted for donor age, recipient diabetes mellitus, urgent listing status, bypass time, and total ischemic time. RESULTS: Among 194 patients in both cohorts, 140 patients (72.1%) were men and 36 (18.6%) had ischemic cardiomyopathy. The odds ratio of primary graft dysfunction in the control group was 2.99 (95% CI, 1.02- 8.75) compared with the Glasgow experience group. CONCLUSIONS: Our novel approach was associated with significant reductions in primary graft dysfunction, with a trend toward improved 1-year survival. Larger studies are needed to show differences after further adjustment for known confounders of primary graft dysfunction. We believe this novel technique is safe, cost-effective, and reproducible.

Mechanical circulatory support for refractory cardiogenic shock post-acute myocardial infarction-a decade of lessons.

BACKGROUND: There are 0.9 catheterization labs per 100,000 inhabitants in Scotland for percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), which are much less accessible to patients in remote and rural areas. An uncommon but sinister sequalae following AMI is cardiogenic shock (CS) that could be refractory to inotropic support. CS complicates 5-15% of AMIs occurring in ST-segment elevation myocardial infarctions (STEMIs). Outcomes of CS are poor with mortalities of up to 90% reported in the literature in the absence of experienced care. We report our experience as the tertiary referral centre in Scotland for MCS and heart transplantation over 8 years. METHODS: A retrospective review of prospectively collected data was undertaken on all patients registered to the MCS service. The database was interrogated for patient demographics, type of mechanical circulatory support (MCS) and duration of MCS support, PCI-outcomes and survival to 30 days. A time-to-event analysis was performed using patient survival as the primary outcome measure. RESULTS: Twenty-three patients (16 male, 7 females) were included. The median age of the patients as 50 years (range, 45-56 years). VA-ECMO was the initial MCS of choice in 17 (73.9%) patients with BIVAD for 4 (17.4%) patients and LVAD for 2 (8.7%) patients. Thirty-day mortality was 21.8% in this cohort, however survival to discharge was 52.2%. Eleven (47.8%) patients recovered without the need for any further support, however only 9 (81.8%) patients in this subgroup survived to discharge. Three (13.0%) patients received a durable LVAD. In this subgroup, one patient was transplanted whereas two patients died due to complications while on support. The median length of in-hospital MCS support was 4 days. Median in-hospital stay was 27 days. Long-term follow up of up to 8 years demonstrates a high mortality beyond 30-day up to the first 6-month post MCS support. CONCLUSIONS: MCS usage in these patients carries a high mortality in the early post-implantation period. However, there is a significant benefit to patients who survive the initial bridging period to recovery or destination therapy.

Does a balloon atrial septostomy performed before arterial switch surgery increase adverse neurological outcomes?

This best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was whether the use of balloon atrial septostomy (BAS) before the arterial switch surgery for transposition of the great arteries (TGA) improved the final outcome. Altogether more than 251 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The search was further limited to recent articles since the results have improved compared with previous years, due to newer equipment and techniques. This narrowed the search to five papers that have focused on this issue since 2006 when a study of 29 term neonates identified BAS as major risk factor for focal brain injury and reinvigorated the debate of adverse neurological outcome especially in the context of the fact that total correction by the arterial switch procedure is routine in neonates now. Subsequently, a prospective study of 64 newborn infants followed by another study of 26 neonates with TGA, have shown no association between BAS and brain injury. Similarly, in a study of more than 2000 cases of dTGA, no association has been found between BAS and increased risk of clinical stroke either in the neonatal period or in follow-up hospitalizations. On the other hand, another nationwide data analysis of 8681 patients with TGA, has shown increased risk of stroke in patients undergoing BAS but it could only show association and not establish causation of the complication. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated.

Massive spontaneous hemothorax during the immediate postpartum period.

Nontraumatic hemothorax is a rare cause of postpartum respiratory distress. We present a case of massive spontaneous hemothorax, which presented during the immediate postpartum period and was initially treated as pulmonary embolism. Further investigation revealed a tiny lung nodule: although pulmonary arteriovenous malformation was considered, the imaging appearances tended to counter this interpretation. Eventually, in the absence of another cause for spontaneous hemothorax, on either clinical or imaging grounds, we diagnosed spontaneous arteriovenous malformation. Its management is discussed herein.

Emergency valve replacement in rheumatic heart disease.

BACKGROUND AND AIM OF THE STUDY: Emergency valve replacement is defined as surgery undertaken to correct valvular heart disease which otherwise would have proved fatal within 24 h. METHODS: Among 1,742 patients who underwent valve replacement during the past 15 years at the authors' institution, 61 who had emergency surgery formed two groups. Group 1 (n = 24) had a previous good circulatory status but suffered a sudden change in valvular function, in the initial period after closed mitral valvotomy (CMV), and in later years after balloon aortic valvotomy (BAV) or balloon mitral valvotomy (BMV) for aortic or mitral valvular stenosis. Group 2 (n = 37) had chronic decompensated rheumatic valvular disease and acute low cardiac output. RESULTS: Four deaths occurred in group 1 (17%) during the early stage of the study, but no deaths have occurred during the past five years. Mean follow up was 13.5 months (range: 5-30 months). Among 20 survivors, 14 were in NYHA class I, and six in class II. Ten deaths occurred in group 2 (27%), including two during the past eight years among patients who had surgery. Mean follow up was 37.7 months (range: 8-96 months). Among 27 survivors, 11 were in NYHA class I, 12 in class II, two in class III and two in class IV. CONCLUSION: In this potential terminally ill group of patients, surgery offers the only option for survival.

Unruptured aneurysm of the sinus of Valsalva presenting with right ventricular outflow obstruction.

Sinus of Valsalva aneurysms rarely present until rupture occurs. We describe the case of a patient who presented with acute right heart failure and upon investigation was found to have an unruptured sinus of Valsalva aneurysm causing right ventricular outflow obstruction; there was an associated subaortic ventricular septal defect. To the best of our knowledge, only 1 other case with these features has been reported in the medical literature. The diagnosis was made by transthoracic echocardiography and cardiac catheterization. Through an aortic and right ventricular approach, we successfully excised the aneurysmal right coronary sinus, closed the ventricular septal defect, and replaced the aortic valve.