Heart Transplant Outcomes After Total Artificial Heart.

BACKGROUND: We sought to compare heart transplant (HTX) outcomes from patients with a total artificial heart (TAH), biventricular assist device (BiVAD), or left ventricular assist device (LVAD) as a bridge to transplant (BTT). Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS)-Scientific Registry of Transplant Recipients (SRTR) created a dataset with TAH or durable mechanical circulatory support (MCS) who reached HTX between 2006 and 2015. METHODS: The retrospective analysis compared TAH outcomes with those with a BiVAD or LVAD before HTX. The primary outcome was posttransplant survival at 1, 36, and 60 months. Secondary outcomes included simultaneous heart-kidney transplants, donor characteristics, and mortality risk factors. INTERMACS-SRTR cohort had, at the time of HTX, 2762 patients with LVAD; 205 BiVAD (139 durable and 66 temporary RVAD); 176 TAH (6 prior HeartMate II). RESULTS: Sixty months after HTX, mortality rates were 16.5% in the total group: LVAD 15.2%, BiVAD 22.4%, and TAH 29%. Survival differed between the LVAD, the TAH, and BiVAD but not between the BiVAD and TAH groups. One-year survival and complication rates were similar across groups-there was no difference in survival by donor age in the overall cohort. There was a difference in TTD based on recipient age in the LVAD group but not in BiVAD or TAH groups. Occurrence of HTX-kidney and post-transplant dialysis were higher in the TAH versus LVAD and BiVAD groups. CONCLUSIONS: The TAH is an efficacious BTT. Refinements in technology and patient selection may improve outcomes.

Blood Cancer and the Heart: Light Chain Cardiomyopathy in Refractory Multiple Myeloma.

We report a case of a 57-year-old woman with a history of multiple myeloma (MM) and light chain (AL) amyloidosis who presented due to worsening dyspnea on exertion. Her MM has been refractory to multiple chemotherapy regimens and two autologous bone marrow transplantation. Diagnostic evaluations including serum kappa and lambda chains, echocardiogram, pyrophosphate cardiac scan, and cardiac magnetic resonance were indicative of a progression to AL cardiomyopathy. Addition of daratumumab to her regimen appeared to ameliorate the progression of AL cardiomyopathy. However, it was stopped due to adverse effects of pancytopenia and allergic reactions including skin rash and hives. She was hospitalized for heart failure exacerbation and died approximately 2 months following the discontinuation of daratumumab. This case highlights the late presentation of AL cardiomyopathy in refractory MM.

Outcomes of lung transplant recipients with preoperative atrial fibrillation.

Background Preoperative atrial fibrillation is associated with poor outcomes after cardiac surgery, but its effect on lung transplantation outcomes remains unknown. Methods We retrospectively reviewed the charts of 235 patients who underwent lung transplantation in our institution from 2013 to 2015, analyzing demographics, length of stay, survival, readmissions, and cardiac events. Mean recipient age was 59 ± 11 years, and 142 (60.4%) were men. Patients were grouped according to pre-transplantation atrial fibrillation status (atrial fibrillation/no atrial fibrillation). Results The atrial fibrillation group ( n = 38; 16.2%) was significantly older with a longer ischemic time, more postoperative atrial arrhythmias (73.7% vs. 20.8%, p = 0.01), and a longer median postoperative length of stay (16 vs. 13 days, p = 0.02). The median total hospital stay in the first postoperative year was also higher in the atrial fibrillation group (27 vs. 21 days, p = 0.25). Short-term survival and survival during follow-up did not differ significantly between groups. Conclusions Lung transplant recipients with preoperative atrial fibrillation are at increased risk of adverse cardiovascular outcomes and longer hospital stay. Preoperative atrial fibrillation may portend adverse events after lung transplantation.

Role of total artificial heart in the management of heart transplant rejection and retransplantation: case report and review.

Cardiac allograft rejection and failure may require mechanical circulatory support as bridge-to-retransplantation. Prognosis in this patient group is poor and implantable ventricular assist devices have had limited success due to organ failure associated with the high dose immunosuppression required to treat ongoing rejection. We present a case from our institution and the world-wide experience utilizing the SynCardia CardioWest Total Artificial Heart (TAH-t; SynCardia Systems, Inc., Tucson, AZ, USA) for replacement of the failing graft, recovery of patient and end-organ failure with ultimate bridge to retransplantation. We present our experience and review of world-wide experience for use of TAH-t in this type patient.

Left ventricular assist devices: physiologic assessment using echocardiography for management and optimization.

Left ventricular assist devices (LVAD) are being deployed increasingly in patients with severe left ventricular dysfunction and medically refractory congestive heart failure of any etiology. The United States Food and Drug Administration (FDA) recently approved the use of the Thoratec Heartmate II (Thoratec Corporation, Pleasanton, CA, USA) for outpatient use. Echocardiography is fundamental during each stage of patient management, pre-LVAD placement, during LVAD placement, for postoperative LVAD optimization and long-term follow-up. We present a pragmatic and systematic echocardiographic approach that serves as a guide for the management of left ventricular assist devices.

Antibody-mediated rejection in heart transplantation: case presentation with a review of current international guidelines.

Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limitations and the need for future research and innovation.

Comparison of Novacor and HeartMate vented electric left ventricular assist devices in a single institution.

We compared the survival outcomes, left ventricular assist device (LVAD)-related hospitalization, stroke, infection, panel reactive antibody, and blood product use data among 13 Novacor and 51 HeartMate system recipients. Stroke was significantly higher in Novacor patients, as was blood product use at the time of heart transplantation, likely due to long-term anti-coagulation, while the LVAD-related hospitalization and infections did not differ between the 2 groups. A positive panel reactive antibody was seen more among the HeartMate patients, but did not have a significant clinical impact and may not represent a true allosensitization.

Acute aortic syndromes: aortic dissections, penetrating aortic ulcers and intramural aortic hematomas.

Acute aortic syndromes, including dissections, intramural hematomas and penetrating aortic ulcers, are a catastrophic clinical entity that are relatively uncommon. A high index of clinical suspicion along with proper imaging modalities are critical in making a prompt and accurate diagnosis for immediate management and to improve survival of the patient.