British societies guideline on the management of emergencies in implantable left ventricular assist device recipients in transplant centres.

An implantable left ventricular assist device (LVAD) is indicated as a bridge to transplantation or recovery in the United Kingdom (UK). The mechanism of action of the LVAD results in a unique state of haemodynamic stability with diminished arterial pulsatility. The clinical assessment of an LVAD recipient can be challenging because non-invasive blood pressure, pulse and oxygen saturation measurements may be hard to obtain. As a result of this unusual situation and complex interplay between the device and the native circulation, resuscitation of LVAD recipients requires bespoke guidelines. Through collaboration with key UK stakeholders, we assessed the current evidence base and developed guidelines for the recognition of clinical deterioration, inadequate circulation and time-critical interventions. Such guidelines, intended for use in transplant centres, are designed to be deployed by those providing immediate care of LVAD patients under conditions of precipitous clinical deterioration. In summary, the Joint British Societies and Transplant Centres LVAD Working Group present the UK guideline on management of emergencies in implantable LVAD recipients for use in advanced heart failure centres. These recommendations have been made with a UK resuscitation focus but are widely applicable to professionals regularly managing patients with implantable LVADs.

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.

Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma.

Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.

Primary graft dysfunction after heart transplantation: a thorn amongst the roses.

Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.

Recurrent myocardial infarction in a 50-year-old woman.

CLINICAL INTRODUCTION: A 50-year-old woman presented with an inferoposterior ST-elevation myocardial infarction (STEMI) and underwent emergency percutaneous coronary intervention (PCI). Angiography revealed acute occlusion of the circumflex and right coronary (RCA) arteries. PCI was uncomplicated. Her medical history included asthma, hypertension and chronic sinusitis.Three months later, she presented with a non-STEMI (NSTEMI), and angiogram showed a new focal stenosis in the left anterior descending artery. Pressure wire assessment induced severe coronary spasm. After liberal intracoronary nitrate, fractional flow reserve measured 0.71, so a further stent was implanted. Six days later, she was readmitted with another NSTEMI. Repeat angiogram revealed patent stents, with severe spasm of the distal RCA which improved following nitrate (figure 1A,B). Four days later, she was readmitted with further NSTEMI. Coronary angiography was not felt to be appropriate, and she was discharged with vasodilator therapy.heartjnl;105/12/960/F1F1F1Figure 1(A) Angiogram of RCA pre nitrates; (B) Angiogram of RCA post nitrates; (C) CT brain post cardiac arrest; (D) CMR post cardiac arrest.The following day, she had an out-of-hospital ventricular fibrillation (VF) arrest and was successfully resuscitated. CT brain showed no evidence of neurological injury (figure 1C). Cardiac magnetic resonance imaging (CMR) was performed prior to implantable cardioverter defibrillator (ICD) implantation (figure 1D). Eosinophils had been persistently elevated with a peak of 1.78×109 (normal: 0.02-0.5×109). Antinuclear antibodies and antineutrophil cytoplasmic antibodies (ANCA) were negative. QUESTION?: What is the diagnosis for her recurrent acute coronary syndrome and VF arrest?Aggressive atherosclerotic coronary artery disease.Prinzmetal's variant angina.Loeffler endocarditis.Coronary vasculitis.

Patient survival and therapeutic outcome in the UK bridge to transplant left ventricular assist device population.

OBJECTIVE: To study the survival and patient outcome in a population of UK patients supported by an implantable left ventricular assist device (LVAD) as a bridge to heart transplantation. METHODS: Data on all adult patients (n=342) who received a HeartMate II or HVAD as a first long-term LVAD between January 2007 and 31 December 2013 were extracted from the UK Ventricular Assist Device (VAD) Database in November 2015. Outcomes analysed include survival on a LVAD, time to urgent listing, heart transplantation and complications including those needing a pump exchange. RESULTS: 112 patients were supported with the Thoratec HeartMate II and 230 were supported with the HeartWare HVAD. Median duration of support was 534 days. During the study period, 81 patients required moving to the UK urgent waiting list for heart transplantation. Of the 342 patients, 85 (24.8%) received a heart transplant, this included 63 on the urgent list. Thirty-day survival was 88.9%, while overall patient survival at 3 years from LVAD implant was 49.6%. 156 patients (46%) died during LVAD support; the most common cause of death on a VAD was a cerebrovascular accident. There was no significant difference between the two devices used in any outcome. CONCLUSIONS: In a population of patients with advanced heart failure, who have a very poor prognosis, support with an implantable LVAD allowed a quarter to receive a heart transplant in a 3-year period. Overall survival of the cohort was about 50%. With improvement in technology and in post-LVAD management, it is likely that outcomes will improve further.

Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices.

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

The incremental prognostic and clinical value of multiple novel biomarkers in heart failure.

AIMS: In recent years there has been an increase in the number of biomarkers in heart failure (HF). The clinical role for these novel biomarkers in combination is not clear. METHODS AND RESULTS: The following novel biomarkers were measured from 628 patients recently hospitalized with decompensated HF; mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), copeptin, high-sensitivity cardiac troponin T (hs-cTnT), ST2, galectin-3, cystatin C, combined free light chains (cFLC) and high sensitivity C-reactive protein (hsCRP). The incremental prognostic value of these novel biomarkers was evaluated within an extensive model containing established predictors of mortality. During a mean (SD) follow-up of 3.2 (1.5) years, 290 (46%) patients died. Elevated concentrations of all novel biomarkers were associated with an increased unadjusted risk of mortality but only two-thirds were independent predictors following multivariable analysis. Using dichotomized cut-points from receiver operating characteristic analysis, MR-proADM, hs-cTnT, cFLC, hsCRP, and ST2 remained independent predictors of mortality. Further dichotomization into low (0-2 elevated biomarkers) or high (at least three of the five biomarkers elevated) risk groups provided greatest incremental prognostic value (hazard ratio 2.20, 95% confidence interval 1.37-3.54; P = 0.001) and improved the performance of the model (C-statistic 0.730 from 0.721, net reclassification index 32.5%). CONCLUSION: The novel biomarkers included in this study added little, if any, incremental prognostic value on their own to a model containing established predictors of mortality. However, following dichotomization, five of the novel biomarkers provided incremental prognostic value. There was a clear gradient in the risk of death with increasing numbers of elevated novel biomarkers, with the presence of at least three identifying patients at greatest risk of mortality.