Sensitisation and post-transplant course after the implantation of ventricular assist device.

The purpose of this study was to evaluate sensitisation, occurring because of bridging with VAD, and development of rejection episodes after transplantation in selected groups of patients using triple drug immunosuppression, without induction or desensitisation therapy. Sensitisation using standard complement dependent cytotoxicity was tested in 16 patients awaiting cardiac transplantation before VAD placement, one month post-implantation and on a six-monthly basis later on. Long-term (955+/-998 days) post-transplant course of six transplanted post-VAD patients was compared with 19 non-bridged recipients (follow-up time 1425+/-1273 days) of the same age. One-third of VAD recipients had developed anti-HLA antibodies one month post-implantation; 4/16 patients were sensitised six months after implantation. No de novo sensitisation development was revealed in VAD group post-transplantation. All sensitised patients independent of VAD placement underwent graft rejection episodes. Only 1 of 6 VAD recipient was treated because of grade 2R rejection, compared to 6/19 in the non-bridged group, P=0.63. None of the patients had failed because of early graft rejection. In conclusion, VAD devices used in our centre cause low level risk for anti-HLA antibodies development. There were no differences in survival due to immunologic reasons between VAD bridged and non-bridged patients.

Intra-aortic balloon counterpulsation in decompensated cardiomyopathy patients: bridge to transplantation or assist device.

OBJECTIVES: The crucial decision to progress from pharmacological treatment of acute decompensated heart failure to institution of assist device or transplantation begins with evaluation of the chances for a successful recovery. We tested whether the intra-aortic balloon counterpulsation (IABP) could give us the necessary time for clinical decision-making and preserve adequate circulation until it is made. METHODS: We assessed 11 dilated cardiomyopathy patients of NYHA class IV, listed for heart transplantation or a ventricular assist device (VAD), who had conventional IABP placed. Heart function prior to and after IABP insertion as well as hemodynamics, end-organ function (renal and hepatic), frequency of complications and clinical outcomes were assessed. RESULTS: The duration of intra-aortic balloon pump insertion ranged from 72 to 360 h (mean 181.54+/-81.65). After 48 h of intra-aortic balloon pump support, there was a significant increase of mean systemic arterial pressure from 74.5+/-9.6 to 82.3+/-4.7 mmHg (P=0.02), and ejection fraction from 14.7+/-6.4 to 21.0+/-8.6 (P=0.014). Meanwhile improvement of cardiac index, pulmonary wedge pressure and end-organ perfusion markers did not reach statistical significance. Three patients were successfully weaned off the balloon and recovered without additional interventions, two patients were transplanted and three were supported with counterpulsation until the implantation of assist device. Three patients died due to progressive heart failure, two after IABP removal and one after VAD implantation. There was no incidence of infection, limb ischemia, thrombus, or embolic complications. CONCLUSIONS: Our data showed that intra-aortic balloon pump support may be successfully and safely used in the acute decompensated dilated cardiomyopathy patients, as an urgent measure of cardiac support, to stabilize the patient and maintain organ perfusion until transplant is available, VAD is placed or patient is weaned from IABP.

[Heart assist (Vilnius University experience)]. / Pagalbine kraujotaka (Vilniaus universiteto patirtis).

Over the last three decades, the results of heart surgery have significantly improved. However, the number of patients at the last stages of heart deficiency has increased. Prevention provided to the patients suffering from heart diseases has improved the quality of their life and increased their lifetime. In spite of that, most of these patients sooner or later need a surgical treatment: heart surgery operation or heart transplantation. The visible damage to haemodynamics of the patients waiting for heart operations and particularly heart transplantations or after them has drawn the focus of heart surgeons to the mechanical systems of heart assist. In many cases they help to cure patients after post-cardiotomic or post-transplant cardiogenic progressive circulation and poly-organic deficiency. They also are regarded effective as a bridge to heart transplantation. In the Heart Surgery Center of Vilnius University, heart assist has been applied since 1976. Contrapulsation with intraaortic balloon pump has been applied to 856 patients, which after heart operations have developed progressive heart deficiency. Four methods of balloon insertion into aorta were used: through the a. iliaca incision (337 cases); through the a. femoralis punction (287 cases); through the ascending aorta (171 cases) and through the ascending aorta using tourniquets (61 cases). The best results were achieved employing intraaortic balloon pump after aorta-coronary bypass surgery: 67% patients were discharged from hospital. The worst results follow heart transplants, as intraaortic balloon pump was successful only to 28% of patients. In general, the total number of patients to whom the heart assist method was successful is 454 (53%). The second heart assist method that has been applied in our centre is the use of extracorporeal membranous oxigenator. It has been employed since 1998 to the patients with the critical respiration and heart deficiency. Extracorporeal membranous oxigenator has been used to 8 patients, to whom pharmaceutical treatment and intraaortic balloon pump were inefficient. Unfortunately, only one of the patients after 105 days was successfully disconnected from the extracorporeal membranous oxigenator, while maintaining his good haemodynamics. The third method of heart assist is the employment of artificial Berlin Heart ventricles. From 1999 up to 2003, 15 artificial Berlin Heart ventricles have been connected to thirteen patients, 7 of them as a bridge to heart transplant. One of the patients has already lived for over 2 years, while 6 patients had heart transplantation. There have been 8 post-cardiotomic patients with incorporated artificial Berlin Heart ventricles. The most experience has been accumulated in the use of intraaortic balloon pump. The fact that 53% of patients were discharged from hospital after such treatment indicates its efficiency. We have little experience in the employment of extracorporeal membranous oxigenator, therefore it is difficult to make conclusions. Whereas the application of Berlin Heart artificial ventricles is an effective method of assist circulation (heart assist), being a bridge to heart transplantation and effective in a long-term treatment.

[The intraaortic balloon pumping--old problems and innovation]. / Intraaortine kontrapulsacija. Senos problemos ir naujoves.

UNLABELLED: Method of this treatment in Vilnius University Heart Surgery Clinic was started in 1976. The intraaortic balloon pumping in the urgent primary mechanical circulator support device for postcardiotomic heart failure. Method of this treatment was started in 1976. Demand of intraaortic balloon pumping was for 744 postcardiothomic patients (5.4%). The heart pathology that required postcardiotomic intraaortic balloon pumping were: heart valve replacement or repair - 385, coronary artery bypass grafting - 316, complex heart operations - 34, after heart transplant - 6, coronary artery bypass grafting plus left ventricle remodelation - 3. Four methods of intraaortic balloon insertion were used: incision of a. iliaca externa were performed for 332 patients, by means of transcutaneus a. femoralis punction - 248, by means of incision of ascending aorta - 154, and by means of incision of ascending aorta with tourniquets - 10. RESULTS: One hundred seventy nine patients after valve replacement and repair operations were successfully disconnected from intraaortic balloon pumping and 157 (41%) discharged from the hospital. The best results were in aortic valve replacement patients and coronary artery bypass grafting patients 64-67% was disconnected from intraaortic balloon and 64-57% discharged from the hospital. Totally 411 (55%) postcardiotomic patients were successfully disconnected and 373 (50%) discharged from the hospital. Main complications of the treatment by intraaortic balloon pumping were: aortic balloon thrombosis - 34, rupture of balloon - 6, aortic dissection - 4, peripheral artery perforation and aneurysm - 3, bleeding from area of balloon insertion - 2. Intraaortic balloon pumping duration ranged from 3.5 to 141 hours. CONCLUSION: Best results were in patients group with intraaortic balloon pumping who underwent coronary artery bypass grafting and aortic valve replacement. The insertion intraaortic balloon through ascending aorta with tourniquets is more physiological and it is no need of thoracotomy to extract the balloon.