Multislice computed tomography-guided surgical repair of acquired posterior left ventricular aneurysms: demonstration of mitral valve and left ventricular reverse remodelling.

OBJECTIVES: Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms. METHODS: Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD). RESULTS: Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD. CONCLUSIONS: MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms.

The long-term impact of various techniques for tricuspid repair in Ebstein's anomaly.

OBJECTIVE: We describe a repertoire of repair techniques according to type of Ebstein's anomaly to correct tricuspid valve (TV) incompetence, and report long-term ventricular function and functional outcomes. METHODS: Sixty-eight patients (mean age, 26.9 ± 7.3 years) with Ebstein's anomaly (type A, n = 21; type B, n = 23; type C, n = 15; type D, n = 9) underwent correction of TV incompetence under normothermic cardiopulmonary bypass. The atrialized ventricle, TV, and subvalvar apparatus were inspected to analyze the precise morphology and determine which leaflet was the most mobile. Various repair strategies (anterior and/or posterior annulorrhapy, Sebening stitich, double-orifice valve technique, with bidirectional Glenn anastomosis if necessary) were used according to the presenting morphology and applied according to the type of Ebstein's anomaly. In all, the atrialized right ventricle (RV) was incorporated into the contractile RV by partial closure of the natural annulus using the most mobile leaflet for valve competence. RESULTS: The mean duration of follow-up was 13.25 ± 1.3 years (median, 9.34 years; range, 1-24 years). The mean New York Heart Association class improved from 3.4 to 1.3 (P < .001). The mean severity of TV incompetence was reduced from 3.2 to 1.3 (P < .001). Exercise tolerance tests demonstrated improved maximal oxygen uptake from a mean of 15 ± 7.8 ng/kg/min preoperatively to a mean of 24.9 ± 2.0 ng/kg/min postoperatively (P < .02). Displacement tissue Doppler imaging was used to evaluate overall cardiac performance of the RV and left ventricle and interventricular septum. The mean basal, middle, and apical ventricular strain improved significantly from preoperative values of 18.08%, 15.6%, and 13.9%, respectively to postoperative values of 25.7% (P < .011), 23.7% (P < .001), and 19.36% (P < .05), respectively. Freedom from reoperation was 100% at 1 year, 98.3% at 5 years, and 92.9% at 20 years. Early mortality was 2.9%, and late mortality was 5.8%. The overall survival rate was 97.6% at 30 days, 92.7% at 5 years, and 91.26% at 20 years. CONCLUSIONS: The various repair techniques, all of which preserve the atrialized chamber and are used individually according to morphology, provide satisfactory long-term ventricular function and functional outcome even in severe types of Ebstein's anomaly.

Altered right ventricular function in the long-term follow-up evaluation of patients after delayed aortic reimplantation of the anomalous left coronary artery from the pulmonary artery.

This study aimed to evaluate regional and global ventricular functions in the long term after aortic reimplantation of the anomalous left coronary artery from the pulmonary artery (ALCAPA) and to assess whether the time of surgical repair influences ventricular performance.The study examined 20 patients with a median age of 15 years (range 3-37 years) who had a corrected ALCAPA and 20 age-matched control subjects using echocardiography and tissue Doppler imaging (TDI). The median follow-up period after corrective surgery was 6 years (range 2.6-15 years). Seven patients underwent surgery before the age of 3 years (early-surgery group), whereas 13 patients had surgery after that age (late-surgery group). The TDI-derived myocardial strain of the interventricular septum (IVS), lateral wall of the left ventricle (LV), and lateral wall of the right ventricle (RV) in the basal and mid regions were examined, and a mean was calculated. The pulsed Doppler-derived Tei index was used to assess global left ventricular function. No significant differences were found between the early-surgery group and the control group regarding the regional myocardial strain or the Tei index. Compared with the early-surgery group, the late-surgery group had a significantly higher Tei index (mean 0.37; range 0.31-0.42 vs. mean 0.52; range 0.39-0.69; p < 0.005), a lower strain percentage of the lateral wall of the LV (mean 29; range 17-30 vs. mean 9; range 7-23), IVS (mean 23; range 21-31 vs. mean 19; range 13-25), and lateral wall of the RV (mean 23; range 21-31 vs. mean 19; range 13-25). The age at operation correlated significantly with the Tei index (r = 0.84, p < 0.001) and inversely with the mean strain of the lateral wall of the LV (r = -0.53, p = 0.028), IVS (r = -0.68, p = 0.003), and lateral wall of the RV (r = -0.68, p = 0.003). At the midterm follow-up evaluation after corrective surgery of ALCAPA, not only the left but also the right ventricular function seemed to be affected in patients with delayed diagnosis and late surgical repair but preserved among the younger patients with early diagnosis and corrective surgery.

Temporary right ventricular mechanical support in high-risk left ventricular assist device recipients versus permanent biventricular or total artificial heart support.

Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25-70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty-six patients (38 men; median age 54.5 years, range: 25-70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28-68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90-day and 6-month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1-year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction.

Further experience with the "no-react" bioprosthesis in patients with active infective endocarditis: 11-year single center results in 402 patients.

OBJECTIVES: We investigated early, midterm, and long-term results following valve replacement with the "No-React" bioprosthesis in patients with active infective endocarditis (AIE).Patients and Methods Between February 2000 and February 2011, a total of 402 patients (median 61 years, 17 to 91 years) received "No-React" bioprostheses due to single valve AIE in 315 (aortic valve replacement n = 158, aortic conduit n = 30, mitral valve replacement n = 116, tricuspid valve replacement n = 11) and double valve AIE in 87 cases. Prosthetic AIE was found in 105 patients (26.1%). Mean follow-up was 2.8 ± 3.2 years (1 month to 11.4 years) with 1,124 patient years, completed in 97.1%. This retrospective study analyzes both prospectively updated data (n = 255) and patients recently operated upon (n = 147). RESULTS: There was a highly significant difference in the survival between patients operated on urgently and patients operated on in an emergency (30-day, 1-, 5-, and 10-year survival were 80.9 ± 2.3%, 63.8 ± 2.9%, 48.3 ± 3.3%, and 39.7 ± 4.1% vs. 61.3 ± 4.5%, 45.0 ± 4.7%, 33.1 ± 4.6%, and 14.0 ± 5.1%, respectively, p < 0.001), due to native versus prosthetic AIE (p = 0.032), single versus double valve replacement (p = 0.005), and with or without abscess formation (p < 0.001). Thirty-day, 1-, 5-, and 10-year freedom from reoperation due to recurrent endocarditis were 100%, 95.1 ± 1.4%, 86.4 ± 2.6%, and 82.1 ± 3.6% and due to structural valve deterioration (SVD) were 100%, 100%, 98.9 ± 0.8%, and 91.4 ± 4.0%, respectively. There was no difference in prosthesis durability between the older (> 60 years) and the younger patients. CONCLUSIONS: Our experience in the use of "No-React" bioprostheses in patients with native and prosthetic AIE shows satisfactory early, midterm, and long-term results, in particular low rates of reoperation due to recurrent endocarditis and SVD. Because these prostheses are readily available and their implantation straightforward, we strongly recommend their use in patients with AIE. Patients' survival differed significantly depending on their surgical urgency. Early mortality was independently predicted by septic shock, abscess formation, and number of implanted valves besides age per 10 years.

Outcomes of HeartWare Ventricular Assist System support in 141 patients: a single-centre experience.

OBJECTIVES: A third-generation ventricular assist device, the HeartWare Ventricular Assist System, has demonstrated its reliability and durability in animal models and clinical experience. However, studies of a large series of applications are still lacking. We evaluate the safety and efficacy of the HeartWare pump in 141 patients with end-stage heart failure at a single centre. METHODS: A total of 141 patients (116 men and 25 women with a mean age of 52 years) in New York Heart Association (NYHA) Class IV received implantation of the HeartWare Ventricular Assist System between August 2009 and April 2011 at the Deutsches Herzzentrum Berlin. The outcomes were measured in terms of laboratory data, adverse events, NYHA functional class and survival during device support. RESULTS: The HeartWare system provided an adequate haemodynamic support for patients both inside and outside the hospital. NYHA class improved to I-II. Organ function and pulmonary vascular resistance improved significantly. In this cohort of patients, 14 patients underwent heart transplantation, one had had the device explanted following myocardial recovery, one had changed to another assist device, 81 were on ongoing support and 44 died. The overall actuarial survival rates at 6 and 12 months were 70 and 67%, respectively, and the 3-, 6- and 12-month survival rates on a left ventricular assist device (LVAD) support for bridge to transplantation patients were 82, 81 and 79%, respectively. Infection and bleeding were the main adverse events. Four patients underwent an LVAD exchange for pump thrombosis. CONCLUSIONS: The HeartWare system provides a safe and effective circulatory support in a population with a wide range of body surface areas, with a satisfactory actuarial survival time and an improved quality of life. It can be used for univentricular or biventricular support, being implanted into the pericardial space with simplified surgical techniques.

State of the art in paediatric heart transplantation: the Berlin experience.

Enormous progress has been made in paediatric heart transplantation since the first unsuccessful effort by Kantrowitz in 1967. Early reports of children undergoing heart transplantation showed alarmingly high perioperative mortality rates of 25-60%, with the diagnosis of congenital heart disease (CHD) representing a particularly high-risk subset compared with cardiomyopathy. Many of these early failures were related to poor patient selection, suboptimal immunosuppression and technical problems. We learned a great deal from these earlier difficulties. Presently, with more refined techniques, better-defined patient selection criteria, excellent graft rejection monitoring and optimal immunosuppression, the ISHLT 2011 registry reported a 10-year survival rate of 60% for patients transplanted for end-stage CHD and >70% for those transplanted for cardiomyopathy. The technical dilemmas in complex CHD were overcome by surgical ingenuity and creativity, innovative solutions and careful surgical planning, adapting the complex recipient anatomy to the normal donor anatomy. The miniaturized Berlin Heart pulsatile ventricular assist devices in children as a bridge to transplantation have revolutionized treatment and become a significant contribution in heart-failure therapy. The intramyocardial electrogram and echocardiographic strain rate imaging have been employed as non-invasive techniques of rejection monitoring. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy, the main cause of cardiac allograft loss and a leading cause of mortality after the first year post-transplantation. The questions of whether a transplanted heart in a newborn grows to adult size along with the child and whether the dimensional cardiac growth allows adequate function over time have been largely answered in our previous investigations. As more transplanted children reach adulthood, concerns about their life expectancy when they have reached 10 years of life post-transplant are raised, particularly with respect to establishing partnerships and families, their ability to earn a living and the fulfilment of personal life perspectives. Some heart-transplanted patients require retransplantation to remain alive. The disparity between the demand for and supply of donor hearts makes retransplantation an ethical issue. We 'do not refuse' any patient who needs retransplantation. Mechanical circulatory support devices for long-term use are now largely available to accommodate such cases.

Factors associated with the need of biventricular mechanical circulatory support in children with advanced heart failure.

OBJECTIVES: Postimplantation right ventricular dysfunction is associated with increased morbidity and mortality in ventricular assist device (VAD) recipients. This study aimed to determine the preoperative risk factors for severe right heart failure needing biventricular mechanical circulatory support in children with end-stage heart failure. METHODS: We reviewed data from 84 children supported with long-term VADs at the German Heart Institute Berlin between January 1999 and October 2010. Right ventricular assist device (RVAD) support was needed for 24 (29%) patients, and the other 60 (71%) were implanted with left ventricular assist devices (LVADs). RESULTS: The median age at implantation was 7 years (12 days-18 years), and the median support time was 41 days (1-432 days). Of the 84 patients, the overall survival to transplantation or recovery of ventricular function was 69%. Compared with children implanted with LVAD, patients receiving biventricular support had significantly higher postoperative mortality (P = 0.04). The multivariate logistic regression indicated that decreased milrinone use was the only preoperative factor independently associated with increased requirement for biventricular support (odds ratio: 0.1, 95% confidence interval: 0.04-0.64, P = 0.01). Children treated with milrinone preoperatively showed improved survival after implantation (P = 0.04). CONCLUSIONS: Paediatric patients needing biventricular support had significantly higher postoperative mortality. Preoperative milrinone use might decrease the risk of severe right ventricular failure requiring additional RVAD insertion and improve postimplantation survival in children with advanced heart failure.

Clinical, haemodynamic and echocardiographic features of early cardiac graft dysfunction.

BACKGROUND: The main cause of early death after heart transplantation (HTx) is so-called early primary or secondary graft failure (GF). The risk of profound GF has not declined in the past decade, as the consequence of the liberalisation of donor acceptance criteria because of the scarcity of donors. It is therefore important to try to diagnose graft failure and recognise the mechanisms of early graft dysfunction. AIM: To establish haemodynamic and echocardiographic criteria of early GF to define patients who should be considered for assist device support or re-transplantation. METHODS: Between January 2000 and March 2009, 116 HTx patients were studied. On the basis of echocardiography and continuous invasive monitoring, three groups were identified: (1) The true graft failure group (GF) consisted of 46 patients; (2) The latent right ventricular (RV) dysfunction group (RV-D) consisted of 25 patients with small left ventricular (LV) chamber (〈 39 mm) and RV ejection fraction (RVEF) 〈 50%; (3) The control group consisted of 45 consecutive HTx patients without any haemodynamic complications. RESULTS: Postoperatively, only the GF group required large doses of norepinephrine (〉 0.3 µmg/kg/min) and inhalative NO (40 ppm). Nevertheless, right and left filling pressures were significantly higher than in the controls (right 12 ± 3.6 vs. 9.0 ± 2 and left atrial pressure 13.0 ± 3.2 vs. 9.6 ± 2 mm Hg, both p 〈 0.001). Cardiac index was significantly smaller (2.9 ± 0.7 vs. 3.7 ± 0.9, p 〈 0.001) but neither pulmonary artery pressure (29.5 ± 6 vs. 29.7 ± 7 mm Hg) nor transpulmonary gradient (6 ± 5 vs. 5.1 ± 5 mm Hg) nor pulmonary vascular resistance (273 ± 97 vs. 287 ± 144 dyn × s × cm-5) differed significantly from those of the control group. In the GF group, LV end diastolic dimension (LVEDD) was significantly smaller and function poorer than in controls (39.8 ± 5 vs. 44.4 ± 5 mm, respectively, p = 0.001). RV function was also significantly worse (RVEF 42.2 ± 14% vs. 56.0 ± 9%), respectively, p = 0.001), whereas RV dimension did not differ significantly. Mechanical support after failure of the initial medical treatment was necessary in 37% of patients; 29 (63.0%) patients from the GF group died, the cause of death being sepsis with multi-organ failure. In the RV-D group, remodelling was quite similar but LVEF was excellent and maximal systolic velocity from the posterior wall was significantly higher than in GF. No death occurred. CONCLUSIONS: True early GF represents a grave haemodynamic situation with high mortality. Bedside echocardiography helps to distinguish between latent RV dysfunction and true GF.

Pre-explant stability of unloading-promoted cardiac improvement predicts outcome after weaning from ventricular assist devices.

BACKGROUND: Detection of cardiac recovery that allows long-term cardiac stability after ventricular assist device (VAD) explantation is a major goal. After normalization of ventricular diameters during unloading, the pre-explant left ventricular ejection fraction (LVEF) allows the detection of patients with the potential to remain stable after VAD explantation. However, some patients with LVEF >45 before VAD explantation show early recurrence of heart failure (HF). We aimed to find out if unstable improvement can be recognized before VAD explantation. METHODS AND RESULTS: Among 96 patients weaned from VADs since 1995, a relatively homogenous group of 53 patients with nonischemic chronic cardiomyopathy (CCM) was selected for the study. The pre-explant stability of major parameters of LV function, size, and geometry that were measured by echocardiography during serial "off-pump" trials was tested for relationship with cardiac stability after VAD explantation. LVEF, systolic peak wall motion velocity (Sm), end-diastolic diameter (LVEDD), end-diastolic relative wall thickness (RWT(ED)) and end-diastolic short/long-axis ratio (S/L(ED)) were selected for evaluation. In postweaning unstable patients, the selected parameters showed relevant instability already before VAD explantation during the time period between best cardiac improvement and VAD explantation and also during the final off-pump trial just before VAD explantation. For all parameters, there were significant differences (P<0.05) in pre-explant changes between patients with and without postweaning cardiac stability. Using the optimal cutoff values obtained from receiver-operating characteristic analysis, we found for our selected parameters predictive values for postexplant cardiac stability of ≥1 year, ≥3 years, and ≥5 years, ranging between 94 and 100, 92, and 100, and 78 and 100, respectively. Using for all parameter changes the cutoff value of 10, we found similar predictive values for cardiac stability of ≥1 year, ≥3 years, and ≥5 years, ranging between 93 and 97, 90 and 96, and 83 and 92, respectively. CONCLUSIONS: Our results strongly suggest the possibility to improve the prediction of postexplant transplant/VAD-free outcome in CCM patients with cardiac improvement during VAD support by analyzing the pre-explant stability of several LV off-pump echocardiographic parameters during serial off-pump trials.

Arterial wall histology in chronic pulsatile-flow and continuous-flow device circulatory support.

BACKGROUND: Continuous-flow (CF) ventricular assist devices (VAD) are an established option for treatment of end-stage heart failure. However, the effect of long-term CF with lack of peripheral arterial wall motions on blood pressure regulation and end-organ arterial wall sclerosis, especially in the case of long-term support (> 3 years), remains unclear. METHODS: Tissue samples obtained at autopsy from liver, kidney, coronary arteries, and brain from 27 VAD recipients supported for > 180 days between 2000 and 2010 were histologically examined to assess vascular alterations, including perivascular infiltrate, intravascular infiltrate, wall thickness, thrombosis, endothelial cell swelling, vessel wall necrosis, and peri-vascular fibrosis. Pulsatile-flow (PF) devices had been inserted in 9 patients and CF devices had been inserted in 16. The pathologist was blinded to the group distribution. Demographic, pharmacologic, and clinical data were retrospectively analyzed before surgery and during the follow-up period of up to 24 months. RESULTS: Median duration of support was 467 days (range, 235-1,588 days) in the PF group and 263 days (range, 182-942 days) in the CF group. Demographic and clinical data before and after surgery were similar. Amiodarone was more often used during follow-up in CF group than in the PF group (61% vs 10%, p = 0.009). Throughout the follow-up period, mean arterial pressure did not differ between recipients of the 2 pump types, nor did systolic and diastolic pressure, except at 2 weeks after VAD implantation, when systolic blood pressure was higher (p = 0.05) and diastolic lower (p = 0.03) in the PF group. Histologic studies did not identify any relevant differences in arterial wall characteristics between the 2 groups. CONCLUSION: Long-term mechanical circulatory support with CF devices does not adversely influence arterial wall properties of the end-organ vasculature.

Simultaneous aortic valve replacement in left ventricular assist device recipients: single-center experience.

INTRODUCTION: Aortic valve regurgitation or the presence of a mechanical aortic valve prosthesis is a relative contraindication for implantation of left ventricular assist devices (LVAD). However, concomitant aortic valve replacement by a biological prosthesis is one of the options in this situation. We analyzed our recent experience with left ventricular assist device implantation and concomitant aortic valve replacement. METHODS: Between January 1, 2008 and January 15, 2012, 318 adult patients (>18 years old) were supported with a long-term implantable LVAD in our institution. In 19, simultaneous aortic valve replacement (6 redo and 13 primary procedures) was performed. Patients were divided into 2 groups according to INTERMACS (IM) level: Group 1 (n = 7) consisted of patients with IM level 1-2 and Group 2 (n = 12) of IM level 3-4 patients. As a control cohort we analyzed all LVAD recipients during the study period (n = 299, study group excluded). The control cohort was similarly divided into two groups according to the IM level: Group 3 (n = 162) consisted of patients with IM level 1-2 and Group 4 (n = 137) of those with IM level 3-5. Perioperative data and outcomes in all groups were retrospectively analyzed and compared (Group 1 compared to Group 3; and Group 2 to Group 4). RESULTS: In study Groups 1 and 2 all patients were male; in Groups 3 and 4, 80% and 88% respectively were male. Median age distribution in Groups was 55, 61, 54, and 57 years respectively. Patients from Group 2 were significantly older than those from Group 4 (p = 0.039). Body mass index was significantly lower in Group 1 than in Group 3 (p = 0.033). Cardio-pulmonary bypass time was significantly longer in Groups 1 and 2 compared with Groups 3 and 4 respectively (p=0.001). Patients from Group 1 had a trend more often to develop right ventricular failure requiring a right ventricular assist device (RVAD) than those in Group 3 (p = 0.09). Intensive care unit stay duration of mechanical ventilation and in-hospital mortality in Group 1 were significantly higher than in Group 3 (p = 0.025, p = 0.005, p = 0.038). Patients from Group 2 had similar outcomes compared to those from Group 4. CONCLUSIONS: In stable patients, simultaneous aortic valve replacement and LVAD implantation are not associated with an impaired outcome. In patients with cardiogenic shock an additional aortic valve replacement may impair outcome; therefore alternative techniques should be considered.

Influence of size disparity of transplanted hearts on cardiac growth in infants and children.

OBJECTIVE: We aimed to evaluate the influence of size disparity of the transplanted heart on cardiac growth in infant and child recipients by comparing donor body surface area (BSA) and cardiac dimensions during transplantation to the corresponding parameters of the recipient over a period of time. METHODS: A retrospective review of medical and echocardiographic records of 147 children (5.3 ± 4.0; median, 4.1; range, 1 month-15 years) who underwent orthotopic heart transplantation was done. The patients were divided into age groups as follows: less than 1 year (n = 23), 1 to 2 years (n = 26), more than 2 to 5 years (n = 18), more than 5 to 10 years (n = 27), and more than 10 to 15 years (n = 53). Donor/recipient BSA ratio was determined during transplantation. Cardiac dimensions were measured 30 days after transplantation and compared at 1 year, 2 to 5 years, and 5 to 10 years after transplantation. RESULTS: There were no significant differences in the ventricular end-diastolic diameter, volumes, and mass among those with a donor/recipient BSA ratio of less than 0.80, 0.8 to 1.2, and more than 1.2 (P = .80, .44, and .48, respectively). In all the cardiac dimensions and volumes measured, donor-recipient mismatch did not influence the continuous growth of the heart, as indicated by the measured parameters, in accordance with the recipients' increase in BSA over time. All calculated Z-scores at 1 year, 2 to 5 years, and 6 to 10 years after transplantation were normal when indexed to BSA. CONCLUSIONS: This study demonstrates that despite size disparity of a transplanted heart, it undergoes normal growth in diastolic dimensions, volumes, and myocardial mass over time as appropriate for body growth after cardiac transplantation in infants and children.

Prediction of true circulatory decompensation in chronic heart failure for optimal timing of mechanical circulatory support: non-invasive arterial-ventricular coupling.

BACKGROUND: Prospective comparative studies to predict the risk of hemodynamic deterioration in patients referred for transplantation were performed on the basis of standard invasive and non-invasive data and new wave intensity (WI) parameters. METHODS AND RESULTS: Study Group 1 consisted of 151 consecutive outpatients (age 48.7 ± 12 years; 110 men) with end-stage dilative cardiomyopathy. Group 2, consisting of 11 consecutive patients (age 50 ± 11 years; 6 men) with sinus rhythm and "true" decompensation, was used to create "critical values" of WI. There were no demographic or somatic (weight and height) differences between the groups. The follow-up period of ambulatory patients was 31 ± 8 months. Non-invasive WI was studied in the common carotid artery. Complete invasive and non-invasive data were also recorded on the day of investigation. During follow-up 44 pts were lost; there were 15 cardiac deaths (10%), life-saving ventricular assist device implantation in 10 (6.6%) and transplantation in 19 (12.7%). For statistical purposes this group was named the "events" Group B (n = 44). A predisposing factor for events (death, "true" decompensation and "urgent" transplantation in ambulatory patients) was low first peak ("cut-off value" assessed in Group 2 < 4100 mmHg*s³) (OR 45.6, CI 14.5-143.3, p < 0.001). Less powerful predictors of the risk of deterioration were pulmonary capillary pressure (PCP), diastolic pulmonary artery pressure (PAP) and E/A mitral wave relation (p = 0.05). CONCLUSIONS: The new ventricular-arterial coupling parameter 1st peak of WI can potentially be used to distinguish patients at high risk for true deterioration and death. This parameter can be used to predict the need for assist device implantation.

Predictors of in-hospital mortality in children after long-term ventricular assist device insertion.

OBJECTIVES: This study aimed to determine the pre-implantation predictors for in-hospital mortality in children with ventricular assist device (VAD) support. BACKGROUND: Candidate selection is of critical importance for improved outcomes in patients supported with VAD. However, risk factors for post-VAD survival in children are still not clearly understood. METHODS: From June 1996 to December 2009, 92 children underwent implantation of a long-term VAD at Germany Heart Institute Berlin. Data on all these patients were retrospectively analyzed, and pre-operative risk factors for in-hospital survival after VAD implantation were identified by multivariate logistic regression. RESULTS: Of the 92 subjects, the median age at implantation was 7 years (range 12 days to 18 years), and the median support time was 35 days (range 1 to 591 days). The overall survival rate to transplantation or recovery of ventricular function was 63%. Independent predictors of in-hospital mortality in children included congenital etiology (odds ratio [OR]: 11.2; 95% confidence interval [CI]: 2.6 to 47.5), norepinephrine requirement (OR: 6.9; 95% CI: 1.4 to 31), C-reactive protein level >6.3 mg/dl (OR: 4.9; 95% CI: 1.1 to 22.1), and central venous pressure >17 mm Hg (OR: 4.6; 95% CI: 1.1 to 20). CONCLUSIONS: Congenital etiology, pre-operative norepinephrine requirement, higher serum C-reactive protein, and central venous pressure were associated with increased in-hospital mortality in children with VAD support. Optimal candidate selection and timing of VAD insertion may be of great importance for improved outcomes in children with advanced heart failure.

Adaptive growth and remodeling of transplanted hearts in children.

OBJECTIVE: We aimed to evaluate the adaptive growth and remodeling behavior of the transplanted heart in pediatric heart-transplant recipients by comparing donor body surface area (BSA) and cardiac dimensions during transplantation with the corresponding parameters of the recipient over a period of time. METHODS: A retrospective review of medical and echocardiographic records of 167 children (8.65 ± 5.98, median 9; range 0-17 years) who underwent orthotopic heart transplantation between 1987 and March 2010 was done. RESULTS: In the first 30 days post-transplantation, right- and left-ventricular end-diastolic diameters, volumes, and myocardial mass were found to be significantly increased (z score 3.96, p < 0.000) in relation to the recipients' BSA. Within the first year of post-transplantation, there was a significant reduction in the right-ventricular diameter (z score, -1.0 to +1.6, p = 0.000), left-ventricular diameter (z score -1.0 to +1.9, p = 0.000), right-ventricular end-diastolic volume (z score -1.3 to +1.9, p = 0.000) and left-ventricular end-diastolic volume (z score -1.3 to +1.8, p = 0.000), right-ventricular mass (z score, -1.4 to +1.7, p = 0.000) and left-ventricular mass (z score, -1.4 to +1.8, p = 0.000). During subsequent follow-up periods of 2-5 and 6-10 years, the aforementioned cardiac dimensions and volumes increased appropriately in accordance to the BSA (p = 0.000). In all the cardiac dimensions and volumes measured, donor-recipient mismatch did not influence the continuous growth of the measured parameters, which was in accordance to the recipients' BSA over time. Kaplan-Meier survival analysis showed a survival rate of 61.7% at 10 years. There is no statistically significant difference in survival rate among patients with varying donor-recipient weight ratios and donor-recipient BSA ratios (p = 0.53). CONCLUSIONS: This study demonstrates that the transplanted heart undergoes remodeling processes and grows adaptively, in accordance to the BSA, over a period of time.