Search

Background/Purpose Sensitization, the presence of preformed anti-human antibody in recipients, restricts access to ABO-compatible donors in heart transplant. Desensitization therapy works by reducing preformed antibodies to increase the chances of a negative crossmatch or permit safe transplantation across positive crossmatch. There is no consensus regarding the desensitization protocol in cardiac patients, and the outcome of desensitization remains under debate. Methods Twenty-five consecutive sensitized heart transplant recipients received perioperative desensitization in our institution from 2012 to 2019. One-year patient survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients. Results Within the first year after transplant, patient survival in sensitized recipients was 76%. Infection was the major cause of death. The cumulative incidence of rejection was 8% for antibody-mediated rejection and 16% for acute cellular rejection. No significant difference in 1-year survival or rejection rate could be demonstrated between sensitized and nonsensitized recipients. Conclusion Acceptable early outcomes in patient survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity crossmatch- or panel-reactive antibody-directed urgent immunomodulation strategies, while infection remains the major concern.

Purpose The number of waitlisted patients requiring mechanical circulatory support (MCS) as a bridge to heart transplantation is increasing. The data concerning the results of double-bridge strategy are limited. We sought to investigate the post-transplant outcomes across the different bridge strategies. Methods We retrospectively reviewed a heart transplantation database from Jan 2009 to Jan 2019. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. The pre- and post-transplant characteristics and variables of patients bridged with the different types of MCS were collected. The post-transplant survival was compared using Kaplan-Meier survival analysis. Results A total of 251 heart transplants were reviewed; 115 were without MCS and 136 with MCS. The patients were divided to five groups: Group 1 (no MCS): n=115; Group 2 (IABP): n=15; Group 3 (ECMO): n=33; Group 4 (ECMO-VAD): double-bridge (n=59); Group 5 (VAD): n=29. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p Conclusion Double bridge may not lead to worse mid-term results in patients who have the opportunity to receive a transplantation. Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome.

Background: The outcome of open-heart surgery for patients with liver cirrhosis (LC) varies widely, indicating multifactorial influences on liver injury after cardiopulmonary bypass (CPB). Methods: This observational single center study evaluated adult LC patients receiving open heart surgery with CPB during 2007 and 2017. The primary endpoint was post-operative hypoxic hepatitis (POHH), defined by post-operative serum glutamate oxaloacetate transaminase and glutamate pyruvate transaminase more than 10 times the pre-operative value. Results: In total, 61 patients were included in the study, of whom 14 (18.7%) developed POHH. Hospital mortality of non-POHH group (4.3%) was similar to that estimated using Euroscore II (4.0%), but that of the POHH group (21.4%) was 2.7 times as that estimated using Euroscore II (8.0%). Model for End-Stage Liver Disease (MELD) score and CPB duration were found as independent risk factors for POHH by multivariate logistic regression. POHH incidence was 0.0% if MELD 20 regardless of CPB duration. For those with MELD between 5 and 20, POHH incidence increases as CPB duration increases. Conclusion: For LC patients undergoing cardiac surgery with CPB, the incidence of POHH is highly associated with MELD score and CPB duration. To prevent POHH, the CPB duration should be shortened for those with MELD score between 5 and 20, and CPB be avoid for those with MELD >20. Keywords: Liver cirrhosis, Open heart surgery, Cardiopulmonary bypass, MELD score, Post-operative hypoxic hepatitis

Purpose Desensitization therapy through reducing preformed antibody to increase the chances of a negative cross-match or permit safe transplantation across positive crossmatch. There was no consensus regarding desensitization protocol in cardiac patients, and the outcome of desensitization in sensitized recipient was still under debate. Methods Consecutive 25 sensitized heart transplant recipients received peri-operative desensitization in our institution from 2012 to 2019. One-year survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients in our institution. Results One-year survival after transplant was 76% in sensitized recipients. Infection was the major cause of death. Incidence of rejection in the first year after transplant was 8% for antibody-mediated rejection and 16% for acute cellular rejection. Compared with the outcome in non-sensitized recipients, no significant difference in 1-year survival or rejection rate (sensitized vs. non-sensitized, survival 76 vs. 84.6%, P = 0.32; antibody-mediated rejection rate 8 vs. 3.1%, P = 0.41; acute cellular rejection rate 16 vs. 6.2% P = 0.20) could be demonstrated. Conclusion Acceptable early outcomes in patient's survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity (CDC) crossmatch - or panel reactive antibody (PRA) - directed urgent immunomodulation strategies, while infection remains the major concern.

Background Extracorporeal membrane oxygenation (ECMO) has been proven effective in life support for patients with refractory cardiopulmonary failure. Deteriorating patients who have removed their first ECMO support and required second or more courses of ECMO support have rarely been discussed. Methods and Results All the records of the patients who experienced at least 2 courses of ECMO during single admission were retrieved. Survival was defined as survival to discharge. Demographic data and clinical information were compared between survival and nonsurvival groups. There were 86 patients who received at least 2 courses of ECMO in the 20-year database, and 27 (31.3%) were Conclusions The decision to perform repeated ECMO implantation is a complex and difficult process. Despite the arguments debating the consumption of resources and increased complications, there are still nearly 1 out of 3 patients who will survive to discharge. More than 2 courses of ECMO may be carefully considered for further rescue.

Slide tracheoplasty is the preferred approach for treating long-segment congenital tracheal stenosis (CTS). However, little research has been conducted on the tracheobronchial anatomy before and after slide tracheoplasties in patients with CTS.We reviewed 23 patients with CTS who received slide tracheoplasties. We measured the intrathoracic tracheal length and the carina angle from computed tomography images. To account for each patient's body size, we divided the intrathoracic tracheal length by the length of the thorax to obtain the trachea-thorax ratio (TTR). These measurements were used to compare patients before and after slide tracheoplasties as well as normal control subjects.Two patients had upper tracheal CTS and 21 patients had lower tracheal CTS. For the 21 patients with lower tracheal stenosis, their TTRs before slide tracheoplasty were 0.42 ± 0.04, which were significantly larger than those of the control subjects (0.32 ± 0.04; p0.0001). After slide tracheoplasty, the TTR was 0.32 ± 0.04, similar to the control TTRs (p = 0.94). The carina angle was significantly wider in the 21 patients than in the control subjects (120.7 ± 11.7 degrees versus 86.4 ± 13.1 degrees; p 0.0001). After slide tracheoplasty, the carina angle was significantly narrower (from 120.7 ± 11.7 degrees to 92.2 ± 15.2 degrees; p0.0001), which was similar to control subjects.The trachea was longer and the carina angle wider in patients with lower tracheal CTS than in control subjects. Excessive tracheal length is favorable for slide tracheoplasty. Slide tracheoplasty not only corrects CTS, but also restores tracheobronchial morphology.

Extracorporeal cardiopulmonary resuscitation (ECPR) has gradually come to be regarded as an effective therapy, but the hospital mortality rate after ECPR is still high and unpredictable. The present study tested whether age-adjusted Charlson comorbidity index (ACCI) can be used as an objective selection criterion to ensure the most efficient utilization of medical resources. Adult patients (age &ge, 18 years) receiving ECPR at our institution between 2006 and 2015 were included. Data regarding ECPR events and ACCI characteristics were collected immediately after the extracorporeal membrane oxygenation (ECMO) setup. Adverse events during hospitalization were also prospectively collected. The primary endpoint was survival to hospital discharge. The second endpoint was the short-term (2-year) follow-up outcome. A total of 461 patients included in the study were grouped into low ACCI (ACCI 0&ndash, 3) (240, 52.1%) and high ACCI (ACCI 4&ndash, 13) (221, 47.9%) groups. The median ACCI was 2 (interquartile range (IQR): 1&ndash, 3) and 5 (IQR: 4&ndash, 7) for the low and high ACCI groups, respectively. Cardiopulmonary resuscitation (CPR)-to-ECMO duration was comparable between the groups (42.1 &plusmn, 25.6 and 41.3 &plusmn, 20.7 min in the low and high ACCI groups, respectively, p = 0.754). Regarding the hospital survival rate, 256 patients (55.5%) died on ECMO support. A total of 205 patients (44.5%) were successfully weaned off ECMO, but only 138 patients (29.9%) survived to hospital discharge (32.1% and 27.6% in low and high ACCI group, p = 0.291). Multivariate logistic regression analysis revealed CPR duration before ECMO run (CPR-to-ECMO duration) and a CPR cause of septic shock to be significant risk factors for hospital survival after ECPR (p = 0.043 and 0.014, respectively), whereas age and ACCI were not (p = 0.334 and 0.164, respectively). The 2-year survival rate after hospital discharge for the 138 hospital survivors was 96% and 74% in the low and high ACCI groups, respectively (p = 0.002). High ACCI before ECPR does not predict a poor outcome of hospital survival. Therefore, ECPR should not be rejected solely due to high ACCI. However, high ACCI in hospital survivors is associated with a higher 2-year mortality rate than low ACCI, and patients with high ACCI should be closely followed up.

Purpose Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR. Methods Adult patients who received ECPR in our institution (2006–2016) were classified into groups 1, 2, and 3 (18–65, 65–75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge. Results In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3, P = 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of 60 min, respectively (P = 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (P = 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (P = 0.274). Conclusion On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome. Electronic supplementary material The online version of this article (10.1007/s00134-018-5496-y) contains supplementary material, which is available to authorized users.

Purpose: To report our midterm results of the crossover chimney technique to preserve the internal iliac artery (IIA) in patients with aortoiliac aneurysms (AIA) and isolated common iliac artery aneurysms (CIAA). Methods: Between May 2012 and January 2014, 14 consecutive patients (mean age 77.3 years; all men) with 17 AIA, isolated CIAAs, or abdominal aortic aneurysms with short CIAs underwent elective endovascular aneurysm repair (EVAR) with the crossover chimney technique to preserve the IIA. Follow-up assessment, including computed tomographic angiography or duplex ultrasound, was performed at 1, 6, and 12 months and annually thereafter. Results: Technical success, defined as successful preservation of IIA without intraoperative type I or III endoleak, was 100%. Over a mean 14.3 months (range 6–21), primary patency was 92.8%. There was no early or late procedure-related mortality. Among the 17 iliac aneurysms excluded, the sac diameter significantly (at least 5 mm) decreased in 3, decreased

OBJECTIVES Patients with acute (ACTBAD) or chronic complicated Type B aortic dissection (CCTBAD) undergoing thoracic endovascular aortic repair (TEVAR) remain at high risk for late aorta-related events. Few data exist on the comparison of aortic remodelling and outcomes after TEVAR between both groups. METHODS Forty-nine patients of TEVAR for CCTBAD (n = 26) and ACTBAD (n = 23) were retrospectively reviewed at our centre. RESULTS The overall 30-day mortality was 4%. Cumulative freedom from all-cause mortality (ACTBAD: 77.6%, CCTBAD: 68.8%; P = 0.76), aneurysmal-related mortality (ACTBAD: 88.2%, CCTBAD: 95.0%; P = 0.63) and the 3-year reintervention rate (ACTBAD: 92.3%, CCTBAD: 95.6%; P = 0.94) were the same in both groups. Aortic remodelling was significant (P

Background Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes. Methods Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease. Results Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30–63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients ( P = .59). Conclusions There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease.

Summary Objective Clot embolism remains a concern due to flushing of clot and thrombolytic agent centrally in the process of percutaneous pharmacomechanical thrombolysis (PMT) for a thrombosed prosthetic arteriovenous access (PAVA), which might be reduced by a modified technique. Methods We retrospectively review this modified technique that uses two balloon-catheters in crisscross fashion and occludes both ends of PAVA during thrombolysis. Underlying stenotic lesions were dilated simultaneously with balloon angioplasty when needed. Results Among the 23 patients treated, 21 (91.3%), 10 (43.5%), and seven (30.4%) presented significant stenosis at the outflow, intragraft, and inflow segments of PAVA, respectively. The median duration of follow-up was 310.0 (range, 288.0–327.0) days. Anatomic success was achieved in 12 out of 23 (52.2%). Clinical success for successful dialysis was achieved in all patients. The median primary patency and secondary patency were 126.0 days (range, 7.0–316.0) days and 308.0 days (range, 84.0–327.0), respectively. Conclusion We believe this method is safe and effective in dissolving PAVA thrombus as well as treating culprit stenosis. It may reduce concerns of flushing of clot and thrombolytic agent into the central circulation in the process of PMT.

Background The most serious complication after heart transplantation is allograft dysfunction. Patients presenting with compromised hemodynamics show a high incidence of mortality. The most common reason for allograft dysfunction is rejection. We have employed steroid pulse therapy combined with plasmapheresis for hemodynamically compromised patients after heart transplantation. Methods and Results Steroid pulse therapy and plasmapheresis were performed on 35 patients who underwent orthotopic heart transplantation for graft dysfunction. Thus treatment rescued ventricular function and improved the ejection fraction in 77% of patients, among who ever 71.4% showed improved New York Heart Association (NYHA) functional class. Conclusions Steroid pulse therapy combined with plasmapheresis improved the cardiac contractility and NYHA functional class of most heart transplant recipients with graft dysfunction.