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We present 2 cases of Aspergillus endocarditis occurring in lung transplant recipients, both of whom were treated with early surgical intervention and triazole anti-fungal agents. Neither had evidence of airway colonization/infection with Aspergillus post-transplant, suggesting hematogenous spread of fungi at the time of surgery as a possible mechanism of infection. One case was successfully treated and discharged from the hospital, but, despite initial recovery, death occurred 10 months later due to a recurrence of Aspergillus endocarditis. Aspergillus endocarditis should be considered a relapsing disease and survivors of the condition should receive ongoing anti-fungal therapy.

Assessment of myocardial recovery during left ventricular assist device (LVAD) support is difficult to perform both safely and effectively. We developed a test involving short-term interruption of LVAD support with measurements of several hemodynamic and echocardiographic parameters at rest and, whenever possible, after exercise, to investigate inotropic reserve.After full heparinization, the HeartMate I XVE device was switched off. MAP, heart rate (HR), ejection fraction (EF) and left ventricular dimensions were measured on switching off, after 5, 10 and 15 minutes, and after 6-minute walk (6MW).In total, 207 serial tests were performed on 22 patients. A total of 97.6% of the patients tolerated the tests. Of the 202 tolerated tests, 130 were performed on 16 patients who had their device explanted due to myocardial recovery (recovered group), and 72 on 6 patients who did not recover and were transplanted (non-recovered group). After device discontinuation there was an immediate drop in mean arterial blood pressure (MAP), a rise in HR, a reduction in EF and increases in ventricular dimensions. These changes tended to be more marked in the non-recovered group. After 6MW, the recovered group had a significant rise in HR and EF and a non-significant increase in MAP, whereas, the non-recovered group there was a significant drop in MAP compensated by a rise in HR. The distance walked in the recovered group was significantly higher (544 +/- 102 vs 418 +/- 109 meters, p0.05). MAP, pulse pressure and EF were strong predictive factors for recovery.Acute discontinuation of the device to assess recovery is safe and well tolerated and is followed by specific changes in hemodynamic and echocardiographic parameters. This helps in the assessment of recovery, particularly with regard to findings taken after exercise.

Background Primary graft failure after heart transplantation is a well-recognized catastrophic complication with a high mortality rate. It is becoming more frequent due to the increasing use of marginal donors. In these difficult cases a ventricular assist device (VAD) as a bridge to recovery or as a bridge to re-transplantation can be used. The recently introduced Levitronix Centrimag centrifugal pump might be an ideal device for this purpose. Methods In this study we describe 2 patients with primary graft failure who received a Levitronix in the last 2 years, immediately after failure to wean from cardiopulmonary bypass. Biventricular support was necessary in both patients. Results One patient was successfully re-transplanted after 2 days of support, and subsequently discharged. After 16 months she has good ventricular function with no symptoms of cardiac failure. The second patient showed signs of ventricular recovery after a few days and was weaned from the device after 7 days, with good graft function. No device-related complications were recorded. After 14 days he was discharged from the intensive care unit (ICU), and a post-operative echocardiogram showed normal dimensions, good ejection fraction and no valvular regurgitation. He was discharged home 26 days after the transplant. Conclusions In our experience, the Levitronix Centrimag seems to be safe and effective in the treatment of primary graft failure, achieving effective circulatory support and ventricular off-loading. We propose its use in isolated or biventricular graft failure either as bridge to re-transplant or as a bridge to recovery.

Background The Levitronix ventricular assist device (VAD) is a centrifugal pump designed for extracorporeal support and that operates without mechanical bearings or seals. The rotor is magnetically levitated so that rotation is achieved without friction or wear, which seems to minimize blood trauma and mechanical failure. The aim of this study is to report our early results with the Levitronix Centrimag device. Methods Between June 2003 and April 2005, 18 patients (pts) were supported using the Levitronix at our institution. Fourteen were male. Mean age was 40.3 ± 18.3 (range 8 to 64) years. Indications for support at implantation were: post-cardiotomy cardiogenic shock in 12 cases (Group A), and bridge to decision regarding long-term ventricular support in 6 cases (Group B). Results Mean support time was 14.2 ± 15.2 days for all patients (range 1 to 64 days). Operative (30-day) mortality was 50% (9 pts). Six pts were in Group A and 3 pts were in Group B. Overall, 6 pts (33%) were discharged home and are presently alive and well (mean follow-up 13 months, range 5 to 17 months). Bleeding requiring re-operation occurred in 8 cases (44%), cerebral thromboembolism in 1 and pulmonary embolism in 1. There were no device failures. Conclusions The Levitronix functioned well and proved to be useful in patients with extremely poor prognosis previously considered non-suitable for a long-term assist device. The device was technically easy to implant and manage. There was no device dysfunction and complications were acceptable or consistent with other devices. Survival to explant or a definitive procedure (VAD or transplantation) was encouraging.

Purpose: Infectious complications are a major cause for morbidity and mortality in children following lung transplantation. Further, lung transplant candidates and recipients are at high risk of infections from vaccine preventable diseases. However, well established vaccination and monitoring guidelines do not exist. We explored the current vaccination and monitoring guidelines of pediatric lung transplant centers. Methods and Materials: In April 2006, a self-administered questionnaire was distributed to the 18 pediatric lung transplant centers within the International Pediatric Lung Transplant Collaborative (Canada/Europe/USA). One member of each lung transplant centre provided information regarding vaccination guidelines in children before and after lung transplantation. Descriptive statistic analysis was used to analyze data. Results: Sixteen of 18 centers (89%) surveyed responded to the questionnaire. Pre-transplant, national vaccination guidelines are followed. Eleven centers reported post-transplant vaccination guidelines. Vaccine was more commonly provided by the primary care physician pre-transplant (69%) than post-transplant (38%). 56% of transplant centers do not delay transplantation due to administration of live virus vaccination, but aim to wait for a minimum of 3-4 weeks between live virus vaccine administration and possible transplantation. Post-transplant, 50% of centers recommend live vaccines for household contacts. Pre-transplant monitoring of response to prior vaccination was performed rarely except for varicella (88%). Only 44% of transplant centers measure for response to vaccination post-transplant, mostly hepatitis B. Conclusions: Current vaccination guidelines of pediatric lung transplant centers are heterogeneous. There is little knowledge with regards to vaccine response in children following lung transplantation.

ventricular assist devices (LVAD) on renal function is uncertain. Methods and Materials: We retrospectively reviewed 100 patients who received either continuous (n 70; mean age 51.5 11.6 yrs, 83.3% male, 40% ischemic) or pulsatile (n 30; mean age 57.8 8.7 yrs, 93.4% male, 36.7% ischemic) LVAD implantation as a bridge to transplant therapy from 1994 to 2006. Renal function was assessed by 2 calculated glomerular filtration rates (GFR) using the Modification of Diet in Renal Disease (MDRD)-derived GFR and Cockcroft-Gault-derived creatinine clearance (CrCl) at LVAD implantation, in the post-implant period (wk 1, 2, 3, 4; mo 2, mo3), and at transplantation. Results: There was no difference in patient survival between the 2 groups. The 6-month Kaplan-Meier estimate of survival was 60.6% for the continuous and 63.7% for the pulsatile device group. In the continuous and pulsatile device groups, 31 (44.4%) and 15 (50%) patients, respectively, underwent transplantation. At LVAD implantation, neither estimates of renal function showed a difference between the 2 groups (Continuous: GFR 63.2 22.7 mL/min/1.73m, CrCl 77.3 30.8 mL/min; Pulsatile: GFR 54.1 22.9 mL/min/1.73m, CrCl 65.1 31 mL/min). Similarly, in the post-implant period, neither estimates of renal function showed a difference between the 2 groups. At transplantation, with the Cockcroft-Gault calculated CrCl, the estimated renal function in the continuous device group was significantly improved compared to the pulsatile device group (Continuous: 94.7 24.8 mL/min; Pulsatile: 74.6 26.4 mL/min; p 0.015). Conclusions: Continuous flow LVADs provide adequate blood flow to maintain renal function that is comparable to pulsatile flow devices.

Purpose: Recent advances have led to an increasing number of treatment options for patients with advanced heart failure. Many of these options increase life expectancy with a varying effect on quality of life. In order to provide care that reflects patients’ wishes, we must first identify what their preferences are. This study determined the treatment preferences of patients with heart failure (HF) stratified by NYHA Class II and IV symptoms for three distinct treatment options: optimal medical management (OMM), oral inotropes or LVAD support. Methods and Materials: We enrolled 92 patients (NYHA II 49, NYHA IV 43). Each patient completed a treatment tradeoff instrument, Minnesota Living with HF Questionnaire (MLHFQ) and visual analog scales (VAS) for perceived severity of overall heath, dyspnea and fatigue. Results: Compared to class II patients, those with class IV symptoms had significantly worse MLHFQ scores, dyspnea, fatigue and overall health (p 0.05). In rank order, the most preferred treatment options were inotropes, LVAD and OMM. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patients in the worst terciles of MLHFQ and VAS scores did not significantly differ in their treatment preferences versus those in the lower terciles. By multivariate analysis, MLHFQ, VAS and NYHA Class did not influence treatment choices. However, older patients (age 60years) were less likely to prefer aggressive treatment with LVAD therapy compared to younger patients. Conclusions: The results of this study suggest patients with heart failure prefer treatment options that improve quality of life. There does not appear to be an effect of functional or symptom status on treatment preference and the finding of no difference between groups suggests treatment preferences may be decided early in the course of illness. Although the results of this study cannot be assumed to predict individual preferences they may serve as an impetus for clinicians to discuss end-of-life treatment preferences with patients early in their course of illness.

PREOPERATIVE VARIABLES THAT PREDICT POSTOPERATIVE COURSE AND MAY AIDE TIMING OF LVAD IMPLANTATION S. Haj-Yahia, G. Tasca, M. Amrani, M. Petrou, N. Banner, J. Pepper, G. Dreyfus, A. Khaghani, E.J. Birks, Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, United Kingdom; NHLI, Imperial College for Thecnology, science and Medicine, London, United Kingdom