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Case report: 18-year-old female was hospitalized for acute heart failure three years after a heart transplant. Echocardiography showed thickened walls and reduced systolic function of both ventricles (left ventricular ejection fraction, LVEF 30%). Pulse steroid therapy was started after urgent cardiac biopsy (Bx). Because of the development of cardiogenic shock, a venous-arterial (VA) ECMO (extracorporeal membrane oxygenation) had to be set up. Bx showed a mixed type of acute rejection: antibody-mediated rejection grade pAMR 1(I+) and cell-mediated rejection grade 3R. Luminex® confirmed the existence of numerous anti-HLA donor specific antibodies (DSA) class I (A11, A30, B13, B35) and class II (DR3, DR15, DR51, DQ2, DPA1*02) with maximal MFI 13000 for anti-DQ2. Plasmapheresis, intravenous immunoglobulin (IVIg) and antithymocite globulin (ATG) were immediately initiated. On the fourth day, both ventricles had normal wall thickness and improved systolic function (LVEF 40%). The patient was successfully weaned from ECMO. Rituximab was applied at the end of the second week. Control Bx showed no cell-mediated rejection, while immunohistochemistry remained positive. Coronary angiography was normal. Five additional plasmapheresis cycles were performed and IVIg was administered, whereupon echocardiography showed normal left ventricle size and wall thickness, while right ventricle was normal in size but had slightly reduced function. Bx showed no cell- or antibody-mediated rejection. Seven weeks after treatment initiation DSA class I and class II were all negative, except anti-DQ2 (MFI 6100) (Figure 1). 12 months later the patient is stable, without signs of rejection or graft function deterioration. Conclusion: This case shows the importance of acute mechanical circulatory support in heart transplant patients with critical heart failure and, therefore, gaining additional time to run tests and wait for therapeutic effects (i.e. bridge-to-decision, bridge-to-recovery). By combining steroids, plasmapheresis, IVIg, ATG and rituximab, we interacted with complex immune mechanisms of mixed cell- and antibody-mediated acute graft rejection, and ultimately provided not only survival, but also the complete recovery of the patient. [ABSTRACT FROM AUTHOR]

Introduction: Advanced heart failure affects only a small percentage of patients with heart failure (HF), but never the less, is a growing public problem. Heart transplantation was a gold standard of treatment for many years, but in the last 10 years novel advanced treatment methods have become available as a therapy.1 Case report: In this case report we will show a 52 years old patient who was hospitalized in Department of Intensive Cardiac Care due to HF. Patient had biventricular dilative cardiomyopathy and had cachexia on admission. Because he was on inotropic support and his vital signs needed to be continuous monitoring, he needed intensified nursing care. His medical treatment was complicated with hemodynamic instability and eventually he underwent placement of veno-arterial extracorporeal membrane oxygenation, and 3 days after that he had been upgraded to central circulatory support of both ventricles. During that time, diagnostic workup for heart transplant was completed and he was listed for urgent heart transplant via „Eurotransplant”. After 20 days a suitable organ was offered, and he underwent the procedure with a good result during recovery. Conclusion: Medical care of patient with mechanical heart support is quite a challenge to nurses. However, her role is a crucial in multidisciplinary approach. Beside physical, educational and psychological help provided by nurse to a patient, she also coordinates work of the health team, navigates patient through the health system and allocates education and support for patient family members. Efficient team work with a focus on quality communication can significantly prevent work errors and can improve patient content with provided service. [ABSTRACT FROM AUTHOR]

Introduction: Mechanical circulatory support is becoming a more common therapy for end-stage heart failure in intensive cardiac care unit, and currently there are several types of devices that can be used as bridge therapy to recovery phase or hearth transplantation. Extracorporeal membrane oxygenation (ECMO) replaces heart and lung function using extracorporeal blood flow and it can be used as mechanical support in cardio-circulatory or respiratory failure.1 In a patient on ECMO support there is a strong activation of inflammatory response in a short period of time, usually due to shock before the initiation of support, but also, due to long, non-physiological blood flow through the piping, rotational pump and the oxygenator, where there is higher possibility of development of infection. In this phase patients are hemodynamically unstable, dependent on vasoactive support and substitution of intravenous fluids with a raise in inflammatory markers seen in laboratory results. Adsorbers for extracorporeal blood purification (CytosorbTM) can absorb molecules ranging from 5 to 55 kDa, which is the size where cytokines and some metabolites such as bilirubin, bile acids and ammonium can be absorbed, and it can be used to control inflammatory response which eventually can damage blood vessel walls and lead to target organs damage. Case report: This case report will show a 38-year-old patient who was hospitalized in Department of Cardiac Intensive Care after deterioration of his primary condition (cardiomyopathy) with hemodynamic instability, which lead to placement of both left and right sided mechanical circulatory support with an adsorber. This led to a decrease of inflammatory markers with good clinical and microbiological response. Patients soon underwent heart transplantation without any major complications and fast recovery. Conclusion: Use of adsorber via ECMO machine or dialysis machine is a very complex procedure which needs responsible approach to intervention and the only guarantee of success lays in a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Extracorporeal Membrane Oxygenation (ECMO) is an extracorporeal technique of providing prolonged cardiac and respiratory support that is used in patients with lifethreatening forms of heart or lung failure. There are two basic forms of ECMO support: venous-venous (V-V) and venous-arterial (V-A) ECMO.1,2 This paper presents experience with the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO). Since 2017, peripheral VA ECMO support has been applied in 16 patients (14 men and 2 women). The most common indication for application is cardiogenic shock (62.5%). The average time period spent on the VA ECMO is 64 hours. Of the reported complications, the most common is bleeding (mostly at the canulation site) which is present in 56.2% of cases. Of the total number of patients, 13 (81.3%) were successfully separated from ECMO support, and 9 (56.3%) survived untill the discharge or untill the transfer to another institution. The application of the VA ECMO in the cardiology intensive care unit has greatly improved the chances of survival of the most critical patients. [ABSTRACT FROM AUTHOR]

The therapy for patients with ischemic cardiomyopathy and advanced heart failure (AHF) is based on the optimal medical therapy, device-based therapies (implantable cardioverter-defibrillators and cardiac resynchronization therapy) and coronary revascularization. The decision to perform coronary artery bypass grafting (CABG) is difficult because of higher operative morbidity and mortality, uncertain benefit (lack of predictive factors including viability testing) and undefined guidelines. Ten-year of the follow-up from the largest randomized trial (STICHES) of CABG compared with medical therapy showed a mortality benefit in CABG patients1. Percutaneous coronary intervention (PCI) seems to be reasonable alternative to CABG. However, there is a lack of clinical trials testing PCI versus medical therapy and CABG in AHF. The observational study that compared PCI using drug eluting stents with CABG in AHF patients showed no significant difference in death, greater risk of myocardial infarction and need for repeat revascularization but a significantly lower risk of stroke in PCI2. In PCI patients in whom complete revascularization was achieved, there was no difference in myocardial infarction between PCI and CABG. However, PCI in AHF is considered as a high risk procedure and should be initiated only after full consideration of various factors and after developing a detailed plan. In our experience, there are some measures that need to be performed in order to improve outcome and to avoid complications. Important is to optimize patient's clinical status and perform pulmonary decongestion. Staged approach to revascularization, especially in complex lesions, is preferred to avoid high total amount of contrast agents (leading to pulmonary oedema and contrast nephropathy) and cardiogenic shock in the case of abrupt artery closure (because of low contractile reserve). Suitable PCI support equipment should be timely considered3. Because of low rate of complications (compared to the extracorporeal membrane oxygenation), easy to use and low price (compared to Impella), the intra-aortic balloon pump is especially convenient for short term haemodynamic support in patients where short ischemic period is expected during PCI. [ABSTRACT FROM AUTHOR]