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Background The post-market Registry to Evaluate the HeartWare Left Ventricular Assist System (ReVOLVE) is an investigator-initiated registry established to collect post–CE Mark Trial clinical data on patients receiving a HeartWare ventricular assist device (HVAD) in the European Union and Australia. Methods The ReVOLVE is a multi-center, prospective, single-arm registry performed at seven centers in Europe and two in Australia. Herein we describe a total of 254 commercial HVAD implants according to labeled indications between February 2009 and November 2012. Summary statistics included patients’ demographics, adverse events, length of support and outcomes. Results Compared with the clinical trial supporting the CE Mark of the HeartWare system, patient selection differed in that patients were older, and there were higher proportions of females and patients with idiopathic cardiomyopathies in the ReVOLVE cohort. Duration of support ranged from 1 to 1,057 days, with a mean of 363 ± 280 days (median 299.5 days). Transplantation was done in 56 patients (22%), explant for recovery was performed in 3 patients (1%), 43 died while on support (17%), and 152 (60%) remain on the device. Success in patients with the HeartWare system was 87% at 6 months, 85% at 1 year, 79% at 2 years and 73% at 3 years. Adverse event rates were low, comparable or improved when compared to the CE Mark Trial. Conclusion Real-world use of the HeartWare system continues to demonstrate excellent clinical outcomes in patients supported with the device.

Aims Dilated cardiomyopathy (DCM) patients have abundant levels of norepinephrine secondary to failure of the norepinephrine transporter uptake mechanism. Little is known about the effects of an LV assist device (LVAD) on cardiac sympathetic innervations and norepinephrine transporter dysfunction. This study examines the effects of continuous-flow HeartMate II LVAD on cardiac sympathetic innervations using [123I]metaiodobenzylguanidine ([123I]MIBG) nuclear imaging. Methods and results After injecting 431 ± 21 MBq of [123I]MIBG, planar scintigraphy was performed at 15 min and 4 h in 14 consecutive non-diabetic non-ischaemic DCM patients. Scans were executed early post-LVAD implantation (T1) and prior to either device explantation for myocardial recovery or transplant listing (T2). [123I]MIBG measured parameters included early and delayed heart–mediastinum (H/M) ratios and washout rate (W/O). Catecholamine levels were measured using liquid chromatography–mass spectrometry. Following 208.4 ± 85.5 days of LVAD support, both early and delayed H/M ratios increased by 42.1% (P < 0.001) and 54.7% (P < 0.001), respectively. The W/O rate decreased by 46% (P = 0.003). Plasma norepinephrine, epinephrine, and dopamine decreased significantly in correlation with [123I]MIBG parameters. Ten patients had recovered and had their device explanted as they had demonstrated a higher percentage change in delayed H/M ratio, W/O rate, and norepinephrine levels. Linear regression analysis revealed a strong correlation between percentage changes in both norepinephrine and epinephrine and myocardial recovery. Conclusion Combination therapy with LVAD and drug resulted in enhancement of [123I]MIBG uptake in DCM patients.

Extracorporeal membrane oxygenation (ECMO) may be used safely as a bridge to lung transplantation in carefully selected elderly patients. We report the case of a 70-year–old patient bridged on ECMO before transplantation. A brief discussion on improving outcomes for the elderly and patients bridged on ECMO in general is presented.

Background— We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. Methods and Results— We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, β-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the β 2 -agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2±12.6 years (16 male patients), patients were on 2.0±0.9 inotropes, 7 (35) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39±0.43 L · min −1 · m −2 , pulmonary capillary wedge pressure was 31.5±5.7 mm Hg, and heart failure history was 3.4±3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2) were explanted after 286±97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70±7, left ventricular end-diastolic diameter was 48.6±5.7 mm, left ventricular end-systolic diameter was 32.3±5.7 mm, mV̇ o 2 was 21.6±4 mL · kg −1 · min −1 , pulmonary capillary wedge pressure was 5.9±4.6 mm Hg, and cardiac index was 3.6±0.6 L · min −1 · m −2 . Estimated survival without heart failure recurrence was 83.3 at 1 and 3 years. After a 430.7±337.1-day follow-up, surviving explants had an ejection fraction of 58.1±13.8, left ventricular end-diastolic diameter of 59.0±9.3 mm, left ventricular end-systolic diameter of 42.0±10.7 mm, and mV̇ o 2 of 22.6±5.3 mL · kg −1 · min −1 . Conclusions— Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.

Objective Optimum strategy for salvage in patients with acutely decompensated end-stage heart failure and severe multiorgan dysfunction is complex. We present our experience with prolonged CentriMag (Levitronix, Waltham, Mass) support for transitioning patients after successful salvage from bridge to decision directly to transplant. Methods Records of patients who underwent salvage with a CentriMag as bridge to decision and later to transplant were reviewed. Between June 2003 and June 2008, 4 patients in cardiogenic shock from acute decompensated end-stage heart failure and multiorgan dysfunction underwent salvage with biventricular CentriMag as bridge to decision. Three were male. Mean age was 39.3 years (range 24–52 years). Three had dilated cardiomyopathy; 1 had ischemic cardiomyopathy. All had preoperative mechanical ventilation, large doses of multiple inotropes, and intra-aortic balloon support. All also had acute liver and renal failure and metabolic acidosis. Results After mean postimplant period of 43 days (range 7–70 days), patients had reversal of end-organ dysfunction; after mean waiting time of 31 days (range 21–67 days), all were transplant listed. Mean mechanical circulatory support was 87.7 days (range 26–105 days). No thromboembolic or neurologic events or mechanical failures occurred. Posttransplant mean ventilation and intensive care unit stay were 2 and 4 days (ranges 1–4 and 3–7 days), respectively. All patients were discharged home and remain alive and well. Conclusion CentriMag use as long as 3 months appears to be safe and cost-effective for bridging selected patients directly to transplant after salvage. Further clinical experience is still needed.

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 The UK Government funds ventricular assist device (VAD) implantation as bridge to transplantation (BTT) at three centers. Results from this program have not been published. Methods All 70 VAD implants for BTT, 71 inotrope-dependent and 179 non-VAD transplant candidates, accepted for transplantation between April 2002 and December 2004, were prospectively monitored for survival to transplantation, survival overall and quality of life. Results Of the 70 VAD patients, 31 (44%) survived to heart transplantation, 4 (6%) were bridged to recovery and 5 remained on support at the end of the study. Thirty patients (43%) died while on support. Overall survival from VAD implant was 52% at 1 year. Ten percent of non-VAD inotrope-dependent patients and 9% of routine transplant candidates died while on the waiting list. For transplant recipients, 12-month post-operative survival was 84%, 85% and 84%, respectively, for VAD, inotrope-dependent and routine transplant candidates. VAD and non-VAD patients had similar post-transplant adverse event rates. Conclusions There was a role for VAD bridge to transplant for selected patients in the UK, despite the availability of an effective urgent transplant list. VAD patients who underwent transplantation had survival rates similar to other transplant candidates.

Background We sought to evaluate the effect of center volume on patient survival. Methods We performed a retrospective analysis on nationwide data from the Scientific Registry of Transplant Recipients provided by United Network for Organ Sharing pertaining to lung transplantation (LT) recipients transplanted between 2005 and 2013. Centers were categorized into 4 groups based on their annual volume as follows: less than 20, 20 to 29, 30 to 39, and greater than or equal to 40 LTs. Baseline characteristics were compared and Kaplan–Meier analysis was used to estimate survival. Results A total of 13,506 adult recipients underwent LT during the study period. Of these, 2,491 (18.4%) patients were transplanted in centers with volume less than 20, 2,562 (19.0%) in centers with volume 20 to 29, 2,998 (22.2%) in centers with volume 30 to 39, and 5,455(40.4%) in centers with volume greater than or equal to 40. Survival was poorest in the lowest volume centers (1-year 81.4% vs 85.5% and 5-year 49.7% vs 56.5%, respectively). Conclusions Post-LT survival in low volume centers is significantly lower than in high volume centers but the explanatory power of volume as a predictor of survival is low.

Mechanisms underlying the rapid deterioration of heart failure patients who subsequently require left ventricular assist device (LVAD) support are poorly understood. Matrix metalloproteinases (MMPs) and the tissue inhibitors of metalloproteinases (TIMPs) play a key role in myocardial remodelling and heart failure. We hypothesized that MMP and TIMP expression would be altered in these patients.Quantitative polymerase chain reaction was used to measure myocardial messenger RNA levels of MMP1 to MMP14, TIMP1 to TIMP4, collagen I and collagen III in 24 dilated cardiomyopathy (DCM) patients with deteriorating clinical status who required LVAD support (LVAD Group) and in 7 stable DCM patients undergoing transplantation without need for LVAD support (Tx Group).Levels of MMP1, MMP8 and TIMP4 were higher in the LVAD Group compared with the Tx Group (188% +/- 141%, 646% +/- 432%, and 66% +/- 33% higher, respectively, p0.05) whereas MMP2, MMP9, MMP10, MMP11, and MMP14 levels were similar. MMP3, MMP7, MMP12, and MMP13 were undetectable. All TIMPs were generally higher in the LVAD group, but only TIMP4 reached significance. Collagen I and III were not altered. We tested for correlations between MMP and TIMP expression with myocardial cytokine levels. MMP8 correlated positively with interleukin-6 and interleukin-1beta, suggesting a link between cytokines and MMPs in these patients.The data show that high myocardial collagenase (MMP1 and MMP8) expression without compensatory changes in collagen or TIMP expression is a feature of patients requiring LVAD support. This may be linked in part to elevated cytokine expression and suggests collagenase activity may be an important therapeutic target in deteriorating heart failure.

Background In patients with severe heart failure, prolonged unloading of the myocardium with the use of a left ventricular assist device has been reported to lead to myocardial recovery in small numbers of patients for varying periods of time. Increasing the frequency and durability of myocardial recovery could reduce or postpone the need for subsequent heart transplantation. Methods We enrolled 15 patients with severe heart failure due to nonischemic cardiomyopathy and with no histologic evidence of active myocarditis. All had markedly reduced cardiac output and were receiving inotropes. The patients underwent implantation of left ventricular assist devices and were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse remodeling. Once regression of left ventricular enlargement had been achieved, the β 2 -adrenergic–receptor agonist clenbuterol was administered to prevent myocardial atrophy. Results Eleven of the 15 patients had sufficient myocardial recovery to undergo explantation of the left ventricular assist device a mean (±SD) of 320±186 days after implantation of the device. One patient died of intractable arrhythmias 24 hours after explantation; another died of carcinoma of the lung 27 months after explantation. The cumulative rate of freedom from recurrent heart failure among the surviving patients was 100% and 88.9% 1 and 4 years after explantation, respectively. The quality of life as assessed by the Minnesota Living with Heart Failure Questionnaire score at 3 years was nearly normal. Fifty-nine months after explantation, the mean left ventricular ejection fraction was 64±12%, the mean left ventricular end-diastolic diameter was 59.4±12.1 mm, the mean left ventricular end-systolic diameter was 42.5±13.2 mm, and the mean maximal oxygen uptake with exercise was 26.3±6.0 ml per kilogram of body weight per minute. Conclusions In this single-center study, we found that sustained reversal of severe heart failure secondary to nonischemic cardiomyopathy could be achieved in selected patients with the use of a left ventricular assist device and a specific pharmacologic regimen.

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.

Background Transplantation for patients with a high pulmonary vascular resistance (PVR) carries an increased risk of mortality and right heart failure following heart transplantation and continues to be a major problem. We evaluated the use of hearts from patients who underwent heart and lung transplantation for primary pulmonary hypertension (PPH) as part of a domino procedure because these hearts have hypertrophied right ventricles used to increased pulmonary pressures, but could have a compromised left ventricle or irreversible damage of the right ventricle. Methods We reviewed 12 patients with PVR >4 Wood units who underwent orthotopic heart transplantation between 1989 and 1998 using hearts from donors with PPH as part of a domino procedure. Results We studied 10 men and 2 women, mean age 42.9 years. Mean PVR was 5.3 (range, 4–9) Wood units. Mean ischemia time was 85.3 minutes, and mean donor age was 32 years. Actuarial survival was 75% at 1 year and 75% at 5 years. In the early post-operative period, 3 patients had temporary arrhythmias, 2 required permanent pacemaker implantation, 1 had atrial fibrillation, and 1 had ventricular tachycardia that required defibrillator implantation. At a mean follow-up of 7.8 years, 2 patients had developed asymptomatic transplant coronary disease (both at 8.5 years after transplantation), 1 moderate and 1 very mild; the rest had none. Mean left ventricular ejection fraction at latest follow-up was 70.1% (range, 63%–78%). Right ventricular function assessed clinically and by echocardiography was adequate in the short and long term. Conclusions Our results suggest that heart and lung recipients with PPH can provide useful donor hearts to patients with increased PVR and that these hearts function well in the intermediate and long term.

A 24-year-old woman with cystic fibrosis underwent bilateral sequential lung transplantation and unintentionally received an ABO incompatible graft (blood type A(1) graft into a type O recipient). The recipient had a high titer of IgG anti-A antibody (256 by the indirect antiglobulin test). Emergency treatment included antibody removal by plasmapheresis and additional immunosuppression with mycophenolate, rabbit antithymocyte globulin and polyspecific intravenous immunoglobulin. Subsequently, immunoadsorption and the anti-CD20 antibody rituximab were used to remove anti-A antibody and inhibit its resynthesis. Early graft function was good; one episode of rejection at Day 46 responded promptly to treatment with methylprednisolone. Subsequently, graft function continued to improve and anti-A antibody titers remained low. No infectious or other complications were encountered. The treatment regimen that we adopted may prove useful in other cases of unplanned ABO-incompatible organ transplants. The successful outcome suggests that planned ABO-incompatible lung transplants may be possible.

Cytokine activation in the myocardium of deteriorating patients with heart failure who undergo left ventricular assist-device (LVAD) implantation has been documented, but the underlying mechanisms remain poorly understood. We hypothesized the innate immune system is activated with expression of Toll-like receptor 4 (TLR4), leading to cytokine activation in these patients.We used quantitative real-time reverse-transcriptase polymerase chain reaction to measure TLR4, interleukin-1 (IL-1) receptor, IL-1 beta, IL-6, and tumor necrosis factor alpha (TNF-alpha) mRNA expression in myocardial samples from 36 patients. We compared 18 patients who underwent LVAD implantation with 18 patients with less severe heart failure who underwent elective heart transplantation.Toll-like receptor 4 expression was 1.69-fold greater (p0.05) and IL-1 receptor expression was 3.64-fold greater (p0.0001) in the deteriorating patients who required LVADs. Myocardial TNF-alpha (1.71-fold, p0.05), IL-6 (2.57-fold, p0.005), and IL-1 beta (9.78-fold, p0.001) also were increased in the LVAD candidates. Toll-like receptor 4 expression correlated strongly with IL-1 receptor expression (r= 0.75, p0.0001) and with IL-1 beta expression in individual patients (r = 0.7, p0.0001). Interleukin-1 receptor expression also correlated with IL-1 beta expression (r = 0.78, p0.0001) within patients. We found no correlation between TLR4 and either TNF-alpha or IL-6 expression.Patients who required LVAD support showed evidence of innate immune system activation, indicated by an increase in the key effector molecule TLR4 associated with a specific pattern of cytokine expression in the myocardium.

Background: Hearts transplanted from patients undergoing heart–lung transplantation (domino hearts) are unique because they have not been subjected to the deleterious effects of brain-stem death. This study examines the incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts. Methods: We retrospectively reviewed angiographic and clinical data from 97 patients who survived more than 1 year after domino heart transplantation at our hospital. Duration of follow-up ranged from 1 to 11 years after transplantation. The diagnosis of coronary artery disease was based on angiographic criteria. Results: At 1 year, freedom from angiographic coronary artery disease was 99% (70% confidence interval [CI], 97–100), at 5 years it was 83% (70% CI, 78–89), and at 10 years it was 77% (70% CI, 70–84). Donor age, cystic fibrosis in the donor, organ ischemia time during transplantation, and acute rejection after transplantation did not influence risk for the disease. We found an increased incidence of coronary disease in hearts from male donors compared with those from female donors: freedom from disease at 5 years was 72% (70% CI, 63–81) in men vs 93% (87–99) in women. Thirteen patients experienced coronary artery disease at a median of 3 years after transplantation; 4 patients died but most patients remained asymptomatic with angiographically mild disease at their last follow-up examination. Conclusions: We found decreased incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts compared with that reported in recipients of cadaveric hearts. This data supports the continued practice of domino heart transplantation and also supports the hypothesis that brain death may contribute to the development of transplant coronary artery disease in recipients of hearts transplanted from cadaveric organ donors.

Objective: We sought to examine our management and outcome of lung carcinoma occurring after thoracic organ transplantation. Methods: We performed a retrospective review of cases of primary lung carcinoma diagnosed between 1990 and 2000 in patients who have previously undergone thoracic transplantation at our institution. Results: Seventeen patients were identified (1 lung and 16 heart transplants). Median time from transplantation to diagnosis of lung carcinoma was 89 months (range, 46-138 months). Predominant presentation was as an incidental finding at chest radiography (13/17). All patients had smoked cigarettes before transplantation, with 5 continuing to smoke after transplantation. Histologic types were squamous (n = 11), adenocarcinoma (n = 3), small cell (n = 2), and undifferentiated (n = 1). Revised International Union Against Cancer (UICC) clinical stage at the time of diagnosis was stage I or II in 11 of 17 patients. Of these, 9 underwent surgical resection; 2 patients unfit for surgical intervention had radiotherapy. Surgical procedures were lobectomy (n = 5), wedge excision (n = 3), and no resection (n = 1). Median survival after diagnosis was 12 months for all patients and 24 months if the tumor was resected. Six patients who had surgical resection subsequently died (survival of 2, 9, 21, 21, 36, and 67 months); 2 remain alive after 12 and 54 months, respectively. Conclusions: When possible, surgical intervention should be undertaken for early stage lung cancer occurring after thoracic transplantation because medium-term survival is achievable. Sublobar excisions and definitive radiotherapy should be considered if comorbidity prevents optimal surgical treatment. J Thorac Cardiovasc Surg 2002;124:1190-7

Background Hearts explanted from the recipients of heart–lung transplants provide a unique source of transplants from live donors. This article presents long-term results with this procedure at our center. Methods We performed a retrospective chart review of domino transplantations performed in our institution between 1989 and 1998. Results We analyzed 131 domino transplants (123 orthotopic, 8 heterotopic). Domino hearts were from patients with cystic fibrosis (69%), primary pulmonary hypertension (15%), and other diagnoses (16%). The mean recipient pulmonary vascular resistance (PVR) was 3.1 Wood units, 25% of patients having values >4 Wood units. Thirty-day mortality was 13%. The 1-, 5-, and 10-year graft survival was 75% (70% confidence interval [CI], 65–74), 70% (70% CI, 65–74), and 58% (70% CI, 52–64), respectively. Patients with PVR >4 Wood units had 1-year survival (76%; 70% CI, 69–84) similar to that of patients with PVR of ≤4 units (74%; 70% CI, 69–80). Recipients of hearts from patients with cystic fibrosis survived longer (5-year survival, 76%; 70% CI, 71–82) vs 65% for non–cystic fibrosis hearts (70% CI, 57–74) p = 0.09). One-year survival was decreased after transplantation of hearts from female donors (66%; 70% CI, 60–72)) compared with hearts from male donors (85%; 70% CI, 79–90); p = 0.06). Late deaths caused by coronary artery disease and malignancy were uncommon. Conclusion Although the rate of early mortality after domino transplantation was slightly higher than after cadaveric transplantation, we noted a remarkably low long-term attrition rate in recipients of domino grafts, up to 10 years. In addition, successful transplantation of patients with high PVR supports the hypothesis that heart–lung recipients may provide superior donor hearts for this patient group, many of whom traditional listing criteria would exclude.

Here we report the treatment of native heart complications (aortic regurgitation, ventricular fibrillation and heart failure) following a heterotopic heart transplant by excision of native heart and relocation the heterotopic heart in the orthotopic position. The patient was a 24 year old woman who had received a heterotopic transplant at the age of 9 years from a 9 year old donor. The donor heart had grown sufficiently to allow it to support her adult circulation.

Background —Myocardial failure is an important problem after heart transplantation. Right ventricular (RV) failure is most common, although its mechanisms remain poorly understood. Inflammatory cytokines play an important role in heart failure. We studied the expression of tumor necrosis factor (TNF)-α and other cytokines in donor myocardium and their relationship to the subsequent development of RV failure early after transplantation. Methods and Results —Clinical details were obtained, and ventricular function was assessed by transesophageal echocardiography in 26 donors before heart retrieval. A donor RV biopsy was obtained immediately before transplantation, and each recipient was followed for the development of RV failure. Reverse transcriptase–polymerase chain reaction was performed to detect TNF-α, interleukin-2, interferon-γ, and inducible nitric oxide synthase expression. Eight of 26 recipients (30.8%) developed RV failure. Seven of these 8 (87.5%) expressed TNF-α, but only 4 of the 18 (22.2%) who did not develop RV failure expressed TNF-α ( P P Conclusions —TNF-α expression in donor heart cardiac myocytes seems to predict the development of RV failure in patients early after heart transplantation.

Objectives: Allografts offer many advantages over prosthetic valves, but allograft durability varies considerably. Methods: From 1969 through 1993, 618 patients aged 15 to 84 years underwent their first aortic valve replacement with an aortic allograft. Concomitant surgery included aortic root tailoring (n = 58), replacement or tailoring of the ascending aorta (n = 56), and coronary artery bypass grafting (n = 87). Allograft implantation was done by means of a "freehand" subcoronary technique (n = 551) or total root replacement (n = 67). The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or viable (unprocessed, harvested from brain-dead multiorgan donors or heart transplant recipients, n=127). Maximum follow-up was 27.1 years. Results: Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20 years. Ten- and 20-year rates of freedom from complications were as follows: endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic valve replacement, 81% and 35%. Multivariable Cox analyses identified several valve- and procedure-related determinants: rising allograft donor age and antibiotic-sterilized allograft for mortality; donor more than 10 years older than patient for endocarditis; rising donor age minus patient age, rising implantation time (from harvest to aortic valve replacement), and donor age more than 65 years for tissue failure; and rising donor age minus patient age, young patient age, rising implantation time, and subcoronary implantation preceded by aortic root tailoring for redo aortic valve replacement. Estimated 10- and 20-year rates of freedom from tissue failure for a 70-year-old patient with a viable valve from a 30-year-old donor and no other risk factors were 91% and 64%; the figures were 71% and 20% if the donor age was 65 years. The rates of freedom from tissue failure for a 30-year-old patient with a 30-year-old donor were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor. Beneficial influences of a viable valve were largely covered by short harvest time (no delay for allografts from brain dead organ donors or heart transplant recipients) and short implantation time. Conclusions: Primary allograft aortic valve replacement can give acceptable results for up to 25 years. The late results can be improved by the use of a viable allograft, by matching patient and donor age, and by more liberal use of free root replacement with re-implantation of the coronary arteries rather than tailoring the root to accommodate a subcoronary implantation. (J Thorac Cardiovasc Surg 1999;117:77-91)

Background Availability of cadaveric organs continues to be the key factor limiting the number of transplants performed. Donor with bacterial meningitis is often considered to be controversial for organ retrieval. The purpose of this retrospective study was to review the long-term outcome of orthotopic heart and lung transplantation at our institution, from donors who died as a result of meningitis. Methods Between July 1986 and July 2006, 39 adult patients who underwent heart and lung transplantation performed with organs from cadaveric donors with bacterial meningitis were retrospectively studied. Donors and recipients were identified by a prospectively kept database. Bacterial meningitis was identified either with positive blood or cerebrospinal fluid culture and positive signs and symptoms. All patients had one or more of these criteria. There were 15 heart, 12 lung (4 bilateral), and 12 heart-lung transplants. Results All donors had identified pathogens: Neisseria meningitidis (n = 21; 53.8%), Streptococcus pneumoniae (n = 16; 41%), and Haemophilus influenzae (n = 2; 5.2%). Adequate antimicrobial therapy before organ retrieval and after transplant was administered. The hospital mortality was 10.2% (n = 4). There were no infectious complications caused by meningeal pathogens. Other causes of hospital mortality were rejection (n = 2), intracranial bleeding (n = 1), and staphylococcus sepsis (n = 1). The mean posttransplant follow-up was 5.35 ± 5.54 years (range, 1 month to 18.9 years). Conclusions Intrathoracic organ transplantation using donors with bacterial meningitis is an acceptable strategy. No organism ( Neisseria meningitides, Streptococcus pneumoniae , and Haemophilus influenzae ) could be identified as contraindication because no recipient died of infectious-related diseases.

After Mustard or Senning procedures, transplantation remains the only option for some patients who present at late stage with severe systemic (right) ventricular failure. In some circumstances these patients may require urgent mechanical circulatory support to bridge them to transplantation. The use of mechanical support poses considerable potential and actual specific problems both in terms of insertion and management of the device. We report the case of a 17-year-old patient who had a left ventricular assist device implanted from the right ventricle to the aorta for "end-stage" heart failure 15 years after the Mustard procedure. The specific problems are discussed and a management scheme is proposed.

Aims To investigate the response to inhaled prostacyclin in patients with primary and secondary pulmonary hypertension and to compare its effects to those of intravenous prostacyclin and inhaled nitric oxide. Methods and results Twelve patients with pulmonary hypertension (seven primary and five secondary) were studied. All patients had a pulmonary artery balloon flotation catheter inserted into the proximal pulmonary artery and radial arterial line. Prostacyclin was nebulized with 81. min−1 of oxygen and administered in doses increasing from 15 to 50 ng. kg−1. min−1 via a facemask. Eight of these patients also received intravenous prostacyclin in doses of 1 to 5 ng.kg−1.min−1 and nitric oxide in doses of 10 to 100 ppm via a facemask. Haemodynamic measurements were taken during each treatment. In the 12 patients, nebulized prostacyclin produced a significant reduction in mean pulmonary artery pressure from 56±5 to 45±4 mmHg ( P =0·0001). The pulmonary vascular resistance decreased by 38% from 964±169 to 595±116 dyne s−1.cm−5 ( P =0·0001). Direct comparison with inhaled nitric oxide and intravenous prostacyclin in eight patients demonstrated that nebulized prostacyclin produced a greater fall in mean pulmonary artery pressure than the other two agents without any significant effect on systemic arterial pressure. Conclusion Nebulized prostacyclin appears to be more effective at reducing pulmonary artery pressure in patients with pulmonary hypertension when compared to intravenous prostacyclin and inhaled nitric oxide. This could have important clinical implications for the management of patients with pulmonary hypertension.

There is increasing evidence that pathological changes in the myocardium during chronic heart failure (CHF) are partly regulated through the activation of the renin-angiotensin system (RAS), an effect mediated by the angiotensin II type 1 receptor (AT1R). We examined the expression of cardiac AT1R mRNA in normal (atria, n=7; ventricle, n=3) and end-stage CHF human hearts (atria, n=8; ventricle, n=14). Tissue was snap-frozen immediately after explantation during orthotopic cardiac transplantation; control specimens were obtained from healthy donor hearts rejected for technical reasons. Northern blots of purified total mRNA from each tissue were hybridized with a random primed radiolabeled probe for the coding sequence of AT1R. Stringent conditions were used for both hybridization (5X SSC, 65 degrees C) and washing (0.5X SSC, 0.1% SDS, 65 degrees C) of the membrane. Left and right atrial tissue showed low levels of AT1R mRNA expression in the controls, with statistically significant upregulation of expression in tissue from pathological hearts; CHF atria 1.28+/-0.86 optical density (OD) units, control atria 0.56+/-0.31 OD units, P=0.05 (mean+/-s.d.). There were undetectable levels in ventricles from either control (2/2) or dilated hearts (7/7). The results were independent of the etiology of the heart failure and suggest that increased levels of atrial AT1R mRNA may occur in response to elevated atrial pressures in heart failure.

Background: Children with advanced heart failure, particularly those with elevated pulmonary vascular resistance, pose a difficult management problem because the normal donor right ventricle cannot cope with the high pulmonary resistance and because of the relative shortage of donor organs of an appropriate size for this age group. Methods: In an attempt to address these issues and evaluate the role of heterotopic transplantation in this context, we operated on 12 children, six boys and six girls, in the period between January 1, 1991, and March 31, 1996. Their ages ranged from 11 months to 15.2 years (mean 81.6 ± 62.8 months) and their mean weight was 23.3 kg (range 7.6 to 56.8 kg). Eight patients (66.6%) had significant elevation of pulmonary artery pressure (pulmonary artery systolic pressure=66 ± 9.4 mm Hg, mean transpulmonary gradient=22.3 ± 3.4 mm Hg). In all patients the donor pulmonary artery was anastomosed to the recipient right atrium without the use of any prosthetic material. Ischemic times varied between 135 and 255 minutes (mean 182.1 ± 30.7 minutes). The immunosuppression regimen included cyclosporine and azathioprine. Steroids were not routinely used. Results: One patient died in the hospital of acute rejection on postoperative day 16. Three patients had lobe collapse within 1 week and all were treated successfully. Two late deaths (18.2%) occurred as a result of cardiac rejection 3 months and 2 years after the operations. Nine survivors (75%) are alive, active, and growing normally at a mean follow-up of 2.2 years (range 11 months to 4.75 years). Repeated cardiac catheterization performed in seven patients with preoperative pulmonary hypertension showed a slow progressive drop in mean pulmonary artery pressure. No significant change was observed in the function of the recipient hearts. Conclusion: We conclude that heterotopic heart transplantation is feasible for a selected group of children with good medium-term results, notably regression of pulmonary artery pressure, normal growth, and lack of long-term chest complications. (J Torac Cardiovasc Surg 1997;113:1042-9)

Objective: To describe a technique of direct revascularisation of the bronchial artery using the left IMA and assess its medium term results in patients undergoing left single lung transplant (SLT). Methods: Between March 1991 and September 1993, 22 patients who underwent direct bronchial revascularisation at the time of left SLT (20 pedicled IMA, one free IMA, and one direct anastomosis to the aorta) have been followed up for a minimum period of 1 year (mean 30 ± 12 months). Their mean age was 47.8 ± 9.6 and the original disease was emphysema in 19, lymphangioleiomyomatosis in two, and pulmonary fibrosis in one. The mean ischaemia time was 269.7 ± 23.4 min. Results: There was one early death (4.5%) and 3 patients were re-explored for bleeding. The actuarial survival at 1 and 3 years was 91 ± 0.4% and 82.6 ± 1%, respectively. Bronchial healing was excellent in all patients and angiographic studies showed patent vascular anastomosis in all 22 patients, with good run off in 20 and poor in two. One patient developed clinical obliterative bronchiolitis at 22 months (4.5%) during a period of follow up varying from 12 to 43 months (mean 30 S.D. 12). At last follow up the mean FEVI was 1.4 ± 0.4 and the mean FVC was 2.2 ± 0.6. On average, each patient developed 1.5 ± 0.6 infection episodes and 1 ± 0.2 acute lung rejection. Conclusion: It is concluded that the medium term results of direct bronchial revascularisation are good. However the influence of this procedure on long term results needs further investigation.

Ischemic airway complications are common after en bloc double-lung transplantation with tracheal anastomosis. The aim of this study was to evaluate the effects of a direct revascularization of the donor bronchial artery with the recipient internal thoracic artery on airway perfusion.Seven patients undergoing double-lung transplantation with tracheal anastomosis were investigated intraoperatively and postoperatively (12 to 36 hours) with endoscopic laser Doppler flowmetry. Sixteen patients undergoing coronary artery bypass grafting served as a control group.Two patients who had double-lung transplantation with tracheal anastomosis died of sepsis and multiorgan failure 1 week after transplantation. In the remaining 5 patients healing of the anastomosis was excellent during the observation period of 3 to 52 months. In 5 patients clamping of the attached internal thoracic artery induced a reduction of the laser Doppler flowmetry signal from 10% to 60%. In the 2 patients with the highest graft perfusion level, no clamping effect could be detected. Compared with the control group, perfusion was significantly higher in the transplanted airways intraoperatively, at 71 versus 55 arbitrary perfusion units (p0.01). Postoperative transplant airway perfusion values were not significantly different from the intraoperative value. The coefficient of variation of repeated measurements was higher in the transplanted airways, with a coefficient of variation of 0.22 versus 0.17 in the control group (p0.01), indicating heterogeneous transplant airway perfusion.This study has documented that revascularization with the internal thoracic artery supplies the transplanted airway with additional oxygenated blood.

Background— Left ventricular assist device (LVAD) treatment is known to lead to structural and functional cellular modifications in the heart. The relevance of these changes for clinical recovery is unknown. Methods and Results— We compared properties of cardiomyocytes obtained from tissue taken at explantation of the LVAD in patients with clinical recovery with those obtained from hearts of patients who did not show clinical recovery, thus requiring transplantation. Compared with myocytes taken at implantation, both the recovery and nonrecovery groups showed ≈50% reduction in cell capacitance, an index of cell size. However, action potential duration shortened, L-type Ca 2+ current fast inactivation was more rapid, and sarcoplasmic reticulum Ca 2+ content was increased in the recovery compared with the nonrecovery group. Conclusions— These results show that specific changes in excitation-contraction coupling, and not regression of cellular hypertrophy, are specifically associated with clinical recovery after LVAD and further identify sarcoplasmic reticulum Ca 2+ handling as a key functional determinant in patients with heart failure.

Two hundred seventy-five unprocessed, viable homograft ("homovital") aortic valves were used for aortic valve replacement in patients aged 1.5 to 79 years (mean 45.8 +/- 19 years) with maximum follow-up of a 14-year period (mean 4.8 years). Ninety-two percent (252 patients) had New York Heart Association class III or IV functional status before operation and 25 underwent emergency operation. Valves were harvested under sterile conditions and kept in nutrient medium 199. Freehand (subcoronary) technique was used in 147 patients and freestanding root replacement was used in 128. Cumulative survival rates for the whole group were 92% +/- 2% at 5 years and 85% +/- 3% at 10 years, as compared with 96% +/- 2% and 94% +/- 4%, respectively, for the 98 patients who underwent isolated root replacement. Multivariate analysis determined that root replacement with associated procedures and operation for prosthetic endocarditis were risk factors for death, whereas previous xenograft valve, operation for endocarditis, and operation for aortic regurgitation were risk factors for reoperation. Actuarial rates for freedom from degenerative valve failure diagnosed at operation, by postmortem examination, or by routine echocardiography were 94% +/- 2% at 5 years and 89% +/- 3% at 10 years. Recipient age younger than 30 years and previous xenograft valve were risk factors for late degeneration. We conclude that homovital valves demonstrate good durability, particularly in patients older than 30 years, who had a 10-year freedom from degeneration rate of 97%.

ObjectiveThe proportion of patients who can be bridged with left ventricular assist devices to myocardial recovery and the long-term outcome of these patients is unknown.MethodsWe investigated the outcomes of patients bridged to recovery compared with those bridged to transplantation. All left ventricular assist devices were implanted as a bridge to transplantation with a very proactive program of promoting myocardial recovery. A total of 40 patients were bridged to recovery and 52 to transplantation. Of the bridged to recovery (explanted) group, 33 were men (age, 32.8 ± 11.8 years), 37 had dilated cardiomyopathy (familial in 3, peripartum cardiomyopathy in 3) and 3 had myocarditis. Of the bridged to transplantation (transplanted) group, 42 were men (age, 42.3 ± 12.5 years; P

Background . We have previously shown, by means of electron beam tomography, the pattern of calcification of the aortic root wall of homografts and porcine xenografts after aortic root replacement. However, application of similar methods for cusp calcification raises specific problems that have not been addressed before. Methods . A new method for localizing and quantifying calcification of the aortic valve cusps has been evolved. Intravenous contrast-enhanced electron beam tomography was introduced to visualize the aortic cusps. This technique was applied to quantify cusp calcification in 37 patients after aortic root replacement with a homograft (group H) or a Medtronic Freestyle valve (group F) at set intervals between 6 months and 2 years. A calcification score in Hounsfield units (HU) and a calcified volume score in cubic millimeters were calculated. Results . The aortic leaflets were clearly visualized in all patients. The mean calcium score in the cusps was 28.8 ± 64.4 HU in group F and 62.4 ± 66.9 HU in group H ( p = not significant). The mean calcified volume score was 327.0 ± 425.9 mm 3 in group F and 642.0 ± 443.0 mm 3 in group H ( p = not significant). Conclusions . Contrast enhancement electron beam tomography is a useful tool for quantification of calcium in the aortic valve leaflets. Our preliminary results show a tendency toward more calcification in the homografts. This needs to be studied further in a bigger cohort of patients followed up for longer periods.

Background : Heart transplantation (HTx), the gold standard therapy for advanced heart failure, is limited by donor availability; alternative therapies are now becoming available. Aim: We examined the outcome of HTx with current immunosuppressive and adjunctive therapy. Design and methods: We analysed the outcome of 399 consecutive patients who underwent transplantation at our centre (1995–2007). Prior to HTx 23% (98) required inotropic support, 8.5% (34) an intra-aortic balloon pump and 11% (43) a ventricular assist device. Results: Actuarial patient survival was 86% at 30 days, 79% at 1 year and 62% at 10 years. Survival was similar regardless of the heart failure severity, P = 0.22. The cumulative incidence of allograft vasculopathy, Costanzo grade ≥2, was 7% at 5 years and 23% by 10 years with an 11% cumulative probability of requiring a percutaneous coronary intervention by 10 years. Allograft function was preserved with a mean ± SD left ventricular ejection fraction of 73 ± 7% at 1 year and 74 ± 8% at 10 years. The cumulative incidence of malignancy by 10 years was 27% (skin malignancy 13% and post transplant lymphoproliferative diseases 10%). The cumulative incidence of developing chronic kidney disease (CKD) with an estimated glomerular filtration rate ≤45 ml/min/1.73 m2 was 42% at 1 year, 62% at 5 years and 72% at 10 years and of requiring long-term renal replacement therapy was 10.6% at 10 years. Conclusion: HTx provided good medium-term survival for patients with advanced heart failure, independent of its severity. The incidence of allograft vasculopathy was lower than reported previously but malignancy and CKD remain cause for concern.

Objectives The aim of this study was to conduct an initial clinical evaluation of the new HeartWare Ventricular Assist System (HeartWare, Inc., Framingham, Massachusetts) in a multicenter, prospective, nonrandomized single-arm clinical trial. Background Heart failure is a worldwide epidemic. The effectiveness of heart transplantation and medical therapy is limited, resulting in the emergence of mechanical circulatory support as a primary treatment for end-stage heart disease. Left ventricular assist devices that use rotary pumps are small and durable, which might reduce morbidity and mortality during support. Methods Fifty heart transplant candidates with New York Heart Association functional class IV symptoms were supported at 5 international centers by the HeartWare System for 180 days, until heart transplant, myocardial recovery and device explant, or death. Patients who continue to be supported have been followed for a minimum of 2 years. Results Of the 50 patients, 20 (40%) received transplants, 4 (8%) had the pump explanted after myocardial recovery, and 17 (34%) continue support at 2 years. Nine (18%) patients died during support from sepsis (n = 3), multiple organ failure (n = 3), or hemorrhagic stroke (n = 3). The actual survival at 6, 12, and 24 months was 90%, 84%, and 79%, respectively. In the survivors, measures of quality of life showed a significant improvement over baseline values. Significant improvements were found for recognition memory at 3 months after implant (p = 0.006). The most frequent adverse events were infection and bleeding. Conclusions Patients with end-stage heart failure can be safely and effectively supported by the HeartWare Ventricular Assist System with improved quality of life and neurocognitive function.

Background Third-generation rotary blood pumps have magnetically levitated rotors that eliminate mechanical wear over the years. Together with their potential for miniaturization, these pumps seem suitable for long-term support of patients with a wide range of body surface areas (BSA). Recently, the novel HVAD pump (HeartWare Inc, Framingham, MA), a miniaturized centrifugal pump with a hydrodynamic, magnetically levitated rotor, became ready for clinical application. Methods In a multi-institutional trial in Europe and Australia, 23 patients (mean age, 47.9 ± 12 years) in end-stage heart failure were enrolled in 5 centers. The primary end point of the bridge-to-transplant study was survival to heart transplant or survival to 180 days on the device, whichever occurred first. Follow-up data at 1 year are presented. The small size of the device allows for intrapericardial placement of the pump. Results Implant procedures were generally fast and uneventful. Mean duration of support was 167 ± 143 days (range, 13–425 days), and mean blood flow provided by the pump was 6.1 ± 1.1 liters/min. At the 180-day end point, 2 patients had undergone successful transplant at 157 and 175 days, 2 patients died while on the device, and 19 patients continued pump support for more than 180 days. Actuarial survival after 6 months was 91% and was 86% at the 1-year follow-up. Conclusions The design of the HVAD pump enables a quick and less invasive implantation. The results to date demonstrate satisfactory long-term survival with excellent quality of life in this cohort of 23 patients of the initial multi-institutional Conformite Europeene (CE) mark trial.

Testing of native myocardial function in patients with continuous-flow pumps is challenging as reduction/cessation of the pump could result in regurgitation, although the amount and significance of this regurgitation remains unknown. The aim of this study was to determine the optimal speed at which to assess the native left ventricular (LV) function and the physiologic response to speed reduction.Fifteen male patients with a HeartMate II (HMII) device were studied prospectively on 46 occasions. Measurements were performed serially at three device speed settings: baseline speed; 6,000 rpm; and either 5,000 rpm (Group A) or 4,000 rpm (Group B). The device's forward and reverse velocity (Vmax(f), Vmax(r)), forward and reverse velocity time integral (VTI(f), VTI(r)) and blood volume (BV) were also measured using Doppler with LV echocardiographic parameters and peripheral hemodynamics.No adverse incidents were reported. Speed reduction to 6,000 rpm resulted in a significant decrease in Vmax(f), VTI(f) and BV. There was no significant difference in either forward or reverse flow with further speed reduction in either group. Speed reduction to6,000 rpm did not have a significant effect on LV loading.Speed reduction in patients with the HMII device is safe. There was no difference between 6,000 rpm and lower speeds, suggesting that 6,000 rpm is sufficient to assess native myocardial function. The absence of significant retrograde filling suggests that LV loading is a physiologic response to speed reduction at 6,000 rpm.

This paper reports our experience in treating localized airway obstruction with expandable metal stents. Nine patients were treated for malignant obstruction and 6 for benign obstruction. The main indications for treatment were imminent asphyxia, breathlessness and/or repeated chest infections. All but 2 patients had received other treatments before referral. Seven patients with malignant obstruction had extrinsically compressed airways and all derived a sustained symptomatic improvement. Two patients with recurrent tracheal obstruction caused by intraluminal tumor gained lasting relief with the use of a covered expandable metal stent. All 6 patients with benign strictures were improved, although 2 developed recurrent obstruction caused by granulation tissue growing within, and beyond the stent. It is concluded that the expandable metal stent provides an effective and noninvasive method of relieving large airway obstruction. As the long-term tissue tolerance to this type of stent is not known, caution is advised in the management of benign strictures. In patients with malignant obstruction, however, the expandable metal stent would appear to have considerable potential as a palliative treatment.

The role of heterotopic heart transplantation in coronary heart disease has not been defined. Between 1983 and 1988, 28 patients with end-stage ischemic heart disease were managed by heterotopic heart transplantation and adjunctive operation on the recipient heart: coronary artery bypass grafts and aneurysmectomy, 20; coronary artery bypass grafts, 5; and aneurysmectomy, 3. Indications were feasibility of operative procedures to the recipient heart and small donor size (61% of the donors were less than 15 years). The 1-year and 5-year actuarial survival was 79% and 63%. Of the 22 patients who survived to 2-year follow-up, all of whom had been severely limited (New York Heart Association grade III/IV) preoperatively, 20 were in grades I or II at 2-year follow-up (p less than 0.001). In 14 of 22 patients (64%), the recipient heart augmented the donor cardiac output substantially, and in 4 the recipient heart supported the patient when the donor heart failed to eject. In conclusion, this series demonstrates the efficacy of heterotopic transplantation combined with operation to the recipient heart in the management of patients with end-stage ischemic heart disease.

Objective: The HeartMate II (HM II) LVAD is a small, quiet, continuous-flow, left ventricular assist device (LVAD) for circulatory support in advanced heart-failure patients, with over 2000 implants worldwide. This article reports on the European experience with this device. Methods: The HM II was implanted in 571 patients at 64 European institutions. In 72% of cases (411 patients), implantation has taken place at least 6 months before the closing date of the study (1 August 2008). Patients (19% female, 70% ischaemic aetiology) were on maximum medical therapy, including inotropic support. Body surface area ranged from 1.30 to 2.50 m 2 and age from 14 to 75 years (mean: 51 ± 14 years; n = 115, 28% over age 60 years). The intention of support was to provide a bridge to transplantation (73%), destination therapy (21%) and a bridge to recovery (6%). Adverse events were documented in the first 53 patients — for obtaining the Conformite Europeenne (CE) Mark (group A) — from a European multicentric study (Struber et al. [Struber M, Sander K, Lahpor J, Ahn H, Litzler P-Y, Drakos SG, Musumeci F, Schlensak C, Friedrich I, Gustafsson R, Oertel F, Leprince P. HeartMate II left ventricular assist device; early European experience. Eur J Cardiovasc Surg 2008;34(2):289-94.]: 101 patients) and from a single-centre study (UMCU, The Netherlands: 30 patients). Results: The mean support duration ranged from 0 to 1019 days with a mean of 236 ±214 days (249 patients: >6 months, 119: 1 year, 12: >2 years; total support time: 293 years). The overall survival to transplantation, recovery or ongoing device support at the end of the study was 69% (284) with an early mortality of 17.5% and late mortality of 13.5%. Of the surviving patients, 23% have been transplanted, 4% had their device removed after recovery of the left ventricle and 42% are still ongoing. Adverse events included bleeding (ranging from 42% in group C to 59% in group A), percutaneous lead infections (A: 0.19, B: 0.61 and C: 0.18 events per patient year), pocket infections (A: 0.08, B: 0.07 and C: 0.09 events per patient year), ischaemic stroke (A: 0.06, B: 0.09 and C: 0.04 events per patient year), haemorrhagic stroke (B: 0.07, C: 0.04 events per patient year) and transient ischaemic attacks (TIAs; A: 0.08, B: 0.02 and C: 0.13 events per patient year). Conclusions: These results support the use of the HM II continuous-flow LVAD for long-term support as a bridge to transplantation and possibly for destination therapy. Future emphasis should focus on minimising adverse events such as infections, bleeding and neurological events.

Summary Background Cardiac transplantation is a life-saving procedure in infants and children with advanced cardiomyopathy. However, it is greatly limited by shortage of paediatric donors and the complications of long-term immunosuppression, including post-transplant lymphoproliferative disorder (PTLD). We report the management of an infant who had heterotopic cardiac transplantation for advanced cardiomyopathy with secondary pulmonary hypertension who developed seemingly incurable PTLD. Methods An 8-month-old girl presented in 1994 with signs of severe heart failure, secondary to dilated cardiomyopathy. At age 11 months, the patient underwent a heterotopic cardiac transplantation. Findings The patient developed many episodes of PTLD associated with Epstein-Barr virus infection that were resistant to several therapies, including reduction of immunosuppression. Native heart recovery enabled removal of the donor heart 10·5 years after the original operation to allow complete cessation of immunosuppression. Her postoperative course was uncomplicated and the outcome was excellent. 3·5 years after surgery, the patient remains well, in complete remission from her PTLD, and has normal cardiac function. Interpretation This case shows several issues relating to the use of heterotopic cardiac transplantation in infants and the capacity of the heart to recover. It also provides new insights into the interaction between the immune system with several aspects of modern management of post-transplantation PTLD. Funding None.

In February, 2007, a 32-year-old man presented with a 3week history of shortness of breath on exertion. He had no important medical history and was not taking any medication. His blood pressure was 100/80 mm Hg, he had a sinus tachycardia of 110 beats per min, and a respiratory rate of 18 breaths per min. His neck veins were distended and more pronounced on inspiration. On examination, his pulse was rapid and weak in character but did not alter with respiration. Heart sounds were quiet on auscultation of the praecordium. On the basis of these fi ndings, a clinical diagnosis of cardiac tamponade was suspected. A chest radiograph demonstrated an enlarged heart, and echocardiography showed a large pericardial eff usion with a mediastinal mass compressing the left atrium (fi gure, A), associated diastolic collapse, and severely impaired left ventricular function (ejection fraction 33%). Emergency pericardiocentesis was done and 1700 mL of blood-stained fl uid was drained; microscopy showed red blood cells and macrophages, but cytology and tumour markers were negative. CT of the chest and abdomen (fi gure, B) showed a 6∙4×7∙5×7∙5 cm vascular mediastinal mass with central necrosis and numerous feeding vessels. Subsequent cardiac catheterisation showed multiple feeding branches from the coronary arteries and a large bronchial vessel supplying part of the tumour. The combination of a pericardial eff usion, vascular mediastinal mass, and unexplained left ventricular dysfunction raised the diff erential diagnoses of arteriovenous malformation, haemangioma, thymoma, lymphoma, and phaeochromocytoma. Measurement of urinary catecholamines showed elevated levels of dopamine (12 674 nmol/24 h; normal range 70–1900) and noradrenaline (3281 nmol/24 h; 63–471) with normal adrenaline levels. A 123I-metaiodobenzylguanidine (MIBG) scan showed uptake in the region of the mass, confi rming that the lesion was an extra-adrenal phaeochromo cytoma, also known as a paraganglioma. Embolisation was done to de-vascularise the tumour before surgery; prior blockade with phenoxybenzamine and propranolol was done to control blood pressure and prevent tachyarrhythmias. During surgical excision a magnesium sulphate infusion achieved stable intraoperative haemodynamics. The tumour was successfully excised from the left atrial roof. The patient made an unremarkable post-operative recovery. Histology confi rmed the diagnosis of a paraganglioma. Within 6 weeks of surgery his left ventricular function had substantially improved (ejection fraction 54%). When last seen in June, 2007, the patient was asymptomatic. Cardiac tamponade is a life-threatening clinical syndrome requiring prompt recognition and management. The diagnosis is made clinically by raised jugular venous pressure or neck vein distension (Kussmaul’s sign if more pronounced on inspiration), hypotension, and muffl ed heart sounds. This combination is known as Beck’s triad and is observed in 10–40% of cases. Pulsus paradoxus may also be seen. Tamponade occurs when fl uid accumulation in the pericardial cavity causes a substantial rise in intra-pericardial pressure. At least 200 mL of fl uid must accumulate before the cardiac silhouette is aff ected on chest radiography. Echocardiography is a readily available, inexpensive, and easy to use tool to investigate cardiac tamponade and possible causes, for example mass infi ltration, as in our case. Extra-adrenal phaeochromocytomas are rare vascular tumours; it is useful to remember the rule of 10s: 10% of phaeochromocytomas are extra-adrenal, 10% are malignant, 10% are familial, and 10% are bilateral. MIBG scanning is a valuable technique for identifying tumour deposits in conjunction with CT and MRI. Features suggestive of malignancy include very high dopamine levels and vascular invasion. Close liaison between radiologists, oncologists, endocrinologists, geneticists, cardiologists, anaesthetists, and cardiothoracic surgeons is required to ensure optimum management. Underlying paraganglioma should be considered as a diff erential diagnosis in cases of cardiac tamponade, particularly in the young.

Background Ventricular assist devices are effective in severe end-stage cardiac failure but outcomes remain poor in critically ill patients. Cheaper and less invasive short-term devices have been used in this setting. We report our experience with the Levitronix CentriMag short-term ventricular assist device as a potential bridge prior to deciding whether a more expensive device should be used or whether transplantation should be undertaken. Methods Since August 2003, 16 moribund patients (14 males; age 32.7 ± 14.9 [range 16 to 62] years) have been supported with the CentriMag device as a “bridge to decision.” Twelve patients had an intra-aortic balloon pump pre-operatively, 13 had multi-organ failure, 11 had septic shock, and in 5 patients the neurologic status was uncertain at the time of insertion of the device. Results Operative mortality was 18.7% (3 patients). Seven patients (43.7%) were reoperated for bleeding. The mean support duration was 46.9 ± 32.3 (range 6 to 111) days. There were 2 late deaths during Levitronix utilization. Follow-up was 12.8 ± 12.5 (range 0.6 to 43) months. Eleven patients (68.7%) are currently alive and well: 2 patients recovered and had the Levitronix device explanted; 6 patients were upgraded to a long-term device; and 3 patients were bridged directly to transplantation. The actuarial survival at 1, 6 and 12 months was 85.7%, 64.9% and 64.9%, respectively. There were no instances of device failure. Conclusions The Levitronix device is effective in rescuing critically ill “moribund” patients and can provide an opportunity for low-cost support and optimization of their condition prior to deciding whether a more expensive device should be placed or if transplantation should be undertaken. Better candidate selection for further procedures can then be allowed.

Longer term quality of life (QOL) outcome in patients who have had a left ventricular assist device (LVAD) explanted due to myocardial recovery (bridge to recovery, BTR) remains uncertain. This study evaluates the QOL of those patients and compares them to bridge-to-transplant (BTT) and transplanted (Tx) patients.Anonymized QOL Short Form (SF)-36 questionnaires were sent to a total of 72 patients, including: 14 BTR patients (3.6 +/- 1.9 years since LVAD removal); 29 BTT patients (3.3 +/- 2.3 years since transplantation); and 29 Tx patients (3.8 +/- 0.6 years since transplantation).Questionnaires were returned by 78.6%, 79.3% and 56.7% of patients from the BTR, BTT and Tx groups, respectively. In all but two of the domains of the SF-36 questionnaire, scores were significantly better in the BTR group compared with the BTT and Tx groups. Analysis of the two main dimensions and the total SF-36 score between the three groups showed that: (i) physical health dimension tended to be better in BTR (71.9 +/- 21) vs BTT (64.5 +/- 23.2) and Tx (41.4 +/- 48) groups (p = not statistically significant [NS]); (ii) mental health dimension was better in both BTR (78 +/- 16.1) and BTT (71.4 +/- 21.1) groups compared with the Tx group (39.4 +/- 44, p0.05); and (iii) total SF-36 score was significantly higher in the BTR and BTT groups compared with the Tx group (76.8 +/- 17.6 and 69 +/- 21.1 vs 41.4 +/- 48, p = NS).BTR patients appear to have better QOL than both BTT and Tx patients. In addition, BTT patients seem to have a better QOL compared with Tx patients, suggesting that placement of ventricular assist devices could improve the physiologic outcome for transplanted patients.

Objective Rotary axial flow pumps have several potential advantages and disadvantages over pulsatile pumps. The Jarvik 2000 is distinctive in being intracardiac. We report our experience in 22 patients. Methods The Jarvik 2000 was implanted in 15 men and 7 women. Mean age was 38.8 (range 23–59) years, preoperative diagnosis was dilated cardiomyopathy in 16, postpartum cardiomyopathy in 3, ischemic heart disease in 2, and chronic allograft failure in 1. Twenty-one patients were in New York Heart Association class IV, and 1 patient was in class III. Nineteen patients were on inotropic support, 6 were supported with an intra-aortic balloon pump, and 2 patients had been salvaged with a Centrimag (Levitronix) ventricular assist device. The median pulmonary vascular resistance was 3 Wood units; median pulmonary capillary wedge pressure was 26.6 mm Hg; and mean Cardiac Index was 1.5 L/min/m 2 . Results There were 2 early deaths and 6 late deaths. The average postoperative ventilation time and Intensive Treatment Unit stay was 2.2 and 10 days, respectively. One patient required a right ventricular assist device for short-term support and another for medium-term support. Seven patients were bridged to transplant, 3 had myocardial recovery, and 4 are ongoing. Mean and total duration of support was 280.5 and 6172 days, respectively. Driveline failures were noted in 3, but there were no pump infections or failure. Conclusion The Jarvik 2000 provides satisfactory intermediate-term results as a bridge to transplant or recovery. It appears to be associated with a low rate of serious driveline or pump infections and technical failure. However, bleeding complications due to the required anticoagulation treatment frequently occurred.

Background— After left ventricular–assist device (LVAD) support, a proportion of patients recover sufficient ventricular function to enable explantation of the device. The exact molecular mechanisms involved in myocardial recovery remain unknown. Cytoskeletal proteins are essential for the structure and function of the cardiac myocyte and might play a major role. Methods and Results— A total of 15 patients with nonischemic cardiomyopathy who required LVAD implantation were studied; 6 recovered sufficiently to allow explantation of the device compared with 9 who did not recover and required transplantation. LV myocardial samples were collected at implantation and explantation/transplantation. Affymetrix microarray analysis was performed on the paired samples and analyzed with reference to sarcomeric and nonsarcomeric cytoskeletal proteins. In the recovery group, of the nonsarcomeric proteins, lamin A/C increased 1.5-fold ( P P P P P P P α 2-actinin decreased by 1.6-fold at the time of explantation ( P P =0.001) in the recovered group but increased by 1.7-fold ( P Conclusions— Myocardial recovery was associated with a specific pattern of changes in sarcomeric, nonsarcomeric, and membrane-associated proteins, which could have important implications in understanding the mechanisms involved.

In an attempt to reduce some or all of the complications resulting from the use of biventricular assist devices after mechanical circulatory support, we have developed and applied a minimally invasive technique for explantation of right ventricular assist devices.

Valve repair is preferred over replacement in the management of mitral regurgitation when technically possible. Central to the achievement of a durable result is precise assessment of the anatomic abnormality present before repair, as well as accurate intraoperative evaluation of the adequacy of repair accomplished. Cardioplegic techniques commonly employed permit inspection of the valve in a flaccid, arrested state, which may not accurately reflect its function in the contractile heart. The repair can be tested under normal loading conditions only after separation from cardiopulmonary bypass. An alternative technique of myocardial management employing mild hypothermia, continuous aortic root perfusion, and intermittent fibrillation is described that provides an opportunity to directly examine the valve under physiologic conditions before, during, and after completion of the repair.

The full homograft root replacement has been regarded as the 'gold standard' for aortic valve replacement (AVR). Xenograft full root AVR may offer similar theoretical advantages, but no prospective randomized trials to compare the two valve substitutes have been reported to date.A total of 147 patients (mean age 66.2 years; range: 40-82 years) was randomized to undergo either Medtronic Freestyle (group F; n = 80) or homograft (group H; n = 67) root AVR. Coronary artery bypass grafting was associated with root AVR in 55 patients (37.4%). Follow up included routine clinical and echocardiographic assessments.Overall, there were seven early deaths (4.8%). The early mortality rate for isolated root AVR was 2.1% in group F (1/47) and 2.2% in group H (1/45) (p = NS). There were four late deaths in group F, and two in group H. Actuarial survival was 83+/-5% and 84+/-4% (p = NS) at five years, in groups F and H, respectively. No patient required reoperation on the aortic valve. Overall, there were eight thromboembolic events and six anticoagulant-related bleeding events; these were equally divided between the two groups. After a median follow up of 45 months, most patients in both groups were in NYHA class I, and the mean trans-aortic gradient was 6+/-1 mmHg in group F and 5+/-2 mmHg in group H (p = NS). Mild aortic regurgitation was recorded in 1/26 patients (4%) of group F, and in 1/16 (6%) of group H.The Medtronic Freestyle porcine xenograft appears to be a good alternative to homografts for full aortic root replacement, at least in the mid term.

Objective: To report 10 years survival in children under the age of 16 years undergoing heart transplantation in a single institution. Methods: One hundred and thirty nine/one hundred and ninety three patients (73%) survived more than 1 year after transplant. Seventy four (53%) of these survived more than 10 (10.0–20.1) years. Age at operation was 10 days–15.5 (mean 8.1) years. Patients were maintained on ciclosporin and azathiaprine alone. Routine steroids only given to 4 patients for either persistent rejection or deteriorating renal function. Rejection diagnosed on clinical or echocardiographic grounds. No routine biopsies were performed. Bi-annual coronary angiography was used to diagnose graft coronary disease. Results: Graft coronary disease was found in 8 patients (11%), 2 were re-transplanted and have survived 4.3–7.2 years since. Two patients are alive without intervention 2.0–13.0 years from initial diagnosis. Two patients have undergone interventional procedures 11 and 16 years after transplantation and are alive 3 and 4 years, respectively, later. Seven patients have had post transplant lymphoproliferative disease (PTLD) and 6 have had no recurrence for 3–13 years after treatment. Impaired renal function with abnormal serum creatinine levels is increasingly common-11 patients have developed end stage renal failure, 7 requiring renal transplantation, hypertension occurred in only 3 patients other than those in renal failure. Late rejection episodes associated with probable non-adherence occurred in 7 patients. There were 10 late deaths; 2 from graft coronary disease; 1 from PTLD; 3 from renal failure; 3 from acute rejection and 1 from infection. Conditional actuarial survival from 1 year post transplant was 76 and 67% at 10 and 15 years, respectively. Conclusions: Survival for more than 10 years is increasingly realistic. In this age group adherence and deteriorating renal function are major challenges. q 2005 Elsevier B.V. All rights reserved.