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There is critical need for a greater number of donor hearts for transplantation. The demand can be relieved, in part, by an extension of preservation time. This necessitates new methods of preservation and development of means to assess the functional condition of the preserved heart. We report a heart-preservation system designed for long-term preservation support and discuss issues specifically related to extended heart preservation. This article presents methodology to assess ventricular compliance and to quantify coronary flow distribution during the use of microperfusion preservation. Ventricular adenosine triphosphate (ATP) concentrations are directly related to the immediate post-preservation function: however, direct measurement of ATP is not clinically available. Based on the premise that ventricular compliance relates directly to the ventricular ATP concentrations, we performed sequential ventricular compliance measurements using a simple left ventricular balloon during a 24 h preservation period. A porcine heart model was employed using a continuous, hypothermic, antegrade, microperfusion system for 24 h and measurements were made at specific intervals during the preservation time. The compliance measurements were ascertained by pressure-volume curves using a flaccid balloon inserted into the left ventricle through the mitral valve. In addition, to assess microvascular function during the preservation interval, regional coronary flow measurements were performed using a microsphere technique. We report that after 12 h of preservation there was a twofold reduction in ventricular compliance which decreased further by fivefold at 18 h. In contrast, there was a time-dependent decrease in left ventricular coronary flow, especially with the left-ventricular subendocardial region significantly decreasing by 50% at 12 h. In conclusion, a simple ventricular-compliance balloon provided a direct measurement of ventricular compliance of the preserved heart which may provide an indirect estimate of the ventricular high-energy phosphates of the preserved heart prior to transplantation. [ABSTRACT FROM AUTHOR]

Objectives: There is limited data examining donor vasopressor and/or inotrope medications (vasoactives) on pediatric orthotopic heart transplant (OHT) outcomes. We aim to evaluate the effects of vasoactives on pediatric OHT outcomes., Methods: The United Network for Organ Sharing database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. Exclusion criteria included multiorgan transplants and recipient age >18. Donors receiving vasoactives at the time of procurement were compared to donors not on vasoactives, including the number of vasoactives and the type. End-points of interest were survival at 30 days and 1 year as well as post-transplant rejection at 1 year. Logistic and Cox models were used to quantify survival end-points., Results: Of 6462 donors, 3187 (49.3%) were receiving at least one vasoactive. Comparing any vasoactive medication versus none, there was no difference in 30-day survival (p = .27), 1 year survival (p = .89), overall survival (p = .68), or post-transplant rejection (p = .98). There was no difference in 30-day survival for donors receiving 2 or more vasoactive infusions (p = .89), 1 year survival (p = .53), overall survival (p = .75), or post-transplant rejection at 1 year (p = .87). Vasopressin was associated with decreased 30-day mortality (OR = 0.22; p = .028), dobutamine with decreased 1-year mortality (OR = 0.37; p = .036), overall survival (HR = 0.51; p = .003), and decreased post-transplant rejection (HR = 0.63; p = .012)., Conclusions: There is no difference in pediatric OHT outcomes when the cardiac donor is treated with vasoactive infusions at procurement. Vasopressin and dobutamine were associated with improved outcomes. This information can be used to guide medical management and donor selection., (© 2023 Wiley Periodicals LLC.)

Purpose: The purpose was to evaluate the effects of the most commonly used cardiac donor inotropes/vasopressors on subsequent post-heart transplant survival., Methods: Adult heart transplant recipients from January 2000 to June 2022 were identified in the United Network for Organ Sharing (UNOS) database. Exclusion criteria included: multiorgan transplants, donor age < 15, and recipient age < 18. Donors receiving vasoactive medications at the time of procurement were compared to donors not receiving these medications. Those on vasoactive medications were stratified by medication: phenylephrine, dopamine, dobutamine, norepinephrine and epinephrine, the combination of these agents, and the concomitant administration of vasopressin with any single agent alone or in combination. The primary area of interest was short-and-long-term survival. Survival at 30 days, 1 year, and long-term (Median = 13.6 years) was compared using logistic and Cox models to quantify survival endpoints., Results: A total of 45,198 donors met inclusion criteria and had data on the use of vasoactive agents available. Mean donor age was 32.3 years with 71% male. Vasoactive medications and potential combinations included phenylephrine in 8156 donors (18.0%), dopamine in 9550 (21.1%), dobutamine in 718 (1.6%), epinephrine in 332 (.73%), and norepinephrine in 4854 (10.7%). A total of 25,856 donors (57.2%) were receiving vasopressin at the time of procurement. There was no impact of donor inotropes on 30-day survival. Donors receiving one inotrope and no vasopressin were associated with increased 1 year mortality (OR 1.14; p = .021), as were donors receiving 2+ inotropes and no vasopressin (OR 1.26; p = .006). For individual agents, 1 year mortality was increased for dopamine (OR 1.11; p = .042) and epinephrine (OR 1.59; p = .004)., Conclusions: There is no difference in heart transplant recipient survival at 30 days when the donor is receiving inotropes without vasopressin at the time of procurement. Inotropic support without vasopressin is associated with greater 1 year mortality. The impact of donor inotropic support on long term heart transplant survival, and the interaction with vasopressin warrants further study., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Heart transplantation volumes have increased in recent years, yet less than a third of donors are typically accepted for transplantation. Whether donor sex, donor drug use, or perception of increased risk affects utilization for transplantation is unclear., Methods: The United Network for Organ Sharing database was queried for donors from January 1, 2007, to December 31, 2017. Donor toxicology was collected when available. Multivariate analysis was conducted to examine correlations with donor utilization., Results: Between January 1, 2007, and December 31, 2017, there were 87 816 heart donors aged ≥15 years. The mean age was 42.7±15.8 years, and 24 831 donors (28.3%) were utilized for heart transplantation. Subsequent analyses focused on donors between 15 and 39 years old. The strongest associations with donor acceptance were for male donor sex, blood type, hepatitis C antibody, donor age, left ventricular hypertrophy, and history of donor drug use. After removing hepatitis C, Public Health Service Increased Risk was identified as a strong negative predictor. Most positive drug toxicology results were associated with donor nonuse except for donors between 15 and 19 years of age. Exceptions included alcohol, marijuana, and cocaine. Opiates were associated with less utilization at all donor ages. The Public Health Service Increased Risk status was associated with significantly less utilization in all age groups except 15- to 19-year-old donors., Conclusions: While male donors were preferentially utilized, donors with drug use or those deemed Public Health Service Increased Risk were significantly less utilized for heart transplantation. Further consideration of such donors would be appropriate particularly as the demand for transplantation continues to increase.

The total artificial heart (TAH) provides full biventricular cardiac replacement, pulsatile perfusion at flows of 7-9 L/min at low filling pressures. This allows organs that are failing to recover and for the potential cardiac recipient to become a better transplant candidate. Postimplant patients are mobile and able to go through physical rehabilitation in a hospital or at home. The risks are acceptable as shown by the authors. TAH use in more transplant centers could save lives in many transplant candidates., (© 2022 Wiley Periodicals LLC.)

Objective: Venoarterial extracorporeal membrane oxygenation is a rescue therapy for patients in cardiogenic shock. We hypothesize that patients bridged to heart transplant with extracorporeal membrane oxygenation have decreased survival., Methods: The United Network of Organ Sharing database was retrospectively reviewed from January 1, 1999, to March 31, 2018, for heart transplant recipients. Recipients bridged with any form of mechanical support and those without support were compared with recipients bridged with extracorporeal membrane oxygenation. The primary end point was restricted mean survival time through 16.7 years., Results: Of 26,918 recipients, 15,076 required no pretransplant mechanical support (56.0%). Support patients included 9321 with left ventricular assist devices (34.6%), 53 with right ventricular assist devices (0.2%), 258 with total artificial hearts (1.0%), 686 with biventricular assist devices (2.6%), 1378 with intra-aortic balloon pumps (5.1%), and 146 who required extracorporeal membrane oxygenation (0.5%). In the first 16.7 years post-transplant, compared with recipients bridged with extracorporeal membrane oxygenation, estimated adjusted restricted mean survival time was higher in patients who required no mechanical support (16.6 months [14.0-19.4]) and patients with a left ventricular assist device (16.5 months [99% confidence interval, 13.9-19.2]), an intra-aortic balloon pump (11.2 months [8.3-14.7]), or a biventricular assist device (6.6 months [3.6-10.3]). Restricted mean survival time in patients with a right ventricular assist device or a total artificial heart was similar to patients with extracorporeal membrane oxygenation., Conclusions: Recipients bridged with extracorporeal membrane oxygenation were estimated to survive 16.6 months less than nonmechanical circulatory support recipients. Bridge to heart transplant with extracorporeal membrane oxygenation is a viable option, and these patients should be considered transplant candidates., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Heterotopic heart transplantation (HHT) is rare in the modern era. When used as a biologic left ventricular assist, HHT provides pulsatile flow, supports the left ventricle with a physiologic cardiac output, responds to humoral stimuli, and with modern immunosuppression may offer long-term untethered survival. This study was undertaken to compare survival of HHT with orthotopic heart transplantation (OHT) to assess its viability in the modern era. In the United Network for Organ Sharing database, from January 1999 to December 2020, there were 27691 bicaval OHT, 13836 biatrial OHT, 1271 total OHT, and 51 HHT with sufficient follow-up. Survival was analyzed using restricted mean survival time (RMST) through 4 years as the outcome. In the first 4 years after transplant, compared with HHT, differences in RMST were 0.1 years (99% CI: -0.4 to 0.5 years) for bicaval OHT, 0.0 years (99% CI: -0.4 to 0.5 years) for biatrial OHT, and 0.0 years (99% CI: -0.5 to 0.4 years) for total OHT. In this cohort, survival was indistinguishable between HHT and OHT recipients in the first four years. Thus, HHT might be a viable alternative to durable mechanical circulatory assist particularly with size mismatched grafts or for patients with refractory pulmonary hypertension., (© 2021 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Introduction: Given the known deleterious cardiac effects of brain death (BD) physiology, we hypothesized that time from cardiac donation referral to procurement (donor support time [DST]), would negatively impact cardiac transplant recipient survival., Methods: The United Network for Organ Sharing database was queried from 2007 to 2018, identifying 22,593 donor hearts for analysis. Multivariate logistic models for 30-day and 1-year survival, as well as Cox models for overall survival and posttransplant rejection, were used to assess adjusted outcomes., Results: median DST was 3 days (interquartile range: 2-5 days). Ischemic time; distance between donor and recipient hospitals; and recipient age, creatinine, waitlist time, and length of stay were adjusted predictors of survival and rejection. DST was not associated with either outcome in aggregate; however, differential association by donor race was identified, with DST in any race recipient associated with 4% higher odds of 1-year mortality (p = .001; p value for interaction .005) but only a trend towards worse overall mortality (p = .064; p value for interaction .046)., Conclusion: Thus, duration of exposure to BD physiology may have a differential impact on recipient outcomes based on donor race, suggesting that additional research is needed on donor immunologic, socioeconomic, and healthcare access factors that may impact cardiac transplant recipient outcomes., (© 2021 Wiley Periodicals LLC.)

The authors present an excellent large cohort review and complete analysis of long-term heart transplant survival including multiple institutions. Most studies on long-term heart transplant survival have single-center institutional experience. The authors present a comprehensive national review of the United Network for Organ Sharing Database (UNOS). The paper reflects the early transplant era through 1998 and demonstrates the long-term survival of this time., (© 2020 Wiley Periodicals LLC.)

Background: Few studies directly compare outcomes between the most commonly used preservation solutions in pediatric heart transplantation in a large cohort of recipients. The purpose of this study is to investigate the effect of cardiac preservation solution on survival in pediatric heart transplant recipients., Methods: The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from 01/2004-03/2018 for pediatric donor hearts. Saline, University of Wisconsin (UW), "cardioplegia," Celsior, and Custodiol preservation solutions were evaluated. The primary endpoints were recipient survival at 30 days, 1 year, and long term., Results: After exclusion criteria, 3012 recipients had preservation solution data available. The most common preservation solution used was UW in 1203 patients (40%), followed by Celsior in 542 (18%), cardioplegia in 461 (15%), saline in 408 (14%), and Custodiol in 398 (13%). Survival of recipients whose donor hearts were procured with UW was as follows: 97%-30 day, 92%-1 year; Celsior: 97%-30 day, 92%-1 year; cardioplegia: 97%-30 day, 91%-1 year; saline: 97%-30 day, 91%-1 year; and Custodiol: 96%-30 day and 92%-1 year. Analysis of Cox models for 30-day and long-term survival revealed no statistical differences when comparing UW to Celsior (p = .333), cardioplegia (p = .914), saline (p = .980), or Custodiol (p = .642) in adjusted models., Conclusions: There were no significant differences in 30-day or 1-year survival detected between commonly used preservation solutions in the pediatric heart transplant population., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Heart and lung procurements are multiphased processes often accompanied by an array of complex logistics. Approaches to donor evaluation and management, organ procurement, and organ preservation vary among individual procurement teams. Because early graft failure remains a major cause of mortality in contemporary thoracic organ transplant recipients, we sought to establish some standardization in the procurement process. This paper, in this vein, represents an international consensus statement on donor heart and lung procurement and is designed to serve as a guide for physicians, surgeons, and other providers who manage donors to best optimize the clinical status for the procurement of both heart and lungs for transplantation. Donation after brain death (DBD) and donation after circulatory determination death (referred to as donation after circulatory death [DCD] for the remainder of the paper) for both heart and lung transplantation will be discussed in this paper. Although the data available on DCD heart donation are limited, information regarding the surgical technique for procurement is included within this consensus statement. Furthermore, this paper will focus on adult DBD and DCD heart and lung procurement. Currently, no certification, which is either recognized and/or endorsed by the transplant community at large, exists for the training of a cardiothoracic procurement surgeon. Nevertheless, establishing a training curriculum and credentialing requirements are beyond the scope of this paper., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist that compare the predominant cardiac preservation solutions (CPSs)., Materials and Methods: The United Network for Organ Sharing database was retrospectively reviewed from January 1, 2004 to March 31, 2018, for donor hearts. Of 34,614 potential donors, 21,908 remained after applying the exclusion criteria. The CPS analyzed included saline, the University of Wisconsin (UW), cardioplegia, Celsior, and Custodiol. The primary endpoints were recipient survival and posttransplant rejection. Logistic and Cox models were used to quantify survival endpoints., Results: Saline was used as the CPS in 2549 patients (12%), UW in 10,549 (48%), cardioplegia in 1307 (6%), Celsior in 5081 (23%), and Custodiol in 2422 (11%). Donor age ranged from 15 to 68 y (mean = 32.0 y, median = 30.0 y), and 71% were male. Adjusted survival probabilities of recipients whose donor hearts were procured with saline was 96% 30 d, 90% 1 y, UW: 97% 30 d, 92% 1 y, cardioplegia: 95% 30 d, 87% 1 y, Celsior: 96% 30 d, 90% 1 y, and Custodiol: 97% 30 d, 92% 1 y. When these comparisons were adjusted for donor age, sex, ethnicity, ischemic time, recipient age, sex, ethnicity, creatinine, ventricular assist device (VAD), length of stay, region and days on waiting list, cardioplegia solution was demonstrated to have a higher risk of death (30 d, 1 y, overall) and posttransplant rejection versus UW (odds ratio 1.70, P = 0.001; odds ratio 1.63, P < 0.001; hazard ratio 1.22, P < 0.001; hazard ratio 1.21, P < 0.001, respectively)., Conclusions: Cardioplegia solutions for cardiac preservation are associated with a higher mortality in heart transplant recipients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The 70 cc total artificial heart (TAH) has been utilized as bridge to transplant (BTT) for biventricular failure. However, the utilization of 70 cc TAH has been limited to large patients for the low output from the pulmonary as well as systemic vein compression after chest closure. Therefore, the 50 cc TAH was developed by SynCardia (Tucson, AZ) to accommodate smaller chest cavity. We report the first TAH exchange from a 70 to 50 cc due to a fit difficulty. The patient failed to be closed with a 70 cc TAH, although the patient met the conventional 70 cc TAH fit criteria. We successfully closed the chest with a 50 cc TAH.

Primary cardiac sarcomas, although rare, are aggressive and lethal, requiring thorough surgical resection and adjuvant chemotherapy for the best possible outcome. We report the case of a 32-year-old woman who underwent total artificial heart implantation for right-sided heart failure caused by right ventricular angiosarcoma. For the first several weeks in intensive care, the patient recovered uneventfully. However, a postoperative liver biopsy indicated hepatocellular injury consistent with preoperative chemotherapy. She developed continuing liver failure, from which she died despite good cardiac function.

Background: In view of limited data on the subject of graft and patient survival differences between African American (AA) and non-AA heart transplant recipients, we reviewed our experience., Hypothesis: There is a higher mortality among AA recipients compared with non-AA recipients after cardiac transplantation., Methods: The study included all AA patients who have received a heart transplant in our center since 1983. Stepwise Cox regression was used for covariates affecting the survival. The χ(2) test was employed to identify the effects of a mechanical assist device and pretransplant creatinine (Cr) on the outcomes in AA and non-AA patients. Kaplan-Meier curves were used to examine survival., Results: The average survival among AA recipients was 5.4 years, compared with 12 years for the non-AA recipients, with 1-, 5-, and 10-year survival rates of 80%, 55%, and 25%, respectively. This was found to be statistically inferior to the survival probabilities of 92%, 78%, and 58% for the non-AA group (P < 0.005). Based on stepwise Cox regression, the variables such as ethnicity (P < 0.05), pretransplant Cr (P < 0.05), presence of a mechanical assist device (P < 0.005), and United Network for Organ Sharing (UNOS) status at transplant (P < 0.05) independently predicted the outcomes. Kaplan-Meier analysis of pretransplant Cr level and survival showed that the AA group did significantly worse for all Cr classes., Conclusions: There is a statistically significant difference in outcomes between AA and non-AA patients after cardiac transplantation. African American patients have decreased survival over a period of time. Pretransplant Cr, ethnicity, presence of a mechanical assist device, and UNOS status at transplantation are independent predictors of outcomes., (© 2014 Wiley Periodicals, Inc.)

To enhance ambulation and facilitate hospital discharge of total artificial heart (TAH)-supported patients, we adapted a mobile ventricular assistance device (VAD) driver (Excor) for TAH use and report on the performance of Excor-driven TAH patients discharged home. Ten patients stabilized on a TAH, driven by the CSS ("Circulatory Support System"), were progressively switched over to the Excor in hospital over 14 days as a pilot, with daily hemodynamics and laboratory parameters measured. Twenty-two stable TAH patients were subsequently placed on the Excor, trained, and discharged home. Clinical and hemodynamic parameters were followed. All pilot study patients were clinically stable on the Excor, with no decrease in TAH output noted (6.3 + 0.3 L/min [day 1] vs. 5.8 + 0.2 L/min [day 14], p = 0.174), with a trend suggesting improvement of both hepatic and renal function. Twenty-two TAH patients were subsequently successfully discharged home on the portable driver and were supported out of hospital for up to 598 days (range, 2-598; mean = 179 ± 140 days), remaining ambulatory, New York Heart Association (NYHA) class I or II, and free of readmission for 88.5% of the time of support. TAH patients may be effectively and safely supported by a mobile drive system. As such, the utility of the TAH may be extended to support patients beyond the hospital, at home, with overall ambulatory freedom.

Beginning at age 11 years, our patient has had four heart transplants. Now, 26 years later at age 37, he is fully active. This case is presented to document a unique experience and to consider the difficult decision-making process and ethical issues of multiple cardiac retransplantation.

Objective: The SynCardia Total Artificial Heart (SynCardia Systems Inc, Tucson, Ariz) has been used as a bridge to cardiac transplantation in 930 patients worldwide and in 101 patients in our program. Our experience with SynCardia Total Artificial Heart implantation documents its indications, safety, and efficacy., Methods: Data regarding preoperative condition, mortality, and morbidity have been reviewed and analyzed., Results: From January 1993 to December 2009, 101 patients had bridge to transplant procedures with the SynCardia Total Artificial Heart. Ninety-one percent of cases were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, and the remaining 9% of cases were failing medical therapy on multiple inotropic medications. The mean support time was 87 days (median, 53 days; range, 1-441 days). Pump outputs during support were 7 to 9 L/min. Adverse events included strokes in 7.9% of cases and take-back for hemorrhage in 24.7% of cases. Survival to transplantation was 68.3%. Causes of death of 32 patients on device support included multiple organ failure (13), pulmonary failure (6), and neurologic injury (4). Survival after transplantation at 1, 5, and 10 years was 76.8%, 60.5%, and 41.2%, respectively. The longest-term survivor is currently alive 16.4 years postimplantation., Conclusions: These patients were not candidates for left ventricular assist device therapy and were expected to die. The SynCardia Total Artificial Heart offers a real alternative for survival with a reasonable complication rate in appropriate candidates who otherwise might have been assigned to hospice care., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Blood coagulation is the most significant complication of vascular biomaterials. A straightforward, sensitive, and standard measure of the compatibility of these materials with whole blood (hemocompatibility) is necessary to avoid coagulation. Current techniques used quantify only individual clotting components and are poor predictors of coagulation. The thromboelastograph (TEG) provides a measure of overall clot formation from whole blood. Although TEG is very common in clinical settings, its application to biomaterials is limited partly due to difficulty in sample preparation. In this protocol, whole blood samples are incubated with (1) biomaterials (tube with clamped ends) and (2) endothelial cells cultured on biomaterial surfaces (12-well plate) under controlled shearing conditions (10 rpm on rocker, at 37°C), and then the blood is transferred to the TEG to measure clot formation. TEG clearly discriminates among the R-times (time until initial clot formation) of expanded poly(tetrafluoroethylene), poly(urethane), and Tygon tubing. Marked differences in R-time are also seen when endothelial cells are cultured on various extracellular matrix proteins and proteoglycans. Thus, R-time provides a robust metric of overall thrombogenicity of biomaterials, and these procedures provide a standardized method for TEG to facilitate direct comparison among candidate biomaterials undergoing in-vitro testing., (Copyright © 2011 Wiley Periodicals, Inc.)

Anticoagulation of children on mechanical circulatory support presents a challenge. We implanted 28 devices in children and infants using a consistent anticoagulation protocol. We performed a retrospective review of all children implanted in our program with mechanical assist devices since 1997. Heparin, dipyridamole, and aspirin were used for anticoagulation and antiaggregation. Coagulation monitoring included thromboelastography (TEG), platelet aggregration studies, international normalized ratio, partial thromboplastin time, and platelet count. Twenty-eight children, ages 1 month to 16 years (mean 5.3; median 2.4 years), were implanted for 3-107 days (mean 27; median 17). Eighteen received left ventricular assist devices, seven received biventricular assist devices, and three received total artificial hearts. Adverse events during the 720 days of device support included the following: six (21%) reoperations for bleeding; seven strokes (25%): two fatal, two with a mild residual deficit, and three without deficit; and three (11%) visceral emboli: two fatal and one nonfatal. There were eight deaths (29%). Causes of death were embolic (four), graft failure post-transplantation (one), preimplant anoxic brain damage (two), and postexplant heart failure (one). 24/28 (86%) survived to transplantation or weaning from device and 20/28 (71%) were discharged from the hospital, 10 after transplantation and 10 after native heart recovery. All 20 early survivors survived long term. We describe an anticoagulation protocol based upon TEG and platelet aggregation studies and using heparin, aspirin, and dipyridamole. Adequate anticoagulation is more difficult in children. However, 71% of the patients in our study survived long term., (© 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Heterotopic heart transplant (HHT) has traditionally been thought of as creating 2 parallel circulations. We present a case of using the donor heart as a "biologic left ventricular assist" (bio-LVA). The heterotopic technique used consisted of 4 anastomoses: the donor heart pulmonary artery (PA) to the native heart right atrium, the superior vena cava to superior vena cava, the left atrium to left atrium, and the aorta to aorta. A 9-year-old boy with restrictive cardiomyopathy, a PA pressure of 85/53 mmHg, received a HHT because he would probably not be able to tolerate an orthotopic heart transplant secondary to elevated PA pressure. He is currently alive 14 years post-transplantation.

Objective: Left ventricular assist device (LVAD) experience and follow-up data in children are limited. We report the deployment and successful weaning from LVAD in young children with severe heart failure (HF)., Design: From 2004--2009, 13 children suffering from HF were placed on LVAD. All presented with a dilated left ventricle (LV) with severely reduced contractility, secondary to myocarditis, atrial arrhythmia or idiopathic HF. This study reports their outcomes and longitudinal follow-up., Results: Of 13 young children with HF (ages 1 month--6 years; mean 19.2 months) placed on LVAD: eight weaned to recovery and successful hospital discharge, one was transplanted and four died. Echo follow-up in the weaned patients (mean age 22.1 months) revealed significant improvements from pre-LVAD measurements: LV end-diastolic dimension (LVED) mean z-score decreased from +4.8 to +0.95 (P < .001); fractional shortening (FS %) improved from a mean of 9.3% to 33% (P < .001); and the degree of mitral regurgitation (MR) significantly improved (P < .05). Time to LVAD deployment from HF diagnosis was more likely to be less than 30 days in the successfully weaned patients (100%) than patients who died or were transplanted (20%); P = .007., Conclusions: LVAD support can be utilized as a bridge to recovery in young children with HF. Following LVAD weaning, children sustain improvements in LV size, function and degree of MR. LVAD deployment less than 30 days from HF diagnosis improves the likelihood of successful weaning and illustrates that children with acute etiologies of HF are more likely to achieve recovery., (© 2011 Copyright the Authors. Congenital Heart Disease © 2011 Wiley Periodicals, Inc.)

Limited information about long-term survivors of heart-lung transplant recipients exists. We report a 57-year-old man who has now survived 25 years after a heart-lung transplant. Initial induction and maintenance immunotherapy was rabbit anti-thymocyte globulin, cyclosporine, azathioprine, and methylprednisolone. This patient is currently alive and working 25 years later and has continued good function of the heart-lung graft,without evidence of bronchiolitis obliterans., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: Our hypothesis is that cardiac retransplantation is a viable option for selected recipients. Furthermore, in some patients multiple retransplantations are reasonable., Methods: We studied 23 patients who had all received an elective second, third, or fourth cardiac transplant over a 25-year period. Comparisons were made with 792 primary transplantations. Subsequent retransplantations (third and fourth time) were elective and included in the evaluation., Results: Twenty-three patients electively received a second, 4 a third, and 1 a fourth transplant for coronary vasculopathy or chronic graft failure. Sixteen (70%) patients were men, and 7 (30%) were women. Median survival in years for primary cardiac recipients was 10.7 years; for a second transplantation, median survival from the date of retransplantation was 9.3 years. Average age at the time of first transplantation was 47.8 years, and it was 44.3 years at the time of second transplantation. No significant difference was noted in Kaplan-Meier survival curves between patients undergoing primary transplantation and elective retransplantation. Survival at 1 year for patients undergoing a first transplantation was 88.8%, and it was 81.8% for patients undergoing retransplantation. Patient survival at 10 years was nearly identical for patients undergoing first-time transplantation and those undergoing retransplantation (58%). All 5 third- and fourth-time transplant recipients survived., Conclusions: Cardiac retransplantation is a reasonable option for elective recipients with coronary vasculopathy or chronic graft failure. Survival for groups undergoing primary transplantation and retransplantation is similar. Careful selection of this small group of cardiac recipients (3% of the total) might be the key to success., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A 39-year-old man with a dilated cardiomyopathy was treated for recurrent life threatening ventricular arrhythmias with an automatic defibrillator and multiple antiarrhythmic agents. After transplant, the donor heart was asystolic probably secondary to these agents. A biventricular paracorporeal device supported the patient for four days and the heart recovered. He remains NYHA class I seven years later.

Combined, single-donor, heart and kidney transplant (HKTx) recipients have survival rates comparable with those after heart transplantation alone. Although HKTx provides superior outcomes in patients with dual-organ failure, appropriate single-donor organ pairs are very scarce. Mechanical circulatory support thus seems an attractive option as a bridge to HKTx. We report the case of an adult with end-stage cardiomyopathy and renal failure who was successfully bridged to combined, single-donor HKTx with a total artificial heart. Infectious complications associated with the CardioWest cavity were encountered prior to transplantation. The patient recovered and was discharged 14 days after transplantation. At 4 months post-transplantation, the patient required single-vessel coronary stenting for a high-grade stenosis. At 1 year, he has had no further complications and has excellent function of both transplanted organs. Despite limited availability of same donor organ pairs, patients with combined cardiac and renal failure can be bridged effectively to transplant with the CardioWest total artificial heart., (Copyright © 2010 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

We report two cases at a single institution, a 52-year-old man and a 25-year-old woman, who had failures of their CardioWest total artificial hearts (TAH) from central venous lines that caused obstruction of the right ventricular inflow valves. Each patient was noted to have decreasing TAH outputs for a few days before this catastrophic device arrest. Both patients died; one suddenly and one during a protracted period, as a result of catheter entrapment of the disc of the Medtronic Hall right ventricular inflow valve.

Background: Peripartum cardiomyopathy is a life threatening illness. If maximal medical therapy fails, patients may then be treated with mechanical circulatory support devices and (or) cardiac transplantation. Our purpose is to demonstrate the long-term efficacy of these surgical interventions., Methods: A retrospective review of 18 patients diagnosed with peripartum cardiomyopathy from 1994 to 2009 was conducted., Results: Eighteen patients were referred with a median of seven year delay between onset of symptoms and presentation. Eight (44%) had medical therapy with only one death at five years, seven are alive, and two patients are awaiting transplantation. Six patients were implanted with devices. From this group, there were two hospital deaths, one native heart recovery, and three heart transplants with 100% survival. Four patients (21%) were treated with transplantation alone and all survived. Combined device and (or) transplant survival was 80% at one year., Conclusions: The natural history of this group varied; 38% of the medically treated patients are stable on medical therapy (3 of 8) and 67% of the device patients (4 of 6) are alive. One of six device patients (17%) was successfully bridged to native heart recovery. Mechanical assist devices can be used as a bridge to recovery or as a bridge to cardiac transplantation for the treatment of peripartum cardiomyopathy patients who fail medical management. In addition, cardiac transplantation alone is also a viable treatment option for patients who fail medical management and do not require a mechanical assist device., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tricuspid regurgitation (TR) is a relatively common abnormality in normal adults as well as after orthotopic heart transplantation (OHT). A few studies have shown reduction in the incidence of TR after OHT by total bicaval surgical anastomosis technique. Other studies reported no significant difference in the rates of TR between the standard and bicaval techniques., Objective: Evaluate and compare the degree of TR after OHT by standard and bicaval anastomosis techniques., Method: Echocardiograms from the first 56 consecutive patients that had the total bicaval surgical technique performed were retrospectively reviewed and compared with the last 57 consecutive patients who had the standard biatrial technique performed. Patients with adequate two-dimensional and Doppler echocardiograms were included., Results: No statistical difference was observed for each grade of TR at both early and late time points. No significant difference was observed between the TR velocities of both biatrial and bicaval anastomosis patients at different periods., Conclusion: There appears to be no difference between the TR severity and TR velocity at early and late time points regardless of anastomotic technique.

Cardiac transplant recipients with patent foramen ovale (PFO) are at risk for right-to-left shunting. Failure to identify this abnormality can have serious posttransplant consequences. In this article, we describe a cardiac transplant recipient with hypoxemia where a PFO was diagnosed postoperatively despite direct surgical investigation at the time of orthotopic heart transplantation (OHT). Transthoracic echocardiography with bubble study is relatively inexpensive, noninvasive, and simple and can be a useful method to identify PFO/atrial septal defect. Thus, authors recommend critically screening both donor and recipient hearts prior to OHT.

Background: Safety and efficacy studies of various mechanical circulatory support devices are important, but may not be strictly comparable. Lacking prospective randomized studies for different devices, we believe that comparison of risk factor analyses may give the surgeon a tool more powerful than current studies for matching a patient with an appropriate device. In this paper, we report risk factor profiles for bridge to transplantation with the CardioWest total artificial heart and summarize reports for other devices., Methods: A multiinstitutional risk factor analysis of the CardioWest total artificial heart, as a bridge to transplantation in 81 patients, was conducted. Univariate analyses were performed on 43 preimplantation prognostic factors. From this group, eight factors were chosen for multivariate analysis. Our results were compared with all recent risk factor analyses for other devices., Results: Independent predictors for death at three intervals by multivariate analysis were as follows: "implant to transplant": history of smoking (odds ratio, 34); "implant to 30 days after transplant": history of smoking (odds ratio, 10.00), prothrombin time greater than 16 seconds (odds ratio, 4.76); and "implant to 1 year after transplant": prothrombin time greater than 16 seconds (odds ratio, 3.85). The major difference between this experience and multiple reported experiences with left ventricular assist devices is that for left ventricular assist devices, but not for the temporary CardioWest total artificial heart, right heart failure, high central venous pressure, and being on a ventilator (with or without sepsis) were independent predictors of mortality., Conclusions: Risk factors for bridge to transplantation with the CardioWest total artificial heart are different from those reported for left ventricular assist devices. Recognition of these risk factor differences may facilitate appropriate device selection.

Background: Endomyocardial biopsy remains the gold standard to assess cardiac rejection in cardiac transplantation patients. The aim of this study is to evaluate the supportive role and benefits of real-time sonography in central venous access for cardiac biopsy., Study Design: Between January and September 2006, a retrospective review was carried out for the performance of central venous access using real-time sonography on 74 transplantion patients undergoing 305 cardiac biopsies by a single operator. The study included 56 male and 18 female patients, some of whom had severe dyspnea, obesity, dehydration, peripheral and pulmonary edema., Results: All patients underwent successful central venous access using real-time ultrasonic guidance. With increasing experience as a sonographer, central venous access became less invasive and traumatic and more precise and successful. The supportive role of real-time sonography was associated with less major complications and greater patient comfort, even among conscious patients with severe dyspnea and obesity in non-Trendelenburg position using routine local anesthesia., Conclusions: Use of real-time sonography during percutaneous sheath insertion of the right internal jugular vein and the right subclavian vein provides an improved means to safe and quick access for cardiac biopsies with high success rates and low complication rates.