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Az extracorporalis cardiopulmonalis resuscitatio alkalmazásának gyakorisága egyre nő mind a kórházon belüli, mind a kórházon kívüli keringésmegállás ellátásában. A legújabb újraélesztési irányelvek is egyre inkább beépítik javaslataik közé az extracorporalis keringéstámogató eszközök használatát elhúzódó újraélesztés esetén, bizonyos szelektált betegcsoportokban. Mindezek ellenére kevés bizonyíték áll rendelkezésünkre a beavatkozás hatékonyságáról, és még számos nyitott kérdés maradt megválaszolatlanul azt illetően, hogy milyen körülmények között, mely betegcsoportokban van a leginkább létjogosultsága ennek a modalitásnak. Fontos kérdés a terápia időzítése és helyszíne, illetve lényeges az extracorporalis technikákat alkalmazó személyzet megfelelő kiképzése. Összefoglalónkban röviden áttekintjük, hogy a jelenlegi szakirodalom és ajánlások szerint milyen esetekben merülhet fel az extracorporalis újraélesztés megkezdése, milyen típusú mechanikus keringéstámogatás az elsőként választandó az újraélesztés alatt, milyen tényezőket gondoljunk át alkalmazása során, illetve milyen szövődményekre számítsunk. Orv Hetil. 2023; 164(13): 510–514.

Összefoglaló. Bevezetés: A pericarditis constrictiva egy krónikus gyulladásos folyamat révén kialakuló betegség, melynek során a pericardium elveszíti rugalmasságát, gátolja a szív működését, végső soron szívelégtelenséghez vezet. Egyetlen oki terápiája sebészi. A műtéti megoldásként legelterjedtebben alkalmazott teljes pericardiectomia hosszú időtartamú műtét, amely akár 18%-os műtéti kockázattal járhat, és amelyhez az esetek jelentős részében szívmotor alkalmazása szükséges. Célkitűzés: Egy, az irodalomból már ismert, de csak ritkán és a legtöbbször csak a hagyományos pericardiectomia kiegészítéseként alkalmazott műtéti eljárás, a „turtle cage” pericardiectomia hatásosságának, eredményeinek, lehetséges előnyeinek vizsgálata. Módszer: 2008 és 2021 között Klinikánkon 33 „turtle cage” műtétet végeztünk pericarditis constrictiva miatt. A posztoperatív 30 napos időszak eredményeit több, a nemzetközi irodalomban megjelent közlemény adataival hasonlítottuk össze. Eredmények: Az intraoperatív kép alapján minden esetben sikeres volt a beavatkozás, a 33 beteg egyikénél sem volt szükség szívmotor alkalmazására (0%), szemben a vizsgált közleményekkel. A 33 beavatkozás során 1 beteget veszítettünk el (3%), valamint 1 páciensnél volt szükség vérzés miatti reoperációra (3%), 4 betegnél dialízisre (12,1%). Ezen eredményeink összevethetők a nagy esetszámot felvonultató közleményekkel, és szignifikánsan jobbak az egyik megjelenített európai centrum eredményeinél. Következtetés: Az általunk alkalmazott „turtle cage” pericardiectomia önmagában is megfelelő eljárás a pericarditis constrictiva szívsebészeti kezelésére. Alkalmazásával minimalizálható a szívmotor használatának szükségessége, ezáltal a műtéti kockázat. Eredményeink a technikának köszönhetően még a nagy esetszámú, sok tapasztalattal rendelkező centrumok eredményeivel is összevethetők, azokkal megegyezők. Orv Hetil. 2022; 163(10): 393–399. Summary. Introduction: Constrictive pericarditis is a disease caused by a chronic inflammatory process, which is characterized by the pericardium’s loss of flexibility, inhibiting the function of the heart, ultimately causing heart failure. The only definitive therapy is surgical. Total pericardiectomy, which is the most common surgical approach, is a lengthy procedure with up to 18% operative risk, and it often requires the use of cardiopulmonary bypass. Objective: The evaluation of the effectiveness, results and possible advantages of a surgical technique, “turtle cage” pericardiectomy, which is described in the literature, although rarely used, mainly in addition to conventional pericardiectomy. Method: Between 2008 and 2021, we performed 33 “turtle cage” procedures on patients with constrictive pericarditis in our Institute. We compared the results of the 30-day postoperative period with internationally published data from multiple sources. Results: Based on intraoperative findings, the procedure was successful in all cases, there were no instances when the use of cardiopulmonary bypass was required (0%). During the 33 procedures, we lost 1 patient (3%), reoperation was necessary for postoperative bleeding in 1 case (3%), and postoperative dialysis was necessary in 4 cases (12.1%). These results are comparable to those published by high-volume centres, and significantly better than those of one of the European centres published. Conclusion: The “turtle cage” pericardiectomy, as performed in our Institute, is suitable for the treatment of constrictive pericarditis on its own. With its use, we were able to minimize the use of cardiopulmonary bypass and the operative risk. Our results with this technique are comparable to those of the high-volume, highly experienced centres. Orv Hetil. 2022; 163(10): 393–399.

Flow-shop scheduling is considered. The order of operations must be the same for each job to minimize the maximum completion time. The Simulated Annealing algorithm is a standard approximate solution method in scheduling and optimization in general. Since the algorithm depends on cooling as a heuristic to generate better approx- imations, choosing the strategy with which the temperature decreases can affect the final result.

Flow-shop scheduling problems are classic examples of multi-resource and multi-operation optimization problems. This paper demonstrates our model and simulation for solving Flow-shop scheduling optimization problems with resource availability constraints to minimize makespan. Working hours, transfer times and setup times are taken into account. Working hours could be interpreted in two ways. In the first option, operations must fit into a single available time slot. In the second option, the simulation could cut operations across multiple time slots. We propose a simulation algorithm that accounts for both scenarios and could be used with any permutation-based exact, heuristic, or search algorithm.

Treatment of the coronavirus disease (COVID-19) is still challenging due to the lack of evidence-based treatment protocols and continuously changing epidemiological situations and vaccinations. Remdesivir (RDV) is among the few antiviral medications with confirmed efficacy for specific patient groups. However, real-world data on long-term outcomes for a short treatment course are scarce.This retrospective observational cohort study included real-life data collected during the second and third wave of the COVID-19 pandemic in Hungary (September 1, 2020-April 30, 2021) from inpatients at a University Center (n = 947). Participants consisted of two propensity score-matched cohorts (370/370 cases): Group RDV including patients receiving RDV and supplementary oxygen and Group standard of care (SOC) as control. The primary outcome was the effect of 5-day RDV treatment on 30- and 60-day all-cause mortality. Multivariate analyses were performed to assess the effect of RDV by different covariates.Group RDV included significantly more patients from the alpha variant wave, with greater frequency of comorbidities diabetes and anemia, and larger degree of parenchymal involvement. All-cause mortality at 30- and 60-day were significantly lower in Group RDV compared to Group SOC. Significant risk reduction of 60-day all-cause mortality was observed for RDV treatment in men and patients with COPD or multiple comorbidities.Hospitalized COVID-19 patients with 5-day RDV treatment had significantly lower 30- and 60-day all-cause mortality, despite their more severe clinical condition. Men and patients with multiple comorbidities, including COPD, profited the most from RDV treatment in the long term. Due to the ongoing COVID-19 pandemic, effective treatment regimens are needed for hospitalized patients.

Mechanical circulatory support (MCS) was introduced in the 1960s, of which there is short-, mid- and long-term forms. This brief review discusses our experiences with the primary modality used in Hungary, the veno-arterial extracorpo­real membrane oxygenator (VA-ECMO). We introduced the device with the most relevant information and summarized our clinic’s registry with patient characteristics and results in whom we applied this modality next to data of international studies. We collected data retro- and prospectively from 2012 to 2020 from patients treated with the VA-ECMO at our clinic. The primary endpoint we used was all cause mortality in this patient population of critical condition. Every indication, potential peripheral-central conversion and primary operation technique was involved in the analysis. We found that age above 65 and initial pH under 7.2 significantly affects mortality data. Acute coronary syndrome (ACS) as primary indication showed to be nearly significant, and acute rejection after hTX was a beneficial clinical scenario regarding survival. In international literature diabetes mellitus, elevated levels of lactate, kidney- and hepatic insufficiency were identified as contributing mortality predictors as well. Our results mostly coincide with the international mortality and risk factor data. Time is a very important factor for the survival of these patients. Therefore, it is very important to refer the patient’s refractory to non-MCS therapy to centers with VA-ECMO capability in time.

Introduction Mechanical circulatory support (MCS) has been established as a means of augmenting circulation in patients with critically decreased systolic function due to a variety of underlying clinical reasons. Different methods of MCS may be used, with the venous-arterial extracorporeal membrane oxygenation system (VA-ECMO) being one of the most utilized devices in everyday care. Aim To determine independent predictors influencing mortality outcomes following VA-ECMO therapy in a large, unselected, adult, critically ill patient population in cardiogenic shock (CS). Material and methods Data on 235 consecutive, real-world VA-ECMO treatments were assessed. Analysis was conducted for all subjects requiring MCS with the VA-ECMO as the first instalment, regardless of underlying cause or eventual upgrade. All potential clinical factors influencing mortality were examined and evaluated. Results Overall mortality was ~66% at median 28 days follow-up and significantly depended upon pH < 7.3 (HR = 3.56; p < 0.001), and age ≥ 65 years (HR = 1.96; p = 0.001). Acute coronary syndrome (ACS) as an indication for VA-ECMO displayed a nearly significant value (HR = 1.44; p = 0.07). Heart transplant (hTX) primary graft failure as an indication for the VA-ECMO displayed a clearly favorable outcome (HR = 0.51, p = 0.025); all data based on multivariate Cox regression analysis. Conclusions Mortality in patients requiring VA-ECMO remains high. We conclude that only decreased pH values and advanced age clearly influence mortality in this MCS scenario. ACS also bodes unfavorably, whereas hTX as an indication clearly shows better survival.

Objectives Thyroid dysfunction has been shown to be associated with increased all-cause mortality and severity of chronic heart failure in critical illness and severe cardiac diseases. The present study was conducted to ascertain the relationship between perioperative free triiodothyronine and free tetraiodothyronine (fT4) levels and postoperative adverse outcomes after heart transplantation (HTX). Design Retrospective, observational study. Setting Single-center study in a quaternary care university clinical center. Participants The study comprised adult patients who underwent HTX between 2015 and 2019 and had at least 1 perioperative thyroid hormone laboratory test on the day of surgery or in the 24 hours before/after the procedure (free triiodothyronine, fT4, and thyroid-stimulating hormone). Interventions No interventions were applied. Measurements and Main Results The primary outcome was primary graft dysfunction (PGD), defined by the consensus conference of the International Society for Heart and Lung Transplantation. A total of 151 patients were included in the final analyses. Twenty-nine (19.2%) patients had PGD. Fourteen (9.3%) patients had low fT4 levels. An independent association was found between fT4 and PGD (odds ratio 6.49; 95% confidence interval 2.26-18.61; p = 0.001), with adjusted multivariate Cox regression models. Conclusion The perioperative fT4 level could be a prognostic marker of adverse outcomes in HTX. The authors suggest appropriate perioperative monitoring of fT4 levels. Additional research is warranted to examine the optimal timing, dosage, and method of replacement.

Introduction: Veno-arterial extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with severe heart failure due to different etiologies. Current prognosis with veno-arterial extracorporeal membrane oxygenation is unsatisfactory, and the risk stratification is still challenging. Therefore, we aimed to evaluate the predictive value of different baseline model for end-stage liver disease scores for survival in patients with veno-arterial extracorporeal membrane oxygenation. Methods: We conducted an observational, retrospective study of consecutive veno-arterial extracorporeal membrane oxygenation-treated patients between January 2012 and August 2018. The four types of model for end-stage liver disease scores—model for end-stage liver disease, international normalized ratio-excluded model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium—were calculated preoperatively. Veno-arterial extracorporeal membrane oxygenation was used based on the four clinical indications: primer graft failure after heart transplantation, weaning failure from cardiopulmonary bypass, acute myocardial infarction with refractory cardiogenic shock, and bridge to transplantation or bridge to candidacy. The primary endpoint of the study was overall mortality. The secondary endpoint was in-hospital mortality. We performed univariable and multivariable Cox regression analyses. Results: Data from 135 patients were analyzed. The median follow-up was 952 days (interquartile range = 417–1555 days). In-hospital mortality was 62.2%, and overall mortality was 71.1%. The multivariable Cox regression analysis is adjusted for indication, and the survival after veno-arterial extracorporeal membrane oxygenation score showed that the following scores were associated with overall mortality: model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01–1.07; p = 0.016), modified model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01–1.06; p = 0.006), and model for end-stage liver disease with sodium (hazard ratio = 1.05; 95% confidence interval = 1.02–1.08; p = 0.001). Conclusion: Model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium scores could be useful in the risk stratification of veno-arterial extracorporeal membrane oxygenation treatment in varying clinical indications.

Abstract: Use of 3D planning and 3D printing is expanding in healthcare. One of the common applications is the creation of anatomical models for the surgical procedure from DICOM files. These patient-specific models are used for multiple purposes, including visualization of complex anatomical situations, simulation of surgical procedures, patient education and facilitating communication between the different disciplines during clinical case discussions. Cardiac and thoracic surgical applications of this technology development include the use of patient-specific 3D models for exploration of ventricle and aorta function and surgical procedural planning in oncology. The 3D virtual and printed models provide a new visualization perspective for the surgeons and more efficient communication between the different clinical disciplines. The 3D project was started at the Semmelweis University with the cooperation of the Thoracic Surgery Department of the National Institute of Oncology in 2018. The authors want to share their experiences in 3D designed medical tools. Orv Hetil. 2019; 160(50): 1967–1975.

Összefoglaló. Bevezetés: A pericarditis constrictiva egy krónikus gyulladásos folyamat révén kialakuló betegség, melynek során a pericardium elveszíti rugalmasságát, gátolja a szív működését, végső soron szívelégtelenséghez vezet. Egyetlen oki terápiája sebészi. A műtéti megoldásként legelterjedtebben alkalmazott teljes pericardiectomia hosszú időtartamú műtét, amely akár 18%-os műtéti kockázattal járhat, és amelyhez az esetek jelentős részében szívmotor alkalmazása szükséges. Célkitűzés: Egy, az irodalomból már ismert, de csak ritkán és a legtöbbször csak a hagyományos pericardiectomia kiegészítéseként alkalmazott műtéti eljárás, a "turtle cage" pericardiectomia hatásosságának, eredményeinek, lehetséges előnyeinek vizsgálata. Módszer: 2008 és 2021 között Klinikánkon 33 "turtle cage" műtétet végeztünk pericarditis constrictiva miatt. A posztoperatív 30 napos időszak eredményeit több, a nemzetközi irodalomban megjelent közlemény adataival hasonlítottuk össze. Eredmények: Az intraoperatív kép alapján minden esetben sikeres volt a beavatkozás, a 33 beteg egyikénél sem volt szükség szívmotor alkalmazására (0%), szemben a vizsgált közleményekkel. A 33 beavatkozás során 1 beteget veszítettünk el (3%), valamint 1 páciensnél volt szükség vérzés miatti reoperációra (3%), 4 betegnél dialízisre (12,1%). Ezen eredményeink összevethetők a nagy esetszámot felvonultató közleményekkel, és szignifikánsan jobbak az egyik megjelenített európai centrum eredményeinél. Következtetés: Az általunk alkalmazott "turtle cage" pericardiectomia önmagában is megfelelő eljárás a pericarditis constrictiva szívsebészeti kezelésére. Alkalmazásával minimalizálható a szívmotor használatának szükségessége, ezáltal a műtéti kockázat. Eredményeink a technikának köszönhetően még a nagy esetszámú, sok tapasztalattal rendelkező centrumok eredményeivel is összevethetők, azokkal megegyezők. Orv Hetil. 2022; 163(10): 393-399.Constrictive pericarditis is a disease caused by a chronic inflammatory process, which is characterized by the pericardium's loss of flexibility, inhibiting the function of the heart, ultimately causing heart failure. The only definitive therapy is surgical. Total pericardiectomy, which is the most common surgical approach, is a lengthy procedure with up to 18% operative risk, and it often requires the use of cardiopulmonary bypass.The evaluation of the effectiveness, results and possible advantages of a surgical technique, "turtle cage" pericardiectomy, which is described in the literature, although rarely used, mainly in addition to conventional pericardiectomy.Between 2008 and 2021, we performed 33 "turtle cage" procedures on patients with constrictive pericarditis in our Institute. We compared the results of the 30-day postoperative period with internationally published data from multiple sources.Based on intraoperative findings, the procedure was successful in all cases, there were no instances when the use of cardiopulmonary bypass was required (0%). During the 33 procedures, we lost 1 patient (3%), reoperation was necessary for postoperative bleeding in 1 case (3%), and postoperative dialysis was necessary in 4 cases (12.1%). These results are comparable to those published by high-volume centres, and significantly better than those of one of the European centres published.The "turtle cage" pericardiectomy, as performed in our Institute, is suitable for the treatment of constrictive pericarditis on its own. With its use, we were able to minimize the use of cardiopulmonary bypass and the operative risk. Our results with this technique are comparable to those of the high-volume, highly experienced centres. Orv Hetil. 2022; 163(10): 393-399.

BACKGROUND The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery. METHODS The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure. RESULTS The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions. CONCLUSION Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

In this article we summarize the results of the first 3 years after launching the Hungarian Lung Transplantation Program. Patients and Methods The first lung transplant in Hungary was carried out on December 12, 2015, with the collaboration of the National Institute of Oncology and the Semmelweis University. Up to December 31, 2018, a total of 62 lung transplants were performed. Data were analyzed retrospectively. Patients were listed for lung transplant after the indication was established by the National Lung Transplantation Committee. Donor lungs were procured from brain-dead donors only. Results Within this period our team was involved in 87 lung procurements, 61 of which resulted in bilateral lung transplant and 1 in single-sided transplant. The operative approach was unilateral thoracotomy (n = 1), bilateral thoracotomy (n = 1), or clamshell incision (n = 60) with venoarterial extracorporeal membrane oxygenation support. The underlying disease of the recipients was obstructive lung disease (n = 30), lung fibrosis (n = 11), cystic fibrosis (n = 18), primary pulmonary hypertension (n = 2), histiocytosis-X syndrome (n = 1), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and retransplant because of bronchiolitis obliterans syndrome (n = 1). The youngest patient was 13 years of age, while the oldest was 65 years. Three patients died in the early postoperative phase. One-year survival was 80%. Discussion The number of cases rises steadily in the Hungarian Lung Transplantation Program, which is exceptional compared with the start of other centrums. The incidence of complications and mortality is comparable with those of other experienced centers around the world. Our future goal is to broaden our waiting list, thus increasing the number of lung transplants carried out.

Background After its initial difficulties were overcome, lung transplantation became an accepted and effective treatment for end-stage lung disease. Patients can take part in almost all kinds of sports after lung transplantation, including high-altitude mountaineering, which is an extreme sport even for healthy individuals. Several articles have been published about high-altitude tolerance of transplanted patients. However, this was the first high-altitude expedition that included only lung transplant patients. Methods The Vienna lung transplantation team organized an expedition in 2017 to conquer the peak of Mount Kilimanjaro, which consisted of 10 lung transplanted patients and 24 accompanying medical personnel. The participants were tested before and several times during the hike to evaluate their general and cardiopulmonary status, the severity of altitude sickness, and radio-morphologic changes. The results of the lung transplanted patients were compared to the results of their healthy companions. Results The group started at 2360 meters and reached the 5895-meter-high summit of Mount Kilimanjaro after 6 days on June 18, 2017. Eight transplant patients and 24 escorting medical personnel reached the peak. This means that the success rate was 94%, which is significantly higher than the reported 85% for this route. The 2 transplant patients who did not make the summit turned back on the first and second day because they lacked the necessary fitness for the trip. We did not see a significant difference in the results regarding cardiopulmonary status or the severity of altitude sickness, although we observed mildly higher blood pressure and altitude sickness score results in the lung transplant group. Conclusion Based on our experiences, we can state that a stable patient after lung transplantation who attains the necessary physical fitness can achieve similar or even better physical results than an average healthy individual.

Background Pituitary dysfunction after brainstem death can cause various hormone deficiencies in potential heart donors. The aim of this study was to evaluate the relationship between hormone replacement therapy (HRT; including antidiuretic hormone analog, thyroid hormone, and methylprednisolone) in heart donors and the recipients’ outcomes after heart transplantation (HTx). Methods We retrospectively analyzed HTxs performed between January 2012 and October 2018. Donor and recipient characteristics were retrieved with a focus on endocrine parameters and HRT. The primary outcome was primary graft dysfunction (PGD). Secondary outcomes were the 30-day and 2-year mortality of the recipients. Univariate and multivariate Cox regression analyses were applied. Results The study included 297 HTxs. PGD occurred in 56 recipients (18.9%). In the multivariable Cox analysis, methylprednisolone and thyroxine treatment in donors were associated with a lower odds for PGD (odds ratio [OR], 0.43; 95% CI, 0.19-1.01; P = .052; and OR,: 0.34; 95% CI, 0.15-0.76; P = .009, respectively). In multivariate analysis, thyroxine treatment in donors was associated with a lower odds of PGD (OR, 0.38; 95% CI, 0.17-0.86; P = .020). Donor thyroxine supplementation also had a beneficial effect on recipients’ 2-year survival (OR, 0.53; 95% CI, 0.29-0.96; P = .036). Conclusions Combined thyroxine and methylprednisolone treatment could be a protective factor against PGD. Thyroxine administration was associated with better 2-year survival in recipients.

Abstract: The authors give a short introduction of the Hungarian and the international history of adult heart transplantation, and highlight the similarities in the evolution of the two programs. Their aim was to show how the Hungarian post-transplant survival changed in the last five years. They wanted to investigate how all the changes they had made in the program affected the post-transplant results. They investigated 496 heart transplantation data and compared to international data. Orv Hetil. 2018; 159(46): 1869–1875.

Abstract: The mechanical circulatory support (MCS) program of the Semmelweis University Heart and Vascular Centre has become established over the last five years. The main requirements of our MCS program to be developed first were the Heart Transplantation and Heart Failure Intensive Care Unit and a well trained medical team. The wide range of mechanical circulatory support devices provides suitable background for the adequate treatment of our patients in all indications. In this review, we present our results related to extracorporeal membrane oxygenation (ECMO) supports performed in the last five years. Between 2012 and 2017, we applied MCS support in 140 cases, among them 111 patients received ECMO support. The leading indications of ECMO support were the following: primary graft failure after heart transplantation (33 cases), postcardiotomy cardiogenic shock (18 patients), acute decompensation of end-stage heart failure (14 patients), acute myocardial infarction complicated with refractory cardiogenic shock (37 patients), cardiogenic shock developed after transcatheter aortic valve implantation (3 patients), malignant arrhythmia due to drug intoxication (1 patient) and acute respiratory distress syndrome (4 cases). The mortality of patients receiving ECMO support was 46%. The analysis of the results of ECMO support needs to change our approach. The mortality results show that we lost the half of our patients. However, the mortality in the conventionally treated patients would have been 100% without ECMO. In fact, we could save the life of half of these patients. Orv Hetil. 2018; 159(46): 1876–1881.

Abstract: The first lung transplantation in Hungary was performed on 12th of December, 2015. It was a joint effort of the National Institute of Oncology and the Semmelweis University. Hereby we summarise the results and experiences from the first three years. Until August, 2018, 55 lung transplantations were performed in Hungary. This was a retrospective analysis. All patients were listed according to the recommendation of the Lung Transplantation Committee. All implanted lungs have been procured from brain dead donors. Postoperative treatment and rehabilitation of the patients were continued at the Semmelweis University. Between 12. 12. 2015 and 31. 07. 2018, our team performed 76 organ retrievals: out of 45 Hungarian offers, 23 came from Eurotransplant countries and 8 outside of the Eurotransplant region. From these donations, 54 double and 1 single side transplantations were successfully performed. The surgical approach was single side thoracotomy (n = 1), bilateral thoracotomy (n = 1) and in the majority of the cases clamshell incision (n = 53). For the intraoperative veno-arterial extracorporeal membrane oxygenation support was used. The extracorporeal membrane oxygenation support had to be prolonged in 3 patients into the early postoperative period, two other recipients were bridged to transplant with extracorporeal membrane oxygenation. In the same time period, one combined lung-kidney transplantation was also performed. The distribution of recipients according to the underlying disease was: chronic obstructive pulmonary disease (n = 28); idiopathic pulmonary fibrosis (n = 8); cystic fibrosis (n = 12); primary pulmonary hypertension (n = 2); hystiocytosis-X (n = 1); bronchiectasis (n = 2); lymphangioleiomyomatosis (n = 1); and re-transplantation following bronchiolitis obliterans syndrome (n = 1), respectively. The mean age of recipients was 47.5 ± 15.18 years. The youngest recipient was 13 years old. We unfortunately lost 12 patients on our waiting list. The mean intensive care unit stay was 24.6 ± 18.18 days. Two patients were lost in the early postoperative phase. Tracheostomy was necessary in 13 cases due to the need of prolonged ventilation. 1-year survival of the recipients was 82.96% (until 31. 07. 2018). When looking at the first three years of the program, the case numbers elevated quickly throughout the years which is rather unique when compared to other centres in their starting period. Perioperative mortality and morbidity is comparable with high-volume lung transplantation centres. In the future we would like to increase the number of patients on the waiting list, thus increasing the total number of transplantations performed, and we are also planning to implement the use of the ex vivo lung perfusion system (EVLP) in our program. Orv Hetil. 2018; 159(46): 1859–1868.

Use of 3D planning and 3D printing is expanding in healthcare. One of the common applications is the creation of anatomical models for the surgical procedure from DICOM files. These patient-specific models are used for multiple purposes, including visualization of complex anatomical situations, simulation of surgical procedures, patient education and facilitating communication between the different disciplines during clinical case discussions. Cardiac and thoracic surgical applications of this technology development include the use of patient-specific 3D models for exploration of ventricle and aorta function and surgical procedural planning in oncology. The 3D virtual and printed models provide a new visualization perspective for the surgeons and more efficient communication between the different clinical disciplines. The 3D project was started at the Semmelweis University with the cooperation of the Thoracic Surgery Department of the National Institute of Oncology in 2018. The authors want to share their experiences in 3D designed medical tools. Orv Hetil. 2019; 160(50): 1967-1975.Absztrakt: A 3D tervezés és 3D nyomtatás nyújtotta lehetőségek folyamatosan bővülnek az orvosi gyakorlatban. A technológia leggyakoribb felhasználási területe a 3D anatómiai modellek nyomtatása sebészi döntéstámogatás céljából. Az így személyre szabott és kinyomtatott modelleknek számos egyéb felhasználási területük van: komplex anatómiai szituációk pontos megjelenítése, az adott beteg sebészi beavatkozásának szimulációja a tényleges beavatkozást megelőzően, betegoktatás és a különböző diszciplínák között az eset megbeszélésének megkönnyítése. A technológia szívsebészeti vonatkozásában kiemelendő a kamrákat és a nagyereket érintő elváltozások 3D anatómiai modellezése és funkcionális elemzése, míg a mellkassebészetben az onkológiai betegek erősen vaszkularizált tumorának eradikálásakor lehet a sebészi terápia felállításában szerepe. A virtuális és 3D nyomtatott modellek új diagnosztikai lehetőséget jelentenek, melyek segítségével egyes sebészi beavatkozások standardizálhatók, így személyre szabott terápiás döntéseket lehet kidolgozni. A 3D projekt a Semmelweis Egyetemen 2018-ban kezdődött a Semmelweis Egyetem Városmajori Szív- és Érgyógyászati Klinikájának és az Országos Onkológiai Intézet Mellkassebészeti Osztályának kooperációja során. A szerzők a technológia ismertetése mellett az eddigi 121 tervezés és 49 személyre szabott 3D nyomtatás során megszerzett tapasztalataikat és a technológia orvosi szempontból való előnyeit ismertetik. Orv Hetil. 2019; 160(50): 1967–1975.

Lung transplant is an effective way to treat many end-stage lung diseases. However, one of the main barriers of allograft organ transplant is still the immunologic rejection of transplanted tissue, which is a response of the HLA molecules. Rejection is a complex process involving both T-cell-mediated delayed-type hypersensitivity reactions and antibody-mediated hypersensitivity reactions to histocompatibility molecules on foreign grafts. We report the case of a 25-year-old female patient with cystic fibrosis who underwent 2 lung transplants because of her initial diagnosis and appearance of bronchiolitis obliterans syndrome after the first transplant. Only 13 months after the second transplant, despite the therapies applied, a new rejection occurred associated with high mean fluorescent intensity donor-specific antibody levels, which resulted later in the death of the patient. The present case draws attention to the importance of matching HLA molecules between donor and recipient in addition to immunosuppressive therapy.

Absztrakt A szívtranszplantáció kiemelt projekt lett a Semmelweis Egyetemen belül. Ennek megfelelően a szívátültetés és a mechanikus keringéstámogatás finanszírozása is rendkívüli jelentőséget kapott. A szerzők a transzplantációs és műszíves betegek költségeinek összehasonlításáról végzett költséghatékonysági számítási modell felépítéséről számolnak be. A modell megalkotásánál direkt allokációs költségszámítást, döntésifa-modellt, inkrementális költséghatékonysági rátát és költséghatékonysági térképmódszert használtak. Módszerükkel össze tudják hasonlítani a műszívbeültetésen átesett és a szívtranszplantációs betegcsoportok kezdeti, perioperatív és utókezelési költségeit. Modelljük alkalmas lehet hosszú távú utánkövetés és kellő elemszámú beteg bevonásával költséghatékonysági elemzések elkészítésére, gazdasági döntéstámogató következtetések meghozatalára.

Background Mechanical circulatory support (MCS) has been established as a means of augmenting circulation in critically ill patients due to a variety of underlying clinical reasons. Different methods of MCS may be applied with the venous-arterial extracorporeal membrane oxygenation (VA-ECMO) system being one of the most utilized in everyday care. Objectives Our aim was to determine independent predictors of mortality following VA-ECMO therapy in a large, unselected, adult, critically ill patient population requiring MCS. Methods Data on 181 consecutive, real-world VA-ECMO treatments have been assessed. Analysis was conducted for all subjects requiring MCS with the VA-ECMO as first instalment, regardless of underlying cause or eventual upgrade. All potential clinical factors influencing mortality were examined and evaluated. Results Overall mortality amounted to ≈65% at a median follow-up of 28 days and depended upon: glomerular filtration rate of 0.05). Surprisingly, neither the need for resuscitation during MCS nor any ECMO implantation indication influenced mortality by itself (p>0.05). Conclusions We have found that mortality in critically ill patients requiring VA-ECMO use remains very high. Decreased renal function and advanced age were found to influence mortality in our all-comers patient population, while traditional predictors of cardiovascular mortality did not have a significant effect on survival.

Thoracic organ transplantation made a fresh start in Hungary with the first double lung transplant in December 2015. This major leap in Hungarian transplantation was preceded by almost 10 years of preparation, new infrastructure development, and structural changes not only at the organizational level but in human resources as well. In the following years, until recently, altogether 47 lung transplants were performed on 24 men and 23 women. The underlying pathologies were as follows: chronic obstructive pulmonary disease, 25; cystic fibrosis, 11; idiopathic pulmonary fibrosis, 7; as well as other diseases, including bronchiectasis, eosinophilic granuloma, lymphangioleiomyomatosis, and primary pulmonary hypertension in 4 cases. The youngest recipient was 13 and the oldest was 65 years old. Overall survival rates at 30 days and at 1 year were 96% and 82%, respectively. No patients were lost in the cystic fibrosis and other diseases group, whereas the 1-year survival rates of the chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis groups were 73% and 71%, respectively. The results show the robustness and viability of the program, although there is still opportunity for further improvement. In this short paper, we summarize the fields of possible further cooperation of thoracic and cardiac teams as well as future challenges facing the new Hungarian lung transplant program.

Introduction Lung transplantation is the only successful treatment option for patients experiencing end-stage lung disease. Results have improved significantly in the last decade; however, the number one limiting factor is still the shortage of donor lungs. Due to the discrepancy between available donor lungs and patients awaiting lung transplantation, many centers have reintroduced donation after cardiac death (DCD). According to their results, DCD and donation after brain death (DBD) are comparable in terms of survival and graft function. Currently in Hungary, donation is only allowed from DBD donors; however, due to the Eurotransplant agreement, non-heart-beating donation (NHBD) organs can be transplanted into Hungarian patients, and in some cases Hungarian transplant teams can also take part in NHBDs within the Eurotransplant region. The Hungarian experience. A Hungarian patient received a lung from a 15-year-old uncontrolled DCD in Vienna. The donor was reanimated for 54 minutes and after lung procurement the lungs were put on ex vivo lung perfusion and later successfully implanted into the Hungarian recipient. The recovery was very successful and the patient is still alive. The Hungarian Lung Transplantation Team was involved in a controlled Maastricht III donation in 2017. A 49-year-old female donor was reported from Ghent, Belgium. A multiorgan donation was carried out with 15 minutes of warm ischemic time in the case of the lungs. Conclusion DCD is an effective, safe, and available method to increase the donor pool. In the case of controlled donations, the necessary protocols have already been prepared. Although DBD is working very successfully in Hungary, infrastructural developments, education of professionals, and social preparations are all needed to implement a DCD protocol in Hungary.

The mechanical circulatory support (MCS) program of the Semmelweis University Heart and Vascular Centre has become established over the last five years. The main requirements of our MCS program to be developed first were the Heart Transplantation and Heart Failure Intensive Care Unit and a well trained medical team. The wide range of mechanical circulatory support devices provides suitable background for the adequate treatment of our patients in all indications. In this review, we present our results related to extracorporeal membrane oxygenation (ECMO) supports performed in the last five years. Between 2012 and 2017, we applied MCS support in 140 cases, among them 111 patients received ECMO support. The leading indications of ECMO support were the following: primary graft failure after heart transplantation (33 cases), postcardiotomy cardiogenic shock (18 patients), acute decompensation of end-stage heart failure (14 patients), acute myocardial infarction complicated with refractory cardiogenic shock (37 patients), cardiogenic shock developed after transcatheter aortic valve implantation (3 patients), malignant arrhythmia due to drug intoxication (1 patient) and acute respiratory distress syndrome (4 cases). The mortality of patients receiving ECMO support was 46%. The analysis of the results of ECMO support needs to change our approach. The mortality results show that we lost the half of our patients. However, the mortality in the conventionally treated patients would have been 100% without ECMO. In fact, we could save the life of half of these patients. Orv Hetil. 2018; 159(46): 1876-1881.Absztrakt: A mechanikus keringéstámogatás az elmúlt 5 évben programmá fejlődött a Városmajori Szív-és Érgyógyászati Klinikán. Mindehhez szükséges volt a megfelelő Szívtranszplantációs és Szívelégtelenségi Intenzív Osztály kialakítása, valamint a megfelelő eszköz- és humánerőforrás-fejlesztés. Jelenleg már a teljes mechanikus keringéstámogatási arzenállal rendelkezünk, aminek köszönhetően minden indikációban és minden stratégiában ellátást tudunk biztosítani mind rövid, mind közép-, mind pedig hosszú távon a végleges műszívbeültetéssel bezárólag. Munkánkban megvizsgáltuk az elmúlt 5 évben végzett extracorporalis membránoxigenátor (ECMO-) beültetéssel szerzett eredményeinket. Klinikánkon 2012 és 2017 között összesen 140 betegnél alkalmaztunk mechanikus keringéstámogatást, valamennyi esetben konvencionális terápiával nem stabilizálható szívelégtelenség esetén. ECMO-terápiát 111 alkalommal végeztünk: szívátültetést követően 33 alkalommal, 18 alkalommal szívműtét utáni postcardiotomiás szindróma miatt, 37 esetben akut myocardialis infarctus utáni akut keringési elégtelenség miatt, 14 alkalommal végstádiumú szívelégtelen betegek akut keringésmegingása miatt, 4 esetben súlyos légzési elégtelenség, 1 esetben gyógyszermérgezés miatti malignus ritmuszavar, 3 esetben szövődményes katéteres aortaműbillentyű-implantáció állt a háttérben. A 2018. első félévi adataink a korábbi adatok és indikációk tendenciáját tükrözik, az esetszám jelentős emelkedésével. Eredményeink szerint a terápia összesített mortalitása 46% volt. A mechanikus keringéstámogatás eredményeinek vizsgálatakor elengedhetetlen a paradigmaváltás. A mortalitási adatokat nézve betegeink felét elveszítettük, ugyanakkor ebben a betegcsoportban a betegek 100%-a meghalt volna a konvencionális terápia mellett, vagyis az ECMO-terápia sikerességének megítélésekor nem a mortalitási, hanem a túlélési adatokat kell tekinteni. Orv Hetil. 2018; 159(46): 1876–1881.

The first lung transplantation in Hungary was performed on 12th of December, 2015. It was a joint effort of the National Institute of Oncology and the Semmelweis University. Hereby we summarise the results and experiences from the first three years. Until August, 2018, 55 lung transplantations were performed in Hungary. This was a retrospective analysis. All patients were listed according to the recommendation of the Lung Transplantation Committee. All implanted lungs have been procured from brain dead donors. Postoperative treatment and rehabilitation of the patients were continued at the Semmelweis University. Between 12. 12. 2015 and 31. 07. 2018, our team performed 76 organ retrievals: out of 45 Hungarian offers, 23 came from Eurotransplant countries and 8 outside of the Eurotransplant region. From these donations, 54 double and 1 single side transplantations were successfully performed. The surgical approach was single side thoracotomy (n = 1), bilateral thoracotomy (n = 1) and in the majority of the cases clamshell incision (n = 53). For the intraoperative veno-arterial extracorporeal membrane oxygenation support was used. The extracorporeal membrane oxygenation support had to be prolonged in 3 patients into the early postoperative period, two other recipients were bridged to transplant with extracorporeal membrane oxygenation. In the same time period, one combined lung-kidney transplantation was also performed. The distribution of recipients according to the underlying disease was: chronic obstructive pulmonary disease (n = 28); idiopathic pulmonary fibrosis (n = 8); cystic fibrosis (n = 12); primary pulmonary hypertension (n = 2); hystiocytosis-X (n = 1); bronchiectasis (n = 2); lymphangioleiomyomatosis (n = 1); and re-transplantation following bronchiolitis obliterans syndrome (n = 1), respectively. The mean age of recipients was 47.5 ± 15.18 years. The youngest recipient was 13 years old. We unfortunately lost 12 patients on our waiting list. The mean intensive care unit stay was 24.6 ± 18.18 days. Two patients were lost in the early postoperative phase. Tracheostomy was necessary in 13 cases due to the need of prolonged ventilation. 1-year survival of the recipients was 82.96% (until 31. 07. 2018). When looking at the first three years of the program, the case numbers elevated quickly throughout the years which is rather unique when compared to other centres in their starting period. Perioperative mortality and morbidity is comparable with high-volume lung transplantation centres. In the future we would like to increase the number of patients on the waiting list, thus increasing the total number of transplantations performed, and we are also planning to implement the use of the ex vivo lung perfusion system (EVLP) in our program. Orv Hetil. 2018; 159(46): 1859-1868.Absztrakt: Magyarországon az első tüdőtranszplantációt 2015. 12. 12-én végeztük el az Országos Onkológiai Intézet és a Semmelweis Egyetem együttműködésével. Cikkünkben az elmúlt két és fél év eredményeit összegezzük. 2018 augusztusáig 55 tüdőtranszplantációra került sor. Az adatfeldolgozást retrospektív módszerrel végeztük. A várólistára helyezés a Tüdő Transzplantációs Bizottság javaslatára történt. A donortüdők agyhalott donorokból származtak. A posztoperatív gondozás a Semmelweis Egyetemen folytatódott. 2015. 12. 12. és 2018. 07. 31. között 76 szervkivételen vettünk részt: 45 magyar, 23 Eurotransplant-, 8 Eurotransplanton kívüli országban, ezekből 54 kétoldali és 1 egyoldali tüdőtranszplantáció valósult meg. A műtéteket egyoldali (n = 1), kétoldali thoracotomiából (n = 1) vagy ’clamshell’ betolásból (n = 53), venoarterialis extrakorporális membránoxigenizáció-támogatással végeztük. Három esetben az extrakorporális membránoxigenizáció-támogatást a posztoperatív szakban prolongáltuk, másik két betegnél extrakorporális membránoxigenizáció-bridge terápiát követően végeztük el a transzplantációt. Egy kombinált tüdő-vese transzplantáció is történt. A recipiensek alapbetegsége krónikus obstruktív tüdőbetegség (n = 28); fibrotizáló tüdőbetegség (n = 8); cystás fibrosis (n = 12); elsődleges pulmonalis hypertonia (n = 2); histiocytosis-X (n = 1); bronchiectasia (n = 2); lymphangioleiomyomatosis (n = 1) és bronchiolitis obliterans szindróma miatti retranszplantáció (n = 1) volt. Átlagéletkoruk 47,5 ± 15,18 év volt. A legfiatalabb beteg 13 éves volt. A várólistán 12 beteg hunyt el. A betegek átlagosan 24,6 ± 18,18 napot töltöttek az intenzív osztályon. A korai posztoperatív időszakban 2 beteget vesztettünk el. Tartós lélegeztetési igény miatt tracheostomát 13 esetben készítettünk. A betegek 1 éves túlélése 82,96% volt. A hazai tüdőtranszplantációs programban gyorsan emelkednek az esetszámok, ami más centrumok indulásához képest kivételes eredmény. A szövődmények és halálozások aránya más, nagy esetszámú centrumok számainak megfelel. A jövőben a várólista bővítését, az esetszámok további növelését, és az ’ex vivo lung perfusion’ (EVLP-) rendszer használatának bevezetését szeretnénk megvalósítani. Orv Hetil. 2018; 159(46): 1859–1868.

The authors give a short introduction of the Hungarian and the international history of adult heart transplantation, and highlight the similarities in the evolution of the two programs. Their aim was to show how the Hungarian post-transplant survival changed in the last five years. They wanted to investigate how all the changes they had made in the program affected the post-transplant results. They investigated 496 heart transplantation data and compared to international data. Orv Hetil. 2018; 159(46): 1869-1875.Absztrakt: A szerzők rövid történeti áttekintést adnak a felnőttszív-átültetés nemzetközi és hazai fejlődéséről, megvilágítva párhuzamokat, kiemelve egy program evolúciójának sajátosságait. Megvizsgálják a Magyarországon transzplantációra kerülő recipiensek betegadatait, melyeket összehasonlítanak nemzetközi adatokkal. Céljuk bemutatni, hogyan változott az elmúlt öt évben a szívtranszplantáció eredményessége, és ezt milyen módszerekkel, a programban végrehajtott változtatások révén érték el. Ehhez 496 transzplantáció adatait vizsgálták meg, és hasonlították össze a nemzetközi adatokkal. Orv Hetil. 2018; 159(46): 1869–1875.

Objective The effect of thyroid dysfunction on adverse outcomes has been studied in many different patient populations. The objective of this study was to investigate the effect of thyroid hormone supplementation of donors and recipients on postoperative outcomes after orthotopic heart transplantation. Design Retrospective. Setting Single center, university hospital. Participants Two-hundred and sixty-six consecutive patients undergoing heart transplantation. Interventions No interventions. Measurements and Main Results Demographic, hemodynamic, and clinical characteristics; donor and recipient United Network for Organ Sharing scores; and information on thyroid hormone support of donors and recipients were recorded. During the median follow-up of 4.59 years (interquartile range 4.26-4.92 y), 70 patients (26.3%) died. After adjustments were made for the United Network for Organ Sharing score, recipients who were treated preoperatively with l-thyroxine had a lower risk for all-cause mortality (adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.06-0.98; p = 0.047) compared with recipients who were not treated with l-thyroxine. In addition, l-thyroxine treatment of donors was associated with a better recipient survival (HR 0.31, 95% CI 0.11-0.87; p = 0.025). Conclusions Pretransplantation thyroid hormone supplementation of donors and recipients was associated with improved long-term survival after heart transplantation.

Introduction: Since the celebration of the 20th anniversary of the first heart transplantation in Hungary in 2012 the emerging need for modern heart failure management via mechanical circulatory support has evolved. In May 2012 the opening of a new heart failure and transplant unit with 9 beds together with the procurement of necessary devices at Semmelweis University accomplished this need. Aim: The aim of the authors was to report their initial experience obtained in this new cardiac assist device program. Method: Since May, 2012, mechanical circulatory support system was applied in 89 cases in 72 patients. Indication for support were end stage heart failure refractory to medical treatment and acute left or right heart failure. Results: Treatment was initiated for acute graft failure after heart transplantation in 27 cases, for end stage heart failure in 24 cases, for acute myocardial infarction in 21 cases, for acute postcardiotomy heart failure in 14 cases, for severe respiratory insufficiency in 2 cases and for drug intoxication in one case. Among the 30 survivor of the whole program 13 patients were successfully transplanted. Conclusions: The available devices can cover all modalities of current bridge therapy from short term support through medium support to heart transplantation or long term support and destination therapy. These conditions made possible the successful start of a new cardiac assist device program. Orv. Hetil., 2015, 156(13), 521–527.

Az epicardialis pacemakerek ritka, de akar eletet veszelyeztető szovődmenye a generatortelepnek a subcostalisan kialakitott zsebből a hasuregbe tortenő elvandorlasa. A szerzők 69 eves nőbeteguk esetet ismertetik, aki aspecifikus hasi panaszokkal jelentkezett a klinika surgőssegi osztalyan. Anamneziseből kiemelendő, hogy korabbi mitralisműbillentyű-műtetet kovetően kialakult III. foku atrioventricularis blokkja miatt epigastrialis pacemakert helyeztek be ugy, hogy a pacemakergeneratort a subcostalisan kialakitott intramuscularis zsebben helyeztek el. Mellkasatvilagitas igazolta, hogy a telep – eredeti helyetől messzire – a Douglas-uregbe vandorolt. A szokatlan helyre es tavolsagra vandorolt keszuleket hasi feltarasbol tavolitottak el, kozvetlenul azt kovetően, hogy uj endocardialis pacemakerrendszer kerult beultetesre. A beteg szovődmenymentesen, a 7. posztoperativ napot kovetően otthonaba tavozott. Orv. Hetil., 2015, 156(4), 154–157.

Heart transplantation is a high priority project at Semmelweis University. In accordance with this, the funding of heart transplantation and mechanical circulatory support also constitutes an important issue. In this report, the authors discuss the creation of a framework with the purpose of comparing the cost-effectiveness of heart transplantation and artificial heart implantation. Our created framework includes the calculation of cost, using the direct allocation method, calculating the incremental cost-effectiveness ratio and creating a cost-effectiveness plane. Using our model, it is possible to compare the initial, perioperative and postoperative expenses of both the transplanted and the artificial heart groups. Our framework can possibly be used for the purposes of long term follow-up and with the inclusion of a sufficient number of patients, the creation of cost-effectiveness analyses and supporting strategic decision-making.

The Hungarian adult heart transplant program, which started in 1992, has changed gradually in the past 20 years. After the early enthusiasm of the first cases it changed significantly and it became an organized programme. However, low donation activity and moderate referral numbers to the national transplant waiting list slowed down the process therefore, heart transplant numbers did not fulfill expectations in the early years. After a moderate increase in 2007 transplant numbers have dropped again until recently when Hungary partially joined Eurotransplant network. Excess fundamental resources allocated to cardiac transplantation by health care professionals and reorganizing transplant coordination as well as logistics forced dramatic changes in clinical management. In 2011 and 2012 major structural changes had been made at Semmelweis University. The newly established transplant intensive care unit and the initiation of mechanical circulatory support and assist device programme increased transplant numbers by 131% compared to previous years, as well as it resulted an 86.63% 30-day survival rate, hence last year was the most successful year of cardiac transplantation ever. Orv. Hetil., 2013, 154, 863–867.

Objectives Cannabis is the most commonly abused illicit drug and the smokers are at the risk of lung infections, bullous emphysema and lung cancer. However, no evidence about the outcomes of lung transplantation (LTx) utilizing the lungs from such donors is available in the literature. Methods We retrospectively analysed lung 'organ offers' and LTx at our centre between January 2007 and November 2013. The outcomes of LTx utilizing lungs from donors with a history of cannabis smoking were compared with the outcomes of those with no such history using unadjusted model as well as propensity score matching. Results A total of 302 LTxs were performed during this period and were grouped depending on the history of cannabis smoking in donors-'cannabis' (n = 19) and control group (n = 283). All the donors in 'cannabis' group were tobacco smokers compared with 43% in the control group. Preoperative characteristics in recipients in both groups were comparable. Intraoperative and post-LTx variables including 1- and 3-year survivals were comparable in both groups. Conclusions The history of donor cannabis smoking does not appear to affect early and mid-term outcomes after LTx and potentially improve the donor pool. As it does not seem to negatively affect the outcomes after LTx, it should not be per se considered a contraindication for lung donation.

Since the celebration of the 20th anniversary of the first heart transplantation in Hungary in 2012 the emerging need for modern heart failure management via mechanical circulatory support has evolved. In May 2012 the opening of a new heart failure and transplant unit with 9 beds together with the procurement of necessary devices at Semmelweis University accomplished this need.The aim of the authors was to report their initial experience obtained in this new cardiac assist device program.Since May, 2012, mechanical circulatory support system was applied in 89 cases in 72 patients. Indication for support were end stage heart failure refractory to medical treatment and acute left or right heart failure.Treatment was initiated for acute graft failure after heart transplantation in 27 cases, for end stage heart failure in 24 cases, for acute myocardial infarction in 21 cases, for acute postcardiotomy heart failure in 14 cases, for severe respiratory insufficiency in 2 cases and for drug intoxication in one case. Among the 30 survivor of the whole program 13 patients were successfully transplanted.The available devices can cover all modalities of current bridge therapy from short term support through medium support to heart transplantation or long term support and destination therapy. These conditions made possible the successful start of a new cardiac assist device program.Bevezetés: Magyarországon 2012-ben ünnepelte 20 éves évfordulóját a szívtranszplantáció, ám a mechanikus keringéstámogató eszközök ezalatt az idő alatt a végstádiumú szívelégtelenség korszerű terápiájának hiányzó láncszemét alkották. 2012 májusában, a Semmelweis Egyetem Szív- és Érgyógyászati Klinikáján átadott szívtranszplantációs és szívelégtelenség intenzív osztály, valamint az ehhez társuló eszközfejlesztések tették lehetővé a műszívprogram elindulását. Célkitűzés: A szerzők a program tapasztalatairól számolnak be. Módszer: 2012 májusa és 2014 decembere között 72 beteget 89 esetben kezeltek mechanikus keringéstámogató eszközökkel. A támogatás indikációja valamennyi esetben terápiarefrakter végstádiumú szívelégtelenség, illetve akut bal- vagy jobbszívfél-elégtelenség volt. Eredmények: Huszonhét esetben szívtranszplantáció utáni akut graftelégtelenség, 24 esetben súlyos végstádiumú szívelégtelenség, 21 esetben akut infarktus, 14 esetben szívműtét utáni akut balszívfél-elégtelenség, két esetben súlyos légzési elégtelenség, egy esetben gyógyszermérgezés következtében kialakult malignus ritmuszavar miatt kezdték el a terápiát. A teljes program 30 túlélő betege közül 13 került sikeres szívtranszplantációra. Következtetések: A rendelkezésre álló sokoldalú műszerparkkal a ma létező valamennyi lehetséges terápiás modalitás megvalósítható a rövid távú keringéstámogatástól a középtávú támogatáson át a szívtranszplantációig vagy a végleges műszívbeültetésig. Orv. Hetil., 2015, 156(13), 521–527.

Migration of a permanent pacemaker generator from their intramuscular pocket to the abdominal cavity is a less frequent, but potentially life-threatening complication. The authors present the case of a 69-year-old woman, who visited the emergency department of the clinic, with complains of non-specific abdominal symptoms. Her past medical history included a complete atrioventricular block diagnosed in 2009 during the mitral valve replacement and since then she had an epicardial permanent pacemaker; the pulse generator was placed into an intramuscular pouch created in the left subcostal region. Surprisingly, radiologic examinations showed that the generator migrated into the pouch of Douglas. Considering patient safety, first a new intracardiac pacemaker was implanted and then the migrated device was removed surgically. The patient was discharged on the seventh postoperative day.Az epicardialis pacemakerek ritka, de akár életet veszélyeztető szövődménye a generátortelepnek a subcostalisan kialakított zsebből a hasüregbe történő elvándorlása. A szerzők 69 éves nőbetegük esetét ismertetik, aki aspecifikus hasi panaszokkal jelentkezett a klinika sürgősségi osztályán. Anamnéziséből kiemelendő, hogy korábbi mitralisműbillentyű-műtétét követően kialakult III. fokú atrioventricularis blokkja miatt epigastrialis pacemakert helyeztek be úgy, hogy a pacemakergenerátort a subcostalisan kialakított intramuscularis zsebben helyezték el. Mellkasátvilágítás igazolta, hogy a telep – eredeti helyétől messzire – a Douglas-üregbe vándorolt. A szokatlan helyre és távolságra vándorolt készüléket hasi feltárásból távolították el, közvetlenül azt követően, hogy új endocardialis pacemakerrendszer került beültetésre. A beteg szövődménymentesen, a 7. posztoperatív napot követően otthonába távozott. Orv. Hetil., 2015, 156(4), 154–157.

Endothelin elicits long-lasting vasoconstriction in the coronary bed. This remarkable spastic response raises the question whether or not the metabolic adaptive mechanisms of the coronaries are activated under endothelin effect. The role of the compensatory mediators adenosine and inosine was investigated before and after intracoronary (i.c.) administration of endothelin-1 (ET-1, 1.0 nmol) using 1-min reactive hyperemia (RH) tests on in situ dog hearts (n=15) with or without blocking the ATP-sensitive potassium (K+(ATP)) channels by glibenclamide (GLIB, 1.0 micromol min(-1), i.c.). The release of adenosine and inosine via the coronary sinus was measured by HPLC during the first minute of RH. Endothelin-1 reduced baseline coronary blood flow (CBF) and RH response (hyperemic excess flow (EF) control vs. ET-1: 81.7+/-13.6 vs. 43.4+/-10.9 ml, P0.01), while it increased the net nucleoside release (adenosine, control vs. ET-1: 58.9+/-20.4 vs. 113.7+/-39.4 nmol, P0.05; inosine: 242.1+/-81.8 vs. 786.9+/-190.8 nmol, P0.05). GLIB treatment alone did not change baseline CBF but also reduced RH significantly and increased nucleoside release (EF control vs. GLIB: 72.1+/-11.7 vs. 31.9+/-5.5 ml, P0.01; adenosine: 18.8+/-4.6 vs. 63.0+/-24.8 nmol, P0.05; inosine: 113.0+/-37.2 vs. 328.2+/-127.5 nmol, P0.05). Endothelin-1 on GLIB-treated coronaries further diminished RH and increased nucleoside release (EF: 21.5+/-8.0 ml, P0.05 vs. GLIB; adenosine: 75.3+/-28.1 nmol, NS; inosine: 801.9+/-196.6 nmol, P0.05 vs. GLIB). The data show that ET-1 reduces metabolic adaptive capacity of the coronaries, and this phenomenon is due to decreased vascular responsiveness and not to the blockade of ischemic mediator release from the myocardium. The coronary effect of ET-1 may partially be dependent on K+(ATP) channels.

Ag/AgCl and Ir-coated electrodes allow the recording of the monophasic action potential (MAP) due to their electrical properties like non-polarisability. This study investigates the correlation of MAP recorded with both types of electrodes. In 20 mongrel dogs (18 +/- 6 kg) an Ag/AgCl and an Ir-coated catheter (Ir) were placed endocardially in the apex of the right ventricle. The effects of isoproterenol and verapamil were investigated during spontaneous rhythm and stimulation simultaneously recorded with both types of electrodes in 10 dogs without AV-node ablation. The correlation at different heart rates were investigated in 10 other dogs with complete AV-block. The morphology and amplitudes of MAP were comparable (AgCl: 15 +/- 7 mV; Ir: 13 +/- 8 mV). Following an i.v. bolus of 2 micrograms/kg isoproterenol the spontaneous rate increased (175 +/- 18 to 245 +/- 25 bpm). During stimulation with 250 ms cycle length the duration shortened (MAPd90: AgCl: 160 +/- 11 to 130 +/- 12 ms; Ir: 154 +/- 18 to 128 +/- 15 ms). The alterations reversed after 20 min. An i.v. bolus of 0.2 mg/kg verapamil decreased the spontaneous rate (167 +/- 11 to 104 +/- 23 bpm) and lengthened the MAPd90 (AgCl: 182 +/- 14 to 220 +/- 13 ms; Ir: 174 +/- 16 to 216 +/- 21 ms) at 300 ms stimulation. The correlation between the MAPd90 of both lead types was r = 0.98 during all measurements. Under the effect of beta-agonist and Ca(2+)-antagonist medication MAP showed a strong correlation recorded with both types of electrodes. Thus, both leads allow the recording of MAP but only the Ir-electrodes with their long-term stability are implantable and allows us to control the effects of drugs with implantable devices.

The Hungarian adult heart transplant program, which started in 1992, has changed gradually in the past 20 years. After the early enthusiasm of the first cases it changed significantly and it became an organized programme. However, low donation activity and moderate referral numbers to the national transplant waiting list slowed down the process therefore, heart transplant numbers did not fulfill expectations in the early years. After a moderate increase in 2007 transplant numbers have dropped again until recently when Hungary partially joined Eurotransplant network. Excess fundamental resources allocated to cardiac transplantation by health care professionals and reorganizing transplant coordination as well as logistics forced dramatic changes in clinical management. In 2011 and 2012 major structural changes had been made at Semmelweis University. The newly established transplant intensive care unit and the initiation of mechanical circulatory support and assist device programme increased transplant numbers by 131% compared to previous years, as well as it resulted an 86.63% 30-day survival rate, hence last year was the most successful year of cardiac transplantation ever.Az 1992. január 3-ával elindult hazai felnőttszív-átültetési program számos fejlődési stádiumon ment át az elmúlt 20 évben. A kezdetben szinte társadalmi munkában beindult tevékenység működési kerete lassan vált szervezetté. Az elmúlt két évtized állandó velejárója volt az alacsony donációs aktivitás és a várólistás betegek alacsony száma, mindez azt eredményezte, hogy a lassan emelkedő műtéti számok ellenére a transzplantációs aktivitás folyamatosan elmaradt a kívánalmaktól. Az Eurotransplanthoz történő részleges csatlakozásunk azonban új kihívást jelentett a hazai felnőttszív-átültetési program számára. Ezen új kihívásoknak és elvárásoknak történő megfelelési szándék azonban kikényszerítette a teljes felnőttszív-átültetési program átszervezését, új alapokra helyezését. A Semmelweis Egyetem Ér- és Szívgyógyászati Klinikáján 2011 ősze és 2012 tavasza közötti fél évben számos olyan strukturális, szemléletmódbeli, képzési változtatást valósítottak meg, amelyek hatására a klinika transzplantációs kapacitása megsokszorozódott, a transzplantációs tevékenység biztonsága sokat javult. Az alapjaiban megújított program eredményeként 2012-ben 131%-kal nőtt a klinikán elvégzett műtétek száma az előző évihez viszonyítva. A 86,63%-os 30 napos túlélési rátájával pedig a húszéves program legeredményesebb évét zárta. Orv. Hetil., 2013, 154, 863–867.

The RIFLE (risk, injury, failure, loss, and end-stage renal disease) classification system was developed to standardize the definition of acute kidney injury (AKI) in adults. We hypothesized that AKI was associated with increased mortality and morbidity.Acute kidney injury was defined as a decrease in the amount of estimated creatinine clearance based on pediatric-modified RIFLE (pRIFLE) criteria. Using propensity score analysis, 325 patients who had AKI were matched to 325 patients who did not have AKI from a database of 1,510 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between AKI and outcome was analyzed after propensity score matching of perioperative variables.Four hundred eighty-one patients (31.9%) had AKI according to the RIFLE categories. Of those 1,510, 173 (11.5%) reached pRIFLE criteria for risk; 26 (1.7%) reached the criteria for injury; and 282 (18.7%) reached the criteria for failure. Fifty-five patients (3.6%) died. The 2 matched groups were well balanced in terms of measured perioperative variables. Mortality rate was 5.2% in the AKI and 2.5% in the matched control group (p=0.09). Occurrence of low cardiac output syndrome (p=0.002), need for dialysis (p0.001), and infection (p=0.03) were significantly higher, and duration of mechanical ventilation (p0.001) and length of intensive care unit stay (p0.001) were significantly longer compared with the matched control group.Acute kidney injury was independently associated with an increased occurrence of postoperative complications but not with mortality after pediatric cardiac surgery.

High blood-flow rate and considerable metabolic activity render the myocardium a possible candidate for infrared (IR) imaging. Cardiothermography is the term used for recording the heart surface temperature. It is a useful tool in monitoring coronary perfusion through epicardial heat emission changes. Elevated heat-emission indicates increased coronary blood flow, while decreased emission represents hypoperfusion. The aim of our study is the early intraoperative cardiothermographic evaluation of arterial and venous bypass graft patency and the quantitative assessment of the temperature changes of the revascularized area. Infrared imaging was complemented by electromagnetic flow measurements on the venous grafts.

According to Bretschneider (1980), optimal myocardial protection can be achieved with myocardial temperatures below 15/spl deg/C. Myocardial temperature can be determined by thermistor needles or by infrared (IR) imaging; the latter method has the advantage of showing the whole anterior-anterolateral myocardial surface instead of providing data on small areas of the myocardium. Inhomogeneous temperature distribution due to occluded or severely stenosed coronaries can also be easily visualized with IR imaging. The aim of our study is to thermographically evaluate the adequacy of myocardial protection using Bretschneider cold antegrade cardioplegia (CP) in patients undergoing elective coronary artery bypass grafting (CABG) or aortic/mitral-valve implantation.

Objectives: To analyze three-dimensional activation patterns of ventricular arrhythmias induced by endothelin-1 in comparison with ischemia-induced tachycardias. Methods: Following AV node ablation, sixty pin electrodes containing four bipoles each were inserted into both ventricles of ten foxhounds. Using a computerized mapping system, this would allow to simultaneously record 240 endo-, epi- and midmyocardial electrograms for reconstruction of the three-dimensional activation pattern. In five dogs, endothelin-1 was infused into the LAD at 60 pmol/min. In another five animals, the LAD was ligated. During the following 40 min, all ventricular arrhythmias were recorded for subsequent analysis. Furthermore, left ventricular conduction times during constant pacing and local effective refractory periods at eight left ventricular sites were determined before and after either intervention. Results: Endothelin-1 had no significant effect on conduction time and refractoriness, whereas ligation prolonged both parameters significantly. Endothelin-1 as well as ligation induced multiple mono- and polymorphic nonsustained ventricular tachycardias. Endothelin-1-induced arrhythmias were exclusively based on focal mechanisms, whereas during ligation, macroreentrant mechanisms were involved in the maintenance of tachycardias in 29% of episodes. Conclusion: The differences in the effects of endothelin-1 and LAD ligation on electrophysiologic properties and the difference in the mechanism of induced ventricular tachycardias support the hypothesis that, apart from vasoconstrictive properties, endothelin-1 exerts an intrinsic arrhythmogenic effect.

Adenosine and inosine are believed to have cardioprotective effects. However, little is known about their possible role in the metabolic autoregulation of human coronaries and in pathologic conditions with supply/demand imbalance of the heart such as coronary artery disease. Since these low molecular weight nucleosides freely diffuse through the monolayer of the visceral pericardium, adenosine and inosine concentrations in pericardial fluid may well reflect the conditions in cardiac interstitium. The pericardial fluid and systemic venous blood adenosine and inosine concentrations were measured in 98 human subjects undergoing heart surgery for coronary artery disease or valvular heart disease. Adenosine and inosine concentrations were measured by HPLC with UV detection. In subjects with coronary artery disease pericardial fluid nucleoside concentrations were significantly higher than in patients with valvular heart disease (adenosine: 1545 (996-3146) nmol/L [median (25th-75th quartiles)] vs. 738 (390-2527) nmol/L, P

The high blood flow rate and the considerable metabolic activity render the myocardium a possible candidate for IR imaging. The study was aimed to test cardiothermography in evaluating arterial bypass graft patency and in assessing myocardial protection during open-heart surgery. Ten patients underwent arterial bypass grafting. Thermograms were obtained immediately before and after opening the grafts. As the bypasses were opened in hypothermia the warmer blood coming from the extracorporeal circulation readily delineated graft and coronary anatomy. By the end of the 5 min observation period, the revascularized area exhibited a temperature increase of 5.9 +/- 0.7 degrees C. The affectivity of antegrade cardioplegia was monitored in 38 patients undergoing either valve implantations or aorto- coronary bypass surgery. Thermographic imags were taken after sternotomy, before aortic cross-clamping and after administrating the 4 degrees C cardioplegic solution. Most of the patients displayed adequate myocardial cooling, moreover the bypass-group exhibited a more profound temperature-decrease. In conclusion, cardiothermography can visualize arterial grafts, recipient coronaries and collaterals seconds after opening by bypass, thus it properly evaluated arterial bypass graft patency. The obtained images could easily be analyzed for qualitative flow- and quantitative temperature changes. Myocardial protection could also be safely assessed with thermography.