Circulatory assist devices as bridge to heart transplantation have become more important as the number of possible recipients has increased and the number of donors remains stable. The number of patients successfully bridged and discharged home after transplantation was determined for the Novacor Left Ventricular Assist System (Baxter Healthcare Corp., Oakland, CA) (LVAS), console and wearable; the TCI Left Ventricular Assist Device (Thermo Cardio Systems Inc., Woburn, MA) (LVAD), pneumatic and electric; the Thoratec LVAD and Biventricular Assist Device (Thoratec Lab Co., Berkeley, CA) (BIVAD); and the CardioWest total artificial heart (CardioWest Tech. Inc., Tuscon, AZ) (TAH). A total of 1,286 devices (14% Novacor console, 14% Novacor wearable, 35% TCI pneumatic, 4% TCI electric, 10% thoratec LVAD, 19% Thoratec BIVAD, and 4% CardioWest TAH) were implanted worldwide since 1984. A total of 776 (60%) patients reached heart transplantation and 687 patients (88.5% of those transplanted) were discharged home. The individual success rate for each device to bridge a patient to heart transplantation and be discharged home is as follows: Novacor LVAS console, 90%; Novacor LVAS wearable, 92%; TCI LVAD pneumatic, 89%; TCI LVAD electric, 89%; Thoratec LVAD, 93%; Thoratec BIVAD, 81%; and CardioWest TAH, 92%. The success rate with all the available systems to bridge a patient to heart transplantation and be discharged home is similar for all devices. The criteria used to determine which system to be used should be individualized for each patient. Some of the factors that should be considered in making a decision on which device to use should include anticoagulation, univentricular vs biventricular failure, mobility, protocol to discharge home, and size of the patient.

Adult↗

PubMedDate not supplied

Cost analysis of the Novacor Left Ventricular Assist System as an outpatient bridge to heart transplantation.

Three patients were bridged to heart transplantation with the wearable Novacor Left Ventricular Assist System (Baxter Healthcare Corp., Oakland, CA) (LVAS). Two have been transplanted and discharged. The third patient remains at home. Hospitalization costs, which include the unit room charge, admission profile to the unit, and daily supply charge, were determined for all patients and compared. The patients were transferred from the surgical intensive care unit to a telemetry unit once they were hemodynamically stable. The projected hospitalization costs, if the patients had remained in the hospital, were calculated to determine probable savings for the third party payer. The average period from admission to placement of the Novacor LVAS was 15 days (range, 7-21 days). The average hospitalization cost from admission to time of Novacor left ventricular assist device implant was $2,240/day, and the average hospitalization cost after implant to discharge was $1,570/day. Hospitalization cost savings were $2,632 for the first patient, $5,922 for the second patient, and $132,124 for the third patient, who has not been transplanted. Although the number of patients is small, the daily hospitalization cost was higher before the Novacor LVAS was implanted. This is related to the severity of the disease and the length of stay in a surgical intensive care unit. There also is a significant cost savings for the third party payer, especially if the patient has to wait a significant amount of time before heart transplantation. These are important considerations in this time of managed care.

Ambulatory Care↗

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Infections with the CardioWest total artificial heart.

The CardioWest total artificial heart is a pneumatically driven device that totally replaces the failing ventricles. It is currently used as a bridge to heart transplantation in selected centers in the United States under a study by the Food and Drug Administration. Twenty-seven patients have undergone placement of the total artificial heart since 1993 with the intention to bridge to transplantation. Inclusion criteria included candidacy for heart transplantation, cardiac index (CI) < 2.0 L/min/m2, and maximal inotropic support. The population consisted of 25 men and 2 women of mean +/- SD age 46.5 +/- 10.3 years, body surface area 2.01 +/- 0.17 m2, and duration of implant 52 +/- 42 days. Initial diagnosis included ischemic cardiomyopathy (n = 10), idiopathic (n = 10), viral (n = 4), valvular (n = 2), and graft failure (n = 1). Infectious complications were defined as systemic (evidence of leukocytosis or fever) or local. The population experienced 64 infections (range, 0-9 per patient): 45 systemic and 19 local. Three patients did not experience any infection. Twenty-five patients reached transplantation, and were discharged home for a survival rate of 92.6%. Two patients died during the bridge, one because of mechanical failure, and one because of infection (mediastinitis). Therefore, death attributable to infections occurred in 3.7%. Previous reports of the total artificial heart experience in the late 1980s described death rates as high as 40%. Although infectious complications are common in patients who are bridged to heart transplantation with the total artificial heart, mortality from infections is 10 times less than previously reported. This may be the result of a better strategy for bridging to transplantation that includes patient selection, mobilization, early central line removal, and waiting until all possible infections are resolved before proceeding to transplantation.

Female↗

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Positive panel reactive antibody titers in patients bridged to transplantation with a mechanical assist device: risk factors and treatment.

Patients who are bridged-to-transplantation with mechanical support have a high incidence of pretransplant sensitization defined by panel reactive antibody (PRA) titers greater than 10. Risk factors for positive PRA in patients with assist devices were investigated. From 1993 to 1997, 17 patients underwent implant surgery with CardioWest C-70 total artificial hearts (TAHs; CardioWest Technologies, Inc., Tucson, AZ), and 13 with Novacor left ventricular assist systems (LVASs; Baxter Healthcare, Novacor Division, Oakland, CA) for bridge-to-transplantation at this institution. Two patients died during implantation of the assist devices. Of the remaining 28 patients, four (14%) were women (3 with TAHs and 1 with an LVAS). All four women (100%) had a positive PRA, whereas only two of the 24 men (8%) had positive PRA (p < 0.0001). The transfusion histories of these patients were reviewed. Using chi-squared analysis (alpha = 0.05), the PRA levels were independent of transfusion of packed red blood cells and fresh frozen plasma. There was an association, however, between platelet transfusions and PRA levels. The times on device awaiting cardiac transplantation were also compared between the PRA positive and PRA negative groups. The average time to transplantation for PRA positive patients was 116 days, whereas the average waiting time for the PRA negative patients was 55 days (p = 0.05). Based on these data, a female patient with consistently positive PRA (93%) after TAH implantation underwent a transplant on post implant day 25 despite a positive lymphocytotoxic crossmatch with the donor. She was treated with plasmapheresis during cardiopulmonary bypass at the time of transplantation, and with four further treatments post transplant. As of this writing, she is alive and well on our standard triple immunotherapy. Therefore, women who are bridged-to-transplantation with assist devices are at risk for positive PRA. It is recommended that patients who are bridged-to-transplantation with assist devices and have high PRA levels be treated with perioperative plasmapheresis. With this aggressive approach, it may no longer be necessary to keep patients on mechanical support for prolonged periods, but possible to perform transplants as soon as suitable donors become available.

Adult↗

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Traumatic avulsion of the innominate artery. Report of a case an review of literature.

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Aged↗

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Sinoatrial node dysfunction in recipients of domino heart transplants: complication of a surgical harvesting technique.

Two of six domino transplantations performed at our institution required permanent pacemaker implantation as a result of persistent sinoatrial node dysfunction and symptomatic nodal rhythm. Retrospective analysis of several potential etiologic factors showed that the only obvious difference between these two patients and the remaining four domino transplant recipients without this complication was the technique used during harvesting of the cardiac graft. The hearts from the two patients with sinoatrial node dysfunction were harvested using a "right atrial cuff preservation" technique, and the hearts of the remaining four patients were harvested with a standard bicaval division technique. Based on this experience, we think that this right atrial cuff preservation harvesting technique carries a potential risk for sinoatrial node damage, and we do not recommend its use for domino transplantation.

Arrhythmia, Sinus↗

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Disc embolization from a Beall mitral valve prosthesis.

Although embolization of the disc from a Beall valve is rare, several reports in the literature have identified patients suffering this complication. This report details the clinical and radiologic course of a patient with an embolized disc from a Model 103 Beall mitral valve prosthesis. The patient lived approximately 39 hours without the disc prior to surgical correction. Depending on the cardiac reserve and the amount of pannus formation, patients may live long enough to allow surgical correction of this complication.

Embolism↗

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A new woven double velour vascular prosthesis.

A new woven double velour vascular prosthesis designed to minimize intraoperative blood loss was implanted in 24 animals. Grafts were examined at 3 to 12 month intervals for healing and were compared to woven non-velour grafts implanted in 13 control animals. At 12 months, the velour grafts were 93 to 98% covered with neointima while the control grafts were only 86% covered with neointima. The neointima on the velour grafts was thinner (60 mu) and more vascular than that on the control grafts. Woven double velour grafts were implanted in 20 patients. Minimal bleeding occurred through the grafts which did not require preclotting, were easy to sew, and did not fray.

Aged↗

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Mycobacterium fortuitum infections of the mediastinum.

The clinical course of a patient with M. fortuitum infection of the mediastinum following open heart surgery is presented. Cure was achieved by aggressive and thorough surgical debridement of the mediastinum (including the edges of the sternum and other involved tissues) and by the administration of antimicrobial agents which are not usually thought to be effective in the treatment of mycobacterial infections.

Amikacin↗

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Persistent lymphatic fistula. Unusual complication of femoro-femoral arterial bypass.

An unusual complication of persistent lymph fistula occurred three months postoperatively following axillo-femoral and femoro-femoral bypass graft. The lymphangiograms demonstrated the precise site of lymph extravasation. Multiple aspirations and local drainage were of no avail and it finally responded to prolonged continuous local pressure over the area of lymph extravasation.

Aged↗

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Perioperative stroke during carotid endarterectomy: the value of intraoperative angiography.

Stroke following carotid endarterectomy is ordinarily attributed to carotid occlusion without adequate shunting, to embolization of air, atheroma, or thrombus, or to the elevation of an intimal flap. In 146 carotid endarterectomies in which intraoperative arteriography was not used, we observed a mortality of 4.8% and an incidence of perioperative stroke of 6.8%. In a subsequent group of patients in which 137 endarterectomies were performed with 107 intraoperative arteriograms to assess the immediate post-surgical results, there was a mortality of 1.5% and an incidence of perioperative stroke of 3.6%. We attribute this difference, in part, to the revision of 12 internal carotid artery defects observed on the arteriograms. Intraoperative arteriography was easy to perform and without complication; however, we recommend that consideration be given to ultrasound as a potentially useful way in the future of assessing technical results.

Arterial Occlusive Diseases↗

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Effect of intra-arterial infusion of PGE1 in patients with severe ischemia of lower extremity.

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Aged↗

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Heart transplantation in patients with treated breast carcinoma.

Since 1987, five women with end-stage cardiomyopathy and a history of treated breast carcinoma have undergone transplantation at our institution. All patients underwent extensive multidisciplinary pretransplantation evaluation to rule out metastatic disease. Disease-free interval before heart transplantation ranged from 5 to 11 years (mean, 7.6 years). All patients received immunosuppression in accordance with a standard protocol of rabbit antithymocyte globulin, cyclosporine, prednisone, and azathioprine. Mean postoperative follow-up is 49 months. All patients are alive and have no symptoms 18 to 73 months after transplantation. In carefully selected patients with a history of breast carcinoma, heart transplantation can be performed with good functional results and satisfactory late survival.

Adult↗

PubMedDate not supplied

Successful treatment of early infective endocarditis and mediastinitis in a heart transplant recipient.

We report a case of bacterial endocarditis in a heart transplant recipient that was diagnosed 6 weeks after operation when a transesophageal echocardiogram revealed vegetations on both sides of the atrial septum. The patient also had postoperative mediastinitis and pericarditis. He underwent two mediastinal explorations, pericardiectomy, and 22 weeks of antibiotics and is free of infection 1 year after transplantation. We presume that the source of infection was contamination of the donor heart by the donor's right lung, which was harvested en bloc with the heart.

Endocarditis, Bacterial↗