We described a simple method of hemostasis in implantation and explantation of HeartMate left ventricular assist device. Wrapping of the inflow cannula, outflow conduit and outflow graft with Vascutek tube graft can localize the bleeding due to patient's coagulopathy, imperfect coating and device defect. During explantation, bivalving the tube graft, leaving the graft in place and no-touch of the adhesion between graft and soft tissue can minimize the dissection and prevent the potential bleeding.

Adult↗

PubMed2000

Combined heart transplantation and resection of dissecting aneurysm of ascending aorta and aortic arch: a case report.

A 21-year-old male patient had suffered from palpitation and exertional dyspnea since October, 1997. He was admitted to our hospital, and a series of examinations were performed. Chest computed tomography (CT) revealed marked dilatation of the ascending aorta (about 7.5 cm at the proximal portion) and aortic annulus, an intimal flap in the ascending aorta and aortic arch was also noted. Cardiac catheterization revealed the pulmonary capillary wedge pressure was 33 mmHg, pulmonary artery pressure was 47/38 mmHg with a mean of 35.4. The cardiac index was 1.01 l/min/m2. Poor left ventricular contractility was shown by a left ventricular ejection fraction (LVEF) of 13.8% and a right ventricular ejection fraction (RVEF) of 5.13% by a radionuclide angiogram (RNA) study. Under the diagnosis of dilated cardiomyopathy and dissecting aortic aneurysm of the ascending aorta and aortic arch, he was put on a waiting list for heart transplantation. On November 11, 1997 he received heart transplantation. Resection of the dissecting aneurysm of the ascending aorta and the aortic arch and replacement with a 26 mm Vascutek graft were performed first under deep hypothermia and retrograde cerebral perfusion. Then while he was rewarming up, heart implantation was performed. He was discharged 30 days after surgery and has been doing well since then. As far as we know, no literature regarding combined heart transplantation and resection of a dissecting aneurysm of the ascending aorta and aortic arch has been reported.

Adult↗

PubMed2000

Current status of artificial hearts and ventricular assist devices.

Currently available approaches for patients with refractory heart failure include intravenous inotropic therapy, partial left ventriculectomy, dynamic cardiomyoplasty, mechanical circulatory support, and heart transplantation. Heart transplantation is limited by the availability of donor organs, which is never expected to meet the increasing demand. Numerous devices have been developed for circulatory support. Currently available devices differ in configuration, anatomic location, flow characteristics, and durability. Many devices are currently available for mechanical support, and they can generally be categorized as follows: 1) pulsatile or continuous blood flow; 2) internal (implantable) or external (extracorporeal); 3) pneumatically or electrically powered; and 4) for short-term or long-term support. Proper selection of patients for a given therapy has a major impact on clinical outcome. Early implantation of implantable devices, before the onset of multiple or irreversible end-organ failure, is essential. Short-term devices are indicated if myocardial recovery is anticipated, as in cases of postcardiotomy shock and acute myocarditis. Long-term devices are indicated for transitioning patients with end-stage myocardial failure to heart transplantation. Long-term assist devices may, in some selected cases, serve as an alternative to heart transplantation. This alternative will benefit both patients in chronic heart failure competing for a limited donor supply and patients with contraindications to transplantation, such as advanced age, previous malignancies, and renal dysfunction. The next generation of blood pumps to be applied clinically is likely to be axial pumps, which are valveless, miniaturized, intraventricular left ventricular assist devices.

Heart, Artificial↗

PubMed2000

Partial left ventriculectomy as a biologic bridge to heart transplantation.

Heart failure refractory to medical treatment is consuming an increasingly large proportion of health care resources. Partial left ventriculectomy has recently been used to treat patients with end-stage dilated cardiomyopathy. A 45-year-old man in end-stage heart failure had progressive exertional dyspnea for 3 years. Cardiac catheterization showed dilated cardiomyopathy with severe pulmonary hypertension and severely impaired left ventricular function. After partial left ventriculectomy, cardiac output increased from 2.11 L/min to 5.0 L/min. The left ventricular ejection fraction measured by radionuclide angiography increased from 13% preoperatively to 28% 1 month after the operation. The patient was discharged and monitored at the outpatient clinic. He had an exercise capacity of NYHA functional class II. However, he received heart transplantation 10 months after the partial left ventriculectomy because of recurrent heart failure. Partial left ventriculectomy improves heart function and may be used as a bridge to heart transplantation as an alternative to ventricular assist devices.

Cardiomyopathy, Dilated↗

PubMed2000

Aorto-right artrial fistula: a rare complication of aortic dissection.

We describe the successful surgical repair of an acute aortic dissection that had caused an aorto-right atrial fistula in a 67-year-old man. The patient was admitted to the hospital on an emergency basis because of severe heart failure. The diagnosis of acute aortic dissection with rupture into the right atrium was confirmed by use of intraoperative transesophageal echocardiography, although rupture of a sinus of Valsalva aneurysm into the right atrium had been suggested initially by 2-dimensional and Doppler transthoracic echocardiography. At surgery, we found the patient to have aortic arch dissection with complete separation of the right coronary artery from the sinus of Valsalva and a false lumen that had ruptured into the right atrium. The aortic arch was repaired directly. The ascending aorta was successfully replaced with a composite graft. Aortic dissection with rupture into the right atrium is extremely rare and leads to death rapidly. As shown in this case, such a condition might be mistaken for an aneurysmal rupture of the sinus of Valsalva, with use of transthoracic echocardiography alone. Transesophageal echocardiography is a useful noninvasive method to further define or confirm the diagnosis. Early surgical intervention is necessary in patients with this condition to prevent profound shock and end-organ failure.

Aged↗

PubMed2000

HeartMate left ventricular assist device for long-term circulatory support.

We describe three successful cases of HeartMate left ventricular assist device (LVAD; Thermo Cardiosystems, Woburn, MA, USA) implantation in patients with end-stage heart failure for long-term circulatory support. Patient 1 was a 34-year-old woman with postpartum cardiomyopathy. Patients 2 and 3 were both males with dilated cardiomyopathy, 50 years and 21 years of age, respectively. They all presented in cardiogenic shock with decreased sensorium and anuria. Temporary mechanical support with an intra-aortic balloon pump or extracorporeal membrane oxygenation (ECMO) was needed for life support. Because bleeding and right ventricular failure often occur after HeartMate LVAD implantation, we used a Vascutek tube (Vascutek Ltd, Inchinnan, Scotland) graft to wrap inflow and outflow valve conduits and ECMO as a bridge to HeartMate LVAD implantation. Following surgery, cardiac output increased from 2.70, 2.06 and 2.53 L/min to 4.50, 5.80 and 5.00 L/min in the three patients. HeartMate LVAD can provide safe and stable long-term circulatory support without the need for anticoagulation. One of the patients remained on HeartMate for 287 days before undergoing successful heart transplantation. Patients with HeartMate LVAD are ambulatory and may be discharged while awaiting heart transplantation. Heart function may recover after long-term ventricular unloading with HeartMate LVAD.

Adult↗

PubMed2000

Surgical revascularization for acute total occlusion of left main coronary artery.

We report our experience with emergency surgical revascularization in 3 patients who were in cardiogenic shock as a result of acute total occlusion of the left main coronary artery. Because they were in profound shock, 2 patients required mechanical support with extracorporeal membrane oxygenation before the operation. Another patient was given moderate inotropic support and treated with an intraaortic balloon pump before surgery, because he had a dominant right coronary artery with extensive collateral circulation to the left coronary artery. All 3 patients underwent surgical revascularization within 20 hours of acute occlusion. Two patients survived, although 1 of them required extracorporeal membrane oxygenation support for 5 days postoperatively. The 3rd patient, despite successful weaning from extracorporeal membrane oxygenation immediately after coronary revascularization, died of hypoxic encephalopathy due to prolonged preoperative resuscitation. Immediate surgical revascularization was an effective treatment in our 3 patients who were in cardiogenic shock due to acute total occlusion of the left main coronary artery. Such factors as abundant collateral vessels from the right coronary artery to the left coronary artery, complete surgical revascularization within 20 hours of acute occlusion, and mechanical circulatory support were deemed important to recovery of left ventricular function. Two of our 3 patients survived.

Adult↗

PubMed2000

Ventricular remodeling of the native heart after heterotopic heart transplantation.

Although ventricular remodeling after long-term unloading of the heart has been reported in patients after the use of medical therapy or left ventricular assist devices, it has rarely been reported in patients after heterotopic heart transplantation. Here, we describe a case of ventricular remodeling of the native heart after heterotopic heart transplantation. A 61-year-old man with end-stage dilated cardiomyopathy underwent heterotopic heart transplantation because of high pulmonary vascular resistance and a small donor heart. After the operation, echocardiography showed ventricular remodeling of the native heart, with decreased size and improved contractility of the left ventricle. Six months after the transplantation, acute graft failure of the donor heart occurred. However, the patient remained in good condition with the support of the improved native heart.

Cardiomyopathy, Dilated↗

PubMed1999

Low incidence of transplant coronary artery disease in Chinese heart recipients.

OBJECTIVES: This study sought to assess the incidence of transplant coronary artery disease (CAD) in Chinese heart recipients. BACKGROUND: The prevalence of transplant CAD detected by angiography at 1, 2 and 4 years after heart transplantation was 11%, 22% and 45%, respectively. The incidence of transplant CAD in Chinese heart recipients has not been reported. METHODS: For those recipients surviving for more than 1 year after transplantation, coronary angiography was performed annually for surveillance of transplant CAD. The recipient characteristics, donor characteristics, rejection episodes, medication and human leukocyte antigen (HLA) mismatches were recorded. RESULTS: Fifty patients were included in this study. Thirteen (26%) recipients had ischemic heart disease. Two patients (4%) had active cytomegalovirus (CMV) infection after transplantation. The mean number of rejection episodes in the 1st year after transplantation was 1.15. Among 47 patients with complete data of donor and recipient histocompatibility antigens, there were seven patients (14.9%) with two or fewer HLA mismatches. Among 74 angiograms of 50 patients reviewed, only one patient had discrete stenosis less than 50% in the middle portion of the left anterior descending artery at 1 year after transplantation. The cumulative incidence of transplant CAD was 2% at 1 year and 2% at 2 and 4 years after transplantation. CONCLUSIONS: The incidence of transplant CAD was low in Chinese heart transplant recipients. Low percentage of ischemic heart disease in recipients, low occurrence of active CMV infection and rejection episodes after transplantation, less racial disparity, and lower HLA mismatches may be the important factors.

Adolescent↗

PubMed1999

Cardiorespiratory response of heart transplantation recipients to exercise in the early postoperative period.

In this study, we evaluated the cardiorespiratory function of orthotopic heart transplantation (OHT) recipients during exercise. Seventeen male OHT recipients, ranging in age from 22 to 60 years, participated in this study 47 +/- 21 days after surgery. The control group consisted of 17 sedentary healthy men. Breath-by-breath measurement of cardiorespiratory function was obtained during the incremental exercise of leg cycling. At peak exercise, the oxygen (O2) uptake (16.5 +/- 3.3 vs 33.9 +/- 8.2 mL.kg-1.min-1), work rate (82 +/- 19 vs 169 +/- 42 watts), heart rate (HR), O2 pulse, and blood lactate level of the OHT recipients were significantly lower than the respective values of the control group. At the ventilatory threshold, the OHT group also showed a significantly lower O2 uptake (10.7 +/- 1.6 vs 18.3 +/- 5.1 mL.kg-1.min-1), work rate (39 +/- 12 vs 89 +/- 33 watts), HR, O2 pulse, ventilatory equivalent for O2, and ventilatory equivalent for carbon dioxide. The OHT recipients showed a high resting HR (97 +/- 7 beats/min) and a low peak HR (123 +/- 14 beats/min) during exercise, and their HR continued to increase for 1 to 3 minutes after cessation of exercise. Our data revealed a low level of cardiorespiratory endurance in OHT recipients during the early postoperative stage. A multidisciplinary cardiac rehabilitation program should be considered to enhance physical functional capacity and quality of life, and promote return to work.

Adult↗

PubMed1999

Heart transplantation with marginal recipients and donors.

With improvements in surgical techniques and management of postoperative complications, heart transplantation can now be performed with donors and recipients who were previously considered unsuitable. In this study, we report the results of heart transplantation with marginal donors and recipients in our hospital. From June 1993 through June 1998, we performed 79 heart transplantations. Marginal recipients were defined as those with high pulmonary vascular resistance (> 6 Wood units), severe renal impairment (serum creatinine > 2 mg/dL and creatinine clearance < 50 mL/min), or severe hepatic dysfunction (ALT and AST > 100 IU/L or serum bilirubin > 2.5 mg/dL). Marginal donors were those with any of the following conditions: old age (> 40 years), size mismatch (donor/recipient body weight ratio < 0.8), history of chronic alcohol use, previous cardiopulmonary resuscitation and hypotension, hepatitis B or C virus positivity, coronary artery disease, high-dose dopamine (> 10 micrograms.kg-1.min-1), or prolonged allograft ischemic time (> 4 hours). Of the 79 transplantations performed, 45 (58%) involved marginal recipients or donors. The 30-day mortality rate was 5%, and the 1-year and 5-year survival rates were 87% and 83%, respectively. The survival rates did not differ significantly between cases involving marginal donors or recipients and those involving nonmarginal donors and recipients. There were 27 marginal recipients (34%), only one of whom died during surgery. Five of six recipients with severe renal impairment needed short-term hemodialysis after transplantation. Recipients with high pulmonary vascular resistance had a higher incidence of early acute rejection (5/10 vs 22/69). Thirty-three (42%) of the patients received transplants from marginal donors, four of whom died during surgery; two died of acute vascular rejection, one of allograft failure caused by prolonged ischemic time, and one of bleeding secondary to preoperative sepsis and coagulopathy. These results show that heart transplantation may be performed in marginal recipients and donors, with acceptable operative mortality.

Adolescent↗

PubMed1999

Heart transplantation in Asia.

BACKGROUND: The first clinical heart transplantation in Asia was performed by Wada in 1968. Due to cultural and religious problems, heart transplantation was rarely performed in Asia until 1987 and since then the number of heart transplantation has increased rapidly. This study was undertaken to investigate the results of heart transplantation in Asia. METHODS: Data was collected through the use of a questionnaire by mail. The questionnaire included information on the year when heart transplantation was started, the number of heart transplantations by year and country population, sex, age and diagnosis of recipients, causes of brain death of the donors, number of centers with an active heart transplantation programs, operative mortality and actuarial survival, brain death and organ transplant legislation. RESULTS: From July 17, 1987 to December 1996, 380 patients received heart transplantation in Asia. Up to 1996, Taiwan had performed 178 cases of heart transplantation. Thailand also started in 1987 and had 95 cases. South Korea started in 1992 and had 65 cases. Singapore and India each had 12 cases. Hong Kong 8 cases, China 7 cases, and the Philippines 3 cases, all started in the early 1990s. The recipient ages ranged from 1 to 70 years with a male to female ratio of 3 to 1. The one-month operative mortality rate ranged from 0 to 25% with an average of 7.4%. The one-year survival rate ranged from 0 to 84% with an average of 78.8%. The 5-year survival rate ranged from 30 to 74.1% with an average of 67. 5%. CONCLUSION: Heart transplantation was well-established in most Asian countries, and the number was increasing. The result and survival rate of heart transplantation in Asia were comparable with that of the world series.

Actuarial Analysis↗

PubMed1998

Clinical trial of FK506 in heart transplant patients in Taiwan: report of 7 cases with immunosuppression switch from cyclosporine to FK506.

Explore the source record for details and available documents.

Adult↗