Multimodal Temporary Mechanically Circulatory Assistance for Primary Graft Dysfunction after Heart Transplantation—A Case Report

Abstract Background Primary graft dysfunction (PGD) remains a serious complication after heart transplantation (HTx). Although there is no therapy available, veno-arterial extracorporeal life support (va-ECMO), may be a bailout strategy in selected cases. Especially in patients with severe biventricular failure, chances of survival remain poor. Case Summary Here we report a case of a 56-year old patient suffering from severe PGD after HTx with biventricular failure (ejection fraction < 20%) who was successfully bridged to recovery of the donor graft by temporary multimodal mechanically circulatory assistance by combining both, va-ECMO and a microaxial pump (Impella®, Abiomed, Inc., Danvers, MA, USA), a concept also referred as ECMELLA. During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications with need for four re-thoracotomies and temporary open chest situation. Nevertheless, ventricular function recovered and the patient could be weaned from mechanical circulatory support after twelve days. During follow-up, the patient recovered and was successfully discharged. After the following rehabilitation, the patient now shows no persistent signs of heart failure with normal biventricular function of the cardiac graft. Discussion ECMELLA may offer a therapeutic option for patients with severe PGD after HTx. Special awareness and further studies addressing targeted anticoagulation strategies for patients on dual-mechanical support are needed to diminish the incidence of bleeding complications.

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Salvage of severe primary graft dysfunction following heart transplantation using extracorporeal life support

Baylor University Medical Center Proceedings ◽

10.1080/08998280.2018.1498724 ◽

2018 ◽

Vol 31 (4) ◽

pp. 482-486

Author(s):

Katalin Martits-Chalangari ◽

Omar Hernandez ◽

Aayla K. Jamil ◽

Huanying Qin ◽

Joost Felius ◽

...

Keyword(s):

Heart Transplantation ◽

Life Support ◽

Extracorporeal Life Support ◽

Primary Graft Dysfunction ◽

Graft Dysfunction

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Effect of Time of Intraoperative Circulatory Support on Incidence of High-Grade Primary Graft Dysfunction (PGD): Multicenter Analysis on Use of Extracorporeal Life Support (ECLS) during Lung Transplantation

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2020.01.346 ◽

2020 ◽

Vol 39 (4) ◽

pp. S328-S329

Author(s):

M. Hartwig ◽

G. Loor ◽

B. Bottiger ◽

G. Warnecke ◽

W. Sommer ◽

...

Keyword(s):

Lung Transplantation ◽

Life Support ◽

Extracorporeal Life Support ◽

Circulatory Support ◽

High Grade ◽

Primary Graft Dysfunction ◽

Graft Dysfunction ◽

Multicenter Analysis

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Extracorporeal life support for primary graft dysfunction after heart transplantation

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivy157 ◽

2018 ◽

Vol 27 (5) ◽

pp. 778-784 ◽

Cited By ~ 5

Author(s):

Matteo Pozzi ◽

Chiara Bottin ◽

Xavier Armoiry ◽

Laurent Sebbag ◽

Pascale Boissonnat ◽

...

Keyword(s):

Heart Transplantation ◽

Life Support ◽

Extracorporeal Life Support ◽

Primary Graft Dysfunction ◽

Graft Dysfunction

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Removal of Electrophysiological Devices in the Context of Heart Transplantation: Comparison of Combined and Staged Extraction Procedures

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0041-1736532 ◽

2021 ◽

Author(s):

Moritz Benjamin Immohr ◽

Udo Boeken ◽

Konstantinos Smiris ◽

Sophiko Erbel-Khurtsidze ◽

Daniel Oehler ◽

...

Keyword(s):

Heart Transplantation ◽

Postoperative Morbidity ◽

Kidney Injury ◽

Bleeding Complications ◽

Primary Graft Dysfunction ◽

Device Removal ◽

Graft Dysfunction ◽

Thoracic Bleeding ◽

Infective Complications ◽

Mechanical Assistance

Abstract Background During heart transplantation (HTx), tip of the leads of cardiac implantable electrophysiological devices (CIEPD) has to be cut when resecting the heart. Timing of the removal of the remaining device and leads is still discussed controversially. Methods Between 2010 and 2021, n = 201 patients underwent HTx, of those n = 124 (61.7%) carried a present CIEPD. These patients were divided on the basis of the time of complete device removal (combined procedure with HTx, n = 40 or staged procedure, n = 84). Results CIEPD was removed 11.4 ± 6.7 days after the initial HTx in staged patients. Dwelling time, number of leads as well as incidence of retained components (combined: 8.1%, staged: 7.7%, p = 1.00) were comparable between both groups. While postoperative incidence of infections (p = 0.52), neurological events (p = 0.47), and acute kidney injury (p = 0.44) did not differ, staged patients suffered more often from primary graft dysfunction with temporary mechanical assistance (combined: 20.0%, staged: 40.5%, p = 0.03). Consecutively, stay on intensive care unit (p = 0.02) was prolonged and transfusions of red blood cells (p = 0.15) and plasma (p = 0.06) as well as re-thoracotomy for thoracic bleeding complications (p = 0.10) were numerically increased in this group. However, we did not observe any differences in postoperative survival. Conclusion Presence of CIEPD is common in HTx patients. However, the extraction strategy of CIEPD most likely did not affect postoperative morbidity and mortality except primary graft dysfunction. Especially, retained components, blood transfusions, and infective complications are not correlated to the timing of CIEPD removal.

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The first experience of extracorporal membrane oxygenation application in severe primary graft failure following heart transplantation

Transplantologiya The Russian Journal of Transplantation ◽

10.23873/2074-0506-2020-12-4-301-310 ◽

2020 ◽

Vol 12 (4) ◽

pp. 301-310

Author(s):

I. V. Abdulyanov ◽

I. M. Rakhimullin ◽

M. R. Gaysin ◽

R. R. Khamzin

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Heart Transplantation ◽

Postoperative Period ◽

Mechanical Circulatory Support ◽

Circulatory Support ◽

Primary Graft Dysfunction ◽

Graft Dysfunction ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Extracorporal Membrane Oxygenation

Introduction. The number of surgically treated cases of heart failure by means of orthotopic heart transplantation is increasing every year. At the same time, there is a shortage of optimal donors for heart transplantation, being a factor that leads to a primary graft dysfunction in the intra- and immediate postoperative period. In order to reduce the risk of complications and increase patient survival rates in primary heart graft dysfunction, a number of transplant centers resort to the choice of the treatment by means of mechanical circulatory support, such as extracorporeal membrane oxygenation. Clinical case. In the early postoperative period after heart transplantation, the patient was diagnosed with developing primary graft dysfunction. The clinical response to medication support of hemodynamics was unsatisfactory. Venoarterial extracorporeal membrane oxygenation was performed. On the 4th day, the regional contractility of the left ventricle restored, the ejection fraction of both ventricles increased, their systolic function improved. The patient was discharged on the 21st day in a satisfactory condition. Conclusion. Mechanical circulatory support modalities, such as venoarterial extracorporeal membrane oxygenation, can compensate for the emerging primary myocardial dysfunction in recipients. The efficiency of the extracorporeal membrane oxygenation is achieved not only by knowledge of current clinical recommendations, but also depends on the implementation of other clinics' experience as well as technical readiness of the center and medical personnel' qualification.

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The usefulness of Veno-Arterial Extracorporeal Membranous Oxygenation in Patients with Cardiogenic Shock

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2019.547 ◽

2019 ◽

Vol 7 (11) ◽

pp. 1768-1773

Author(s):

Mohamed Abouelwafa ◽

Waheed Radwan ◽

Alia Abdelfattah ◽

Akram Abdelbary ◽

Mohamed Khaled ◽

...

Keyword(s):

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Life Support ◽

Extracorporeal Life Support ◽

Serum Lactate ◽

Base Deficit ◽

Ecmo Support ◽

Circulatory Support ◽

Arterial Blood ◽

Va Ecmo

BACKGROUND: Venoarterial extracorporeal membranous oxygenation is a form of temporary mechanical circulatory support that gets as a salvage technique in patients with cardiogenic shock, we intended to evaluate the effect of (VA ECMO) support on hemodynamics and lactate levels in patients with cardiogenic shock.AIM: The aim of our study is to detect the ability to introduce veno-arterial extracorporeal membranous oxygenation (VA ECMO) as a temporary extracorporeal life support system (ECLS) in our unit, demonstrate the role of ECMO in cardiogenic shock patients regarding improving hemodynamics and microcirculation, and demonstrate the complications and drawbacks in our first center experience regarding VA ECMO.MATERIAL AND METHODS: This was a single-centre observational study that included 10 patients admitted with cardiogenic shock for which VA ECMO was used as mechanical circulatory support. RESULTS: The MAP increased after initiation of the support. It was 41.8 ± 9.3 mmHg and 59.5 ± 6.8 mmHg (P = 0.005). The use of VA ECMO support was associated with a statistically significant decrease in the base deficit (-10.6 ± 4.2 and -6.3 ± 7.4, P = 0.038). The serum lactate declined from 5.9 ± 3.5 mmoL/L to 0.6 ± 4.4 mmoL/L by the use of VA ECMO; a statistically significant change (P = 0.005).CONCLUSIONS: We concluded that VA ECMO as mechanical support for patients with cardiogenic shock might improve mean arterial blood pressure, base deficit and lactate clearance.

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