Impact of ventricular assistance devices on patients submitted to heart transplantation

Background The introduction of veno-arterial extracorporeal life support (v-a ECLS) widens the spectrum of patients that can be included in the heart transplant program, some examples are extended myocardial infarction, fulminant myocarditis or advanced cardiac insufficiency. In addition to this, the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) extends even more the range of patients that can be benefitted of this therapy as a bridge to transplant. Purpose Our objective is to describe the incidence of v-a ECLS in those patients submitted to a heart transplant and to establish whether or not this technique increases the risk of mortality in this population. Methods Retrospective and descriptive statistical analysis of 82 consecutive patients submitted to heart transplant between 2015 and 2019 in a High Technology University Hospital. Demographic and clinical data, extracorporeal life support, extracorporeal cardiopulmonary resuscitation and assistance device type, together with survival at 30 days and one year were collected. Results 82 patients were transplanted during the study period distributed as follows: 47 (51.69%) were elective and 35 (48.1%) emergent being 25 (30.12%) of grade 1A and 10 (12.19%) of grade 1B. 52% had prior intra-aortic balloon contrapulsation. Patients transplanted under ECLS were 80% men and average age of 53 (SD 15) years old. The most prevalent diagnosis was acute myocardial infarction Killip IV (32%), followed by terminal heart failure (28%). 32% of the patients were under peripheral ECMO, 36% under left ventricular assistance, 20% under biventricular assist device, and 12% required ECPR. 72% of devices were implanted in the operating room and 16% in the ICU. The one-year survival of the sample was 88%. 2 patients died after transplantation (8%) during the first month, and 1 patient died within the first year. All three patients had terminal heart failure and the VAD implant was inserted electively Conclusions ECLS prior to cardiac transplantation allow selected patients to arrive alive to the transplant. The choice among devices is related to the diagnosis and expected duration of the therapy but we have not found in our series effects on subsequent mortality. Survival at one year in the subjects analysed is greater than the national registry of the last 10 years, although the tendency is to improve every year. This new scenario implies an increment of the complexity in the management of these patients and requires an special effort in terms of staff ratio and training. In our centre, the implementation of ECLS resulted in an increment of our staff and formative sessions. Funding Acknowledgement Type of funding source: None

Exercise after Heart Transplantation: Typical Alterations, Diagnostics and Interventions

For the treatment of terminal heart failure, heart transplantation is considered to be the gold standard, leading to significantly improved quality of life and long-time survival. For heart transplant recipients, the development and maintenance of good functional performance and adequate exercise capacity is crucial for renewed participation and integration in self-determined live. In this respect, typical transplant-related alterations must be noted that play a significant role, leading to restrictions both centrally and peripherally. Before patients begin intensive and structured exercise training, a comprehensive diagnosis of their exercise capacity should take place in order to stratify the risks involved and to plan the training units accordingly. Particularly endurance sports and resistance exercises are recommended to counter the effects of the underlying disease and the immunosuppressive medication. The performance level achieved can vary considerably depending on their individual condition, from gentle activity through a non-competitive-level to intensive competitive sports. This paper includes an overview of the current literature on heart transplant recipients, their specific characteristics, as well as typical cardiovascular and musculoskeletal alterations. It also discusses suitable tools for measuring exercise capacity, recommendations for exercise training, required precautions and the performance level usually achieved.

Physiological aspects of myocardial function improving during mechanical circulatory support

In recent years, the mechanical support of blood circulation has proved to be a vital therapy for a terminal heart failure, and is considered as a "bridge" to transplantation or is used on a permanent basis in a patient who can not be included in the waiting list for a donor organ. Recent studies of the critical heart failure treatment during an assist device in situ have shown the myocardial recovery at the molecular and cellular levels. However, the transition of these changes to a functionally stable recovery of the heart function, which would allow the long-term results to be achieved without a heart transplant or switching off the mechanical support, is now rather an exception to the rule. At this time, the cause of the discrepancy between the high rate of recovery at the cellular and molecular levels and the low rate of cardiac function recovery remains poorly understood. Patients with chronic progressive heart failure can demonstrate the normalization of many structural myocardial abnormalities after a mechanical support that is actually a reverse remodeling. However, the reverse remodeling is not always considered equivalent to clinical recovery. The aim of this research is to study a significant improvement in the structure and function of the myocardium during the mechanical support of blood circulation.

El rol de los Cuidados Paliativa en la Insuficiencia Cardiaca Avanzada y Terminal.

Resumen en español Introducción: Los beneficios que los CP aportan a los pacientes con enfermedad oncológica, están claramente establecido desde hace años, no así los beneficios que podrían recibir los pacientes con IC. Objetivos: Evidenciar los beneficios de la inclusión de los CP a los servicios de Cardiología y determinar el manejo de los pacientes con IC avanzada/terminal. Métodos: Se realizó una búsqueda de estudios relacionados con el tema en diferentes bases de datos: Cochrane Medline, Medscape, PubMed Scielo y Tripdatabase en el mes de Setiembre del 2018 utilizando las palabras claves. Resultados y conclusiones: La inclusión temprana de los pacientes con IC avanzada o terminal en los programas de CP trae importantes beneficios para el pacientes su familia/cuidador y al sistema de salud. Abstract Introduction: The benefits that palliative care provides to patients with oncological disease are clearly established for years, but not the benefits that patients with heart failure could receive. Objectives: To demonstrate the benefits of the inclusion of palliative care to Cardiology services and to determine the management of patients with advanced/terminal heart failure. Methods: A search of related studies was carried out in different databases: Cochrane Medline, Medscape, PubMed Scielo and Tripdatabase in the month of September 2018 using the key words. Results and conclusions: The early inclusion of patients with advanced or terminal heart failure in palliative care programs brings important benefits for patients, their family / caregiver and the health system.

P5584Causes of death within the first year after transcatheter aortic valve implantation: Lessons from EVERY-TAVI registry

Background According to current recommendations, transcatheter aortic valve implantation (TAVI) should only be performed among patients with a life expectancy of at least one year. However, many deaths occur within the first year after TAVI. Purpose To assess the causes of death within one year after TAVI. Methods Data was taken between November 2007 and December 2017 from the EVERY-TAVI registry. Patients who died during TAVI or experienced mechanical complications requiring surgery were excluded from the analysis. We assessed the causes of death over 3 periods post-TAVI: within the first 30 days, between 30 and 90 days, and between 90 and 365 days. Results Overall, 2389 patients underwent TAVI without mechanical complications. Among them, 320 (1.3%) died within one year. Age was the main cause of death, accounting for 73 deaths (22.8%), followed by heart failure (20.6%) and infections (18.7%). During the first month, cardiogenic shock was the main cause of death (25.4%), followed by infections (22.2%) and terminal heart failure (20.6%), while age was responsible of only one death (1.6%). During the two following months, heart failure was the main cause of death (33.3%), followed by infections (21.2%), and the percentage of deaths due to age increased to 18.2%. After 3 months, age was the main cause of death (31.4%), followed by infection (16.8%) and heart failure (16.2%). Causes of death within one year of TAVI Cause of death All (n=320) <30 days (n=63) 30–90 days (n=66) >90 days (n=191) Older age, n (%) 73 (22.8) 1 (1.6) 12 (18.2) 60 (31.4) Terminal heart failure, n (%) 66 (20.6) 13 (20.6) 22 (33.3) 31 (16.2) Infection, n (%) 60 (18.7) 14 (22.2) 14 (21.2) 32 (16.8) Terminal renal failure, n (%) 26 (8.1) 4 (6.3) 5 (7.6) 17 (8.9) Cardiogenic shock, n (%) 26 (8.1) 16 (25.4) 4 (6.1) 6 (3.1) Malignancies, n (%) 18 (5.6) 0 (0.0) 2 (3.0) 16 (8.4) Sudden death, n (%) 17 (5.3) 6 (9.5) 2 (3.0) 9 (4.7) Stroke, n (%) 12 (3.7) 4 (6.3) 2 (3.0) 6 (3.1) Accident, n (%) 7 (2.2) 2 (3.2) 0 (0.0) 5 (2.6) Myocardial infarction, n (%) 7 (2.2) 2 (3.2) 2 (3.0) 3 (1.6) Non-cardiac surgery, n (%) 5 (1.6) 1 (1.6) 1 (1.5) 3 (1.6) Pulmonary embolism, n (%) 3 (0.9) 0 (0.0) 0 (0.0) 3 (1.6) Conclusion Cardiogenic shock is the main cause within the first month after TAVI, while older age is the main cause overall and after the initial months, highlighting the need to more carefully selection of patients undergoing TAVI.

Implantable devices: a bridge to heart transplantation

Terminal stage heart failure represents a substantial worldwide problem for the healthcare system. Despite significant improvements (medical heart failure treatment, implantable cardioverters, cardiac resynchronization devices), long-term survival and quality of life of these patients remain poor. Heart transplantation has been an effective therapy for terminal heart failure, but it remains limited by an increasing shortage of available donor organs along with strict criteria defining acceptable recipients.

Successful surgical treatment of terminal heart failure in an adolescent - left ventricular assist device implantation and subsequent heart transplantation

Introduction. Implantation of the new-generation left ventricular assist device (LVAD) is an efficient therapeutic option as a bridge to transplantation in adults, as well as in children and adolescents with small body surface. The aim of this work was to present a case of a successful surgical treatment of terminal heart failure in a male adolescent who had an LVAD implanted as a bridge to heart transplantation. Case outline. The patient, a 17-year-old male, was admitted with the end-stage heart failure due to the dilated cardiomyopathy and implanted LVAD. Fourteen months after LVAD implantation, a successful ?second stage? surgical procedure was performed ? orthotopic heart transplantation preceded by the LVAD explantation. Conclusion. Long-term mechanical circulatory support is an effective and safe method in treatment of the end-stage heart failure as a bridge to transplantation in the adolescent period.

A CASE OF THE «BERLIN HEART EXCOR» BIVENTRICULAR ASSIST DEVICE IMPLANTATION AS A BRIDGE TO HEART TRANSPLANTATION FOR A PATIENT WITH DILATED CARDIOMYOPATHY AND TERMINAL HEART FAILURE

Patients with terminal heart failure, refractory to drug therapy, are severe category of cardiology. The possibility of effective correction of multi-organ failure and an increase in the life-time of patients with critical cardiac insuffi ciency has been proved with the use of biventricular assist device (BiVAD). In this report, we present the case of implantation of the BiVAD «Berlin Heart EXCOR» as a bridge to orthotopic cardiac transplantation to a patient with dilated cardiomyopathy, critical heart failure and a high risk of fatal complications. Despite the complex, long postoperative period after the implantation of «Berlin Heart EXCOR», proceeded with reversible multiorgan and heart failure, dysfunction of BiVAD pumps, it was achieved patient’s recovery, regress of heart failure phenomena and orthotopic heart transplantation was performed after 9 months with a good long-term result.