Ermöglicht die HU-Allokation die Herztransplantation dringlicher Patienten unter Berücksichtigung der Möglichkeiten der modernen Herzinsuffizienztherapie noch zeitgerecht?

Die rasch progredienten Neuentwicklungen der pharmakologischen, interventionellen wie auch konserativ-chirurgischen Therapieverfahren stellen bei unveränderter Indikation zur Herztransplantation die Organallokation immer wieder vor neue Herausforderungen. Hierbei zu berücksichtigen sind die Vorgaben des Transplantationsgesetzes im Hinblick auf die Führung einer bundeseinheitlichen Warteliste sowie die Bestimmungen nach §12,3 für die Vermittlung vermittlungspflichtiger Organe nach den Regeln, die dem Stand der Erkenntnisse der medizinischen Wissenschaft entsprechen, insbesondere nach Erfolgsaussicht und Dringlichkeit für geeignete Patienten. Dies bedeutet a priori die Patienten zu selektionieren welche sowohl die höchste medizinische Dringlichkeit wie auch die besten Überlebenschancen, d.h. den größten komparativen Nutzen, durch eine Transplantation haben. Für die Herztransplantation wurden hierfür von der Organkommission Herz Richtlinien erstellt die nach Akkreditierung durch die Ständige Kommission Organtransplantation der Bundesärztekammer eine Allokation in den Dringlichkeitsstufen T, U und HU vorsehen. Die Erfüllung der Vorgaben des Transplantationsgesetzes wurde anhand eines im dem 3-Jahresintervall vom 01.01.2003 bis zum 31.12.2005 an der Klinik für Herz- und Gefäßchirurgie des UKSH / Campus Kiel herztransplantierten Patientenkollektives überprüft und diese Ergebnisse mit in einem identischen 3-Jahreszeitraum (01.01.1995 bis 31.12.1997) transplantierten Patienten vor Implementierung der neuen Allokationsrichtlinien verglichen. Die Analyse zeigte, dass sich die mittlere Wartezeit von auf Stufe T zu Herztransplantation gelisteter Patienten im Vergleich der Zeiträume 1995 - 1997 zu 2003 - 2005 mehr als verdoppelt hat. Hieraus folgte trotz optimierter Herzinsuffizienztherapie ein zunehmender Anteil auf einer erhöhten Dringlichkeitsstufe gemeldeter Patienten, welcher im Vergleich der beiden Zeiträume von ursprünglich 8,3% auf 87,3% angestiegen ist. Ein solch hoher Anteil dringlichster Patienten steht im Gegensatz zu den Erfahrungen der früheren Jahre wie auch zu den Gegebenheiten der Herztransplantationsprogramme der übrigen Länder des ET-Verbundes (Benelux-Länder, Österreich, Slowenien, Kroatien) unter Anwendung gleicher Konzepte der Herzinsuffizienztherapie. Neben den enormen ökonomischen Kosten durch den sehr hohen Anteil unter intensivmedizinischer Überwachung stationär wartender Patienten kommt es bei limitiertem Spenderpool auch zu Verlängerung der Wartezeit auf der höchsten Dringlichkeitsstufe auf z.T. mehrere Monate. Das Tool der dringlichen Allokation bei vital gefährdeten Patienten verliert hierdurch seine Wirkung und konterkariert die Situation. Wer eine solch lange Wartezeit ohne Implantation eines Kunstherzsystems - welches wiederum den Patienten von einer weiteren HU-Listung ausschließt - überlebt erfüllte eigentlich die Vorraussetzungen für eine HU-Listung. Die lange Wartezeit auf eine Transplantation führt bei den wirklich vital gefährdeten Patienten zu einer progredienten Verschlechterung mit sukzessivem Endorganversagen. Im eigenen Patientenkollektiv sahen wir vor der Transplantation in den Jahren 2003 - 2005 im Vergleich zum den 1995 - 1997 transplantierten Patienten einen signifikant höheren Bedarf an inotroper Kreislaufunterstützung und an Dialysepflichtigkeit sowie einen deutlich höheren Anteil von Patienten mit der intraaortalen Ballonpumpe. Dies resultierte in einer erhöhten Morbidität postoperativ, insbesondere im Hinblick auf die Notwendigkeit von Nierenersatzverfahren nach dem 7. postoperativen Tag und deutlich reduzierten Überlebensraten nach Herztransplantation wie auch in der vorliegenden Analyse gezeigt werden konnte. Die im Vergleich zu den Ergebnissen mit bevorzugter regionaler Allokation in den Jahren 1995 - 1997 transplantierten Patienten nunmehr 2003 - 2005 deutlich schlechteren Überlebensraten sind nicht akzeptabel und erfordern dringend Modifikationen des Allokationssystems. Hierbei ist besonderen Wert auf stringente medizinische Kriterien zu legen, die die Erkrankungsschwere abbilden, mit dem Risiko an der jeweiligen Grunderkrankung zu versterben korrelieren, zweifelsfrei zu erfassen und überprüfbar sind. Das derzeitige HU-Verfahren selektioniert nicht die wirklich terminal Kranken und erlaubt somit auch nicht deren rechtzeitige Transplantation. Es erfüllt somit nach unserer Ansicht nicht die Bedingungen des Transplantationsgesetzes im Hinblick auf die geforderte Zuteilung der vermittlungspflichtigen Organe nach "Erfolgsaussicht und Dringlichkeit". Bei allen Bemühungen die medizinische Situation durch ein modifiziertes Allokationsmodell abzubilden darf nicht außer Acht gelassen werden, dass Verfügbarkeit einer ausreichenden Anzahl geeigneter Spender die Grundvoraussetzung für jegliche Allokation und Transplantation ist

CSA-Induced PRES after Heart Transplantation-Report of Two Cases and Review

Background  Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease possibly associated with the use of calcineurin inhibitors (CNI) like cyclosporine A. Case Description  The case of a patient who developed severe PRES under CNI therapy shortly after heart transplantation is presented here. Cerebral computed tomography led to the diagnose of PRES in our patient. New therapy strategy with a quadruple immunosuppressive protocol (cortisone, mycophenolate mofetil, low-dose CNI, and a mechanistic target of rapamycin inhibitor) was started. Conclusion  Under the quadruple therapy, a neurologic recovery occurred. In PRES, the presented alternative therapy strategy may lead to improving neurological conditions and preserved transplant organ functions

Extracorporeal Life Support as a Bridge to Surgery of Acute Ventricular Septal Defect

Background  Postinfarction ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction (AMI). Surgery represents the treatment of choice. But the optimal timing for surgery is still under debate. Case Description  Here, we present the case of a 70-year-old female patient with an anterior postinfarction VSD leading to cardiogenic shock for whom we used a percutaneous implantation of an extracorporeal life support (ECLS) as a bridge to surgery. After 10 days of ECLS therapy, surgical VSD repair was successfully performed. Conclusion  The strategy of delayed surgery may be a reasonable solution in selected patients with VSD complicating AMI

Acute kidney injury in septua- and octogenarians after cardiac surgery

Background An increasing number of septua- and octogenarians undergo cardiac surgery. Acute kidney injury (AKI) still is a frequent complication after surgery. We examined the incidence of AKI and its impact on 30-day mortality. Methods A retrospective study between 01/2006 and 08/2009 with 299 octogenarians, who were matched for gender and surgical procedure to 299 septuagenarians at a university hospital. Primary endpoint was AKI after surgery as proposed by the RIFLE definition (Risk, Injury, Failure, Loss, End-stage kidney disease). Secondary endpoint was 30-day mortality. Perioperative mortality was predicted with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE). Results Octogenarians significantly had a mean higher logistic EuroSCORE compared to septuagenarians (13.2% versus 8.5%; p < 0.001) and a higher proportion of patients with an estimated glomerular filtration rate (eGFR) < 60 ml × min-1 × 1.73 m-2. In contrast, septuagenarians showed a slightly higher median body mass index (28 kg × m-2 versus 26 kg × m-2) and were more frequently active smoker at time of surgery (6.4% versus 1.6%, p < 0.001). Acute kidney injury and failure developed in 21.7% of septuagenarians and in 21.4% of octogenarians, whereas more than 30% of patients were at risk for AKI (30% and 36.3%, respectively). Greater degrees of AKI were associated with a stepwise increase in risk for death, renal replacement therapy and prolonged stays at the intensive care unit and at the hospital in both age groups, but without differences between them. Overall 30-day mortality was 6% in septuagenarians and 7.7% in octogenarians (p = 0.52). The RIFLE classification provided accurate risk assessment for 30-day mortality and fair discriminatory power. Conclusions The RIFLE criteria allow identifying patients with AKI after cardiac surgery. The high incidence of AKI in septua- and octogenarians after cardiac surgery should prompt the use of RIFLE criteria to identify patients at risk and should stimulate institutional measures that target AKI as a quality improvement initiative for patients at advanced age

Case report—CARMAT: the first experience with the Aeson bioprosthetic total artificial heart as a bridge to transplantation in a case of post-infarction ventricular septal rupture

BackgroundPost-infarction ventricular septal defects remain one of the most feared complications after myocardial infarction with high mortality rates. In special cases, surgical or interventional treatment strategies are technically not feasible and do not always lead to a good outcome.Case presentationA 58-year-old male patient in cardiogenic shock with a very large ventricular septal (VSD) defect (4.9 cm × 5 cm) due to myocardial infarction was presented in our department. Acute stabilization was achieved using peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Neither surgical nor interventional therapy was considered as a sufficient option due to the unsuitable anatomy of the VSD and the patient was listed for heart transplantation. After 2 weeks on ECMO, bleeding and infectious complications occurred. Due to organ shortage, urgent implantation of the bioprosthetic total artificial heart (TAH) Aeson device (CARMAT) remained the only useful strategy to achieve a mid- or long-term bridge to transplantation. After successful implantation and good recovery with the Aeson device, the patient was transplanted 4 weeks after implantation.ConclusionPost-infarction ventricular septal defects are highly challenging and are commonly associated with a poor prognosis. The implantation of the new Aeson TAH device is a promising therapeutic option, allowing a safe and long-term bridging to heart transplantation

Dangerous surgical scavenger hunt: the complicated course of a patient with left ventricular assist device and end-stage renal disease undergoing reconstructive flap surgery

Patients with left ventricular assist devices (LVADs) who develop stage IV sacral pressure sores (SPS) have an increased procedural risk. We present the complications, including severe intra- and postoperative bleeding, diarrhea with metabolic acidosis, volume loss and acute on chronic renal failure, flap dehiscence and late LVAD outflow cannula thrombosis, in a 54-year-old male who underwent diverting ileostomy (DI) and subsequent fasciocutaneous flap (FCF) surgery for stage IV SPS while supported with an LVAD. Our experience suggests that, despite continuous heparinization, life-threatening thrombotic complications, such as device clotting, can occur. Therefore, the benefit of intervention has to outweigh the risk of bleeding, which should be managed with meticulous surgical technique and substitution of red blood cells rather than the reversal of heparinization or the substitution of clotting factors. Continuation of double anti-platelet therapy should also be considered

Sex-specific risk factors for early mortality and survival after surgery of acute aortic dissection type a: a retrospective observational study

Results Women were older (70.7 years vs. 60.6 years; p <  0.001) and showed a higher logistic EuroSCORE I (31.0% vs. 19.7%, p <  0.001). In the male group, a higher portion of smokers (27.6% vs. 16.0%, p = 0.015) and intraoperatively, more complex procedures and longer cardiopulmonary bypass (CPB) (171 min vs. 149 min, p = 0.001) and cross-clamping times (94 min vs. 85 min, p = 0.018) occurred. 30-day mortality was 19.0% in the female and 16.5% in the male group (p = 0.545). Predictive for 30-day mortality in both genders was intraoperative blood transfusion, while in the female group chronic obstructive pulmonary disease (COPD), peripheral arterial disease and preoperative intubation were predictive. Preoperative cardiopulmonary resuscitation and duration of CPB time were predictors only in males. Averaged follow-up time was 5.2 years and survival did not differ between genders, even if it was stratified by age over 70 years. Conclusions This analysis demonstrated a similar and satisfactory survival in both genders after surgical treatment of AADA. Women and men differed significantly in age, unadjusted and adjusted risk factors and complexity of surgical treatment, but gender itself was no risk factor for mortality. These results suggest that the decision-making for surgical treatment should not depend on gender, but that accounting for sex-specific risk factors rather than common risk factors may help to improve the outcome in both genders

Transcatheter aortic valve resection: new mechanical devices

Background To improve periprocedural outcomes of transcatheter aortic valve implantation (TAVI), transcatheter mechanical resection devices were tested for prior ablation of the aortic cusps. Methods Three mechanical transcatheter resection devices were tested in a series of native porcine (n=30) and reassembled calcified human valves (n=54). The resection time, the resected valve area, the number of released cusps, and the degree of surrounding tissue damage were measured. Afterwards, postmortem transapical-transcatheter-resections of the aortic valve in two humans were performed. Results In the native porcine hearts, the Aesculap II device demonstrated significantly shorter resection time compared to the R&R II and the Randstad devices (6.5±2.0 vs. 28.6±24.1 vs. 23.3±14.4 sec; P=0.001). However, it created more lesions in the surrounding tissue (P=0.002). The R&R II achieved a smaller number of resected cusps than the other two devices (2.7±0.7 vs. 1.1±0.7 vs. 2.4±0.5; P<0.001, respectively). It also resected a smaller area of the aortic valve (306.5±149.2 vs. 106.7±29.6 vs. 256.8±81.3 mm2; P=0.09) but a larger mean area of the resected fragments (110.3±41.5 vs. 160.7±29.6 vs. 111.5±43.9 mm2; P=0.01). The resection of the reassembled human valves demonstrated the same results between the devices regarding resection time (P=0.001) and resected area (P=0.016), but not fragment sizes (P=0.610). Finally, transapical-transcatheter-resection of aortic valve was performed in two cadavers. Conclusions Transcatheter aortic valve resection is feasible with variable aortic leaflet resection times and mild risk of lesions of the surrounding tissue

Influence of Age on Postoperative Neurological Outcomes after Surgery of Acute Type A Aortic Dissection

BackgroundAcute type A aortic dissection (AAAD) is considered a fatal disease which requires an emergent surgical intervention. This study focuses onthe neurological outcome after surgical repair in cases of AAAD in comparison between elderly and young patients.Methodsa retrospective analysis of 368 consecutive patients who underwent emergency surgery of ascending aorta in moderate hypothermic circulatory arrest (MHCA) (20-24 °C) and antegrade cerebral perfusion after AAAD between 2001 and 2016. Patients were divided into two groups: those aged 75 years and older (68 (18.5%)) and those younger than 75 years (300 (81.5%)).ResultsComparing both groups, average age was 79.0 ± 3.2 vs. 59.2 ± 10.7 years (p < 0.001); female gender represents 58.8% of elderly patients vs. 28.7% in younger patients (p < 0.001). Intraoperatively, cardiopulmonary bypass time (155 min (131; 187) vs. 171 min (137; 220); p = 0.012), cross-clamping time (79 min (60; 105) vs. 93 min (71; 134); p = 0.001] and circulatory arrest time (29 min (22; 40) vs. 33 min (26; 49); p = 0.011) were significantly shorter in elderly than younger group. Postoperatively, there was no significant difference in delirium (11.8% vs. 20.5%; p = 0.0968) or stroke (11.8% vs. 16.1%; p = 0.369). The 30-day mortality was satisfactory for both groups but significantly higher in the elderly group (27.9% vs. 14.3%; p = 0.007).ConclusionThe current study concluded that surgical treatment of AAAD in elderly patients can be applied safely without increasing risk of neurological complication. However, minimizing operation time may help limit the occurrence of postoperative neurological complication