Antibody-Mediated Rejection in Heart Transplantation: Case Presentation with a Review of Current International Guidelines

Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limitations and the need for future research and innovation

Unexplained Obstruction of an Integrated Cardiotomy Filter During Cardiopulmonary Bypass

Cardiopulmonary bypass (CPB) is considered relatively safe in most cases, yet is not complication free. We present a case of an integrated cardiotomy filter obstruction during CPB, requiring circuit reconfiguration. Approximately an hour after uneventful initiation of CPB the integrated cardiotomy filter became obstructed over several minutes, requiring circuit reconfiguration using an external cardiotomy filter to maintain functionality. Following reconfiguration, CPB was maintained with a fully functional circuit allowing safe patient support throughout the remainder of CPB. Postoperatively, there was no sign of thrombus or mechanical obstruction of the filter, which was sent to the manufacturer for analysis. The cause of the obstruction was unclear even after chemical analysis, visual inspection, and a review of all techniques and products to which the patient was exposed. The patient had a generally routine hospital stay, with no signs or symptoms related to the incident. To our knowledge, this is the first report describing an obstructed integrated cardiotomy filter. An appropriate readiness plan for such an incident includes proper venting of the filter chamber, a method for detecting an obstruction, and a plan for circuit reconfiguration. This case illustrates the need for a formal reporting structure for incidents or “near miss” incidents during CPB

Performance and Safety of an Integrated Portable Extracorporeal Life Support System for Adults

Extracorporeal membrane oxygenation (ECMO) is indicated when conventional measures fail to support a patient during cardiac or respiratory failure. Due to the complicated nature of ECMO, patients often require transport to a tertiary care center. This study retrospectively compared the performance of the Cardiohelp™ (Maquet) life support system with a previously used ECMO circuit when transporting adult patients on venoarterial ECMO between facilities. Two ECMO circuits were compared for performance: 1) the Cardiohelp™ (Maquet) life support system and 2) the “standard” circuit consisting of a Thoratec CentriMag centrifugal pump, Maquet Quadrox-D oxygenator, and a Terumo CDI-500 in-line blood gas analyzer. After analyzing data from 16 patients (eight patients supported with each ECMO system), no differences in patient demographics, percentage of patients successfully weaned from ECMO, percentage of patients surviving to discharge, duration supported on the initial ECMO system, or total duration of ECMO were noted. No patient deaths were related to circuit failure or circuit disruptions in either group. Analysis of the performance of the ECMO circuits and the resulting patient status showed few significant differences between ECMO groups (Cardiohelp™ vs. standard circuit) and time points (the first 8 hours vs. a 24-hour time point). The statistically significant differences were not concerning in terms of appropriate medical support or patient safety. Of interest, the transmembrane pressure was significantly lower for the Cardiohelp™ module vs. the standard oxygenator during the first 8 hours (20.1 [5.3] vs. 37.1 [7.1] mmHg; p < .001) and at 24 hours (21.3 [3.8] vs. 34.8 [7.9] mmHg; p = .001). The Cardiohelp™ portable life support system provides safe and reliable support for adult patients on ECMO during interhospital patient transport as compared to the standard circuit

The Brain-Dead Organ Donor

Addressing all aspects of brain death and thoroughly detailing how a potential organ donor should be maintained to ensure maximum use of the organs and cells, The Brain-Dead Organ Donor: Pathophysiology and Management is a landmark addition to the literature. This first-of-its-kind, multidisciplinary volume will be of interest to a large section of the medical community. The first section of the book reviews the historical, medical, legal, and ethical aspects of brain death. That is followed by two chapters on the pathophysiology of brain death as investigated in small and large animal models. This includes a review of the many hormonal changes, including the neuroendocrine- adrenergic ‘storm’, that takes place during and following the induction of brain death, and how they impact metabolism. The next section of the book reviews various effects of brain death, namely its impact on thyroid function, the inflammatory response that develops, and those relating to innate immunity. The chapters relating to assessment and management of potential organ donors will be of interest to a very large group of transplant surgeons and physicians as well as critical care and neurocritical care physicians and nurses. Neurologists, endocrinologists, neurosurgeons, and pathologists will also be interested, especially in the more basic science sections on various aspects of brain-death and hormonal therapy. Organ procurement organizations and transplant coordinators worldwide will also be interested in this title. Other chapters will be of interest to medical historians, medico-legal experts, and ethicists.CONTENIDO: Introduction, Dimitri Novitzky, David K. C. Cooper, Pages 1-6 -- Historical Aspects of the Diagnosis of Death, Félix Bacigalupo, Daniela A. Huerta Fernández, Pages 7-11 -- The Determination of Brain Death, Curtis M. Keller, Boris Chulpayev, Michael Hoffmann, Pages 13-19 -- Legal Aspects of Brain Death and Organ Donorship, Ricky T. Munoz, Mark D. Fox, Pages 21-35 -- Ethical Issues in Organ Donation from Brain-Dead Donors, Mark D. Fox, Ricky T. Munoz, Pages 37-53 -- Pathophysiology of Brain Death in Small Animal Models, Bernhard Floerchinger, Nicholas L. Tilney, Stefan G. Tullius, Pages 55-64 -- Pathophysiology of Brain Death and Effects of Hormonal Therapy in Large Animal Models, Dimitri Novitzky, Winston N. Wicomb, David K. C. Cooper, Pages 65-90 -- The Efficacy of Thyroid Hormone Therapy in Brain-Dead Heart Donors: A Review of Thyroid Function in Health and Disease, Lawrence E. Shapiro, Tatiana Baron, Pages 91-105 -- The Inflammatory Response to Brain Death, Anne Barklin, Christine Lodberg Hvas, Else Toennesen, Pages 107-119 -- The Influence of Brain Death and Intensive Care Management on Donor Organs: Assessment of Inflammatory Markers, Wayel Jassem, Susan V. Fuggle, Pages 121-129 -- Brain Death-Induced Inflammation: Possible Role of the Cholinergic Anti-inflammatory Pathway, Simone Hoeger, Benito A. Yard, Pages 131-138 -- Innate Immunity and Injury During Brain Death: Opportunities for Intervention, Marc A. Seelen, Henri G. D. Leuvenink, Rutger J. Ploeg, Pages 139-145 -- Selection of the Brain-Dead Potential Organ Donor, Kadiyala V. Ravindra, Keri E. Lunsford, Paul C. Kuo, Pages 147-154 -- Infectious Disease Aspects of the Brain-Dead Potential Organ Donor, Nicole M. Theodoropoulos, Michael G. Ison, Pages 155-176 -- Malignancy in the Brain-Dead Organ Donor, Michael A. Nalesnik, Ron Shapiro, Michael G. Ison, Pages 177-189 -- Early Clinical Experience of Hormonal Therapy in the Brain-Dead Potential Organ Donor, Dimitri Novitzky, Burcin Ekser, David K. C. Cooper, Pages 191-207 -- Assessment, Monitoring, and Management of Brain-Dead Potential Organ Donors in the USA, Demetrios Demetriades, Lydia Lam, Pages 209-216 -- Assessment, Monitoring, and Management of Brain-Dead Potential Organ Donors in Europe, Gabriel J. Echeverri, Bruno G. Gridelli, Pages 217-235 -- Assessment, Monitoring, and Management of Brain-Dead Potential Organ Donors in Australia, Peter S. Macdonald, Anders E. M. Aneman, Deepak Bhonagiri, Daryl A. Jones, Gerry O’Callaghan, Helen I. Opdam et al., Pages 237-249 -- Management of the Brain-Dead Organ Donor: Perspectives of the Transplant Coordinator, Nicole T. Farina, David K. C. Cooper, Pages 251-261 -- Surgical Aspects of Thoracic and Abdominal Organ Procurement from Brain-Dead Donors, Michael J. Anstadt, Paul C. Kuo, Kadiyala V. Ravindra, Pages 263-281 -- Impact of Brain Death on Storage of the Heart, Winston N. Wicomb, David K. C. Cooper, Pages 283-288 -- Impact of Brain Death on Abdominal Organs and Allograft Preservation Strategies, Coney Bae, Anthony Watkins, Scot D. Henry, James V. Guarrera, Pages 289-298 -- Functional Repair of Brain Death-Induced Injury, Henri G. D. Leuvenink, Marc A. Seelen, Rutger J. Ploeg, Pages 299-310 -- Functional Repair of Brain Death-Injured Donor Lungs, Jonathan C. Yeung, Marcelo Cypel, Shaf Keshavjee, Pages 311-320 -- Thyroid Hormone Therapy to the Recipient of a Heart from a Brain-Dead Donor, Dimitri Novitzky, David K. C. Cooper, Pages 321-331 -- Current and Potential Future Trends in the Management of the Brain-Dead Organ Donor, Octavio E. Pajaro, James K. Kirklin, Pages 333-341 -- Maximizing Utilization of the Potential Deceased Donor: The Challenge Continues,Eliezer Katz,Pages 343-35