Recombinant hirudin for extended aortic surgery in patients with heparin-induced thrombocytopenia

AbstractJ Thorac Cardiovasc Surg 1999;118:191-

Pulsatile pediatric ventricular assist devices: Current results for bridge to transplantation

While pulsatile ventricular assist devices have gained widespread use in adult patients awaiting heart transplantation, only very limited experience with these devices exists in the pediatric population. In the past mostly non-pulsatile systems such as ECMO have been used to support pediatric patients with heart failure for very limited periods of time. Only recently have miniaturized pulsatile devices became available. This article describes the technical characteristics of these devices which have been implanted at the Deutsches Herzzentrum Berlin since 1992. The Berlin Heart assist device has since been used in 34 children between the ages of 6 days and 16 years. We report our strategy in patient selection, perioperative care and subsequent heart transplantation. The current literature on mechanical circulatory support in children is reviewed. Copyright 1999 by W.B. Saunders Compan

State of the art in paediatric heart transplantation: the Berlin experience

Summary Enormous progress has been made in paediatric heart transplantation since the first unsuccessful effort by Kantrowitz in 1967. Early reports of children undergoing heart transplantation showed alarmingly high perioperative mortality rates of 25-60%, with the diagnosis of congenital heart disease (CHD) representing a particularly high-risk subset compared with cardiomyopathy. Many of these early failures were related to poor patient selection, suboptimal immunosuppression and technical problems. We learned a great deal from these earlier difficulties. Presently, with more refined techniques, better-defined patient selection criteria, excellent graft rejection monitoring and optimal immunosuppression, the ISHLT 2011 registry reported a 10-year survival rate of 60% for patients transplanted for end-stage CHD and >70% for those transplanted for cardiomyopathy. The technical dilemmas in complex CHD were overcome by surgical ingenuity and creativity, innovative solutions and careful surgical planning, adapting the complex recipient anatomy to the normal donor anatomy. The miniaturized Berlin Heart pulsatile ventricular assist devices in children as a bridge to transplantation have revolutionized treatment and become a significant contribution in heart-failure therapy. The intramyocardial electrogram and echocardiographic strain rate imaging have been employed as non-invasive techniques of rejection monitoring. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy, the main cause of cardiac allograft loss and a leading cause of mortality after the first year post-transplantation. The questions of whether a transplanted heart in a newborn grows to adult size along with the child and whether the dimensional cardiac growth allows adequate function over time have been largely answered in our previous investigations. As more transplanted children reach adulthood, concerns about their life expectancy when they have reached 10 years of life post-transplant are raised, particularly with respect to establishing partnerships and families, their ability to earn a living and the fulfilment of personal life perspectives. Some heart-transplanted patients require retransplantation to remain alive. The disparity between the demand for and supply of donor hearts makes retransplantation an ethical issue. We 'do not refuse' any patient who needs retransplantation. Mechanical circulatory support devices for long-term use are now largely available to accommodate such cases

Simplified technique for implantation of a left ventricular assist system after previous cardiac operations

Implantation of a left ventricular assist system through a left thoracotomy in patients with multiple previous heart operations avoids reopening the sternum and the possible consequent serious complications

Medium-term results of heart transplantation using older donor organs

Background: Donor heart shortage has necessitated the expansion of the donor pool by the use of older hearts. In a 13-year period, 1,070 heart transplants were performed in 1,035 adults at the German Heart Institute Berlin. We divided the patients into 3 groups: Group I, donor age <35 years ( n = 524); Group II, donor age 35 to 50 years ( n = 379); Group III, donor age >50 years ( n = 167). We analyzed post-operative mortality (up to 30 days), cumulative survival rates, cardiac dependent morbidity, and changes in the left/right ventricular ejection fraction as well as freedom from cytomegalovirus infection and freedom from acute rejection episodes grade ≥ 2 (International Society for Heart and Lung Transplantation). We also calculated the rate of cardiac interventions per patient in the groups. Recipients in Group III were significantly older, compared with Groups I and II. The post-operative mortality was 16.8% in Group I, 29.8% in Group II, and 23.4% in Group III. The differences were significant ( p = 0.00001) between Group I and Group II. The long-term cumulative survival rates were significantly better in Group I when compared with Groups II and III ( p < 0.00001 , p = 0.014), but it did not differ between Groups II and III ( p = 0.18). However, cardiac morbidity in Groups I and II was significantly lower when compared with Group III ( p = 0.0009, p = 0.037). Mean left and right ventricular ejection fraction was >55% and did not significantly change in groups for up to 10 years. Freedom from cytomegalovirus infection was not significantly different between Groups II and III ( p = 0.09). Significantly fewer percutaneous transluminal coronary angioplasties were performed in Group I, but comparable numbers were carried out in Groups II and III ( p = 0.53). For retransplantation a similar situation occurred. We did not find significant differences in the mid-term follow-up between patients who received hearts from 35- to 50-year-old donors and from those who had received hearts from donors >50 years, despite increased cardiac morbidity in Group III. Close monitoring of the coronary situation after heart transplantation and expanded indications for revascularization in Group III makes heart transplantation with older hearts a suitable option to save the lives of patients in end-stage heart failure

Heart Transplantation: A Single-Center Experience

Background. The success of heart transplantation led to the extension of the criteria for both recipients and donors. The aim of the study was to evaluate the experience with this therapeutic approach for end-stage heart failure at a single center. Methods. Between April 1986 and January 1996, 1,413 patients were accepted as candidates for heart transplantation. Ventricular assist devices were used as a bridge to transplantation in 173 patients (biventricular assist device in 141 patients and left ventricular assist device in 32 patients). The longest duration of support was 572 days (average, 46 days). Results. Of the 1,413 patients, 891 underwent heart transplantation (65 children/adolescents and 826 adults; 522 (36%) patients died awaiting a donor heart. The average time spent on the waiting list was 107 days. The average recipient age was 44 years, and the age of donors was extended up to 69 years. Eighty-three patients with ventricular assist devices (48%) subsequently underwent heart transplantation. Twenty-five patients (2.7%) underwent retransplantation. The 30-day mortality rate was 14%, and the overall actual survival at 1, 5, and 10 years was 80%, 59%, and 50%, respectively. Ninty-four percent of patients were in New York Heart Association functional class I or II at 1 year, and 44% returned to work after transplantation. Conclusions. Despite the broadening of the selection criteria for both recipients and donors, heart transplantation remains an effective treatment for end-stage heart failure. Nevertheless, this therapeutic approach is severely limited by a considerable disparity between the need and availability of donor organs

Prediction of True Circulatory Decompensation in Chronic Heart Failure for Optimal Timing of Mechanical Circulatory Support: Non-Invasive Arterial-Ventricular Coupling

Background: Prospective comparative studies to predict the risk of hemodynamic deterioration in patients referred for transplantation were performed on the basis of standard invasive and non-invasive data and new wave intensity (WI) parameters. Methods and results: Study Group 1 consisted of 151 consecutive outpatients (age 48.7 ± 12 years; 110 men) with end-stage dilative cardiomyopathy. Group 2, consisting of 11 consecutive patients (age 50 ± 11 years; 6 men) with sinus rhythm and “true” decompensation, was used to create “critical values” of WI. There were no demographic or somatic (weight and height) differences between the groups. The follow-up period of ambulatory patients was 31 ± 8 months. Non-invasive WI was studied in the common carotid artery. Complete invasive and non-invasive data were also recorded on the day of investigation. During follow-up 44 pts were lost; there were 15 cardiac deaths (10%), life-saving ventricular assist device implantation in 10 (6.6%) and transplantation in 19 (12.7%). For statistical purposes this group was named the “events” Group B (n = 44). A predisposing factor for events (death, “true” decompensation and “urgent” transplantation in ambulatory patients) was low first peak (“cut-off value” assessed in Group 2 < 4100 mmHg*s³) (OR 45.6, CI 14.5–143.3, p < 0.001). Less powerful predictors of the risk of deterioration were pulmonary capillary pressure (PCP), diastolic pulmonary artery pressure (PAP) and E/A mitral wave relation (p = 0.05). Conclusions: The new ventricular-arterial coupling parameter 1st peak of WI can potentially be used to distinguish patients at high risk for true deterioration and death. This parameter can be used to predict the need for assist device implantation

Outpatients on mechanical circulatory support

As waiting periods for heart transplantation have lengthened, the application of long-term mechanical circulatory support (MCS) has become more common in patients presenting with cardiogenic shock. Anticipating increased long-term MCS, a policy to discharge patients home has been instituted. This study compares the results of outpatient on MCS to a group of patients remaining hospitalized. We report our 10-year experience with 108 patients on MCS, who were supported for more than 3 months. Group A consisted of 38 patients (25 Novacor, 13 Berlin Heart) who underwent assist implantation from 1996 to 2001. They had a mean support time of 454 days (range 100 to 1074 days) and spent a mean of 326 days (range 20 to 769 days) at home. Group B consisted of 70 patients (24 Novacor, 46 Berlin Heart) who underwent assist implantation between 1991 and 2000. They had a mean support time of 234 days (range 95 to 795 days) and were not discharged. The patients were monitored for complications, hospital readmissions, and causes of death including infections and thromboembolic and bleeding events during the MCS time. Group A total mortality was 16% (6/38). Two patients died from cerebral embolism, one from cerebral hemorrhage, two from systemic infection, and one from multiorgan failure. Thirty-two patients (84%) required 95 readmissions to the hospital due to cerebral embolism (n = 9), bleeding (n = 1), wound infections (n = 23), coagulation disorder (n = 13) for heart transplantation (n = 5), and (n = 44). In group B the mortality was 43% (30/70) for noncardiac reasons and thus significant higher ( p = 0.004, χ 2 test). Causes of death were cerebral embolism (n = 5), cerebral hemorrhage (n = 7), systemic infection (n = 14, significantly higher, p = 0.04, χ 2 test), and multiorgan failure (n = 4). Our experience demonstrates that MCS can be used in outpatients without increased mortality and with an acceptable rate of readmissions (2.8/patient). It ensures the survival of the patient, enables recovery from multiorgan failure, and offers an acceptable quality of life