Heart transplantation: a history lesson of Lazarus

One of the notable advances in modern day medicine is organ transplantation. None more so than the heart. A complex interaction between physiology, surgery and immunology that spanned decades, involving the hard work of many pioneers in their fields. We revisit the contributions of the pioneers as well as marvel at the paradigm shifts in medicine that have made heart transplantation safe and reproducible with in excess of 3000 transplants done yearly today

Heart transplantation: a history lesson of Lazarus

One of the notable advances in modern day medicine is organ transplantation. None more so than the heart. A complex interaction between physiology, surgery and immunology that spanned decades, involving the hard work of many pioneers in their fields. We revisit the contributions of the pioneers as well as marvel at the paradigm shifts in medicine that have made heart transplantation safe and reproducible with in excess of 3000 transplants done yearly today

Introductory editorial: drug-eluting stents or drug-eluting grafts? Insights from proteomic analysis

No abstract available

Primary graft dysfunction after heart transplantation: a thorn amongst the roses

Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation

An overview of different methods of myocardial protection currently employed peri-transplantation

Myocardial protection is integral to the functioning of hearts in day to day cardiac surgery. However, due to the longer ischaemic times, it becomes pivotal in the management of organs during transplantation. There are many different strategies employed to ensure diligent and judicious myocardial protection during donor management, transportation of the heart and the post-operative period. Given the limited supply of organs and the increasing waiting lists for heart transplants worldwide, it has become an area of renewed interest with many innovations and inventions using the principles of basic sciences to improve outcomes of transplanted hearts. The heart procurement process encompasses several of the different myocardial protection strategies in tandem to provide the greatest benefit to the recipients. This review looks at the different modalities employed, which include different types of cardioplegia, the role of biomarkers, the cutting-edge novel therapies, hormonal therapies and ischaemic conditioning strategies

Surgical Treatment of Infective Endocarditis

Infective endocarditis carries a heavy disease burden with a high in-patient mortality. Surgery is the mainstay of treatment in 50% of patients diagnosed with infective endocarditis. Surgery for infective endocarditis can be challenging; a detailed understanding of surgical anatomy is essential and several fundamental principles need to be taken into consideration including optimal timing, radical debridement, decision to repair versus replace as well as the optimal choice for reconstruction. Outcomes of surgery depend on several factors including patient characteristics, the valve (s) involved, the virulence of the organism, and the extent of invasion of the infective process. Despite recent advances in treatment and improved outcomes, there remains areas for potential research including the ideal valve prosthesis/substitute and the optimal material for reconstruction. In this chapter, we will discuss the technical challenges and pitfalls in the surgical treatment of infective endocarditis, the predictors of outcome as well as novel strategies in treatment

ISHLT primary graft dysfunction incidence, risk factors and outcome: a UK national study

Background: Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by ISHLT established diagnostic criteria for PGD. We studied the incidence of PGD across the UK. Methods: We analysed the medical records of all adult patients who underwent heart transplantation between October 2012-October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details and posttransplant complications were compared between the PGD and non PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression. Results: The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31(19%) vs 13(4.5%) (p=0.0001). Donor, recipient and operative factors associated with PGD were: recipient diabetes mellitus (p=0.031), recipient preoperative BIVAD(p<0.001) and preoperative ECMO (p=0.023), female donor to male recipient gender mismatch(p=0.007) older donor age (p=0.010) and intracerebral haemorrhage/thrombosis in donor (p=0.023). Intra-operatively, implant time (p=0.017) and bypass time(p<0.001) were significantly longer in the PGD cohort. Perioperatively, patients with PGD received more blood products (p<0.001). Risk factors identified by multivariable logistic regression were donor age (p=0.014), implant time (p=0.038), female: male mismatch (p=0.033), recipient diabetes (p=0.051) and preoperative VAD/ECMO support (p=0.012), Conclusion: This is the first national study to examine the incidence and significance of PGD after heart transplantation using the ISHLT definition. PGD remains a frequent early complication of heart transplantation and is associated with increased mortality

Percutaneous mitral annuloplasty through the coronary sinus: An anatomic point of view

ObjectiveWe assessed the anatomic relationships among the mitral annulus, coronary sinus, and circumflex artery in human cadaver hearts.MethodsPercutaneous posterior mitral annuloplasty has been proposed to treat functional mitral regurgitation on the basis of the proximity of the coronary sinus to the mitral annulus. However, concern remains about the ability to perform a trigone-to-trigone posterior annuloplasty and the potential for compromise of the circumflex coronary artery. Ten hearts were studied after injection of expansible foam into the coronary sinus and circumflex artery. The mitral annulus perimeter, posterior intertrigonal (T1–T2) and intercommissural (C1–C2) distance, and coronary sinus projection on the native annulus (S1–S2) were measured. The spatial geometry of the coronary sinus was correlated with the circumflex artery route and the distance with the native mitral annulus.ResultsThe projection of coronary sinus annuloplasty achieves at best a commissure-to-commissure annuloplasty 14.5 (6–24) mm behind each trigone: T1–T2: 74 (56–114) mm, C1–C2: 62.2 (48–80) mm, S1–S2: 59.5 (40–80) mm. The coronary sinus was distant from the native annulus (8–14 mm at the coronary sinus ostium, 13.7–20.4 mm at the middle of the coronary sinus, 6.9–14 mm at the level of the great coronary vein). The circumflex artery was located between the coronary sinus and the mitral annulus in 45.5% of cases.ConclusionsThis anatomic study highlights the 3-dimensional structure of the coronary sinus and its distance from the native mitral annulus and fibrous trigones. Human anatomic studies are mandatory for the further development of percutaneous mitral repair technology

Mechanical circulatory support for refractory cardiogenic shock post-acute myocardial infarction-a decade of lessons.

There are 0.9 catheterization labs per 100,000 inhabitants in Scotland for percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), which are much less accessible to patients in remote and rural areas. An uncommon but sinister sequalae following AMI is cardiogenic shock (CS) that could be refractory to inotropic support. CS complicates 5-15% of AMIs occurring in ST-segment elevation myocardial infarctions (STEMIs). Outcomes of CS are poor with mortalities of up to 90% reported in the literature in the absence of experienced care. We report our experience as the tertiary referral centre in Scotland for MCS and heart transplantation over 8 years. A retrospective review of prospectively collected data was undertaken on all patients registered to the MCS service. The database was interrogated for patient demographics, type of mechanical circulatory support (MCS) and duration of MCS support, PCI-outcomes and survival to 30 days. A time-to-event analysis was performed using patient survival as the primary outcome measure. Twenty-three patients (16 male, 7 females) were included. The median age of the patients as 50 years (range, 45-56 years). VA-ECMO was the initial MCS of choice in 17 (73.9%) patients with BIVAD for 4 (17.4%) patients and LVAD for 2 (8.7%) patients. Thirty-day mortality was 21.8% in this cohort, however survival to discharge was 52.2%. Eleven (47.8%) patients recovered without the need for any further support, however only 9 (81.8%) patients in this subgroup survived to discharge. Three (13.0%) patients received a durable LVAD. In this subgroup, one patient was transplanted whereas two patients died due to complications while on support. The median length of in-hospital MCS support was 4 days. Median in-hospital stay was 27 days. Long-term follow up of up to 8 years demonstrates a high mortality beyond 30-day up to the first 6-month post MCS support. MCS usage in these patients carries a high mortality in the early post-implantation period. However, there is a significant benefit to patients who survive the initial bridging period to recovery or destination therapy

Mechanical circulatory support for refractory cardiogenic shock post-acute myocardial infarction-a decade of lessons.

There are 0.9 catheterization labs per 100,000 inhabitants in Scotland for percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), which are much less accessible to patients in remote and rural areas. An uncommon but sinister sequalae following AMI is cardiogenic shock (CS) that could be refractory to inotropic support. CS complicates 5-15% of AMIs occurring in ST-segment elevation myocardial infarctions (STEMIs). Outcomes of CS are poor with mortalities of up to 90% reported in the literature in the absence of experienced care. We report our experience as the tertiary referral centre in Scotland for MCS and heart transplantation over 8 years. A retrospective review of prospectively collected data was undertaken on all patients registered to the MCS service. The database was interrogated for patient demographics, type of mechanical circulatory support (MCS) and duration of MCS support, PCI-outcomes and survival to 30 days. A time-to-event analysis was performed using patient survival as the primary outcome measure. Twenty-three patients (16 male, 7 females) were included. The median age of the patients as 50 years (range, 45-56 years). VA-ECMO was the initial MCS of choice in 17 (73.9%) patients with BIVAD for 4 (17.4%) patients and LVAD for 2 (8.7%) patients. Thirty-day mortality was 21.8% in this cohort, however survival to discharge was 52.2%. Eleven (47.8%) patients recovered without the need for any further support, however only 9 (81.8%) patients in this subgroup survived to discharge. Three (13.0%) patients received a durable LVAD. In this subgroup, one patient was transplanted whereas two patients died due to complications while on support. The median length of in-hospital MCS support was 4 days. Median in-hospital stay was 27 days. Long-term follow up of up to 8 years demonstrates a high mortality beyond 30-day up to the first 6-month post MCS support. MCS usage in these patients carries a high mortality in the early post-implantation period. However, there is a significant benefit to patients who survive the initial bridging period to recovery or destination therapy