Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews.

Unlabelled: The best approach to adverse-event review in solid organ transplantation is unknown. We initiated a departmental case review (DCR) method based on root-cause analysis methods in a high-volume multiorgan transplant center. We aimed to describe this process and its contributions to process improvement.

Destination Therapy: Standardizing the Role of Palliative Medicine and Delineating the DT-LVAD Journey.

Context: Destination therapy (DT) patients face significant challenges as they transition from chronic left ventricular assist device (LVAD) support to comfort-oriented care. Integration of palliative medicine (PM) into the multidisciplinary team is important to facilitate advanced care planning (ACP) and improve quality of life (QoL).

Objectives: We evaluated the impact of a structured programmatic approach to the end-of-life (EOL) process in DT patients as measured by QoL surveys and the utilization of ACP.

Monster Lung Cavity in a Heart Transplant Recipient.

Invasive mucormycosis infections occur in less than 1% of recipients of orthotopic heart transplants. Given the angioinvasive nature of these infections, the mortality rate is high. Little literature exists regarding the presentation and management of these infections.

Ethical Analysis of Withdrawing Total Artificial Heart Support.

Objectives: To describe the characteristics of patients who undergo withdrawal of total artificial heart support and to explore the ethical aspects of withdrawing this life-sustaining treatment.

Patients And Methods: We retrospectively reviewed the medical records of all adult recipients of a total artificial heart at Mayo Clinic from the program's inception in 2007 through June 30, 2015. Management of other life-sustaining therapies, approach to end-of-life decision making, engagement of ethics and palliative care consultation, and causes of death were analyzed.

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.

Mechanical circulatory assist devices: a primer for critical care and emergency physicians.

Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and "decision-making". These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices.

Effect of Continued Cardiac Resynchronization Therapy on Ventricular Arrhythmias After Left Ventricular Assist Device Implantation.

Cardiac resynchronization therapy (CRT) reduces ventricular arrhythmia (VA) burden in some patients with heart failure, but its effect after left ventricular assist device (LVAD) implantation is unknown. We compared VA burden in patients with CRT devices in situ who underwent LVAD implantation and continued CRT (n = 39) to those who had CRT turned off before discharge (n = 26). Implantable cardioverter-defibrillator (ICD) shocks were significantly reduced in patients with continued CRT (1.

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.

SynCardia Portable Freedom Driver: A Single-Center Experience With 11 Patients.

Objective: The portable Freedom Drive (SynCardia Inc, Tucson, AZ USA) for total artificial heart (TAH-t) support was approved for an investigational device exemption study in March 2010. We review our center's experience with the portable driver.

Methods: A retrospective review was conducted of patients who underwent TAH-t implantation and transfer to portable driver from September 2008 to June 2012, with follow-up through December 2012.

Anesthetic pharmacology and perioperative considerations for heart transplantation.

From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.

Lung transplantation: perioperative pharmacology and anesthetic considerations.

In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U.

Role of total artificial heart in the management of heart transplant rejection and retransplantation: case report and review.

Cardiac allograft rejection and failure may require mechanical circulatory support as bridge-to-retransplantation. Prognosis in this patient group is poor and implantable ventricular assist devices have had limited success due to organ failure associated with the high dose immunosuppression required to treat ongoing rejection. We present a case from our institution and the world-wide experience utilizing the SynCardia CardioWest Total Artificial Heart (TAH-t; SynCardia Systems, Inc.

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.

Total lymphoid irradiation in heart transplantation: long-term efficacy and survival--an 18-year experience.

Background: Total lymphoid irradiation (TLI) has been used in transplantation for over 20 years and is currently used in a number of major heart transplant centers as a secondary therapy for recalcitrant recurrent rejection or rejection with hemodynamic compromise. The purpose of this study is to evaluate the long-term risks and efficacy of TLI in the treatment of rejection.

Methods: Between 1990 and 1996, 73 adult patients (from 211 adult transplant recipients) received TLI for recurrent rejection (71%), rejection with hemodynamic compromise (25%), and rejection with vasculitis (4%).

On solid-phase antibody assays.

There is considerable evidence that pre-operative and post-operative anti-human leukocyte antigen (anti-HLA) antibodies are deleterious in thoracic transplantation. While debate continues in heart and lung transplantation on the role of and the diagnosis and treatment of antibody-mediated rejection (AMR), central to the discussion is our ability to detect anti-HLA antibodies. This perspective outlines the concerns elicited by new technology for detection of anti-HLA antibodies using solid-phase assays, and highlights the need for functional assays to further understand the clinical significance of these antibodies.

Balancing rejection and infection with respect to age, race, and gender: clues acquired from 17 years of cardiac transplantation data.

Background: Donor and recipient risk factors for rejection and infection have been well characterized. The contribution of demographic factors, especially age at the time of transplantation to morbidity and mortality due to rejection and infection, is much less well understood.

Methods: Using parametric hazard analysis and multivariate risk-factor equations for infection and rejection events, we quantitatively determined the relationship of fundamental demographic variables (age, race and gender) to infection and rejection.

How much alcohol should we infuse in the coronary artery of hypertrophic cardiomyopathy patients?

Background: Although alcohol septal ablation (ASA) is increasingly used in hypertrophic cardiomyopathy (HC) patients who are refractory to medical therapy, the amount of alcohol that is required has not been well studied. This study sought to determine the amount of alcohol that is necessary to achieve clinical benefits of ASA.

Methods: Myocardial perfusion imaging was used to determine the size of the myocardial infarction produced by ASA in 54 HC patients.

Bronchiolitis obliterans syndrome and survival following lung transplantation for patients with sarcoidosis.

Background: End-stage sarcoidosis is characterized by severe pulmonary fibrosis and is often poorly responsive to medical therapy. Lung transplantation, therefore, may be the only treatment option. Currently, there are few studies evaluating long-term outcomes following transplantation for these patients.

Alcohol septal ablation in a young patient after aortic valve replacement.

A 38-year-old male presented with heart failure symptoms and was diagnosed with aortic valve endocarditis and underlying aortic stenosis in the absence of concentric hypertrophy or bicuspid aortic valve and underwent aortic valve replacement but continued to have symptoms which were then attributed to hypertrophic cardiomyopathy with dynamic left ventricular outflow tract obstruction. He was determined to be unsuitable for myomectomy and underwent successful alcohol septal ablation using transthoracic echocardiographic Doppler and continuous wave velocity monitoring without requiring to cross the aortic valve or to perform transatrial septostomy and left ventricular pressure monitoring. When crossing the aortic valve is a relative or absolute contraindication like in our index case, continuous Doppler velocity recording is a safe and effective alternative approach to monitor the outflow gradient while performing alcohol septal ablation.

Safety of percutaneous dilatational tracheostomy with direct bronchoscopic guidance for solid organ allograft recipients.

Objective: To determine the safety of percutaneous dilatational tracheostomy (PDT) for solid organ allograft recipients, who have increased risks of bleeding and infection.

Participants And Methods: We reviewed the records of patients who underwent solid organ transplant between January 1, 2001, and September 30, 2005, followed by PDT (using the Ciaglia technique) with direct bronchoscopic guidance. We recorded comorbid conditions, number of days from intubation and transplant, positive end-expiratory pressures, ratios of PaO2 to fraction of inspired oxygen, coagulation study findings, complications, and procedure-related mortality rates.

Initial experience with live/real time three-dimensional transesophageal echocardiography.

A new tool has been recently introduced to the echocardiography armamentarium, live/real time three-dimensional (3D) transesophageal echocardiography (TEE). In these cases, we describe our initial experience in 13 patients studied intraoperatively and in the echocardiography suite. This important technology promises improved anatomic definition, diagnostic confidence, and novel views of the complicated cardiovascular pathology encountered in common clinical practice.