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Hariri G, Henocq P, Coutance G, Mansouri S, Tohme J, Guillemin J, Varnous S, Dureau P, Duceau B, Leprince P, Dechartres A, Bouglé A. Perioperative Risk Factors of Acute Kidney Injury After Heart Transplantation and One-Year Clinical Outcomes: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:1514-1523. [PMID: 38664136 DOI: 10.1053/j.jvca.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/17/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES This study aimed to identify perioperative risk factors of acute kidney injury after heart transplantation and to evaluate 1-year clinical outcomes. DESIGN A retrospective single-center cohort study. SETTING At a university hospital. PARTICIPANTS All patients who underwent heart transplantation from January 2015 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors recorded acute kidney injury after heart transplantation. One-year mortality and renal function also were recorded. Risk factors of acute kidney injury were evaluated using a multivariate logistic regression model. Long-term survival was compared between patients developing acute kidney injury and those who did not, using a log-rank test. Among 209 patients included in this study, 134 patients (64% [95% CI (58; 71)]) developed posttransplantation acute kidney injury. Factors independently associated with acute kidney injury were high body mass index (odds ratio [OR]: 1.18 [1.02-1.38] per kg/m2; p = 0.030), prolonged duration of cold ischemic period (OR: 1.11 [1.01-1.24] per 10 minutes; p = 0.039), and high dose of intraoperative dobutamine support (OR: 1.24 [1.06-1.46] per µg/kg/min; p = 0.008). At 1 year, patients who developed postoperative acute kidney injury had higher mortality rates (20% v 8%, p = 0.015). Among 172 survivors at 1 year, 82 survivors (48%) had worsened their renal function compared with preheart transplantation. CONCLUSIONS This study highlighted the high incidence of acute kidney injury after heart transplantation and its impact on patient outcomes. Risk factors such as body mass index, prolonged cold ischemic period duration, and level of inotropic support with dobutamine were identified, providing insights for preventive strategies.
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Affiliation(s)
- Geoffroy Hariri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France.
| | - Paul Henocq
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Guillaume Coutance
- Sorbonne Université, AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Sehmi Mansouri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Joanna Tohme
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France; Université Saint Joseph de Beyrouth - Faculté de Médecine, Service d'anesthésie, réanimation et douleur - Bloc opératoire cardiovasculaire (BOCV), Hopital Hôtel Dieu de France, Beyrouth, Liban
| | - Jérémie Guillemin
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Shaida Varnous
- Sorbonne Université, AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Pauline Dureau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Baptiste Duceau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Pascal Leprince
- Sorbonne Université, AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
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Lechiancole A, Russo CF, Olivieri GM, Maccherini M, Valente S, Pacini D, Suarez SM, Boffini M, Marro M, Pelenghi S, Totaro P, Isola M, Martino MD, Bortolotti U, Livi U, Vendramin I. Prognostic Value of APACHE IV Score in Patients Bridged to Heart Transplantation on ECMO. Clin Transplant 2024; 38:e15370. [PMID: 38922995 DOI: 10.1111/ctr.15370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/05/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Methods for risk stratification of candidates for heart transplantation (HTx) supported by extracorporeal membrane oxygenation (ECMO) are limited. We evaluated the reliability of the APACHE IV score to identify the risk of mortality in this patient subset in a multicenter study. METHODS Between January 2010 and December 2022, 167 consecutive ECMO patients were bridged to HTx; they were divided into two groups, according to a cutoff value of APACHE IV score, obtained by receiver operating characteristic curve analysis for 90-day mortality. Kaplan-Meier survival curves were plotted, and compared through the log-Rank test. Cox regression model was used to estimate which factors were associated with survival. RESULTS The 90-day mortality prediction of the APACHE IV score showed an area under the curve of 0.87 (95% CI: 0.80-0.94), with a cutoff value of 49 (specificity 91.7%-sensibility 69.6%). 125 patients (74.8%) showed an APACHE IV score value < 49 (Group A), and 42 (25.2%) ≥ 49 (Group B). 90-day mortality was 11.2% in Group A and 76.2% in Group B (p < 0.01). Survival at 1 and 5 years was 85.5%, 77% versus 23.4%, 23.4% (p < 0.01) in Groups A and B. Mortality correlated at univariable analysis with recipient age, body mass index, mechanical ventilation, APACHE IV score, and platelets number. At multivariable analysis only APACHE IV score (HR: 1.07 [1.05-1.09, 95% CI]) independently affected survival. CONCLUSIONS The APACHE IV score represents a powerful predictor of survival in patients bridged to HTx on ECMO support, and could guide candidacy of patients on ECMO.
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Affiliation(s)
| | | | | | | | | | - Davide Pacini
- Division of Cardiac Surgery, University Hospital, Bologna, Italy
| | | | | | - Matteo Marro
- Cardiac Surgery Division, University of Turin, Turin, Italy
| | | | - Pasquale Totaro
- Division of Cardiac Surgery, Policlinic Hospital, Pavia, Italy
| | - Miriam Isola
- Department of Medicine, University of Udine, Udine, Italy
| | | | | | - Ugolino Livi
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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Nesseler N, Mansour A, Cholley B, Coutance G, Bouglé A. Perioperative Management of Heart Transplantation: A Clinical Review. Anesthesiology 2023; 139:493-510. [PMID: 37458995 DOI: 10.1097/aln.0000000000004627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.
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Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Research Institute for Environmental and Occupational Health Mixed Research Unit, Rennes, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care Medicine, European Hospital Georges Pompidou, Public Hospitals of Paris, Paris, France; Paris Cité University, National Institute of Health and Medical Research Mixed Research Unit, Paris, France
| | - Guillaume Coutance
- Sorbonne University, Public Hospitals of Paris, Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Bouglé
- Sorbonne University, Clinical Research Group in Anesthesia, Resuscitation, and Perioperative Medicine, Public Hospitals of Paris, Department of Anesthesiology and Critical Care, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
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Lescroart M, Coutance G. Prioritizing the Sickest Among the Sickest: A Matter of Tact and Moderation, but the Game Is Worth the Candle. Transplantation 2023; 107:1436-1437. [PMID: 36653912 DOI: 10.1097/tp.0000000000004519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Mickaël Lescroart
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- Paris Translational Research Centre for Organ Transplantation, Paris Center for Cardiovascular Research - PARCC, INSERM, UMR-S970, Paris, France
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Ohira S, Pan S, Levine A, Aggarwal-Gupta C, Lanier GM, Gass AL, Spielvogel D, Kai M. Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support. Perfusion 2023; 38:473-476. [PMID: 34958280 DOI: 10.1177/02676591211064721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.
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Affiliation(s)
- Suguru Ohira
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Stephen Pan
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Avi Levine
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Chhaya Aggarwal-Gupta
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Alan L Gass
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - David Spielvogel
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Masashi Kai
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
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Lim JH, Lee SY, Ju MH, Kim SH, Choi JH, Chon MK, Lee SH, Hwang KW, Kim JS, Park YH, Kim J, Chun KJ, Lim MH, Lee CH, Je HG. Direct Extracorporeal Membrane Oxygenation Bridged Heart Transplantation: The Importance of Multi-Organ Failure. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:91-99. [PMID: 37180560 PMCID: PMC10172075 DOI: 10.36628/ijhf.2023.0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
Background and Objectives Recently, approximately 40% of all heart transplantation (HTx) in South Korea are performed using the direct extracorporeal membrane oxygenation (ECMO) bridging method. We conducted a study to examine the clinical outcome of direct ECMO-bridged HTx and to investigate the impact of multi-organ failure (MOF). Methods From June 2014 to September 2022, a total of 96 adult patients who underwent isolated HTx at a single tertiary hospital were included in the study. The patients were sub-grouped into ECMO (n=48) and non-ECMO group (n=48), and the ECMO group was subdivided into awake (n=22) and non-awake (n=26) groups based on mechanical ventilator (MV) dependency. Baseline characteristics, 30-day, and 1-year mortality were analyzed retrospectively. Results The 1-year survival rate was significantly lower in the ECMO group (72.9% vs. 95.8%, p=0.002). There was a significant difference in the 30-day survival rate between the awake and non-awake ECMO groups (81.8% vs. 65.4%, p=0.032). In the univariate analysis of logistic regression for 1-year mortality, the odds ratio was 8.5 for ECMO bridged HTx compared to the non-ECMO group, 12.3 in patients who required MV (p=0.003), and 23 with additional hemodialysis (p<0.001). Conclusions Patients who required MV in ECMO bridged HTx showed higher preoperative MOF rates and early mortality than those extubated. When considering ECMO bridged HTx, the severity of MOF should be thoroughly investigated, and careful patient selection is necessary.
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Affiliation(s)
- Ji Hoon Lim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Soo Yong Lee
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Min Ho Ju
- Department of Cardiovascular Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seok Hyun Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jin Hee Choi
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Min Ku Chon
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang Hyun Lee
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Yong Hyun Park
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Junehong Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Kook Jin Chun
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Mi Hee Lim
- Department of Cardiovascular Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chee-hoon Lee
- Department of Cardiovascular Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Gon Je
- Department of Cardiovascular Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Orozco-Hernandez E, DeLay TK, Gongora E, Bellot C, Rusanov V, Wille K, Tallaj J, Pamboukian S, Kaleekal T, Mcelwee S, Hoopes C. State of the art - Extracorporeal membrane oxygenation as a bridge to thoracic transplantation. Clin Transplant 2023; 37:e14875. [PMID: 36465026 DOI: 10.1111/ctr.14875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has revolutionized the treatment of refractory cardiac and respiratory failure, and its use continues to increase, particularly in adults. However, ECMO-related morbidity and mortality remain high. MAIN TEXT In this review, we investigate and expand upon the current state of the art in thoracic transplant and extracorporeal life support (ELS). In particular, we examine recent increase in incidence of heart transplant in patients supported by ECMO; the potential changes in patient care and selection for transplant in the years prior to updated United Network for Organ Sharing (UNOS) organ allocation guidelines versus those in the years following, particularly where these guidelines pertain to ECMO; and the newly revived practice of heart-lung block transplants (HLT) and the prevalence and utility of ECMO support in patients listed for HLT. CONCLUSIONS Our findings highlight encouraging outcomes in patients bridged to transplant with ECMO, considerable changes in treatment surrounding the updated UNOS guidelines, and complex, diverse outcomes among different centers in their care for increasingly ill patients listed for thoracic transplant.
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Affiliation(s)
- Erik Orozco-Hernandez
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Kurt DeLay
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Enrique Gongora
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chris Bellot
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Victoria Rusanov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keith Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Salpy Pamboukian
- Division of Cardiology, University of Washington, Birmingham, Alabama, USA
| | - Thomas Kaleekal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sam Mcelwee
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Hoopes
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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9
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Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant-Change of Paradigm. J Clin Med 2022; 11:jcm11237101. [PMID: 36498676 PMCID: PMC9736223 DOI: 10.3390/jcm11237101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Despite advances in medical therapy and mechanical circulatory support (MCS), heart transplant (HT) remains the gold standard therapy for end-stage heart failure. Patients in cardiogenic shock require prompt intervention to reverse hypoperfusion and end-organ damage. When medical therapy becomes insufficient, MCS should be considered. Historically, it has been reported that critically ill patients bridged with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) directly to HT have worse outcomes. However, when the heart allocation system gives the highest priority to patients on VA-ECMO support, those patients have a higher incidence of HT and a lower incidence of death or removal from the transplant list. Moreover, patients with a short waiting time on VA-ECMO have a similar hazard of mortality to non-ECMO patients. According to the reported data, bridging with VA-ECMO directly to HT may be a solution in the selection of critically ill patients when the anticipated waiting list time is short. However, when a prolonged waiting time is expected, more durable MCS should be considered. Regardless of the favorable results of the direct bridging to HT with ECMO in selected patients, the superiority of this strategy compared to the bridge-to-bridge strategy (ECMO to durable MCS) has not been established and further studies are mandatory in order to clarify this issue.
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Ortiz-Bautista C, Muñiz J, Almenar-Bonet L, Crespo-Leiro MG, Sobrino-Márquez JM, Farrero-Torres M, García-Cosio MD, Díaz-Molina B, Zegrí-Reiriz I, González-Vilchez F, Blázquez-Bermejo Z, López Granados A, Gómez-Bueno M, de la Fuente-Galán L, Blasco-Peiró T, Garrido-Bravo IP, García-Romero E, Rábago Juan-Aracil G, García-Guereta L, Delgado-Jiménez JF. Utility of the IMPACT score for predicting heart transplant mortality. Analysis on a contemporary cohort of the Spanish Heart Transplant Registry. Clin Transplant 2022; 36:e14774. [PMID: 35829691 DOI: 10.1111/ctr.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort. METHODS Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N = 2,810). RESULTS Median value of the IMPACT score was 5 points (IQR: 3, 8). Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥ 15) were 84.4%, 81.5%, 79.3%, 77.3% and 58.5% respectively (Log-Rank test: p<0.001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for one year was 7.56; p = 0.47) and poor discrimination ability (AUC-ROC 0.59) of the IMPACT score as a predictive model. CONCLUSIONS In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Universidade da Coruña, Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica (INIBIC), A Coruña, Spain
| | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María G Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña (UDC), A Coruña, Spain
| | - José M Sobrino-Márquez
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Marta Farrero-Torres
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Clínic, Barcelona, Spain
| | - María D García-Cosio
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Beatriz Díaz-Molina
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Isabel Zegrí-Reiriz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco González-Vilchez
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Zorba Blázquez-Bermejo
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Manuel Gómez-Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia cardiaca avanzada y Trasplante, Servicio de Cardiología, Hospital Universitario Puerta de Hierro de Majadahonda, Madrid, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Elena García-Romero
- Servicio de Cardiología, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases group, Cardiovascular, Respiratory and Systemic Diseases and cellular aging program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Juan F Delgado-Jiménez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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11
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Hansen B, Singer Englar T, Cole R, Catarino P, Chang D, Czer L, Emerson D, Geft D, Kobashigawa J, Megna D, Ramzy D, Moriguchi J, Esmailian F, Kittleson M. Extracorporeal membrane oxygenation as a bridge to durable mechanical circulatory support or heart transplantation. Int J Artif Organs 2022; 45:604-614. [PMID: 35658592 DOI: 10.1177/03913988221103284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with cardiogenic shock may require extracorporeal membrane oxygenation (ECMO) prior to durable mechanical circulatory support (dMCS) or heart transplantation (HTx). METHODS We investigated the clinical characteristics and outcomes of adult patients with ECMO support as bridge to dMCS or HTx between 1/1/13 and 12/31/20. RESULTS Of 57 patients who underwent bridging ECMO, 41 (72%) received dMCS (approximately half with biventricular support) and 16 (28%) underwent HTx, 13 (81%) after the 2018 UNOS allocation system change. ECMO → HTx patients had shorter ventilatory time (3.5 vs 7.5 days; p = 0.018), ICU stay (6 vs 18 days; p = 0.001), and less need for inpatient rehabilitation (18.8% vs 57.5%; p = 0.016). The 1-year survival post HTx was 81.3% in the ECMO → HTx group and 86.4% in the ECMO → dMCS group (p = 0.11). For those patients in the ECMO → dMCS group who did not undergo HTx, 1-year survival was significantly lower, 31.6% (p = 0.001). CONCLUSION Patients on ECMO who undergo HTx, with or without dMCS bridge, have acceptable post-HTx survival. These findings suggest that HTx from ECMO is a viable option for carefully selected patients deemed acceptable to proceed with definitive advanced therapies, especially in the era of the new UNOS allocation system.
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Affiliation(s)
| | | | - Robert Cole
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | - David Chang
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Dael Geft
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Danny Ramzy
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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12
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Favorable Impact of a Multidisciplinary Team Approach on Heart Transplantation Outcomes in a Mid-Volume Center. J Clin Med 2022; 11:jcm11092296. [PMID: 35566420 PMCID: PMC9103698 DOI: 10.3390/jcm11092296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 01/03/2023] Open
Abstract
Although a multidisciplinary team (MDT) approach is recommended for advanced heart failure and heart transplantation (HTx), no studies have investigated the impact of the team approach on post-HTx survival. Thus, we implemented an MDT approach in our HTx program in 2014, with the active involvement of critical care and extracorporeal life support (ECLS) teams and the use of a real-time online information sharing system. We hypothesized that this MDT approach would result in improved survival of patients who had undergone HTx. We enrolled 250 adult patients who underwent HTx between December 2003 and June 2018. They were divided into non-MDT (n = 120; before 2014) and MDT (n = 130; since 2014) groups. The primary outcome was overall mortality. In terms of donor age, diabetes, dialysis, ECLS, and waiting time, the MDT group had more high-risk patients. The MDT approach was found to be an independent predictor of overall survival using a variety of multivariable analytic methods, including inverse probability of treatment weighting analysis. An HF team, a critical care team, and an ECLS team collaboration may improve survival following HTx. To improve the efficiency of the MDT approach, we recommend using a real-time online information sharing system.
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13
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Polastri M, Swol J, Loforte A, Dell'Amore A. Extracorporeal membrane oxygenation and rehabilitation in patients with COVID-19: A scoping review. Artif Organs 2021; 46:30-39. [PMID: 34778984 PMCID: PMC8652633 DOI: 10.1111/aor.14110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022]
Abstract
Background and purpose The coronavirus diseases 2019 (COVID‐19) pandemic posed severe difficulties in managing critically ill patients in hospital care settings. Extracorporeal membrane oxygenation (ECMO) support has been proven to be lifesaving support during the SARS‐CoV‐2 outbreak. The purpose of this review was to describe the rehabilitative treatments provided to patients undergoing ECMO support during the COVID‐19 pandemic. Methods We searched PubMed and Scopus for English‐language studies published from the databases’ inception until June 30, 2021. We excluded editorials, letters to the editor, and studies that did not describe rehabilitative procedures during ECMO support. We also excluded those articles not written in English. Results A total of 50 articles were identified. We ultimately included nine studies, seven of which were case reports. Only two studies had more than one patient; an observational design analyzing the clinical course of 19 patients and a case series of three patients. Extracorporeal support duration varied from 9 to 49 days, and the primary indication was acute respiratory distress syndrome COVID‐19‐related. Rehabilitative treatment mainly consisted of in‐bed mobilization, postural transfers (including sitting), and respiratory exercises. After hospital discharge, patients were referred to rehabilitation facilities. Physiotherapeutic interventions provided during ECMO support and after its discontinuation were feasible and safe. Conclusion The physiotherapeutic treatment of patients undergoing ECMO support includes several components and must be provided in a multidisciplinary context. The optimal approach depends on the patient’s status, including sedation, level of consciousness, ECMO configuration, types of cannulas, and cannulation site.
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Affiliation(s)
- Massimiliano Polastri
- Department of Continuity of Care and Disability, Physical Medicine and Rehabilitation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University General Hospital, Nuremberg, Germany
| | - Antonio Loforte
- Department of Cardiac, Thoracic, Vascular Diseases, Cardiac Surgery and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Andrea Dell'Amore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Division of Thoracic Surgery, University of Padua, Padua, Italy
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14
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Aziz H, Kilic A. How I do it: Totally extrapericardial, ambulatory central venoarterial extracorporeal membrane oxygenation as a bridge to heart transplantation. J Card Surg 2021; 36:4812-4813. [PMID: 34610156 DOI: 10.1111/jocs.16052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Hamza Aziz
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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15
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Ungerman E, Jayaraman AL, Patel B, Khoche S, Subramanian H, Bartels S, Knight J, Gelzinis TA. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part II: Cardiac Transplantation. J Cardiothorac Vasc Anesth 2021; 36:390-402. [PMID: 34657796 DOI: 10.1053/j.jvca.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth Ungerman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Arun L Jayaraman
- Department of Anesthesiology and Perioperative Medicine, Department of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bhoumesh Patel
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, CA
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Steven Bartels
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
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16
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Use of Extracorporeal Life Support for Heart Transplantation: Key Factors to Improve Outcome. J Clin Med 2021; 10:jcm10122542. [PMID: 34201305 PMCID: PMC8228810 DOI: 10.3390/jcm10122542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/11/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022] Open
Abstract
Although patients receiving extracorporeal life support (ECLS) as a bridge to transplantation have demonstrated worse outcomes than those without ECLS, we investigated the key factors in the improvement of their posttransplant outcome. From December 2003 to December 2018, 257 adult patients who underwent heart transplantation (HTx) at our institution were included. We identified 100 patients (38.9%) who underwent HTx during ECLS (ECLS group). The primary outcome was 30-day mortality after HTx. The median duration of ECLS was 10.0 days. The 30-day mortality rate was 3.9% (9.2% in peripheral ECLS, 2.9% in central ECLS, and 1.9% in non-ECLS). The use of ECLS was not an independent predictor of 30-day and 1-year mortality (p = 0.248 and p = 0.882, respectively). Independent predictors of 30-day mortality were found to be higher ejection fraction (p < 0.001), Sequential Organ Failure Assessment score (p < 0.001), and total bilirubin level (p = 0.005). In a subgroup analysis, cannulation type was not a predictor of 30-day mortality (p = 0.275). Early ECLS application to prevent organ failure and sophisticated management of acute heart failure may be important steps in achieving favorable survival after HTx.
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17
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I"IABP"ntentions and E"ECMO"xpectations of New Heart Transplant Donor Organ Allocation Policy. ASAIO J 2021; 67:e71. [PMID: 33031158 DOI: 10.1097/mat.0000000000001285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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18
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Lebreton G, Coutance G, Bouglé A, Varnous S, Combes A, Leprince P. Changes in Heart Transplant Allocation Policy: "unintended" Consequences but Maybe Not so "unexpected…". ASAIO J 2021; 67:e69-e70. [PMID: 33315662 DOI: 10.1097/mat.0000000000001284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Adrien Bouglé
- UMR INSERM 1166, IHU ICAN, Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Shaida Varnous
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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19
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Improved survival after heart transplantation in patients bridged with extracorporeal membrane oxygenation in the new allocation system. J Heart Lung Transplant 2020; 40:149-157. [PMID: 33277169 DOI: 10.1016/j.healun.2020.11.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Historically, patients bridged on extracorporeal membrane oxygenation (ECMO) to heart transplantation (HT) have very high post-transplant mortality. In the new heart transplant allocation system, ECMO-supported patients have the highest priority for HT. However, data are lacking on the outcomes of these critically ill patients. We compared the waitlist and post-transplant outcomes of ECMO-supported patients in the new and old allocation systems. METHODS Adult patients supported by ECMO at the time of listing or transplantation who were registered in the United Network for Organ Sharing database between November 1, 2015 and September 30, 2019 were included. Clinical characteristics, outcomes in the waitlist, and post-transplant survival were compared between the old and new systems. Cox Proportional and subdistribution hazard regression models were used to evaluate the variables contributing to the post-transplant and waitlist outcomes RESULTS: A total of 296 ECMO-supported patients were listed for HT. Of these, 191 were distributed to the old system, and 105 were distributed to the new system. Patients listed in the new system had a higher cumulative incidence of HT (p < 0.001) and lower incidence of death or removal (p = 0.001) from the transplant list than patients listed in the old system. The 6-month survival after transplantation was 74.6% and 90.6% for the old- and new-era patients, respectively (p = 0.002). Among ECMO-supported patients, being listed or transplanted on the new system was independently associated with improved outcomes in the waitlist and after transplantation. CONCLUSIONS With the implementation of the new heart transplant allocation system, ECMO-supported patients have a shorter waitlist time, improved frequency of HT, and improved short-term post-transplant survival.
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20
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Estep JD, Soltesz E, Cogswell R. The new heart transplant allocation system: Early observations and mechanical circulatory support considerations. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32638-6. [PMID: 34756380 DOI: 10.1016/j.jtcvs.2020.08.113] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/30/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Jerry D Estep
- Department of Cardiovascular Medicine, Cleveland Clinic Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, Cleveland, Ohio; Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio.
| | - Edward Soltesz
- Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, Cleveland, Ohio
| | - Rebecca Cogswell
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minn
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21
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Varshney AS, Hirji SA, Givertz MM. Outcomes in the 2018 UNOS donor heart allocation system: A perspective on disparate analyses. J Heart Lung Transplant 2020; 39:1191-1194. [PMID: 32950380 DOI: 10.1016/j.healun.2020.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022] Open
Abstract
The United Network for Organ Sharing (UNOS) implemented a revised donor heart allocation system on October 18, 2018 with principle aims to reduce waitlist mortality, enhance geographic organ sharing, and improve organ distribution equity. Five recently published analyses compared outcomes of heart transplant (HT) recipients transplanted under the revised versus previous system. All demonstrated increased pre-transplant temporary mechanical circulatory support use and graft ischemic times under the revised system. However, despite using data from the same UNOS Registry, three analyses demonstrated increased risk of post-transplant mortality under the revised system, while two others found no significant difference in mortality risk. These studies differed in their analytic cohorts, study periods, follow-up duration, and statistical methodologies. Additionally, some may have introduced survivor bias or violated non-informative censoring. Given these variable findings, longer-term outcome assessment is warranted before the HT community can truly understand the impact of the 2018 UNOS system revision on post-transplant outcomes.
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Affiliation(s)
- Anubodh S Varshney
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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22
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Preoperative Extracorporeal Membrane Oxygenation Implantation in Heart Transplantation. A Cautious Interpretation. Crit Care Med 2020; 48:e630-e631. [PMID: 32568914 DOI: 10.1097/ccm.0000000000004336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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The authors reply. Crit Care Med 2020; 48:e631-e632. [PMID: 32568915 DOI: 10.1097/ccm.0000000000004384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Extracorporeal Membrane Oxygenation Support Prior to Heart Transplantation: "Festina Lente" ("Make Haste Slowly"). Crit Care Med 2020; 48:e538-e539. [PMID: 32433090 DOI: 10.1097/ccm.0000000000004293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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The authors reply. Crit Care Med 2020; 48:e539-e540. [PMID: 32433091 DOI: 10.1097/ccm.0000000000004362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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