Prognostic significance of serum lactate following cardiac transplantation

Aim: Hyperlactatemia is common post-heart transplantation. Lactate measurements in the first 24 h were analyzed with respect to mortality. Methods: A total of 153 consecutive cardiac transplant patients were reviewed. Recipients of organs maintained in a state of ex vivo perfusion were included. Results: A total of 143 heart recipients were included. Hyperlactatemia (>2 mmol/l) was present in all patients. Despite maximum lactate and lactate clearance being significantly higher in nonsurvivors (p = 0.002, p = 0.004), neither receiver operator curve analysis nor multivariate logistic regression showed association with 1-year mortality. In comparison, the minimum lactate was significantly associated with mortality (area under the curve 0.728 [p < 0.001]; odds ratio 1.28 [95% 1.01-162; p = 0.04]). Conclusion: The minimum lactate, a surrogate of persistent hyperlactatemia, was demonstrated to be superior compared with maximum lactate and lactate clearance in determining patient prognosis.

Mechanosensitive molecular mechanisms of myocardial fibrosis in living myocardial slices

AIMS

Altered mechanical load in response to injury is a main driver of myocardial interstitial fibrosis. No current in vitro model can precisely modulate mechanical load in a multicellular environment while maintaining physiological behaviour. Living myocardial slices (LMS) are a 300 μm-thick cardiac preparation with preserved physiological structure and function. Here we apply varying degrees of mechanical preload to rat and human LMS to evaluate early cellular, molecular, and functionality changes related to myocardial fibrosis.

METHODS AND RESULTS

Left ventricular LMS were obtained from Sprague Dawley rat hearts and human cardiac samples from healthy and failing (dilated cardiomyopathy) hearts. LMS were mounted on custom stretchers and two degrees of diastolic load were applied: physiological sarcomere length (SL) (SL = 2.2 μm) and overload (SL = 2.4 μm). LMS were maintained for 48 h under electrical stimulation in circulating, oxygenated media at 37°C. In overloaded conditions, LMS displayed an increase in nucleus translocation of Yes-associated protein (YAP) and an up-regulation of mechanotransduction markers without loss in cell viability. Expression of fibrotic and inflammatory markers, as well as Collagen I deposition were also observed. Functionally, overloaded LMS displayed lower contractility (7.48 ± 3.07 mN mm^-2 at 2.2 SL vs. 3.53 ± 1.80 mN mm^-2 at 2.4 SL). The addition of the profibrotic protein interleukin-11 (IL-11) showed similar results to the application of overload with enhanced fibrosis (8% more of collagen surface coverage) and reduced LMS contractility at physiological load. Conversely, treatment with the Transforming growth factor β receptor (TGF-βR) blocker SB-431542, showed down-regulation of genes associated with mechanical stress, prevention of fibrotic response and improvement in cardiac function despite overload (from 2.40 ± 0.8 mN mm^-2 to 4.60 ± 1.08 mN mm^-2 ).

CONCLUSIONS

The LMS have a consistent fibrotic remodelling response to pathological load, which can be modulated by a TGF-βR blocker. The LMS platform allows the study of mechanosensitive molecular mechanisms of myocardial fibrosis and can lead to the development of novel therapeutic strategies.

Sternal sparing bilateral symmetrical thoracotomy for implantation of left ventricular assist device

Reopening the chest in patients with left ventricular assist devices at the time of a heart transplant is challenging due to adhesions and the possibility of injury to vital structures. The sternal sparing bilateral thoracotomy approach utilized to implant a left ventricular assist device minimizes the chances of such injuries and offers a cosmetically better outcome. We demonstrate a procedure for implanting a left ventricular assist device in a 54-year-old man diagnosed with dilated cardiomyopathy who suffered rapid decompensation despite maximum medical therapy.

Ex vivo lung perfusion made easy

Ex vivo lung perfusion is an indispensable tool in the armamentarium of any lung transplant center. It helps to increase an already shrinking donor pool by offering a chance to assess suboptimal donor lungs in a systematic manner and improve them by treating them with low-molecular-weight perfusate. We offer a stepwise guide to carry out ex vivo lung perfusion on the donor lungs and criteria to accept them for transplants.

Percutaneous Impella CP exchange with preservation of transfemoral access

In patients with cardiogenic shock, the global use of percutaneous mechanical circulatory support using the Impella CP device has increased with early data suggesting potential benefits over conservative management. In the current case report we describe a simple technique facilitating percutaneous Impella CP or RP exchange with preservation of transfemoral access, which does not require the use of a 0.035' wire. This technique allows for percutaneous sealing of the 14F arteriotomy using new closure devices avoiding the traditional cut-down.

Concurrent micro- to macro-cardiac electrophysiology in myocyte cultures and human heart slices

The contact cardiac electrogram is derived from the extracellular manifestation of cellular action potentials and cell-to-cell communication. It is used to guide catheter based clinical procedures. Theoretically, the contact electrogram and the cellular action potential are directly related, and should change in conjunction with each other during arrhythmogenesis, however there is currently no methodology by which to concurrently record both electrograms and action potentials in the same preparation for direct validation of their relationships and their direct mechanistic links. We report a novel dual modality apparatus for concurrent electrogram and cellular action potential recording at a single cell level within multicellular preparations. We further demonstrate the capabilities of this system to validate the direct link between these two modalities of voltage recordings.

Current approaches in retrieval and heart preservation

Fifty years after the first successful heart transplantation, despite multiple advances in the treatment of advanced acute and chronic heart failure, there is still no equivalent to heart transplantation as a long-term treatment for end-stage heart failure. Transplantation is, however, limited by the scarcity and quality of heart allografts. Donors are nowadays significantly older, particularly in European countries, and traumatic head injury as the cause of death has been replaced by intracerebral hemorrhage or hypoxic brain damage in the majority of cases. In addition, many donors have undergone extensive resuscitation efforts. Recipient characteristics have progressively changed too within the last couple of decades; recipients are older, often with comorbidities and nearly half of them are bridged to transplant with a wide variety of mechanical circulatory support devices. These developments have resulted in heart transplant surgery becoming significantly more challenging with longer more complex surgery and increased ischemia times for organs that were previously considered to be borderline or non-transplantable in many cases. To address this, several options have been explored within the last years and as a result, novel strategies have been developed and tested in order to optimize graft preservation and potentially increase the donor pool. The two notable developments are the ability to procure hearts from donors after circulatory death and the advent of ex-vivo perfusion of hearts. This technology has made the transplantation of extended criteria organs, including those from circulatory determined death (DCD) donors possible, and allow for out of body time of more than 12 hours in heart transplantation. In this review, we set out the basis of the current practices in organ procurement, and the opportunities for the future as demands for organ transplantation continue to increase.

Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

Everolimus Versus Mycophenolate Mofetil De Novo After Lung Transplantation: A Prospective, Randomized, Open-Label Trial

The role of mammalian target of rapamycin (mTOR) inhibitors in de novo immunosuppression after lung transplantation is not well defined. We compared Everolimus versus mycophenolate mofetil in an investigator-initiated single-center trial in Hannover, Germany. A total of 190 patients were randomly assigned 1:1 on day 28 posttransplantation to mycophenolate mofetil (MMF) or Everolimus combined with cyclosporine A (CsA) and steroids. Patients were followed up for 2 years. The primary endpoint was freedom from bronchiolitis obliterans syndrome (BOS). The secondary endpoints were incidence of acute rejections, infections, treatment failure and kidney function. BOS-free survival in intention-to-treat (ITT) analysis was similar in both groups (p = 0.174). The study protocol was completed by 51% of enrolled patients. The per-protocol analysis shows incidence of bronchiolitis obliterans syndrome (BOS): 1/43 in the Everolimus group and 8/54 in the MMF group (p = 0.041). Less biopsy-proven acute rejection (AR) (p = 0.005), cytomegalovirus (CMV) antigenemia (p = 0.005) and lower respiratory tract infection (p = 0.003) and no leucopenia were seen in the Everolimus group. The glomerular filtration rate (GFR) decreased in both groups about 50% within 6 months. Due to a high withdrawal rate, the study was underpowered to prove a difference in BOS-free survival. The dropout rate was more pronounced in the Everolimus group. Secondary endpoints indicate potential advantages of Everolimus-based protocols but also a potentially higher rate of drug-related serious adverse events.

Salvage myocardial revascularisation in spontaneous left main coronary artery dissection with cardiogenic shock – the role of mechanical circulatory support

Spontaneous left main coronary artery dissection is a rare cause of acute coronary events or sudden cardiac death, constituting less than 1% of all epicardial coronary artery dissections. It is often fatal and is mostly recognized at post-mortem examination in young victims of sudden death. More than 70% of the reported cases occurred in women, particularly during pregnancy and the peripartum period and those on oral contraceptives. The clinical presentation is highly variable and prognosis varies widely, depending predominantly on the speed of diagnosis. Treatment options include medical therapy, revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and mechanical circulatory support in cases of cardiogenic shock.

We report a case of spontaneous dissection of the left main stem coronary artery, with extension into the left coronary territory, which occurred in a 41-year-old lady, complicated by profound cardiogenic shock requiring recovery with extracorporeal mechanical circulatory support after salvage myocardial revascularization.

Oxygenator in short-term LVAD circuit: a rescue in post-LVAD pulmonary complications

Pulmonary complications after left ventricular assist device (LVAD) implantation, though infrequent, can be potentially catastrophic. A 62-year-old female with cardiogenic shock, supported on short-term LVAD, developed pulmonary oedema. An oxygenator was introduced into the LVAD circuit, which improved the gas exchange and, eventually, after weaning off the oxygenator, the patient received long-term LVAD. The introduction of an oxygenator into the short-term LAVD circuit is a lifesaving manoeuvre in such a situation. It offers freedom of introducing and removing the oxygenator into the LVAD circuit without opening the chest and competing for LVAD flow.

Quality of Life and Bronchiolitis Obliterans Syndrome in Patients after Lung Transplantation

Background

Lung transplantation has become an established and effective treatment for patients with end-stage pulmonary disease.

Objective

To investigate health-related quality of life in correlation with occurrence and degree of bronchiolitis obliterans syndrome after transplantation.

Methods

In a cross-sectional study design, 119 consecutive lung transplant recipients (63.9% bilateral and 36.1% single lung transplants) responded voluntarily to a set of standardized questionnaires (12-Item Short-Form Health Survey, Center for Epidemiologic Studies-Depression Scale, Coping With Everyday Life, Beck Anxiety Inventory, Zerssen list of complaints) that covered health-related quality of life and psychological well being. Also, we performed pulmonary function studies to clinically grade bronchiolitis obliterans syndrome in all patients.

Results

In this cohort, 41.2% of patients developed bronchiolitis obliterans syndrome at a mean interval of 5.6 years after lung transplantation. Actuarial freedom from bronchiolitis obliterans syndrome was 90.1%±2.3% at 1 year, 79.9%±3.7% at 3 years, and 59.5%±4.8% at 5 years after lung transplantation. Recipients with bronchiolitis obliterans syndrome reported significantly lower well being and quality of life than those without bronchiolitis obliterans syndrome, who scored similar to healthy volunteers. In a subanalysis, body functioning ( P<.001) and related areas of coping ( P<.001) were mostly affected by bronchiolitis obliterans syndrome.

Conclusions

Quality of life was negatively affected by the onset of bronchiolitis obliterans syndrome. However, even patients who develop bronchiolitis obliterans syndrome reported a temporary benefit from lung transplantation. In addition to optimal medical care and efforts in preventing bronchiolitis obliterans syndrome, psychological support of lung recipients seems to be essential, especially when bronchiolitis obliterans syndrome occurs.

Effect of donor cardiac arrest and arrest duration on outcomes of lung transplantation

BACKGROUND

Limited data are available about lung transplantation (LTx) from donors suffering cardiac arrest (CA) prior to actual donation.

METHODS

A retrospective analysis of LTx performed between January 2007 and September 2012 was done with the focus on CA in donors. The recipients were grouped depending on the history of donor CA and CA duration (downtime) as: No cardiac arrest ("NoCA"), CA downtime less than 20 min ("CA < 20"), and CA downtime equal to or more than 20 min ("CA > 20"). Early and mid-term outcomes after LTx were compared among the three groups.

RESULTS

A total of 237 LTx were performed during the study period. One hundred eighty-eight patients received organs from "NoCA" donors, 25 from "CA < 20" donors, and 24 patients from "CA > 20" donors. There was a trend toward better overall cumulative survival in both CA groups (log rank p = 0.076) whereas the survival in the "CA > 20" group was significantly better than in the "NoCA" group in the subgroup analysis (log rank p = 0.045). Freedom from bronchiolitis obliterans syndrome (BOS) also increased with increase in CA duration, although it did not reach statistical significance.

CONCLUSIONS

Transplantation of lungs from donors with a history of CA is safe and feasible. Longer duration of cardiac arrest may improve the outcomes after the LTx in terms of survival and freedom from BOS.

Investigation of the Characteristics of HeartWare HVAD and Thoratec HeartMate II Under Steady and Pulsatile Flow Conditions

The aim of this study was to elucidate the dynamic characteristics of the Thoratec HeartMate II (HMII) and the HeartWare HVAD (HVAD) left ventricular assist devices (LVADs) under clinically representative in vitro operating conditions. The performance of the two LVADs were compared in a normothermic, human blood-filled mock circulation model under conditions of steady (nonpulsatile) flow and under simulated physiologic conditions. These experiments were repeated using 5% dextrose in order to determine its suitability as a blood analog. Under steady flow conditions, for the HMII, approximately linear inverse LVAD differential pressure (H) versus flow (Q) relationships were observed with good correspondence between the results of blood and 5% dextrose under all conditions except at a pump speed of 9000 rpm. For the HVAD, the corresponding relationships were inverse curvilinear and with good correspondence between the blood-derived and 5% dextrose-derived relationships in the flow rate range of 2-6 L/min and at pump speeds up to 3000 rpm. Under pulsatile operating conditions, for each LVAD operating at a particular pump speed, an counterclockwise loop was inscribed in the HQ domain during a simulated cardiac cycle (HQ loop); this showed that there was a variable phase relationship between LVAD differential pressure and LVAD flow. For both the HMII and HVAD, increasing pump speed was associated with a right-hand and upward shift of the HQ loop and simulation of impairment of left ventricular function was associated with a decrease in loop area. During clinical use, not only does the pressure differential across the LVAD and its flow rate vary continuously, but their phase relationship is variable. This behavior is inadequately described by the widely accepted representation of a plot of pressure differential versus flow derived under steady conditions. We conclude that the dynamic HQ loop is a more meaningful representation of clinical operating conditions than the widely accepted steady flow HQ curve.

GORD symptoms in lung transplantation: how efficient is the reflux symptom index questionnaire compared to the esophageal impedance test?

OBJECTIVE

As Gastroesophageal reflux disease (GORD) affects long-term survival in lung transplant recipients, the aim of this observational prospective study was to analyze the efficacy of The Reflux Symptom Index Questionnaire (RSI) compared to the esophageal impedance test.

METHODS

Both esophageal impedance studies and RSI questionnaire were routinely performed in all patients who had completed rehabilitation following lung transplantation from June 2013 till March 2014. RSI generates a score of between zero and forty-five, taking into account any symptoms within four wk of the questionnaire. Our analysis considered RSI score cut-offs of 10 and 13 indicating significance of reflux.

RESULTS

Out of 84 patients, 50 (59.5%) had evidence of GORD detected by impedance studies, whereas only 33 (39.2%) and 22 (26.2%) had RSI >10 and 13, respectively. An elevated RSI was not found to be associated with positive impedance studies using a score of either 10 or 13 (p = 0.127 and p = 0.142, respectively); 32.1% (n = 27) and 40.5% (n = 34) were found to have negative RSI and positive impedance test using 10 or 13 as cut-off, respectively.

CONCLUSION

RSI Score is an unreliable predictor of GORD among lung transplant recipients. The authors therefore recommend the routine use of impedance testing in post-transplant patients.

Continuous-Flow Left Ventricular Assist Device Thrombosis: A Danger Foreseen is a Danger Avoided

Left ventricular assist devices (LVAD) are an increasingly implemented therapeutic intervention for patients with end-stage heart failure. A growing body of evidence, however, has shown an elevated risk of device thrombosis, a major complication jeopardizing the patient's post-implantation survival. To date, multiple causative factors for LVAD thrombosis have been identified, such as internal shear stress, device material, infection, and inadequate anticoagulation. Understanding the mechanisms leading to LVAD thrombosis will not only enable device optimization, but also allow for better patient handling, hence improving post-implantation outcome. In this review we highlight the most commonly identified factors leading to LVAD thrombosis and discuss their mechanisms.

Modified technique using Novalung as bridge to transplant in pulmonary hypertension

Patients with idiopathic pulmonary artery hypertension in refractory right ventricular failure may decompensate acutely and die while on the lung transplantation waiting list. We describe such a patient bridged to lung transplantation with a modified surgical technique for left pulmonary artery-to-left atrium bypass using Novalung, a low-resistance diffusion membrane device.

Utilization of the organ care system - a game-changer in combating donor organ shortage

For patients with end-stage heart failure, cardiac transplantation persists to be the gold standard. Nevertheless, the availability of organs remains a main constraint to the treatment. Through mounting usage of ex vivo heart perfusion an increase in organ availability was achieved by reconditioning of organs formerly not regarded as appropriate for transplantation. We propose the future standard application of this state-of-the-art technology to improve the pool of donor organs by evaluating hearts outside standard acceptability criteria.

Utilization of the organ care system as ex-vivo lung perfusion after cold storage transportation

The Organ Care System (OCS) allows perfusion and ventilation of the donor lungs under physiological conditions. Ongoing trials to compare preservation with OCS Lung with standard cold storage do not include donor lungs with suboptimal gas exchange and donor lungs treated with OCS following cold storage transportation. We present a case of a 48-yr-old man who received such lungs after cold storage transportation treated with ex-vivo lung perfusion utilizing OCS.

Ex vivo lung perfusion - state of the art in lung donor pool expansion

Lung transplantation remains the gold standard for patients with end-stage lung disease. Nevertheless, the number of suitable donor lungs for the increasing number of patients on the waiting list necessitates alternative tools to expand the lung donor pool. Modern preservation and lung assessment techniques could contribute to improved function in previously rejected lungs. Ex vivo lung perfusion (EVLP) already demonstrated its value in identification of transplantable grafts from the higher risk donor pool. Moreover, lungs from EVLP did not show significantly different postoperative results compared to standard criteria lungs. This could be explained by the reduction of the ischemia-reperfusion injury through EVLP application. The aim of this article is to review technical characteristics and the growing clinical EVLP experience with special attention to EVLP application for donation after cardiac death (DCD) lungs.

Ex vivo heart perfusion after cardiocirculatory death; a porcine model

BACKGROUND

Donation after cardiocirculatory death (DCD) has lead to an increase in organ availability. However, because of medical, logistic, and ethical issues, the use of hearts from DCD donors for transplantation is not generally considered to be feasible. In this study, we investigated the feasibility of ex vivo resuscitation and assessment of the porcine heart after circulatory death using the organ care system (OCS).

METHODS

Cardiocirculatory death was induced in five pigs by cessation of mechanical ventilation. No heparin was administered. The agonal time (AT) was calculated as the time between a reduction of blood pressure <50 mm Hg or a fall in saturation beneath 70% and the cessation of electrical activity. After a further 15 min of warm ischemia, hearts were procured and implanted into the OCS, mimicking the actual clinical scenario for other organs. Thus, procured grafts were assessed ex vivo over a period of 4 h.

RESULTS

Four hearts were successfully resuscitated on the system (AT 8, 15, 20, and 34 min) Three grafts had excellent visual contractility and lactate trends and were considered to be transplantable. One graft (AT 34 min) had an increased lactate and abnormal contractility being unsuitable for transplantation. One heart with 48-min AT could not be resuscitated.

CONCLUSIONS

Our data show that hearts from nonheparinized DCD porcine donors can be successfully resuscitated using the OCS in a scenario, which closely simulates clinical conditions.

Oxy-RVAD: rescue in pulmonary complications after LVAD implantation

Pulmonary complications after left ventricular assist device (LVAD) implantation seldom occur; however, if present, they may prove catastrophic. An Oxy-RVAD (oxygenator in right VAD circuit) is a lifesaving technique in such cases and allows freedom of introducing and removing an oxygenator into the RVAD circuit without opening the chest and competing with LVAD flow.

Utilization of the Organ Care System Lung for the assessment of lungs from a donor after cardiac death (DCD) before bilateral transplantation

In this manuscript, we present the first experience of evaluating donation after circulatory death (DCD) lungs, using the normothermic preservation Organ Care System (OCS) and subsequent successful transplantation. The OCS could be a useful tool for the evaluation of marginal lungs from DCD donors as it allows a proper recruitment and bronchoscopy in such donations in addition to continuous ex-vivo perfusion and assessment and treatment during transport. The OCS could potentially be a standard of care in the evaluation of marginal lungs from DCD.

Utilization of a novel rib spreader for minimally invasive lung transplantation

Rack-and-pinion-type stainless steel rib spreader was innovated by Truffier in 1914, which was modified by Finochietto to have fenestrated blades and a hand-cranked lever to both separate the arms in a staged fashion and lock them in place at each stop. Its Burford-Finochietto variants with replaceable blades are ubiquitous in open thoracic surgery. Fehling Surgical Instrument, Inc (Acworth, GA) introduced a modified rib spreader-an assembly of movable and adjustable blades, a mobile bridge and spreader arms, which owing to its adaptation of thoracotomy incision provides an optimum exposure without injuring the ribs. The spreader is indispensible in lung transplantation surgery performed especially through minimally invasive (bilateral limited anterolateral thoracotomies with intact sternum) approach.

Use of Foley catheter for insertion of ventricular assist device inflow cannula

Ventricular assist devices are fast becoming an accepted alternative to treat end-stage heart failure, and are being implemented as a bridge to myocardial recovery, a bridge to heart transplantation, or as destination therapy. Positioning of the inflow cannula into the apex of the ventricle is a crucial step due to the risk of sucking in air. We describe an improved method of preparing the insertion site for the ventricular assist device inflow cannula, to minimize the chances of air embolism and blood spillage, which we applied in a 34-year-old man, as a bridge to transplantation.

Successful treatment of ulcerative colitis-related fulminant myocarditis using extracorporeal life support

Myocarditis is a known extraintestinal manifestation of inflammatory bowel diseases, but it rarely leads to acute cardiac pump failure. We report a case of fulminant myocarditis associated with ulcerative colitis treated successfully with an extracorporeal membrane oxygenator.

Pearls and pitfalls in short-term mechanical circulatory assist: how to avoid and manage complications

In today's era, given the worsening risk profiles of patients undergoing cardiac surgery, the increasing number of complex cardiac surgeries, and the increasing number of patients undergoing thoracic organ transplantation, short-term mechanical circulatory assist (MCA) devices are indispensable. MCA devices are capable of supporting heart and lung function and have emerged as potentially lifesaving instruments, but may prove to be as hazardous as helpful due to their inherent tendency toward hemolysis, thromboembolism, and hemorrhage. Although MCA devices are being used regularly at some specialized centers, surgeries involving MCA are not as common as other routine cardiac surgeries, and even though professionals implanting and maintaining short-term MCAs are well acquainted with operating such devices, it is not uncommon to come across complications as a result of minor mistakes committed while dealing with them. Avoiding simple mistakes and taking proper precautions while implanting and maintaining these devices can prevent major catastrophes. We discuss commonly encountered problems and complications during the implantation and maintenance of short-term MCAs and offer reasonable and practical solutions. In addition, crucial issues such as anticoagulation, replacement of the device circuit, and management of the distal perfusion cannula are discussed. Continuous and efficient monitoring of the MCA device and the patient supported on MCA, together with anticipation and avoidance of complications, is key for successful short-term MCA support.

Aortic valve replacement 10 years after lung transplantation

Age-related native pathologic conditions are an inevitable sequela in long-term survivors of solid organ transplantation. A sexagenarian presented with severe aortic valve stenosis 10 years after lung transplantation (LTx). Despite overwhelming concerns of infection because of long-term immunosuppression and the risk of postoperative deterioration of function in transplanted lungs, an open heart surgical procedure with appropriate perioperative management was undertaken, and a successful aortic valve replacement (AVR) was performed.

Minimally invasive access for off-pump HeartWare left ventricular assist device explantation

The implantation of a left ventricular assist device as a bridge to transplantation is a well-established treatment of end-stage heart failure in selected patients. Device-related infection is a well-known complication that may require the removal of the device. We describe a minimally invasive explantation approach with complete removal of all components of a HeartWare left ventricular assist device in a patient with persistent infection related to the device.

Live related donor lobar lung transplantation recipients surviving well over a decade: still an option in times of advanced donor management

As waiting lists for lung transplantation are ever increasing, the number of organ donors is not able to keep pace with it. Living donor lobar lung transplantation is a source of organs which could be lifesaving in end-stage lung disease patients who cannot wait for cadaveric organs due to deteriorating lung function and clinical condition. Two young women with end stage cystic fibrosis received lobes from their relatives and an altruistic friend. They are surviving for more than 12 and 14 years with good lung functions.

Ventricular assist device outflow graft in congenitally corrected transposition of great arteries - a surgical challenge

Congenitally corrected transposition of the great arteries is a complex congenital cardiac anomaly with a wide spectrum of morphologic features and clinical profiles. Most patients are diagnosed late in their life, undergoes surgical repairs, eventually leading to systemic ventricular failure needing heart transplant or mechanical circulatory assistance. As, aorta is located anterior to and left of the PA (Transposition of great arteries), the outflow graft of ventricular assist device traverse across pulmonary artery to reach aorta which poses challenge during further surgical explorations.