A Successful Heart Transplantation Coupled with Temporary Right Ventricular Assist Device Implantation in a Patient with (ir)Reversible Pulmonary Hypertension

Pulmonary hypertension (PH) constitutes one of the main contraindications to heart transplantation (OHT), and elevated pulmonary vascular resistance (PVR) is associated with high risk of posttransplant right heart failure (RVF). In the present case report, a patient with PH is introduced who qualified for heart lung transplantation (HLT) and underwent successful OHT with temporary right ventricle assist device (tRVAD) due to the lack of a suitable heart-lung donor. Temporary RVAD support coupled with optimal medical management may help reverse pulmonary vascular resistance, which was previously deemed as permanent in patients requiring heart transplantation.

Severe Acute Respiratory Distress Syndrome in Potential Organ Donors-Rescue Prone Positioning: A Case Report

Organ transplantation is a recognized treatment for many critical organ insufficiencies. One of the main problems in transplantation is the mismatch between organ donation and demand. It is very important to improve donor eligibility after brain stem death and to minimize insult to donatable organs by appropriate donor management. We present prone positioning as an effective supportive method of organ optimization in patients with acute respiratory distress syndrome with severe hypoxemia and hemodynamic instability.

Effectiveness and Safety Assessment of Citrate Anticoagulation During Albumin Dialysis in Comparison to Other Methods of Anticoagulation

Liver failure is a serious and often deadly disease often requiring MARS (Molecular Adsorbent Recirculating System) therapy. Choosing the safe and effective method of anticoagulation during artificial liver support systems seems to be very difficult and extremely important. The aim of this study was to assess effectiveness and safety of regional anticoagulation with citrate in liver failure patients during MARS. We used a single center observational study. We analyzed 158 MARS sessions performed in 65 patients: 105 (66.5%) sessions in 41 patients with heparin anticoagulation, 40 (25.3%) sessions in 19 patients with citrate, and 13 (8%) sessions in only five patients without anticoagulation, that were excluded from part of the analysis. To determine the effectiveness of regional anticoagulation with citrate, probability of filter survival and changes in laboratory parameters were analyzed according to the applied method of anticoagulation. The safety of citrate was determined by Ca/Ca²⁺ ratio, acid-base balance, bleeding complications, and the need for blood product transfusions. The probability of filter survival in the citrate group was 94% and in the heparin group 82% (P = 0.204). There was no relationship between the method of anticoagulation and effectiveness of MARS therapy in lowering the levels of the analyzed parameters. Only one patient had a Ca/Ca²⁺ ratio higher than he safety margin. There were no statistically significant changes in pH and lactate level irrespective of anticoagulation; bicarbonate dropped significantly only in the heparin group (P = 0.03). The frequency of bleeding complications and the need for transfusions did not differ significantly between groups. Regional anticoagulation with citrate can be an effective and safe method of anticoagulation during MARS therapy, but requires attentive monitoring and further studies in liver failure patients.

Utility of transthoracic echocardiography (TTE) in assessing fluid responsiveness in critically ill patients - a challenge for the bedside sonographer

Transthoracic echocardiography (TTE) has become one of the most important diagnostic tools in the treatment of critically ill patients. It allows clinicians to recognise potentially reversible life-threatening situations and is also very effective in the monitoring of the fluid status of patients, slowly substituting invasive methods in the intensive care unit. Hemodynamic assessment is based on a few static and dynamic parameters. Dynamic parameters change during the respiratory cycle in mechanical ventilation and the level of this change directly corresponds to fluid responsiveness. Most of the parameters cannot be used in spontaneously breathing patients. For these patients the most important test is passive leg raising, which is a good substitute for fluid bolus. Although TTE is very useful in the critical care setting, we should not forget the important limitations, not only technical ones but also caused by the critical illness itself. Unfortunately, this method does not allow continuous monitoring and every change in the patient's condition requires repeated examination.