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Hearts from Donations After Circulatory Death (DCD) Donors – Assessment on Clinically Approved Ex-vivo Organ Care System
472
Heart, Lung and Circulation 2013;22:455–489
2012 ANZSCTS Annual Scientific Meeting
ABSTRACTS
Short Term Results of the ATS 3F Stentless Valve for Aortic Valve and Root Replacement
days to 2.1 years). Average mean pressure gradient was 15 mmHg ± 7 mmHg. No patients had paravalvular leak or significant aortic regurgitation. All patients were NYHA class I or II at followup. Discussion: Aortic valve replacement or modified Bentall procedure with ATS 3F valve is safe, without adding significant time or complexity to the operation. The design of three tabs to suspend the valve avoids the need for a second suture line. It is associated with acceptable postoperative gradients and good short-term outcomes, resulting in good functional outcomes for patients. Further accumulation of cases and long-term outcomes are required. Durability data, reoperation and transcatheter valve in valve experience are future subjects for investigation.
Shoane Ip ∗ , Lucy Marney, Anand Iyer, Sumit Yadav
http://dx.doi.org/10.1016/j.hlc.2013.03.039
The Townsville Hospital, Townsville, Australia
2012 Poster Presentation/Panel 14
Introduction: Biologic prostheses for aortic valve and root replacement have become more common. Different biologic roots have been proposed including homografts, stentless porcine bioroots and fabricated stented valves in grafts. Stentless valves offer theoretical advantages of better haemodynamics, larger effective orifice area, and easier reoperation or facilitation of larger valve in valve transcatheter implantation in the future. This is offset by greater complexity of implantation. The ATS 3F is a newer stentless aortic valve designed with added ease of implantation. We aim to review our short term results using the ATS 3F stentless valve both in aortic valve replacement and contained in the Vascutek Gelweave Valsalva Aortic Root Graft for aortic root replacement via modified Bentall operation. Methods: This is a retrospective data analysis of all patients at a single institution who underwent aortic valve replacement (AVR) or modified Bentall operation with the ATS 3F stentless valve between April 2010 and June 2012. Patient demographics, comorbidities, operative details and follow up correspondence were obtained from patient records. Preoperative and serial postoperative echocardiogram reports were analysed. Outcomes measured were in-hospital and 30 day all cause mortality, postoperative bioprosthetic valve gradients, presence of regurgitation or leak, and NYHA class at followup. Results: We identified 20 patients who underwent AVR or modified Bentall procedure with the 3F valve. The mean age was 62.5 years (range 25–83 years). Eleven patients underwent modified Bentall procedure; of these two patients had surgery for dissection. All aortic root grafts except one were constructed with a 27 mm or 29 mm valve in a 28 mm or 30 mm conduit respectively. Nine patients underwent AVR. Valve sizes ranged from 21 to 27 mm. In total six patients underwent concomitant coronary artery bypass grafting, while two patients underwent concomitant mitral valve procedure. There were no perioperative deaths. Postoperative complications included one pericardial effusion, one re-exploration for bleeding, one early endocarditis and one stroke. No patients underwent reoperation. Median followup to most recent transthoracic echocardiogram was 253 days (range eight
Hearts from Donations After Circulatory Death (DCD) Donors – Assessment on Clinically Approved Ex-vivo Organ Care System
In addition there was invasion of the lung parenchyma, bronchus and mediastinal lymph nodes on the left side. Discussion: The treatment of rare tumours as is the case in pulmonary artery sarcoma requires a multidisciplinary team approach to determine the best management options for the patient. In our case, aggressive surgical intervention was determined to be the best option, with a good short-term outcome. http://dx.doi.org/10.1016/j.hlc.2013.03.038 2012 Poster Presentation/Panel 13
A. Iyer 1,2,∗ , A. Doyle 1,2 , L. Gao 1,2 , G. Kumarasinghe 1,2 , B. Wan 1,2 , A. Jabbour 1,2 , M. Hicks 1,2 , P. Jansz 1,2 , K. Dhital 1,2 , P. Macdonald 1,2 1 Victor 2 St
Chang Cardiac Research Institute, Sydney, Australia Vincent’s Hospital, Sydney, Australia
Introduction: Utilising pharmacological ischaemic postconditioning strategies, we have demonstrated excellent cardiac functional recovery in DCD hearts following 30 min warm ischaemia time (WIT) [1]. This has been validated on an ex-vivo construct in the laboratory. The aim of this study was to assess recovery of DCD hearts in a clinically approved Organ Care System – Transmedics OCS. This ex-vivo perfusion device allows assessment of marginal organs from brain dead donors prior to transplantation (Tx). We hypothesised that the Transmedics OCS would provide a suitable platform to gauge the viability of DCD hearts. Methods: Hearts were exposed to 30 min WIT in a DCD asyphyxia porcine model, before being flushed with Celsior supplemented with glyceryl trinitrate (GTN), Erythropoietin (EPO) and Zoniporide as part of the postconditioning strategy. Hearts were explanted/cannulated for perfusion on the Transmedics OCS (t = 3.5 h). Hearts were assessed by evaluating recovered cardiac rhythm, hourly arterial/venous lactate measurements and overall lactate trends - clinical studies have shown lactate levels of < 5 to correlate with good cardiac function posttransplant and successful wean from cardiopulmonary bypass (CPB) [2]. Results: Five DCD hearts have been assessed to-date, all recovered to a sinus rhythm. Four out of five hearts had lactate extraction (coronary sinus lactate lower than coronary artery inflow lactate) and steadily decreasing lactate levels over the course of ex-vivo perfusion. Four out of five hearts had lactate levels <5, compatible with heart viability for transplantation.
Discussion: DCD hearts with WIT ≤ 30 min display metabolic performances in keeping with successful outcomes post-Tx, and thus appear to be viable for cardiac transplantation. Further assessment of cardiac functional recovery in a porcine Tx model is underway.
Reference [1] Cardiac Transplantation using hearts from Donation after Circulatory Death (DCD) Donors—a viable source of organs? Submitted abstract 65 ANZSCTS Annual Scientific Meeting 2012. [2] Hamed A, Huber J, Lin R, Pogglo EC, Ardehalt A. Serum lactate is a highly sensitive and specific predictor of post cardiac transplant outcomes using the organ care system. J Heart Lung Transplant 2009;28(2):S71.
http://dx.doi.org/10.1016/j.hlc.2013.03.040 2012 Poster Presentation/Panel 15 Innovative Rigid Sternal Closure – Is it Worthwhile in High Risk Median Sternotomy? Sathappan Kumar ∗ , Joseph Politi, Isreal J. Jacobowitz, Sunil Abrol, Mikhail Vaynblat, Greg Crooke, Greg Ribakove Department of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, NY, USA Objective: Midline sternotomy remains gold standard technique for access in cardiac surgery. It is associated complications, such as sternal instability, superficial and deep infections, as well as bony mal and nonunion complications leading to enormous health care cost. We looked for innovative alternative technique to create rigid closure of sternum in high risk median sternotomy to avoid wound problems. The purpose of this study is to evaluate effectiveness of this technique in high risk cohort of patients. Methods: The Sternal Talon (KLS Martin Group, Jacksonville, FL), a lightweight titanium closure device is designed to approximate the sternum, creating a rigid closure by effectively immobilise sternum. Patient selection was limited to patients at high risk for sternotomy complications as per STS national data base criteria. Results: One hundred and eighty-eight high risk patients underwent rigid closure by placement of the Sternal Talon after median sternotomy from April 2010 to August 2012 in our institution. Sixty-three percent of patients were male. BMI range from 22 to 57, Diabetes – 55%, COPD – 78%, current smoker – 28% and long term steroid use 2% and other high risks were 5%. No device related complications were observed. Post operatively no major sternal wound infections, dehiscence or nonunion within 30 days, three patients return to the operating room for bleeding not device related. One postoperative death which was not device related or sternal wound problem. In three patient’s device were removed after three to six-months due to discharging sinus. Three patients had minor superficial wound problems. Conclusions: This new innovative procedure shown to be safe and very effective. Sternal Talon for rigid sternal
2012 ANZSCTS Annual Scientific Meeting
473
closure may be regarded as an alternative to conventional wire closure in high-risk patients to mitigate wound related morbidity and mortality. Prospective randomised study to prove the value of the device in terms of short and long-term stability with lung functions and also cost effectiveness in high-risk patients who undergo cardiac procedure by median sternotomy is warranted. Keywords: High risk median sternotomy; Innovation; Steranl wound infection. http://dx.doi.org/10.1016/j.hlc.2013.03.041 2012 Poster Presentation/Panel 16 48 days Later: Lessons Learnt From 48 days on VenoVenous ECMO Bridging to Lung Transplantation T. Law ∗ , B. Dunne, M. Musk, C. Merry, V. Vincent Royal Perth Hospital, Australia Introduction: Bridging patients with end-stage lung disease to transplantation with Veno-Venous ExtraCorporeal Membrane Oxygenation (VV ECMO) has long been a controversial topic. However, recent advances in the management of patients on VV ECMO prior to lung transplantation have resulted in significant improvements in patient outcomes. Methods: We present the case of a 16-year old girl with Cystic Fibrosis-related Bronchiectasis who deteriorated despite maximal medical therapy, required institution of ECMO, and was successfully supported on VV ECMO for 48 days and underwent successful bilateral lung transplantation. We present this case to highlight the lessons learnt from a difficult case with an excellent outcome. The cornerstones of this successful result were, we believe, the following: 1) Patient selection 2) Completion of pre-transplant workup prior to initiating ECMO 3) Multidisciplinary approach to care, ensuring all specialties are involved prior to initiating ECMO 4) Early extubation/Awake ECMO 5) Management of increased metabolic demands in setting of sepsis 6) Ongoing physiotherapy while on ECMO 7) Use of daily Aspirin to reduce the frequency of oxygenator changes Results: After 48 days on VV ECMO, she underwent successful bilateral lung transplantation. She had an uncomplicated post-operative course and was discharged 31 days post-transplant. She is now eight months posttransplant and continues to improve. She will be starting in University in October of this year. Discussion: This case serves to highlight the key elements that are essential in undertaking to bridge any patient with end-stage lung disease to transplantation with VV ECMO. http://dx.doi.org/10.1016/j.hlc.2013.03.042
ABSTRACTS
Heart, Lung and Circulation 2013;22:455–489
Heart, Lung and Circulation 2013;22:455–489
2012 ANZSCTS Annual Scientific Meeting
ABSTRACTS
Short Term Results of the ATS 3F Stentless Valve for Aortic Valve and Root Replacement
days to 2.1 years). Average mean pressure gradient was 15 mmHg ± 7 mmHg. No patients had paravalvular leak or significant aortic regurgitation. All patients were NYHA class I or II at followup. Discussion: Aortic valve replacement or modified Bentall procedure with ATS 3F valve is safe, without adding significant time or complexity to the operation. The design of three tabs to suspend the valve avoids the need for a second suture line. It is associated with acceptable postoperative gradients and good short-term outcomes, resulting in good functional outcomes for patients. Further accumulation of cases and long-term outcomes are required. Durability data, reoperation and transcatheter valve in valve experience are future subjects for investigation.
Shoane Ip ∗ , Lucy Marney, Anand Iyer, Sumit Yadav
http://dx.doi.org/10.1016/j.hlc.2013.03.039
The Townsville Hospital, Townsville, Australia
2012 Poster Presentation/Panel 14
Introduction: Biologic prostheses for aortic valve and root replacement have become more common. Different biologic roots have been proposed including homografts, stentless porcine bioroots and fabricated stented valves in grafts. Stentless valves offer theoretical advantages of better haemodynamics, larger effective orifice area, and easier reoperation or facilitation of larger valve in valve transcatheter implantation in the future. This is offset by greater complexity of implantation. The ATS 3F is a newer stentless aortic valve designed with added ease of implantation. We aim to review our short term results using the ATS 3F stentless valve both in aortic valve replacement and contained in the Vascutek Gelweave Valsalva Aortic Root Graft for aortic root replacement via modified Bentall operation. Methods: This is a retrospective data analysis of all patients at a single institution who underwent aortic valve replacement (AVR) or modified Bentall operation with the ATS 3F stentless valve between April 2010 and June 2012. Patient demographics, comorbidities, operative details and follow up correspondence were obtained from patient records. Preoperative and serial postoperative echocardiogram reports were analysed. Outcomes measured were in-hospital and 30 day all cause mortality, postoperative bioprosthetic valve gradients, presence of regurgitation or leak, and NYHA class at followup. Results: We identified 20 patients who underwent AVR or modified Bentall procedure with the 3F valve. The mean age was 62.5 years (range 25–83 years). Eleven patients underwent modified Bentall procedure; of these two patients had surgery for dissection. All aortic root grafts except one were constructed with a 27 mm or 29 mm valve in a 28 mm or 30 mm conduit respectively. Nine patients underwent AVR. Valve sizes ranged from 21 to 27 mm. In total six patients underwent concomitant coronary artery bypass grafting, while two patients underwent concomitant mitral valve procedure. There were no perioperative deaths. Postoperative complications included one pericardial effusion, one re-exploration for bleeding, one early endocarditis and one stroke. No patients underwent reoperation. Median followup to most recent transthoracic echocardiogram was 253 days (range eight
Hearts from Donations After Circulatory Death (DCD) Donors – Assessment on Clinically Approved Ex-vivo Organ Care System
In addition there was invasion of the lung parenchyma, bronchus and mediastinal lymph nodes on the left side. Discussion: The treatment of rare tumours as is the case in pulmonary artery sarcoma requires a multidisciplinary team approach to determine the best management options for the patient. In our case, aggressive surgical intervention was determined to be the best option, with a good short-term outcome. http://dx.doi.org/10.1016/j.hlc.2013.03.038 2012 Poster Presentation/Panel 13
A. Iyer 1,2,∗ , A. Doyle 1,2 , L. Gao 1,2 , G. Kumarasinghe 1,2 , B. Wan 1,2 , A. Jabbour 1,2 , M. Hicks 1,2 , P. Jansz 1,2 , K. Dhital 1,2 , P. Macdonald 1,2 1 Victor 2 St
Chang Cardiac Research Institute, Sydney, Australia Vincent’s Hospital, Sydney, Australia
Introduction: Utilising pharmacological ischaemic postconditioning strategies, we have demonstrated excellent cardiac functional recovery in DCD hearts following 30 min warm ischaemia time (WIT) [1]. This has been validated on an ex-vivo construct in the laboratory. The aim of this study was to assess recovery of DCD hearts in a clinically approved Organ Care System – Transmedics OCS. This ex-vivo perfusion device allows assessment of marginal organs from brain dead donors prior to transplantation (Tx). We hypothesised that the Transmedics OCS would provide a suitable platform to gauge the viability of DCD hearts. Methods: Hearts were exposed to 30 min WIT in a DCD asyphyxia porcine model, before being flushed with Celsior supplemented with glyceryl trinitrate (GTN), Erythropoietin (EPO) and Zoniporide as part of the postconditioning strategy. Hearts were explanted/cannulated for perfusion on the Transmedics OCS (t = 3.5 h). Hearts were assessed by evaluating recovered cardiac rhythm, hourly arterial/venous lactate measurements and overall lactate trends - clinical studies have shown lactate levels of < 5 to correlate with good cardiac function posttransplant and successful wean from cardiopulmonary bypass (CPB) [2]. Results: Five DCD hearts have been assessed to-date, all recovered to a sinus rhythm. Four out of five hearts had lactate extraction (coronary sinus lactate lower than coronary artery inflow lactate) and steadily decreasing lactate levels over the course of ex-vivo perfusion. Four out of five hearts had lactate levels <5, compatible with heart viability for transplantation.
Discussion: DCD hearts with WIT ≤ 30 min display metabolic performances in keeping with successful outcomes post-Tx, and thus appear to be viable for cardiac transplantation. Further assessment of cardiac functional recovery in a porcine Tx model is underway.
Reference [1] Cardiac Transplantation using hearts from Donation after Circulatory Death (DCD) Donors—a viable source of organs? Submitted abstract 65 ANZSCTS Annual Scientific Meeting 2012. [2] Hamed A, Huber J, Lin R, Pogglo EC, Ardehalt A. Serum lactate is a highly sensitive and specific predictor of post cardiac transplant outcomes using the organ care system. J Heart Lung Transplant 2009;28(2):S71.
http://dx.doi.org/10.1016/j.hlc.2013.03.040 2012 Poster Presentation/Panel 15 Innovative Rigid Sternal Closure – Is it Worthwhile in High Risk Median Sternotomy? Sathappan Kumar ∗ , Joseph Politi, Isreal J. Jacobowitz, Sunil Abrol, Mikhail Vaynblat, Greg Crooke, Greg Ribakove Department of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, NY, USA Objective: Midline sternotomy remains gold standard technique for access in cardiac surgery. It is associated complications, such as sternal instability, superficial and deep infections, as well as bony mal and nonunion complications leading to enormous health care cost. We looked for innovative alternative technique to create rigid closure of sternum in high risk median sternotomy to avoid wound problems. The purpose of this study is to evaluate effectiveness of this technique in high risk cohort of patients. Methods: The Sternal Talon (KLS Martin Group, Jacksonville, FL), a lightweight titanium closure device is designed to approximate the sternum, creating a rigid closure by effectively immobilise sternum. Patient selection was limited to patients at high risk for sternotomy complications as per STS national data base criteria. Results: One hundred and eighty-eight high risk patients underwent rigid closure by placement of the Sternal Talon after median sternotomy from April 2010 to August 2012 in our institution. Sixty-three percent of patients were male. BMI range from 22 to 57, Diabetes – 55%, COPD – 78%, current smoker – 28% and long term steroid use 2% and other high risks were 5%. No device related complications were observed. Post operatively no major sternal wound infections, dehiscence or nonunion within 30 days, three patients return to the operating room for bleeding not device related. One postoperative death which was not device related or sternal wound problem. In three patient’s device were removed after three to six-months due to discharging sinus. Three patients had minor superficial wound problems. Conclusions: This new innovative procedure shown to be safe and very effective. Sternal Talon for rigid sternal
2012 ANZSCTS Annual Scientific Meeting
473
closure may be regarded as an alternative to conventional wire closure in high-risk patients to mitigate wound related morbidity and mortality. Prospective randomised study to prove the value of the device in terms of short and long-term stability with lung functions and also cost effectiveness in high-risk patients who undergo cardiac procedure by median sternotomy is warranted. Keywords: High risk median sternotomy; Innovation; Steranl wound infection. http://dx.doi.org/10.1016/j.hlc.2013.03.041 2012 Poster Presentation/Panel 16 48 days Later: Lessons Learnt From 48 days on VenoVenous ECMO Bridging to Lung Transplantation T. Law ∗ , B. Dunne, M. Musk, C. Merry, V. Vincent Royal Perth Hospital, Australia Introduction: Bridging patients with end-stage lung disease to transplantation with Veno-Venous ExtraCorporeal Membrane Oxygenation (VV ECMO) has long been a controversial topic. However, recent advances in the management of patients on VV ECMO prior to lung transplantation have resulted in significant improvements in patient outcomes. Methods: We present the case of a 16-year old girl with Cystic Fibrosis-related Bronchiectasis who deteriorated despite maximal medical therapy, required institution of ECMO, and was successfully supported on VV ECMO for 48 days and underwent successful bilateral lung transplantation. We present this case to highlight the lessons learnt from a difficult case with an excellent outcome. The cornerstones of this successful result were, we believe, the following: 1) Patient selection 2) Completion of pre-transplant workup prior to initiating ECMO 3) Multidisciplinary approach to care, ensuring all specialties are involved prior to initiating ECMO 4) Early extubation/Awake ECMO 5) Management of increased metabolic demands in setting of sepsis 6) Ongoing physiotherapy while on ECMO 7) Use of daily Aspirin to reduce the frequency of oxygenator changes Results: After 48 days on VV ECMO, she underwent successful bilateral lung transplantation. She had an uncomplicated post-operative course and was discharged 31 days post-transplant. She is now eight months posttransplant and continues to improve. She will be starting in University in October of this year. Discussion: This case serves to highlight the key elements that are essential in undertaking to bridge any patient with end-stage lung disease to transplantation with VV ECMO. http://dx.doi.org/10.1016/j.hlc.2013.03.042
ABSTRACTS
Heart, Lung and Circulation 2013;22:455–489