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Resolution of Liver Cirrhosis After Cardiac Transplantation in a Patient With a Fontan Circulation
Abstracts
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diagnosis and treatment reduces the incidence of septic embolism and mortality. This study explores the use of MRI for screening of cerebral complications of IE within our institution over a 10-year period. Methodology: Cerebral imaging requests and reports for patients admitted with IE at our institution from 2003-2013 were searched for IE related complications and the presence of symptoms indicating cerebral involvement. Results: Of the total 224 patient admissions with IE, 161 underwent cerebral imaging; 100 had CT alone, 29 had MR alone, and 32 used both CT and MR. Over a 10-year period, MR identified all cerebral complications that were found on preceding CT studies. In 10 admissions MR revealed cerebral complications that were not found using CT. Screening MR identified cerebral complications in 4 admissions where no symptoms were evident. Conclusion: Cerebral MR may provide further evidence of IE in suspected cases to prompt further invasive investigations (e.g. TOE), and lead to more informed management. In order to determine the benefit of screening cerebral MR in patients with IE, further research is warranted into the impact of detecting both symptomatic and asymptomatic cerebral complications on the management and outcomes of these patients. http://dx.doi.org/10.1016/j.hlc.2017.03.080 A ‘Patchy’ Approach to Chest Wall Resection and Reconstruction for Malignancy Gianna Pastore, Miss ∗ , Laura Fong, Dr, Mark Newman, Prof, Lucas Sanders, Dr Sir Charles Gairdner Hospital, Perth, WA, Australia Purpose: Chest wall resection for malignancy can result in a significant defect requiring reconstruction. We noticed at our institution that the use of 2 mm polytetrafluoroethylene (GORE-TEX) patches for chest wall reconstruction was associated with a high rate of postoperative seroma. Local innovation to resolve this problem is to use 4 mm punch biopsy and place perforations in the patch. This allows any accumulated fluid to drain into the pleural cavity to be reabsorbed. We aimed to determine the factors associated with successful reconstruction with the use of a fenestrated GORETEX patch and our rates of postoperative complications, in particular seromas. There is a paucity of literature reporting the rate of postoperative seroma with the use of GORE-TEX patches. Methodology: We conducted a retrospective singleinstitution review of all the patients who underwent chest wall resection and reconstruction using a fenestrated GORETEX patch over a 2.5 year period. Patient characteristics, co-morbidities, operative data, reconstructive methods and materials were recorded. Complications and outcomes were reviewed, as well as the management of these complications. Results: From January 2013 to July 2016, eleven patients underwent chest wall resection and reconstruction with a fenestrated GORE-TEX patch. A multidisciplinary approach was undertaken for all cases with input from orthopaedic surgery
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and plastic surgery where appropriate. There was no 30 day mortality. Mean follow-up time was 15 months. Conclusion: There were no cases of postoperative seroma with use of the fenestrated GORE-TEX patch. http://dx.doi.org/10.1016/j.hlc.2017.03.081 Short Term Follow-Up of Low Ejection Fraction Patients in Townsville Ekta Paw, Dr ∗ , Anand Iyer, Dr, Raj Shukla, Dr, Venkat Vangaveti, Dr The Townsville Hospital, Brisbane, QLD, Australia Purpose: Patients with poor ejection fraction (EF) are often considered high risk candidates for cardiac surgery and require extensive preoperative multidisciplinary planning as they are often associated with increased morbidity and mortality. Methodology: A retrospective audit was conducted on all patients with an EF of 30% or less who underwent cardiac surgery in Townsville in 2014 and 2015. Information was collected regarding: patient demographics; preoperative morbidities; EF; surgical details; use of levosimendan and patient status at most recent follow-up (6 or 12 months post op). Results: There were 25 patients, 84% male and 16% female, with a mean EF of 26.3% (SD 8.0) and a mean age of 58.6 (SD 11.7). Hypertension (64%) and smoking (80%) were the most prevalent risk factors amongst the group. 64% presented urgently for surgery with 32% having had a STEMI. 92% had CABG or CABG with valve surgery. Preoperative optimisation included the use of IABP (64%) and levosimendan (36%). There was a 4% mortality at follow-up and 72% had a postoperative echo, of which 76% showed an improvement of EF. The average improvement was 14% (SD 7.74%). 36% of these had IABPs, 36% had IABP and levosimendan and 28% had neither. Of those, the patients who had both IABP and levosimendan had the greatest increase in ejection fraction at follow up (17% as opposed to 13%) although this was not a statistically significant difference. Conclusion: With more options available for stenting, an increasing number of low EF patients are presenting for surgery. Consideration of IABP or use of levosimendan in conjunction with other preoperative management may increase EF in short-term follow-up and could be improve morbidity for this group of high risk surgical patients. http://dx.doi.org/10.1016/j.hlc.2017.03.082 Resolution of Liver Cirrhosis After Cardiac Transplantation in a Patient With a Fontan Circulation Chin Poh, Dr ∗ , Yves D’Udekem, Prof, Tom Wilson, Dr, Ajay Iyengar, Dr The Royal Childrens Hospital, Melbourne, VIC, Australia Purpose: Liver fibrosis is inevitable over time with a Fontan circulation. However, it no longer contraindicates heart trans-
Abstracts
plantation in this cohort, with similar survival post-transplant in presence of cirrhosis [1]. We discuss a case demonstrating reversal of liver cirrhosis post-transplantation in a patient with a Fontan circulation. Methodology: Serial liver testing via transient elastography (Fibroscan) and pathology before and after heart transplantation was performed in a 28-year-old male with failing Fontan physiology. Renal function was also assessed. Results: The subject was born with double inlet left ventricle, pulmonary stenosis and situs inversus. He developed Fontan failure 18 years after initial atrio-pulmonary Fontan surgery, and had persistent NYHA class III symptoms despite Fontan conversion surgery. Pre-transplant Fibroscan suggested frank cirrhosis with median liver stiffness of 44 kPa (normal < 7 kPa), ultrasound demonstrated evidence of portal hypertension, elevated liver enzymes (GGT 136, ALT 54) and thrombocytopaenia due to hypersplenism. He had moderate renal impairment with significant proteinuria. After successful orthotopic cardiac transplant, there was marked reduction in liver stiffness to 11 kPa. Repeat ultrasound showed normal portal vascular size with reduced splenomegaly. Liver and renal function as well as platelet count have normalised, with resolution of proteinuria. Conclusion: Cardiac cirrhosis in a Fontan circulation is reversible with normalisation of physiology after cardiac transplantation.
Reference [1] Simpson K, Esmaeeli A, Khanna G, et al. Liver cirrhosis in Fontan patients does not affect 1-year post-heart transplant mortality or markers of liver function. J Heart Lung Transplant 2014;33:170–7.
http://dx.doi.org/10.1016/j.hlc.2017.03.083 A Single Centre Overview of Infective Endocarditis - Surgical and Non-Surgical Management Neelprada Pradhan, Dr ∗ , Richard Lu, Dr, Edward Buratto, Dr, Paul Conaglen, Dr, Jonathan Darby, Dr, Philip Davis, Mr, Andrew Wilson, A/Prof, Andrew Newcomb, A/Prof St Vincent’s Hospital, Melbourne, VIC, Australia Introduction: Infective endocarditis (IE) is a disease of high mortality and morbidity. The timing and precise indications of cardiac surgery in IE remains a topic of contention. We aimed to investigate patient characteristics and outcomes in surgically vs conservatively managed patients in order to provide insight into patient selection for surgery. We have also stratified surgical management into early and late groups to examine the effects of timing of surgery on mortality and morbidity. Methods: A retrospective review of all IE patients presenting to St Vincent’s Public Hospital, Melbourne between January 1999 to December 2012 was conducted. Results: 355 IE cases were identified; 109 were managed surgically and 246 conservatively. Surgically managed patients had significantly lower rates of dialysis dependent chronic kidney disease (CKD) and liver disease (p < 0.01) but
S381
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higher rates of active congestive cardiac failure (CCF) and new valvular regurgitation on presentation (p < 0.01). Patients receiving operations had a longer length of stay (p = 0.01). Early surgical management however resulted in a shorter overall length of stay (p < 0.01) compared to delayed surgical management. There was no difference of in-hospital mortality between surgically and medically managed groups found in our data. Conclusion: In our series, relative indications for surgical management were active CCF and new valvular regurgitation. Relative contraindications to surgical management appear to be dialysis dependent CKD and liver disease. Additionally, early surgery resulted in a lower overall length of stay in IE patients compared to the delayed approach. http://dx.doi.org/10.1016/j.hlc.2017.03.084 Prosthetic Valve Endocarditis – A Single Centre Overview Neelprada Pradhan, Dr ∗ , Richard Lu, Dr, Edward Buratto, Dr, Paul Conaglen, Dr, Jonathan Darby, Dr, Philip Davis, Mr, Andrew Wilson, A/Prof, Andrew Newcomb, A/Prof St Vincent’s Hospital, Melbourne, VIC, Australia Introduction: Prosthetic valve endocarditis (PVE) is a serious complication of prosthetic heart valve implantation. The rate of heart valve replacement is increasing due to an ageing population, and although PVE is relatively uncommon, occurring in 3-6% of prosthetic valve patients, the incidence is likely to steadily rise. Methods: This study represents a retrospective review of all PVE patients presenting to St Vincent’s Public Hospital, Melbourne (SVHM) between the dates of January 1999 and December 2012. Results: 57 patients with PVE were identified in this review. The aortic valve was involved in 23 patients (40.4%), mitral valve in 28 patients (49.1%) and tricuspid valve in 2 patients (3.5%). Enterococcus faecalis was the most common organism involved (12 cases). In SVHM, 18 patients were managed surgically and 39 patients managed medically. Surgically managed patients had significantly higher rates of CCF(p < 0.01), NYHA class III/IV dyspnoea(p = 0.03) and new valvular regurgitation(p < 0.01). In-hospital mortality and length of stay was not significantly different between the groups. Early surgical management was associated with a significantly reduced postoperative stay(p < 0.01). Overall, there were 15 in-hospital mortalities (26.3%). On multivariate logistical regression active CCF on admission was the only factor independently predictive of a higher rate of in-hospital mortality (OR 33.37, p = 0.02). Conclusion: At SVHM, PVE patients with CCF, NYHA class III/IV dyspnoea and new valvular regurgitation are more likely to be managed surgically. Early surgery in PVE has a significantly reduced postoperative LoS with no significant impact on complication rates and short-term mortality. http://dx.doi.org/10.1016/j.hlc.2017.03.085
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diagnosis and treatment reduces the incidence of septic embolism and mortality. This study explores the use of MRI for screening of cerebral complications of IE within our institution over a 10-year period. Methodology: Cerebral imaging requests and reports for patients admitted with IE at our institution from 2003-2013 were searched for IE related complications and the presence of symptoms indicating cerebral involvement. Results: Of the total 224 patient admissions with IE, 161 underwent cerebral imaging; 100 had CT alone, 29 had MR alone, and 32 used both CT and MR. Over a 10-year period, MR identified all cerebral complications that were found on preceding CT studies. In 10 admissions MR revealed cerebral complications that were not found using CT. Screening MR identified cerebral complications in 4 admissions where no symptoms were evident. Conclusion: Cerebral MR may provide further evidence of IE in suspected cases to prompt further invasive investigations (e.g. TOE), and lead to more informed management. In order to determine the benefit of screening cerebral MR in patients with IE, further research is warranted into the impact of detecting both symptomatic and asymptomatic cerebral complications on the management and outcomes of these patients. http://dx.doi.org/10.1016/j.hlc.2017.03.080 A ‘Patchy’ Approach to Chest Wall Resection and Reconstruction for Malignancy Gianna Pastore, Miss ∗ , Laura Fong, Dr, Mark Newman, Prof, Lucas Sanders, Dr Sir Charles Gairdner Hospital, Perth, WA, Australia Purpose: Chest wall resection for malignancy can result in a significant defect requiring reconstruction. We noticed at our institution that the use of 2 mm polytetrafluoroethylene (GORE-TEX) patches for chest wall reconstruction was associated with a high rate of postoperative seroma. Local innovation to resolve this problem is to use 4 mm punch biopsy and place perforations in the patch. This allows any accumulated fluid to drain into the pleural cavity to be reabsorbed. We aimed to determine the factors associated with successful reconstruction with the use of a fenestrated GORETEX patch and our rates of postoperative complications, in particular seromas. There is a paucity of literature reporting the rate of postoperative seroma with the use of GORE-TEX patches. Methodology: We conducted a retrospective singleinstitution review of all the patients who underwent chest wall resection and reconstruction using a fenestrated GORETEX patch over a 2.5 year period. Patient characteristics, co-morbidities, operative data, reconstructive methods and materials were recorded. Complications and outcomes were reviewed, as well as the management of these complications. Results: From January 2013 to July 2016, eleven patients underwent chest wall resection and reconstruction with a fenestrated GORE-TEX patch. A multidisciplinary approach was undertaken for all cases with input from orthopaedic surgery
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and plastic surgery where appropriate. There was no 30 day mortality. Mean follow-up time was 15 months. Conclusion: There were no cases of postoperative seroma with use of the fenestrated GORE-TEX patch. http://dx.doi.org/10.1016/j.hlc.2017.03.081 Short Term Follow-Up of Low Ejection Fraction Patients in Townsville Ekta Paw, Dr ∗ , Anand Iyer, Dr, Raj Shukla, Dr, Venkat Vangaveti, Dr The Townsville Hospital, Brisbane, QLD, Australia Purpose: Patients with poor ejection fraction (EF) are often considered high risk candidates for cardiac surgery and require extensive preoperative multidisciplinary planning as they are often associated with increased morbidity and mortality. Methodology: A retrospective audit was conducted on all patients with an EF of 30% or less who underwent cardiac surgery in Townsville in 2014 and 2015. Information was collected regarding: patient demographics; preoperative morbidities; EF; surgical details; use of levosimendan and patient status at most recent follow-up (6 or 12 months post op). Results: There were 25 patients, 84% male and 16% female, with a mean EF of 26.3% (SD 8.0) and a mean age of 58.6 (SD 11.7). Hypertension (64%) and smoking (80%) were the most prevalent risk factors amongst the group. 64% presented urgently for surgery with 32% having had a STEMI. 92% had CABG or CABG with valve surgery. Preoperative optimisation included the use of IABP (64%) and levosimendan (36%). There was a 4% mortality at follow-up and 72% had a postoperative echo, of which 76% showed an improvement of EF. The average improvement was 14% (SD 7.74%). 36% of these had IABPs, 36% had IABP and levosimendan and 28% had neither. Of those, the patients who had both IABP and levosimendan had the greatest increase in ejection fraction at follow up (17% as opposed to 13%) although this was not a statistically significant difference. Conclusion: With more options available for stenting, an increasing number of low EF patients are presenting for surgery. Consideration of IABP or use of levosimendan in conjunction with other preoperative management may increase EF in short-term follow-up and could be improve morbidity for this group of high risk surgical patients. http://dx.doi.org/10.1016/j.hlc.2017.03.082 Resolution of Liver Cirrhosis After Cardiac Transplantation in a Patient With a Fontan Circulation Chin Poh, Dr ∗ , Yves D’Udekem, Prof, Tom Wilson, Dr, Ajay Iyengar, Dr The Royal Childrens Hospital, Melbourne, VIC, Australia Purpose: Liver fibrosis is inevitable over time with a Fontan circulation. However, it no longer contraindicates heart trans-
Abstracts
plantation in this cohort, with similar survival post-transplant in presence of cirrhosis [1]. We discuss a case demonstrating reversal of liver cirrhosis post-transplantation in a patient with a Fontan circulation. Methodology: Serial liver testing via transient elastography (Fibroscan) and pathology before and after heart transplantation was performed in a 28-year-old male with failing Fontan physiology. Renal function was also assessed. Results: The subject was born with double inlet left ventricle, pulmonary stenosis and situs inversus. He developed Fontan failure 18 years after initial atrio-pulmonary Fontan surgery, and had persistent NYHA class III symptoms despite Fontan conversion surgery. Pre-transplant Fibroscan suggested frank cirrhosis with median liver stiffness of 44 kPa (normal < 7 kPa), ultrasound demonstrated evidence of portal hypertension, elevated liver enzymes (GGT 136, ALT 54) and thrombocytopaenia due to hypersplenism. He had moderate renal impairment with significant proteinuria. After successful orthotopic cardiac transplant, there was marked reduction in liver stiffness to 11 kPa. Repeat ultrasound showed normal portal vascular size with reduced splenomegaly. Liver and renal function as well as platelet count have normalised, with resolution of proteinuria. Conclusion: Cardiac cirrhosis in a Fontan circulation is reversible with normalisation of physiology after cardiac transplantation.
Reference [1] Simpson K, Esmaeeli A, Khanna G, et al. Liver cirrhosis in Fontan patients does not affect 1-year post-heart transplant mortality or markers of liver function. J Heart Lung Transplant 2014;33:170–7.
http://dx.doi.org/10.1016/j.hlc.2017.03.083 A Single Centre Overview of Infective Endocarditis - Surgical and Non-Surgical Management Neelprada Pradhan, Dr ∗ , Richard Lu, Dr, Edward Buratto, Dr, Paul Conaglen, Dr, Jonathan Darby, Dr, Philip Davis, Mr, Andrew Wilson, A/Prof, Andrew Newcomb, A/Prof St Vincent’s Hospital, Melbourne, VIC, Australia Introduction: Infective endocarditis (IE) is a disease of high mortality and morbidity. The timing and precise indications of cardiac surgery in IE remains a topic of contention. We aimed to investigate patient characteristics and outcomes in surgically vs conservatively managed patients in order to provide insight into patient selection for surgery. We have also stratified surgical management into early and late groups to examine the effects of timing of surgery on mortality and morbidity. Methods: A retrospective review of all IE patients presenting to St Vincent’s Public Hospital, Melbourne between January 1999 to December 2012 was conducted. Results: 355 IE cases were identified; 109 were managed surgically and 246 conservatively. Surgically managed patients had significantly lower rates of dialysis dependent chronic kidney disease (CKD) and liver disease (p < 0.01) but
S381
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higher rates of active congestive cardiac failure (CCF) and new valvular regurgitation on presentation (p < 0.01). Patients receiving operations had a longer length of stay (p = 0.01). Early surgical management however resulted in a shorter overall length of stay (p < 0.01) compared to delayed surgical management. There was no difference of in-hospital mortality between surgically and medically managed groups found in our data. Conclusion: In our series, relative indications for surgical management were active CCF and new valvular regurgitation. Relative contraindications to surgical management appear to be dialysis dependent CKD and liver disease. Additionally, early surgery resulted in a lower overall length of stay in IE patients compared to the delayed approach. http://dx.doi.org/10.1016/j.hlc.2017.03.084 Prosthetic Valve Endocarditis – A Single Centre Overview Neelprada Pradhan, Dr ∗ , Richard Lu, Dr, Edward Buratto, Dr, Paul Conaglen, Dr, Jonathan Darby, Dr, Philip Davis, Mr, Andrew Wilson, A/Prof, Andrew Newcomb, A/Prof St Vincent’s Hospital, Melbourne, VIC, Australia Introduction: Prosthetic valve endocarditis (PVE) is a serious complication of prosthetic heart valve implantation. The rate of heart valve replacement is increasing due to an ageing population, and although PVE is relatively uncommon, occurring in 3-6% of prosthetic valve patients, the incidence is likely to steadily rise. Methods: This study represents a retrospective review of all PVE patients presenting to St Vincent’s Public Hospital, Melbourne (SVHM) between the dates of January 1999 and December 2012. Results: 57 patients with PVE were identified in this review. The aortic valve was involved in 23 patients (40.4%), mitral valve in 28 patients (49.1%) and tricuspid valve in 2 patients (3.5%). Enterococcus faecalis was the most common organism involved (12 cases). In SVHM, 18 patients were managed surgically and 39 patients managed medically. Surgically managed patients had significantly higher rates of CCF(p < 0.01), NYHA class III/IV dyspnoea(p = 0.03) and new valvular regurgitation(p < 0.01). In-hospital mortality and length of stay was not significantly different between the groups. Early surgical management was associated with a significantly reduced postoperative stay(p < 0.01). Overall, there were 15 in-hospital mortalities (26.3%). On multivariate logistical regression active CCF on admission was the only factor independently predictive of a higher rate of in-hospital mortality (OR 33.37, p = 0.02). Conclusion: At SVHM, PVE patients with CCF, NYHA class III/IV dyspnoea and new valvular regurgitation are more likely to be managed surgically. Early surgery in PVE has a significantly reduced postoperative LoS with no significant impact on complication rates and short-term mortality. http://dx.doi.org/10.1016/j.hlc.2017.03.085