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Background: Infants with single ventricle heart disease and severe atrioventricular valve regurgitation have poor outcomes following conventional staged palliation. As such, ventricular assist device (VAD) placement along with hybrid stage 1 palliation has been proposed as a bridge to heart transplant. We present a novel surgical technique for VAD implantation concurrent with hybrid stage 1 that avoids cardiopulmonary bypass. Methods: We performed a retrospective review of our institutional experience with this novel surgical technique. Results: Three patients (weight, 2.7-3.5 kg; age, 3 to 5 days) underwent hybrid stage 1 with VAD placement, consisting of bilateral 3.5-mm expandable polytetrafluoroethylene (PTFE) pulmonary artery bands, a ductal stent, a 6-mm Berlin Heart outflow cannula onto the main pulmonary trunk with a 10-mm graft, a 6-mm Berlin Heart outflow cannula onto the right atrium, and a 10-mL Berlin Heart pump. In patients with severe aortic arch hypoplasia or coarctation, a 4-mm PTFE graft was sewn from the VAD outflow graft to the innominate artery to protect coronary and cerebral perfusion. Procedures were performed off bypass with minimal blood product use. Patients were extubated on postoperative days 2, 2, and 5. There were no procedural complications. All patients were transferred out of the intensive care unit and demonstrated appropriate weight gain. Anticoagulation strategy was bivalirudin and antiplatelet therapy. The patients underwent transplantation after 149 days, 157 days, and 288 days of support. Conclusions: Off-pump single ventricle VAD placement is technically feasible and can be done at the time of hybrid stage 1 palliation with minimal operative morbidity as a bridge to transplant.
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OBJECTIVES: Due to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes. METHODS: From 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT >365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point. RESULTS: All-cause mortality was significantly worse in patients who were BTT <31 days. Survival at 30 days was 81.5% for BTT <31 days, 94% for BTT 31 to 365 days, 95% for BTT >365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT <31 days, 85% for BTT 31 to 365 days, 88% for BTT >365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD <34 days had significantly increased mortality. CONCLUSIONS: Patients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.
Assuntos
Transplante de Coração/métodos , Coração Auxiliar , Estudos Transversais , Feminino , Transplante de Coração/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Fatores de TempoRESUMO
Introducción: Diversos estudios han demostrado los beneficios del soporte vital extracorpóreo en pacientes críticos con patologías cardiorrespiratorias. El objetivo del presente trabajo consiste en evaluar la experiencia preliminar con el uso del soporte vital extracorpóreo en pacientes con enfermedad pulmonar avanzada, en lista de espera para trasplante pulmonar. Material y métodos: Se realizó un análisis retrospectivo y descriptivo de los pacientes que recibieron soporte vital extracorpóreo como puente al trasplante o a la candidatura para trasplante, entre agosto 2010 y julio 2015. Se analizaron los resultados según: exclusión de la lista de espera, candidatos a trasplante y trasplantes realizados. Se describen complicaciones y causas de mortalidad, tiempos de soporte vital extracorpóreo, asistencia respiratoria mecánica e internación post-trasplante. Se incluyeron 23 pacientes, edad promedio 36 ± 17 años, 61% mujeres. Los diagnósticos principales fueron fibrosis quística (34.8%), fibrosis pulmonar idiopática (30.4%) y fibrosis pulmonar secundaria (13.0%). Resultados: El tiempo medio con soporte vital extracorpóreo fue 14.4 ± 11.7 días; y se realizó veno-venoso en 14 pacientes, veno-arterial en 4, arterio-venoso 3 casos y veno-arterio-venoso en 2. Ocho pacientes no calificaron como candidatos al trasplante y se excluyeron de la lista de espera. Fueron aceptados como puente al trasplante 15 pacientes; 8 fallecieron bajo soporte vital extracorpóreo y 7 lograron ser trasplantados. Post trasplante, un paciente falleció y 6 fueron externados superando el año de supervivencia. Conclusión: En nuestra serie, el 46.7% de los candidatos lograron acceder al trasplante pulmonar bajo soporte vital extracorpóreo. La implementación de un programa de soporte vital extracorpóreo como puente al trasplante pulmonar efectivo requiere acceso a nuevas tecnologías y desarrollo de experiencia por parte del equipo.
Introduction: Several studies have demonstrated that the use of extracorporeal life support (ECLS) improves the recovery of critically ill patients with cardiorespiratory diseases. The purpose of this study was to evaluate a preliminary experience on the use of ECLS as a bridge to lung transplantation. Methods: We conducted a retrospective and descriptive analysis of patients who received ECLS as a bridge to lung transplantation between August 2010 and July 2015. ECLS results were analyzed according to the final status: excluded from the waiting list, confirmed transplant candidacy and transplanted patients. Complications and cause of mortality were evaluated, as well as the length of ECLS, time on mechanical ventilation, length of stay and survival. Twenty-three patients were included, mean age 36±17 years, 61% were female. The most common diagnoses were cystic fibrosis (34.8%), idiopathic pulmonary fibrosis (30.4%) and secondary pulmonary fibrosis (13.0%). Results: Mean time on ECLS was 14.4±11.7 days; veno-venous support was implemented in 14 patients, veno-arterial support in 4 cases, arterio-venous in 3, and veno-arterio-venous in 2. During ECLS, 8 patients did not qualify as candidates for transplantation. Fifteen patients were accepted as candidates for lung transplant, 8 of them died during ECLS, and 7 were transplanted. After transplant, one patient died and 6 were discharged from the hospital. Conclusion: The use of ECLS provided a successful bridge to lung transplantation in 46.7% of the patients. The implementation of an effective ECLS program requires of the conjunction between the technological advances and the development of the center's experience.