Acute kidney injury (AKI) after lung transplantation (LTx) is a common complication. We aimed to assess whether donation after circulatory death (DCD) is associated with an increased risk of AKI and renal replacement therapy (RRT) in the early postoperative period compared to the donation after brain death (DBD). Retrospective data on a cohort (N = 95) of LTx patients (DCD n = 17, DBD n = 78) characterized by no use of ex-vivo lung perfusion were analyzed for the incidence of AKI within 30 postoperative days and incidence of RRT within 7 and 30 days. After optimal full matching, an imbalance remained between the DCD and DBD patients in respect to intraoperative use of cardiopulmonary bypass (CPB). Therefore, a further subset (n = 77) was defined that excluded CPB patients, and matching was repeated (DCD n = 13 vs. DBD n = 63) resulting in a fair balance on a range of preoperative characteristics and intraoperative use of ECMO. In both matched subsets, DCD was associated with around twice higher risk of AKI and RRT within 7 and 30 postoperative days. In conclusion, data suggest that DCD could be associated with worse early renal outcomes in a subset of LTx patients and justify further studies on the topic in order to refine further renal care pathways perioperatively.

OBJECTIVES:Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in acutely deteriorating patients with end-stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplants (LTx) while reducing pretransplant deconditioning. We analyzed early- and midterm postoperative outcomes of patients on VV-ECMO as a BTT and the impact of preoperative VV-ECMO on posttransplant survival outcomes.METHODS:All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with nonbridged LTx recipients.RESULTS:Out of 297 transplanted patients, 21 (7.1%) were placed on VV-ECMO as a BTT. After matching, we observed similar 30-day mortality between BTT and non-BTT patients (4.6% vs. 6.6%, p = .083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, and acute kidney injury). Furthermore, preoperative VV-ECMO did not appear associated with 30-day or 1-year mortality in both frequentist and Bayesian analysis (odds ratio [OR]: 0.35, 95% confidence interval: 0.03-3.49, p = .369; OR: 0.27, 95% credible interval: 0.01-3.82, p = 84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30-day (7.8% vs. 6.5%, p = .048) and 1-year mortality (12.5% vs. 18%, p = .154).CONCLUSIONS:Patients with acute refractory respiratory failure while waiting for LTx represent a high-risk cohort of patients. VV-ECMO as a BTT is a reasonable strategy in adult patients with acceptable operative mortality and 1-year survival comparable to non-BTT patients.

Objectives: Veno-venous extracorporeal membrane oxygenation(VV-ECMO) is increasingly being used in acutely deteriorating patientswith end-stage lung disease as a bridge to transplantation (BTT). It canallow critically ill recipients to remain eligible for lung transplant(LTx) while reducing pretransplant deconditioning. We analyzed early andmid-term postoperative outcomes of patients on VV-ECMO as a BTT and theimpact of preoperative VV-ECMO on posttransplant survival outcomes.Methods: All consecutive LTx performed at our institutionbetween January 2012 and December 2018 were analyzed. After matching,BTT patients were compared with non-bridged LTx recipients.Results: Out of 297 transplanted patients, 21 (7.1%) wereplaced on VV-ECMO as a BTT. After matching, we observed a similar 30-daymortality between BTT and non-BTT patients (4.6% vs. 6.6%,p=0.083) despite a higher incidence of early postoperativecomplications (need for ECMO, delayed chest closure, acute kidneyinjury). Furthermore, preoperative VV-ECMO did not appear associatedwith 30-day or 1-year mortality in both frequentist and Bayesiananalysis (OR 0.35, 95%CI 0.03-3.49, p=0.369; OR 0.27, 95%CrI0.01-3.82, P=84.7%, respectively). In sensitivity analysis, bothsubgroups were similar in respect to 30-day (7.8% vs. 6.5%,p=0.048) and 1-year mortality (12.5% vs. 18%, p=0.154).Conclusions: Patients with acute refractory respiratory failurewhile waiting for LTx represent a high-risk cohort of patients. Weobserved that these patients can be successfully bridged to LTx withVV-ECMO with post-transplant mortality comparable to non-BTT patients.

Recent advances in the management of patients with adult congenital heart disease (ACHD) have led to an increased number of patients who may develop heart failure and require heart transplantation (HTx). The purpose of this study was to evaluate early and mid-term postoperative outcomes after HTx with the use of Organ Care System (OCS) in a cohort of ACHD patients transplanted at our tertiary center. All consecutive HTx performed from January 2015 to January 2019 at our institution were analyzed. Donor and recipient preoperative characteristics, intraoperative course, and perioperative clinical outcomes were evaluated. Nine patients with median age of 44 years (range 17-61 years) underwent isolated HTx for end-stage ACHD during the study period. Mean cold ischemic time was 84 ± 17 minutes. Postoperatively, four patients (44%) needed venoarterial extracorporeal membrane oxygenation (1-7 days). One patient (11%) required surgical re-exploration for bleeding. Thirty-day and 1-year mortality were 11% and 22%, respectively. In our experience, despite the challenges of transplantation in ACHD, these patients can be successfully transplanted with the use of the OCS in a highly specialized center. Careful donor and recipient selection are of paramount importance.

INTRODUCTION:We describe a patient who developed severe aortic regurgitation following Impella left ventricular assist device implantation requiring aortic valve replacement.CASE REPORT:A previously healthy 34-year-old female presented with chest pain and flu-like symptoms. Electrocardiogram showed widespread ST elevation and serum troponin was raised, consistent with myocarditis. Coronary angiography was normal but the right coronary artery dissected. Subsequent cardiogenic shock required veno-arterial extracorporeal membrane oxygenation and Impella implantation. Myocardial function recovered, but upon removal of the Impella, severe aortic regurgitation was present and she underwent aortic valve replacement, making a full recovery.DISCUSSION:Aortic regurgitation is a rare complication of Impella implantation, and to our knowledge, this is the first reported case successfully treated with aortic valve replacement. Veno-arterial extracorporeal membrane oxygenation and Impella used in tandem are relatively novel, and may add synergistic benefit to strategies for acute cardiogenic shock.CONCLUSION:Echocardiography must include frequent assessment of both valvular and myocardial function after Impella removal.

A 15 year old with mixed restrictive/dilated cardiomyopathy from myocardial mitochondrial disorder but normal skeletal muscle mitochondria, presented to a paediatric hospital with symptoms of cardiac failure in 2015. In March 2017 he decompensated despite medical therapy and a Multi-Disciplinary Team opted to insert a HeartwareR (Heartware Inc, Framingham, USA) left ventricular assist device (LVAD) as a rescue bridge to transplant. Poor right ventricular (RV) function and developing tamponade led to poor LVAD flows and he was transferred to our unit in a state of collapse requiring significant vasopressor and inotropic support. The following day, the LVAD was exchanged for a Total Artificial Heart (TAH) (Syncardia Systems LLC, Tucson, USA). The LVAD inflow was found to have deviated into the septum, distorted by severe ventricular hypertrophy. He was listed for a super urgent heart transplant and transplanted 36 days later. His ICU recovery was complicated by prolonged RV failure and vasoplegia. This required 6 days of central veno-arterial extra-coporeal membrane oxygenation (VA ECMO). The sternum was open for 10 days and there were episodes of tamponade and bleeding with a persistent coagulopathy. Following successful ECMO explantation, he had bilateral pneumothoraces and a spontaneous pneumopericardium, which persisted radiologically for 14 days and was managed conservatively. He has been discharged to the ward for rehab of critical care weakness, but requires on-going renal replacement therapy, and has been hospitalised for 249 days at present. He went to the operating room on 10 occasions at this institute and received a total of 63 units of red cells, 22 platelet pools, 34 fresh frozen plasma and 10 courses of prothrombin complex concentrates. The Paediatric Interagency Registry for Mechanical Circulatory Support published in July 2017 reports 364 patients receiving 432 devices in 42 reporting hospitals in the USA.1 80% received an LVAD and 2% a TAH. None converted a LVAD to TAH and then a transplanted heart. 22% of deaths were attributable to ‘circulatory’ causes and a further 26.6% from Multi-Organ Failure. The choice of device to bridge to transplant in this age group is still an evolving process,2 made more difficult in cases of rescue therapy for acute decompensation. This unique case describes some of the challenges involved. References [1] Blume ED et al. “Second annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) resport: Pre-implant characteristics and outcomes”. J Heart Lung Transplant. 2017 Jul 4. Pii: S1053-2498(17). Doi:10.1016/j.healun.2017.06.017 [2] Kirk R et al. ISHLT Guidelines for the Management of Pediatric Heart Failure. International Society for Heart and Lung Transplantation. Bookbaby (pub). 2014