Background. Preservation of donor hearts for transplantation has traditionally been performed with the use of static cold storage. We have developed and tested a novel gravity-powered system of cold crystalloid perfusion for prolonged donor heart preservation.Methods. Greyhounds were anesthetized; their hearts were arrested with cold cardioplegic solution and excised. Hearts were allocated to 12 hours of perfusion preservation (n = 6) or cold storage in ice (n = 5). Non-preserved hearts (n = 5) served as a normal reference group. Perfusion hearts were perfused (20 mL/min, 8-12 degrees C) with a novel oxygenated nutrient-containing preservation solution. After preservation, the recovery of the hearts was assessed in a blood-perfused working heart rig over 2 hours in terms of function, blood lactate level, myocardial adenosine triphosphate, and histology.Results. After 2 hours of reperfusion, in comparison with cold storage hearts, perfused heart function curves showed superior recovery of cardiac output (P = .001), power (P = .001), and efficiency (0.046 +/- 0.01 vs 0.004 +/- 0.003 joules/mL O-2, P = .034). Myocardial adenosine triphosphate content (mmol/mg protein) was reduced significantly from the normal level of 26.5 (15.9, 55.8) to 5.08 (0.50, 10.4) (P = .049) in cold storage hearts but not in perfused hearts. Over a period of 2 hours, lactate levels in the blood perfusate were significantly lower in the perfusion group than in the cold storage group (P < .05).Conclusions. Continuous hypothermic crystalloid perfusion provides myocardial preservation superior to cold storage for long-term heart preservation, with potential applicability to marginal and donation after circulatory death hearts.

Purpose: We previously showed that donation after cardiocirculatory death (DCD) canine hearts can be resuscitated if perfused with warm blood but not if stored in ice (Repse S et al. J Heart Lung Transplant 2010;29:747–55). We subsequently developed a simplified system of cold crystal-loid microperfusion and showed that microperfusion was superior to conventional cold storage for DCD heart preservation as evaluated on an in-vitro rig (ISHLT 2011 Meeting). We have now extended this work to orthotopic transplantation.

1-year survival of end-stage idiopathic pulmonary arterial hypertension (iPAH) in the ISHLT registry is poor. Transplantation for Eisenmenger's syndrome (ES) is rarely reported. We aim to report outcomes in ES transplantation as congenital heart disease (CHD) or complex congenital heart disease (CCHD, more than one defect) comparing to iPAH.

Introduction: We have previously shown in a randomized trial that metabolic therapy reduced myocardial damage, shortened length of hospital stay, and reduced complications after cardiac surgery. We are now integrating metabolic therapy with wellness components (lifestyle education and massage) as part of routine care for all our cardiac surgery patients.

Mechanical circulatory support (MCS) plays a key role in the management of patients with end stage heart failure as a bridge to transplantation and in select cases as destination therapy. A small number provide continuous flow MCS. The effect of continuous flow MCS on the right ventricle (RV) has not been clear, with the suggestion that it could adversely affect RV function over the longer term. In this study we therefore documented the effect of a 3rd generation LV assist device (Ventrassist LVAS) on both the left ventricle (LV) and RV over a 3 month period.

Introduction. Phase II clinical trials of the VentrAssist™ left ventricular assist system, a third generation continuous flow centrifugal pump, as both bridge to transplant and destination therapies, are nearing completion.

Introduction. The ASCTS database provides a vehicle for the collection, storage and manipulation of a large amount of data in relation to the performance of cardiac surgery (OHSx) in Australia. To demonstrate the capabilities of the database for producing a well-formatted automated output for presentation, three questions were asked of the ASCTS database. (1)How many procedures have been performed during a given month and how does that compare to the same month of the previous year? The breakdown should include total cases, average age of patients, total number of coronary artery bypass graft procedures and total number of valve replacements. (2)For all patients operated on in a one-month period, how many developed atrial fibrillation as a complication of OHSx? Details including name, type(s) of surgical procedure and operating surgeon, the incidence of AF confirmed as a percent of all OHSx performed should be shown. (3)Can the aforementioned information be transferred to Microsoft Powerpoint as a well-formatted presentation to auditors, colleagues or other interested parties?

Introduction: Patients are now presenting for cardiac surgery with advanced age and multiple co-morbidities that stress the heart. Antioxidants have protective effects on the stressed senescent myocardium. We assessed the effect of MPM therapy, being preoperative CoQ10 with additional antioxidants and cellular energisers (metabolic therapy), together with exercise and mental stress reduction (holistic) therapy in a randomised clinical trial.

With increasing use of left ventricular assist systems (LVAS) for destination therapy (DT), device reliability and durability become key to successful long-term support. Clinical records from the Novacor LVAS systems were reviewed to quantify device reliability in clinical use.

Background: Primary graft failure (PGF) is the leading cause of early mortality after cardiac transplantation, accounting for 27.1% of deaths within 30 days. PGF is defined as severe dysfunction of the cardiac allograft without any obvious anatomic or immunological cause. The purpose of this study was to analyze our last 9 years of experience with cardiac transplantation to determine predictors of PGF and the influence on survival of our policy of earl), institution of mechanical circulatory support (MCS) in these patients.Methods: Data on 214 consecutive cardiac transplants performed at The Alfred Hospital between January 1996 and August 2004 were reviewed. PGF was defined as right or left or biventricular failure manifesting as hypotension (systolic blood pressure < 90 mm Hg), low cardiac output (cardiac index < 2.0 liter/min/m(2)) and pulmonary capillary wedge pressure > 20 mm Hg after coming off cardiopulmonary bypass despite inotropic Support Of tip to 5 mu g/min adrenaline and without any other obvious cause for the graft dysfunction.Results: PGF developed in 51 patients (24%). Significant factors in the development of PGF were long ischemic time, which became significant over 4 hours (odds ratio, 1.43; p = 0.01) and increased donor age (odds ratio, 1.027; p = 0.045). Fifteen patients required mechanical support, and of these, 10 survived to leave hospital.Conclusions: PGF is the major cause of earl), mortality after cardiac transplantation. Significant risks for PGF are long allograft ischemic time and increased donor age. Once the patient has survived 30 days, however, the longer-term survival is not influenced by PGF. Our management strategy of earl), mechanical Support has yielded good Outcomes in this population with a high risk of early death.

Objective: Primary graft failure remains a significant cause of morbidity and mortality after lung transplantation, and its mechanism is not understood. Previously 2 case reports described fatal primary graft failure due to donor-related unexpected pulmonary embolism. This study investigated the incidence, early outcome, and risk factors of unexpected pulmonary embolism in lung transplantation.Methods: An exploratory retrograde donor lung flush before implantation to diagnose pulmonary embolism (emboli group) or no pulmonary embolism (no-emboli group) was performed in 74 of 122 consecutive lung transplantations.Results: The incidence of macroscopic unexpected pulmonary embolism was 38% (28% clot and 9% fat). In the emboli group, significantly decreased oxygenation (P < .05), increased pulmonary vascular resistance (P < .001), an increased proportion of opacity on chest radiograph (P = .03), prolonged intubation (P < .001) and intensive care unit stay (P < .01), and decreased 1-year survival (P = .03) were seen after transplantation. In multivariate analysis, pulmonary embolism was an independent risk factor for prolonged intubation (hazard ratio, 2.42; P < .01). In logistic regression, death due to trauma with fracture and a smoking history of more than 20 pack-years were significant donor risk factors for pulmonary embolism (adjusted odds ratio, 8.77 and 5.64; P = .02 and .04, respectively). No deleterious effects of the exploratory flush were seen.Conclusions: Unexpected pulmonary embolism is relatively common, is potentially predicted by donor history (but not by arterial blood gas analysis or chest radiograph), and is associated with primary graft failure. Donor lungs with risk factors of pulmonary embolism should undergo an exploratory flush. When pulmonary embolism is diagnosed, further therapeutic strategies must be considered.

Backgrounds. Liberalization of tobacco exposure history as an exclusion to lung donation has recently occurred to increase donor organ availability. This study investigated the effect of donor smoking status and current and cumulative cigarette dose on early and late outcomes in lung transplantation. Methods. From 1995 to 2002, 173 heart-lung and bilateral single-lung transplant recipients were retrospectively reviewed. Seventy-seven (45%) of 173 donors were ever-smokers and 64 of those 77 were current smokers. These were divided into subgroups by current number of cigarettes smoked to investigate acute dose effects and by pack-year to investigate cumulative dose effects. Risks of smoking were assessed by univariate and multivariate hazard regression models. Results. Univariate analysis revealed that there were significant differences between current and cumulative dose subgroups in early postoperative variables, including Pao2/Fio2 ratio, ventilation time, and intensive care unit stay. Additionally, these variables were dose dependent. There was no significant difference in 3-year survival between never-smokers and ever-smokers (73% versus 64%, P=0.27), and a rate of decline of survival was similar. There was a trend for the percentage of patients dying of bronchiolitis obliterans syndrome to be lower in the ever-smokers group compared with the never-smokers group (6% versus 11%, respectively). Multivariate analysis revealed current and cumulative smoking as a risk factor for early but not late outcomes. Conclusions. Donor smoking history had a significant effect on early outcomes in lung transplantation in a current and cumulative dose-dependent fashion. However, no significant effect on late outcomes, including bronchiolitis obliterans syndrome, was seen.

Limitations to the wider deployment of first generation LVAD's has been the attendent morbidity profile. The Ventrassist-LVAS is a novel third generation, mixed flow, implantable, electromechanical pump developed by Ventracor Pty. Ltd. The 300 gram titanium pump features a four lobed hydrodynamically suspended impeller. At 2,300 rpm. the device pumps 5.4 lit/min. at 4.8 watts.

Background Heterotopic heart transplantation was first performed in humans in 1974, the main advantage being the continuing function of the patient's native heart, in the event of life-threatening acute rejection. The effect of cyclosporine on acute rejection saw the heterotopic transplantation technique wane. Our unit revisited heterotopic transplantation in response to a growing number of waiting list patients with high pulmonary artery pressures. We also anticipated an increased cardiac allograft utilization, and improvement of our waiting list times. Methods We retrospectively analyzed 151 patients undergoing heart transplantation by our unit between August 1997 and September 2003. Twenty received allografts in the heterotopic position. This cohort was compared with the 131 contemporary orthotopic heart transplant recipients with respect to their outcomes. Results The indication for transplantation was ischemic cardiomyopathy in 14 (70%) of the heterotopic cohort and 47 (36%) of the orthotopic cohort (p = 0.004), and dilated cardiomyopathy in 3 (15%) and 48 (37%) in the heterotopic and orthotopic groups, respectively (p = 0.06). Heterotopic recipients were significantly older than orthotopic recipients, and they had higher pulmonary artery pressures. The heterotopic donors were also older and the ischemic times were longer. A subgroup analysis was made among those patients who had high pulmonary artery pressures as these groups were better matched. Major morbidity in the heterotopic heart transplantation group consisted of reversible allograft dysfunction in 4 patients, renal dysfunction requiring hemofiltration in 3 patients, profound myopathy in 4 patients, and cerebrovascular events in 2 patients. There were two early deaths in the heterotopic transplant group and eight in the orthotopic group (p = 0.87). Kaplan-Meier survival analysis of survival was performed. Conclusions Heterotopic heart transplantation is a viable transplant option for selected high-risk heart transplant recipients in spite of somewhat poorer outcomes.

VentrAssist (VentrAssist Division, Ventracor Ltd., Chatswood, NSW, Australia) has developed an implantable centrifugal blood pump with an integrated rotor and impeller that is hydrodynamically suspended. Bench testing has been used to assess the performance of the pump under a broad range of operating conditions. This study examined the performance of the pump in vivo up to 90 days implantation. Pumps were implanted via a left lateral thoracotomy. The inflow cannula was inserted at the apex of the left ventricle. The outflow cannula was anastomosed to the descending thoracic aorta. Eighteen implants were performed. Poor recovery from surgery was the main cause of early study termination. These studies demonstrate the suitability of the animal model for evaluation of the VentrAssist rotary blood pump. Further in vivo studies prior to preclinical trials are in progress.

Background: Donor asthma has been regarded as a contraindication to lung transplantation (LTx) because of concerns that pre-existing airway inflammation will predispose to early and late graft dysfunction. The aim of this study was to describe LTx outcomes in which lungs had been transplanted from donors with a history of asthma.Methods: A retrospective chart review was undertaken of 743 consecutive donor lung referrals to the Alfred Hospital between 1990 and September 2002. Seventy-four were noted to have a history of asthma, including 18 in whom asthma was the cause of death, Twenty-seven patients became lung donors, of whom 16 were on asthma treatment (on-treatment group) and 11 were not (no-treatment group).Results: From 27 lung,donors, 35 LTx procedures were performed (16 double LTx [DLTx], 19 single LTx [SLTx]). Five recipients died at <30 days (including 3 of early raft failure in the no-treatment group), and 7 died at >30 days (only 1 due to BOS). The 30-day, 1-year and 5-year survival rates in the on- and no-treatment donor groups were 90% vs 76%, 74% vs 69% and 74% vs 60%, respectively, and were not significantly different from our overall LTx survival rates. There were no significant differences in percent predicted forced expiratory volume in 1 second, ICU stay or hospital stay overall, or when analyzed according to on treatment vs no treatment and SLTx vs DLTx. Only 2 procedures LTx were performed from fatal asthma donors, both of whom had subsequent graft dysfunction and died on Days 73 and 484, respectively.Conclusions: The use of lungs from carefully selected lung donors with a history of asthma may increase the donor pool with acceptable long-term outcomes. The use of fatal asthma donors remains problematic.