Purpose The donation after circulatory death (DCD) pathway is an emerging contributor to heart transplantation. Selected UK centres started their adult programs in 2015, followed by a centrally funded national pilot commencing September 2020. The purpose of this study is to review the activity and outcomes of the UK National DCD heart transplant program during this pilot. Methods Data on DCD heart transplants between September 2020 to August 2021 were extracted from the UK Transplant Registry, held by National Health Service Blood and Transplant. The Registry contains data on all offered organs from potential donors, proceeding donations and organ recipients. Additional data were collected on the DCD Heart travel document. The DCD hearts were procured by 3 specialist retrieval teams, with national organ allocation to all 7 adult and paediatric heart transplant centres. Endpoints The hearts of 143 potential DCD donors were referred for offering during this 12-month period, from all areas of the UK. This resulted in 77 acceptance, 60 retrievals, 33 hearts retrieved and 30 transplants. Direct procurement and machine perfusion was the technique used for all DCD heart retrievals with 2 hearts retrieved during abdominal normothermic regional perfusion. Six procurements were performed by a hybrid team consisting of members from 2 retrieval teams, and 21 were transplanted by a different centre to that of the retrieval team. Median donor and recipient age was 33 (range: 12-50) and 46 (range: 13-62), respectively. Seven recipients were super-urgent and 13 were urgent; with a median wait time of 20 days (range: 1-320). In the same period there were 105 adult and 18 paediatric donation after brain death (DBD) heart transplants; DCDs representing 19% and 22% of the programs, respectively. Two patients died within 30 days, making the 30-day survival rate 93.3% (95% CI: 76-98), similar to the DBD cohort. Extracorporeal membrane oxygenation in the first 30 days was required for 15 out of 30 transplants. Conclusion In the 12-month pilot, DCD heart transplantation was 20% of the total heart transplant activity. This UK wide program was underpinned by unprecedented collaboration between UK cardiothoracic teams, and with abdominal teams, improving communication and shared learning. High volume, specialised procurement teams are key to a successful DCD heart sharing program to overcome challenges from the learning curve.

Introduction This case describes multiple forms of short term mechanical circulatory support (sMCS) used sequentially in the same patient, and illustrates the role of different clinical goals of sMCS. Case Report A 59 year old man with previous coronary artery bypass surgery attended with troponin positive acute coronary syndrome. After workup, he went for PCI to a native coronary chronic total occlusion using anterograde/retrograde wires. Unfortunately, the left internal mammary graft was dissected, and he suffered cardiac arrest. Day 0: Impella CP as bridge to recover y : During resuscitation an Impella CP was placed via his right femoral artery and resolved circulatory arrest. Further PCI was performed to the LIMA ostium with restoration of flow. He was transferred to ITU. Day 3: Peripheral VA-ECMO as bridge to decision: His clinical status improved, but he remained in shock. His support was upgraded to peripheral veno-arterial (VA) extra-corporeal membrane oxygenation (ECMO), leaving the Impella in place as an LV vent. Day 14: BIVAD as bridge to transplantation: He remained MCS-dependent, and had no absolute contraindications to advanced therapies. He went to theatre for implantation of bilateral short term ventricular assist devices (BI-VAD) to optimise his organ support prior to transplantation. He was placed on the super-urgent waiting list. He had intermittent ventricular fibrillation but continued to mobilise on the ITU. Day 48: Transplantation and bridge to recovery with central ECMO: After 34 days on BIVAD, he underwent orthotopic cardiac transplantation. Due to vasoplegia and RV dysfunction, he was weaned from cardiopulmonary bypass onto central ECMO. Day 50: Weaning support - percutaneous RVAD as bridge to recover y : There was persistent RV dysfunction. Central ECMO was exchanged for a Protek RVAD. Day 56: Explant of RVAD: His status continued to improve. The RVAD was weaned and explanted after 6 days. Day 73: Discharge home: He required intense physiotherapy. After 73 days in hospital he was discharged home. At the time of submission he is alive at 291 days post transplant. Summary This man's successful outcome was facilitated by judicious use of sMCS, on each occasion with a clear strategy in mind. Surgically implanted and percutaneous modes were used. Collaboration between cardiologists, intensivists and cardiac surgeons was essential to facilitate optimal care.

Introduction Trichosporonosis and complications at the aorto-allograft anastomosis are rare after cardiac transplantation (CTx). We report a case of Trichosporon endocarditis and mycotic pseudoaneurysm. Case Report A 51 year old female with dilated cardiomyopathy and adult polycystic kidney disease underwent bilateral nephrectomy and was listed for renal transplant (RTx). While waiting, her cardiac status progressed and she was assessed for combined CTx-RTx. Staged surgery was planned, with CTx followed by urgent RTx. She underwent orthotopic CTx in 2017. Early complications (including 2R rejection, drug-induced leucopenia, cytomegalovirus viraemia, and an infected fistula) delayed listing for RTx. Eventually, she underwent cadaveric RTx in 2019. Two weeks after RTx she was admitted with fevers, skin lesions and renal graft dysfunction. She had erythematous papules developing into bullae with ulceration and central necrosis, and loss of vision due to endophalmitis. Mycology from her skin and eye identified fungus of the Trichosporon species and she was treated with antifungal therapy comprising liposomal amphotericin B, Voriconzaole and Flucytosine. Transoesophageal echocardiography showed a large pseudoaneurysm at the aortic anastomosis with vegetations on the suture line and in the cavity. Serial computed tomography showed the pseudoaneurysm increasing in size despite medical therapy, and she underwent aortic valve and root replacement. Explanted tissue confirmed endocarditis with Trichlosporon species. She made a good surgical recovery. Five months after admission she was discharged with good cardiac and renal graft function, on lifelong voriconazole. Summary This is the first report of Trichosporon endocarditis and suture-line pseudoaneurysm after CTx. Haemodialysis was a key risk factor for infection, potentially avoided by earlier RTx. She remains free of recurrent fungaemia on long term suppression after 1 year, but there remains a risk of recurrent infection in the aortic root.

A 45-year-old male heart-lung transplant recipient reported reduced exercise tolerance two months post-transplant. Spirometry, right heart pressures, bronchoscopy, trans-bronchial and endomyocardial biopsy were normal. Investigations demonstrated posterior and leftwards herniation of the heart through the posterior pericardial window created during the transplant operation with secondary 90 degrees forward twist of the left lung. This phenomenon generated mild functional narrowing of the left pulmonary artery demonstrable on magnetic resonance imaging. Cardiac herniation with lung torsion is a rare finding post heart-lung transplantation and usually manifests in the early postoperative period with haemodynamic compromise, requiring immediate correction. Our case demonstrates that heart graft herniation and secondary partial lung torsion can occur in the chronic phase without catastrophic consequences.

The complement fragment C9 is an immunohistologically-detectable component of the terminal membrane attack complex and has been shown to be a simple and sensitive method for the detection of early myocardial necrosis. Primary graft failure and heart transplant (HTx) mortality are exquisitely related to ischaemic time. Using C9, we assessed the extent of ischaemic myocyte necrosis in the first post-HTx right ventricular endomyocardial biopsy and its relation to ischaemic time of the donor heart.

A 56-year-old man developed left heart failure secondary to left to right shunt due to acquired aorto-pulmonary artery (PA) fistula. He had previously undergone aortic root replacement for streptococcal aortic valve endocarditis. A modified strategy involving interventional radiology and surgical technique was employed to deal with this complex surgical challenge. A balloon catheter was placed in the right PA to enable fistula occlusion during cardiopulmonary bypass followed by repair using cardiopulmonary bypass and circulatory arrest.

Cardiopulmonary bypass (CPB) can induce several haemodynamic alterations and therefore influence pharmacokinetics of various drugs. In order to assess the effect of CPB on plasma digoxin levels, these were monitored in patients undergoing open heart surgery involving CPB (n = 11), over a 24 hour period, starting just prior to commencement of surgery. For comparison, plasma digoxin was also monitored in a group of patients (n = 10) who underwent cardiac surgery not involving CPB. In 7 of the 11 patients in the CPB group, plasma digoxin levels (ng/ml) were significantly (p < 0.01) lower at the end of 24 hours (0.654 +/- 0.094) than basal levels (1.3114 +/- 0.2498). In contrast, in the non CPB group, 7 of 10 patients showed significantly higher (p < 0.001) plasma levels (ng/ml) at the end of 24 hours (0.477 +/- 0.125) as compared to basal levels (0.26 +/- 0.098). Thus, rather than the type of surgery, it appears that the pre-operative levels of plasma digoxin influence its pharmacokinetics.

Forty-nine patients underwent surgical excision of left atrial myxomas during a period of 14 years (1982 to 1995). There were 25 male and 24 female patients. In all cases, the diagnosis was based on clinical examination and echocardiography; cardiac catheterization was performed in 9 patients. We considered the diagnosis of myxoma as an indication for early surgery. The myxoma was excised using various approaches: right atrial transseptal incision (38), biatrial incision (9) and superior transseptal approach (2). The latter approach has not been utilized for excision of myxoma before. One patient died in the early postoperative period. New cardiac arrhythmias were observed in 4 patients while the others had an uneventful recovery. Forty-two patients returned for follow-up over a period ranging from 0.4 to 13.6 years. They were evaluated clinically and echocardiographically. All have recovered well and we conclude that left atrial myxoma can be treated with low mortality and morbidity.

Surgery for aneurysms of the aorta is a formidable challenge especially when these aneurysms involve the ascending aorta and the transverse arch. We have used the technique of cardiopulmonary bypass, profound hypothermia and total circulatory arrest with marked reduction in neurological complications. Availability of albumin coated and gelatin sealed grafts, as well as blood components, has reduced the associated bleeding problems. Ninety-six patients with aneurysms of the ascending aorta and the transverse arch were operated upon between 1983 and 1993. Patients with aneurysms of the sinus of Valsalva have not been included in this study. Syphilitic pathology was predominant in the group with late presentation of very large aneurysms. The mortality was 17.71% and was largely due to low cardiac output, prolonged ventilatory support, lung infections, and mediastinitis.