BACKGROUND:Late acute cellular rejection is associated with decreased survival and the development of CAV. Among new immunosuppressive drugs introduced into clinical practice, everolimus, has been shown to be safe in cardiac transplantation. We report our experience with everolimus in heart transplant recipients who developed late acute cellular cardiac rejection.METHODS:Patients with a history of previous rejection episodes who experienced cardiac rejection were switched to an everolimus, cyclosporine, and steroid immunosuppressive regimen. All patients had already received statins and antihypertensive medications. Everolimus, cyclosporine trough levels, and laboratory values were controlled monthly. Drug administration was adapted to an everolimus trough level between 3 and 8 ng/mL, mean maintenance dosage was 0.25 to 1.5 mg twice a day. Death, safety, side effects, biopsy-proven acute rejection episodes, laboratory values, and blood levels were evaluated retrospectively.RESULTS:Four cardiac allograft recipients (two male, two female), at a median of 1473.25 days post-orthotopic heart transplantation (oHTx) (range = 65 to 3045), received 1 to 1.5 mg everolimus per day. Over a follow-up period of at least 2 month (range = 2 to 10) the mortality was 0%. The drug was well tolerated; no acute cellular rejection greater than grade 1a (ISHLT grading) was observed after 2 months. In one patient increased cholesterol values and in two others, elevated triglyceride levels were seen, but were controlled with increased statin therapy. No obvious increased creatinine values were seen with everolimus.CONCLUSION:In conclusion, conversion to an everolimus-based immunosuppressive regimen after late cardiac rejection is safe and effective; no major side effects were observed.

Introduction Computerized heart allograft rejection monitoring (CHARM) used for non-invasive rejection monitoring in heart transplant recipients is based on the analysis of ventricular evoked response (VER) signals. The aim of this study was to evaluate the prognostic validity of the TslewC, a parameter calculated from the VER. Methods During orthotopic heart transplantation, 2 unipolar fractally coated screw-in leads were implanted epimyocardially, one to the left and one to the right ventricle, and connected to a telemetric pacemaker. Recordings of intramyocardial electrograms were performed routinely at the hospital. Data processing was done, artifacts were eliminated, and trend curves of the patients were displayed. TslewC was calculated from the tangent of VER and evaluated from 105 patients. The patients were divided into survivor and non-survivor groups. For statistical analysis, the 2-tailed t-test was performed. Results Patients in the non-survivors group compared with the control group showed a significantly lower TslewC in the final follow-up (p < 0.001). The differences were even more impressive in patients with recorded intramyocardial electrograms 30 days before death or with a cardiac reason for death. Tests were performed to find an optimal prognostic threshold of the TslewC, and the value of 26 mV was finally found. Conclusion TslewC can function as prognostic factor after orthotopic heart transplantation. Further studies should be initiated to provide the prognostic threshold so that patients would not be forced to show up routinely every 4 weeks for follow-up visits. Patients would only have to be admitted to the hospital if the TslewC were less than this prognostic threshold.

BACKGROUND: Heart transplantation is an established therapy for end-stage cardiac disease. METHODS: Overview of the state of the art. RESULTS: More than 60,000 heart transplantations have been performed up to now. Survival rates for 1, 3 and 5 years are 82, 74 and 69%. The half-time of an organ is about 10 years. CONCLUSIONS: Long-term results after heart transplantation are excellent and exceed medical therapy. The number of procedures is limited by the number of organs donated, so patient selection is of special importance.

Background. Organ shortage is a major problem in transplantation. Many potential donors are still lost due to a lack of information and communication. Many transplantation centers report a major donor increase after introducing new donor policies. The aim of this study was to evaluate in retrospective fashion a new donor policy in our region.Methods. For the past 10 years all reported donors from intensive care units (ICUs) in our region were evaluated. Our new policy had 2 main steps: accepting more marginal grafts and using a transplantation representative. The goal was the improved communication with ICUs to support physicans involved in donor care. A public information program was also implemented.Results. In the first year, numbers of donors obviously improved (+60.5%) an remained stable the following year. The mean donor age increased to 41.56 years. The donor pool showed mainly an improved kidney-donation rate (+53%) with also an increase in multiorgan donation (+37%). One year posttransplantation survival was not negatively influenzed by this donor pool. As expected, transplantation activities increased notably, particularly liver transplantation (+31.11%) but also kidney transplantation (+26.73%).Discussion. Many donors are lost because physicans in charge of brain dead patients are. not fully informed about modified donation criteria. The reason for this is a lack of information and communication by transplantation units. Improved surgical techniques and better preoperative, intraoperative, and postoperative treatment have yielded better results with marginal grafts. Immediate graft function in recipients of suboptimal grafts may be delayed, but without a significantly negative impact on patient and graft survival. Because the age of organ recipients is steadily increasing with fewer contraindications for transplants, more organs will be needed.

BACKGROUND: Cardiac resynchronization therapy (CRT) by pacing the left and right ventricles improves symptoms and functional status in patients with left ventricular dysfunction, congestive heart failure and ventricular conduction disturbances. METHODS: Review of the recent literature. RESULTS: The results of several studies have shown the benefit of CRT in a subpopulation of patients with congestive heart failure. In the majority of these patients improvements were found in quality of life, New York Heart Association functional class, distance walked in 6 minutes, peak oxygen uptake and total exercise time. In addition, reverse left ventricular remodeling and reduction of functional mitral regurgitation have been demonstrated. However, 30% of patients undergoing CRT implantation according to currently accepted implant criteria will show no substantial improvement with CRT. CONCLUSIONS: Using atrial-synchronized biventricular pacing in combination with optimal pharmacological therapy has been shown to significantly improve the patients' symptoms.

Background: The Cancion™ Cardiac Recovery System (CRS) is a recently developed extracorporeal device that markedly improves hemodynamics in heart failure animal models. The system superimposes continuous aortic flow on existing pulsatile flow, reducing LV afterload, with possible direct renal circulatory effects, without the need for major surgical intervention. This abstract reports the initial clinical experience with the Cancion™ CRS. Methods: The Cancion™ CRS was connected to the inflow of the centrifugal pump via a percutaneous femoral arterial cannula and to the outflow of the pump via a graft cannula anastomosed to the left axillary artery. Results: Four patients with acute heart failure exacerbation, refractory to i.v. inotropes and diuretics, were placed on the CRS. Patients were supported for an average of 72 hours (24 hours to 5 days) with pump flows between 1.3 to 1.5 (mean, 1.4) l/min. A fifth patient (not shown) died of severe hyperkalemia 2 hours post implant. Conclusion: The Cancion™ CRS, a novel form of cardiac assist, acting through a low-flow, continuous aortic flow loop, markedly improved PCWP, CI and renal function in patients with acute heart failure exacerbation, refractory to i.v. inotropes and diuretics. Hemodynamic and renal functional improvement persisted following discontinuation. These results are encouraging and suggest the need for a prospective randomized trial to explore the potential for routine use in patients refractory to medical therapy.

Animal studies have shown clearly that a peripheral circulatory support system can effectively unload the left ventricle. We report here the first implantation of one such system (Cancion, Orqis Medical, Lake Forest, CA) in a human. The Cancion system consists of a centrifugal pump connected to the circulation via a graft cannula anastomosed to the left axillary artery and a percutaneous cannula placed into the left common femoral artery. Flow is initiated from the femoral to the axillary artery. The system was implanted in a 62-year-old man with ischemic cardiomyopathy suffering from decompensation whose condition had not improved with catecholamine therapy. The Cancion system supported the patient for 3 days, after which it was electively explanted. During the support period, pulmonary capillary wedge pressure dramatically decreased from 28 to 9 mm Hg, left ventricular diastolic dimension decreased from 6.78 to 6.16 cm, creatinine levels decreased from 1.9 to 0.9 mg/dl, cardiac index improved from 1.5 to 2.7 L/min, and ejection fraction improved from 25 to 35%. Together, our data indicate that the Cancion system quickly and effectively improved the patient's hemodynamics. This suggests that the device may one day become a short-term alternative to high dose inotrope therapy and that its application may delay the need for more invasive forms of mechanical circulatory support.

HeartMate VE LVAS has proofen to be an effective device in chronic cardiac mechanical support. Long-term cardiac assistance is impaired by high incidence of percutaneous driveline infections. Quality of life is reduced and mortality and morbidity is increased by this complication. Beside meticulous dressing procedures immobilizing of the driveline exit is one of the major keys for reducing the complication rate. We report of a simply, effective and patient friendly method. A small velcro fastener (Klettostar haft, 3M Innovation) is stucked to the backside of the driveline Y-connector. On the correponding side of the skin a 7x7cm adhesive wound dressing (Cutinova hydro, Beiersdorf) is fixed. On this plate the opposite part of the velcro fastener (4x4cm) is glued. This fixation gives a stable connection between the Y-connector and the patients body. With this mechanism the driveline is well fixed but it can be easily removed by the patient for everyday procedures like wound dressing, showering etc. In our experience the self-adhesive wound dressing is skin protective and there are no signs of skin irritations after more than 150 days. In our view this method of fixation is easy to handle, save, stable and comfortable for the patient. Despite of its simplicity it contributes to reduce the incidence of driveline related complications.

Animal studies have shown that the Orqis™ Medical Cancion™ Cardiac Recovery System (Cancion™ CRS) for peripheral circulatory support can unload the left ventricle. We report the first human experience. The Cancion™ CRS is connected to the circulation via a graft cannula anastomosed to the left axillary artery and a percutaneous cannula placed into the left common femoral artery. Using a centrifugal pump, flow is initiated from the femoral to the axillary artery. A 62-year-old man with chronic congestive heart failure and renal insufficiency awaiting heart transplantation was admitted due to worsening symptoms. He was placed on dobutamine 16 μL/kg/min without signs of improvement. Mean PCWP was 28 mmHg, CI 1.5 L/min/m2, creatinine 1.9 mg/dL and creatinine clearance 48 mL/min. The patient was taken to the operating room where support with the Cancion™ CRS was initiated with flows maintained at 1.3–1.9 L/min. The patient was supported for 3 days and the system was electively removed. There was a decrease in PCWP, LVEDD, and creatinine, and an increase in CI and EF (Table). It appears that the Cancion™ CRS is effective for quickly improving hemodynamics and renal function. Due to easy and fast application, this system may become an excellent short-term alternative to high-dose inotrope therapy, and may delay the necessity for more invasive forms of mechanical circulatory support.Table