Perioperative pain management in thoracic organ transplantation continues to be challenging, with inadequate pain control correlating with extended recovery times, an increased incidence of chronic pain, and an overall poorer outcome. This review highlights the importance of a holistic approach in pain management following heart and lung transplantation, combining conventional pharmacological treatments with non-pharmacological techniques. The incidence of chronic pain in transplant recipients is high, with up to 75% of lung transplant recipients experiencing chronic pain within the first five years post-transplant. The contributing factors include surgical trauma, opioid induced hyperalgesia, graft-related discomfort, and musculoskeletal issues, whilst considering non-surgical influences such as biopsychosocial issues and gender. The implementation of complementary techniques for acute and chronic pain management includes mind-body and kinetic techniques. Recent research demonstrated the potential benefits of auricular acupuncture in reducing post-operative inflammation and pain. Early mobilization, specific respiratory exercises, and positive communication strategies are significant components of comprehensive pain management. Whilst evidence base for complementary interventions is still evolving, integrating them into post-operative care plans reflects a commitment to improving patient care.Greater research should concentrate on evaluating the efficacy of complementary therapy in heart and lung transplant recipients to optimize pain management strategies and enhance post-transplant quality of life.

BACKGROUND:The United Kingdom (UK) was one of the first countries to pioneer donation after circulatory death (DCD) heart transplants. To establish equitable access to DCD hearts, a nationally-funded DCD program was established in 2020. We report the results of this program and examine retrieval techniques, ischemic times and survival. METHODS:This multi-center, retrospective, observational study compared DCD versus donation after brain death (DBD) heart transplant outcomes from 2020 to 2024. DCD hearts were retrieved using direct procurement and perfusion (DPP) with/without abdominal normothermic regional perfusion (A-NRP). Primary outcomes were 1-year survival and severe primary graft dysfunction (PGD). Ischemic times, cannulation techniques, and A-NRP status were analyzed. RESULTS:There were 188 DCD and 523 DBD heart transplants. There was no difference in 30-day (96% DCD vs 95% DBD, p = 0.76) or 1-year survival (87% DCD vs 88% DBD, p = 0.81). There was no difference in severe PGD (unadjusted analysis; 28% DCD vs 24% DBD, p = 0.26). DPP with A-NRP increased ischemic timings (asystole to cardioplegia delivery, 15 mins (n = 22; A-NRP/DPP) vs 13 mins (n = 166; DPP, p = 0.0022). Propensity-matched analysis showed no difference in 90-day survival (86.4% vs 88.6%; p = 0.7828). Papworth cannulation technique reduced ischemic times with no impact on outcomes. Longer implant (p = 0.03) and ex-situ perfusion (p = 0.02) times were associated with severe PGD/death at 1 year. CONCLUSION:DCD heart donation increased UK heart transplantation by 36% compared with DBD alone, with results comparable to DBD. A-NRP/DPP is feasible but prolongs ischemic times, although survival was similar to the DPP group. The main predictors of poor 1-year survival were implant and ex-situ perfusion times.

OBJECTIVES:Chronic thromboembolic pulmonary hypertension is a late complication of acute pulmonary embolism. Though potentially curative, pulmonary thromboendarterectomy (PTE) is technically demanding, with outcomes closely linked to institutional volume and surgeon experience. This study assessed the safety and effectiveness of training in a dedicated fellowship by comparing outcomes of PTEs performed by fellows with those performed by experienced consultant surgeons in a high-volume center. METHODS:Data for all first-time PTEs performed between January 2016 and December 2025 were retrieved. Patients with incomplete data, age younger than 18 years, overseas residency, and those who did not consent to data use were excluded. Cases (through May 2025) where fellows performed bilateral endarterectomy (Group F) were identified and propensity-score matched (1 to 2 ratio) with consultant-led cases (Group C) for an outcome analysis. RESULTS:A total of 1744 PTEs were performed during the study period (median age, 60 years; 55.9% men, in-hospital mortality, 1.9%). Five fellows (52 fellow-months) scrubbed for 629 cases, with 312 cases as first operator (49.6% of scrubbed cases). The propensity-matched outcome analysis study cohort comprised 678 patients. Preoperative characteristics were comparable between groups. Circulatory arrest was longer in Group F (40 vs 35 minutes; P < .001). Groups had similar perioperative complication rates, including reperfusion lung injury, endobronchial bleeding, and extracorporeal membrane oxygenation utilization, with comparable hospital mortality rates. Postdischarge hemodynamic, functional, and quality-of-life outcomes, as well as long-term survival, were similar between groups. CONCLUSIONS:Dedicated PTE training in a high-volume center is safe and does not compromise short- or long-term outcomes. This represents the largest reported experience of training in PTE surgery.

INTRODUCTION:Pulmonary endarterectomy (PEA) is recommended in patients with proximal chronic thromboembolic pulmonary hypertension (CTEPH). However, there is limited and conflicting evidence regarding the use of PH medical therapy as a bridge to PEA. Similarly, there is no consensus on the criteria for continuing or restarting PH medical therapy postoperatively. We assessed the characteristics and long-term outcome of patients receiving PH bridging therapy and identified characteristics of residual PH post-PEA. METHODS:We conducted a secondary analysis of the prospective CURATE registry, evaluating the UK's national CTEPH cohort undergoing PEA between January 1, 2015 and December 12, 2022. Characteristics associated with pre-PEA bridging therapy, post-PEA PH-medical therapy, and long-term outcome were assessed. RESULTS:About 1102 patients underwent PEA, of which 661 (60%) received bridging therapy. Patients treated with bridging therapy had higher mPAP (46 vs 44 mmHg, p = 0.038) and worse functional class (NYHA III 84% vs 76%, p = 0.003) at baseline and showed lower 1- and 3-year survival (93% vs 96% and 89% vs 94%, p = 0.002). Post-PEA, 47% of PEA patients had elevated postoperative mPAP of ≥25mmHg. mPAP >31 mmHg and PVR >336dynes.sec.cm-5 were associated with the initiation of post-PEA PH medical therapy. CONCLUSION:After adjustment for 6MWD, no survival difference was observed between patients treated with PH medical therapy pre-PEA and patients who were not treated. Residual PH defined as mPAP ≥25mmHg affects 47%, however, only 15% of patients receive PH medical therapy post-PEA. As uncertainties remain, further studies are needed to evaluate decision-making for medical PH therapy pre-PEA and for treatment of residual PH.

Heart transplantation (HT) remains the reference therapy for selected eligible patients with advanced heart failure (HF), recent developments in drug and device therapies notwithstanding. The majority of heart transplants are performed in Europe and the USA. However, the rate of heart transplants varies greatly among European countries, ranging from <1 to >10 per million population per annum. Due to donor organ shortage, durable mechanical circulatory support (MCS) became a practical solution for many advanced HF patients, either as a bridge to transplant or as destination therapy. The aim of the present clinical consensus statement of the European Society of Cardiology -Heart Failure Association is to provide a perspective on important issues regarding HT, in particular patient selection, pre-transplant work-up, matching of donor heart and recipient, strategies of bridging patients to transplant with temporary or durable MCS, as well as how to increase the donor organ pool. Furthermore, surgical techniques and complications are discussed, as well as immediate post-transplant, and long-term management including the main aspects of long-term follow up such as rejection surveillance, personalized immunosuppression and managing comorbidities. Cellular and antibody mediated rejection, early cardiac allograft failure, and indications for retransplantation are described. An emphasis is given on the most important post-HT complications, such as cardiac allograft vasculopathy, infections and malignancies. Finally, the need for tailored physical rehabilitation and psychosocial support, and impact of post-transplant status on reproductive health are discussed.

OBJECTIVES:Donation after circulatory-determined death (DCD) heart transplantation has increased the number of hearts available for transplantation by 30%-40%. This may be associated with improved clinical outcomes for patients waiting for transplantation. We compare clinical outcomes from registration on the transplant waiting list before and after establishment of a DCD heart transplant programme. METHODS:Observational cohort study of all patients listed for heart transplantation at a single centre for 3 years before (cohort 1) and 3 years after (cohort 2) the start of a DCD heart transplant programme. Outcome measures included heart transplantation, removal from waiting list due to death or deterioration, removal from waiting list due to improvement or patient choice, and need for mechanical circulatory support (MCS) after listing for heart transplantation. RESULTS:One hundred twenty-nine patients were registered on the waiting list in cohort 1 and 146 patients in cohort 2. Patients in cohort 1 underwent 91 donation after brainstem-determined death (DBD) and 12 DCD heart transplants. Patients in cohort 2 underwent 102 DBD and 32 DBD heart transplants. Compared with cohort 1, patients in cohort 2 had a shorter waiting time for transplantation (45 vs 77 days, P = 0.001) and an increased cumulative incidence of transplantation (P < 0.001). When all patients had reached an end-point, patients in cohort 2 had a lower likelihood of death or removal from waiting list due to deterioration (6% vs 18%, P = 0.011) and fewer patients in cohort 2 required MCS after listing (4.1% vs 13.9%, P = 0.007). CONCLUSIONS:In a single centre, introduction of a DCD heart transplant programme was associated with shorter waiting times for heart transplantation and a lower likelihood of death/deterioration or requirement for MCS while waiting for heart transplantation.

BACKGROUND:Abdominal Normothermic Regional Perfusion (A-NRP) improves outcomes for transplanted abdominal organs from Donation after Circulatory Death (DCD) donors. Concerns have been raised about the effect of A-NRP on lungs procured during multi-organ donation. We present the UK experience of performing direct procurement (DRP) of lungs from DCD donors with A-NRP. METHODS:Retrospective analysis of all 487 UK DCD lung donors between April 1, 2011 and December 31, 2023. Organ transplantation rate and 30-day, 90-day and 1-year survival rates were compared between DRP of DCD lungs, DRP of DCD lungs with A-NRP and donation after brainstem death (DBD) lungs. Primary graft dysfunction (PGD) rates were compared between DCD lungs with and without A-NRP. RESULTS:Three hundred ninety-seven DCD donors resulted in a lung transplant (22 retrieved by DRP with A-NRP). There was no difference in lung transplantation rates between DRP and DRP with A-NRP. Of the 390 first adult-only lung transplants performed from DCD donors, there was no significant difference in 30-day, 90-day and 1-year survival between DRP of DCD lungs and DRP with A-NRP. There was a significant difference in survival between standard DCD donors and DBD donors at 30-days and 90-days, but not 1 year. There was no significant difference in grade 3 PGD rates at 72 hours post-implantation for DCD lungs with or without A-NRP. CONCLUSION:In the UK experience, use of A-NRP is not detrimental to procurement of DCD lungs. We advocate the use of this technique until further studies can explore the safety and efficacy of thoraco-abdominal NRP for lungs in multi-organ retrieval.

Left ventricular diastolic dysfunction in chronic thromboembolic pulmonary hypertension is classically attributed to the negative effects of pulmonary hypertension on left ventricular filling. Recent evidence, however, suggests diastolic dysfunction may exist independent of pulmonary hypertension and moreover may be masked by an under-filled left ventricle. Consecutive patients undergoing pulmonary endarterectomy (2007 – 2018) were included (n=1266). Left ventricular diastolic dysfunction was assessed using pulmonary arterial wedge pressure and in nested cohorts utilising multi-modal cardiac imaging. Diagnostic baseline, outcome data, and long-term mortality outcomes were assessed. 135 individuals had a wedge pressure >15mmHg following surgery, of whom 60% had a normal wedge pressure pre-operatively. No patients had a formal diagnosis of heart-failure preserved ejection fraction. Haemodynamic, functional and patient-related outcomes were all worse in this patient subgroup and associated with a higher requirement for peri-operative non-invasive ventilation and impaired long-term survival. Post-operative cardiac imaging confirmed evidence of left ventricular diastolic dysfunction in patients with an elevated wedge pressure. Pre-operative left atrial dilatation alone predicted post-operative wedge elevation with accuracy (sensitivity 67%, specificity 100%), and was superior to echocardiography. Left ventricular diastolic dysfunction is strongly associated with all pulmonary endarterectomy outcome measures, however the majority of patients do not have an elevated wedge pressure pre-operatively and are not diagnosed with heart failure. Standard pre-operative work-up should include assessment for diastolic dysfunction to aid risk categorisation and guide therapy decisions.

Purpose: The Centrimag ventricular assist device (VAD) is a versatile and reliable method of temporary mechanical circulatory support for patients in refractory cardiogenic shock. Patients with biventricular disease who are unsuitable for implantable LVAD support may be bridged directly to heart transplantation with Centrimag BiVAD support. We report our institutional experience with this strategy over the last decade.

BACKGROUND:Previous studies have demonstrated the safety of pulmonary endarterectomy (PEA) across body mass index (BMI) strata. However, long-term survival and patient-reported outcome measures by BMI strata remain unknown. We examined the impact of preoperative BMI on long-term survival, QOL, and functional outcomes for patients undergoing PEA for chronic thromboembolic pulmonary hypertension (CTEPH). METHODS:Retrospective review of 2,004 patients from the UK National Cohort between 2007 and 2021 undergoing PEA for CTEPH (mean pulmonary artery pressure >20 mm Hg and pulmonary vascular resistance >160 dynes). Patients were stratified into BMI<20, 20 to 29, 30 to 39, 40 to 49, and 50+. All-cause mortality was the primary outcome measure. Secondary outcome measures were 3- to 6-month postoperative hemodynamics, 6-minute walk distance (6MWD), New York Heart Association (NYHA) class, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) scores. RESULTS:Hemodynamics and 6MWD at 3 to 6 months were similar across BMI strata. Patients with BMI 50+ reported the highest incidence of postoperative NYHA III/IV limitation (53.3%, p < 0.001) and the highest residual symptom burden by CAMPHOR (p < 0.001). Five-year survival was lowest in patients with BMI 50+ (70.2%) and BMI<20 (73.4%), while highest in BMI 30 to 39 (88.2%, p = 0.008). Ten-year Kaplan-Meier estimates predicted the lowest survival in BMI 50+ and BMI<20. CONCLUSIONS:PEA remains safe and effective for all patients regardless of BMI. Despite similar hemodynamic outcomes, patients with BMI 50+ are at the greatest risk of long-term all-cause mortality, and patients with BMI 50+ experience residual symptomatic limitation.

Purpose: Direct procurement and preservation (DPP) with ex-vivo normothermic perfusion is the main retrieval method used for donation after circulatory-determined death (DCD) heart transplantation in our centre. The aim of this study is to evaluate the presence of potential predictors of severe primary graft dysfunction (PGD) in this population that can be identified during the period of ex-vivo perfusion.

Purpose: Describe the UK experience of direct retrieval and preservation (DRP) of lungs for transplantation alongside abdominal normothermic regional perfusion (A-NRP), with an analysis of early outcomes for lungs transplanted with this method compared to standard retrieval after circulatory death (DCD).

BACKGROUND: Pulmonary endarterectomy (PEA) is the guideline -recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. METHODS: This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected. RESULTS: One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for "other" reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10 -year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. CONCLUSIONS: Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer -term survival. J Heart Lung Transplant 2024;43:241-250 (c) 2023 International Society for Heart and Lung Transplantation. All rights reserved.

An implantable left ventricular assist device (LVAD) is indicated as a bridge to transplantation or recovery in the United Kingdom (UK). The mechanism of action of the LVAD results in a unique state of haemodynamic stability with diminished arterial pulsatility. The clinical assessment of an LVAD recipient can be challenging because non-invasive blood pressure, pulse and oxygen saturation measurements may be hard to obtain. As a result of this unusual situation and complex interplay between the device and the native circulation, resuscitation of LVAD recipients requires bespoke guidelines. Through collaboration with key UK stakeholders, we assessed the current evidence base and developed guidelines for the recognition of clinical deterioration, inadequate circulation and time-critical interventions. Such guidelines, intended for use in transplant centres, are designed to be deployed by those providing immediate care of LVAD patients under conditions of precipitous clinical deterioration. In summary, the Joint British Societies and Transplant Centres LVAD Working Group present the UK guideline on management of emergencies in implantable LVAD recipients for use in advanced heart failure centres. These recommendations have been made with a UK resuscitation focus but are widely applicable to professionals regularly managing patients with implantable LVADs.

Ten years have passed since we reported percutaneous decommissioning of an implantable left ventricular assist device (LVAD) using 2 Amplatzer vascular plugs in a 17-year-old male who was bridged to recovery after 22 months of LVAD support. While his left ventricular (LV) dimensions never completely normalized and there has been persistent mild impairment of LV systolic function, the patient remains free of heart failure symptoms and his natriuretic peptide level has been well suppressed on guideline-directed medical therapy. He is anticoagulated with Warfarin. There have been no adverse events relating to either the decommissioned LVAD or the percutaneous driveline remnant, or anticoagulation. This case highlights the potential for long-term survival without adverse events in individuals who are left with a redundant implantable LVAD after successful percutaneous withdrawal of mechanical circulatory support.