Purpose: Heart transplantation (HT) with extremely prolonged ischemic time (> 6 hours) is associated with the risk of severe cardiac allograft dysfunction. Preventive (preoperative initiation) veno-arterial extracorporeal membrane oxygenation (VAECMO) has been used to prevent hemodynamic instability during cardiac surgery. Purpose of the study: to determine the effect of preventive VAECMO on the course of the perioperative period in HT with an extremely long cardiac allograft ischemic time (>6 hours).

Objective: to analyze heart transplant (HT) outcomes in patients who suffered cardiac arrest requiring extracorporeal cardiopulmonary resuscitation (ECPR) by peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Materials and methods. The study included 41 patients (14 (34.1%) women and 27 (65.9%) men, aged 42.6 ± 16.8 (40.0 [30.5; 54.0]) years with in-hospital cardiac arrest. The causes of cardiac arrest were acute decompensated heart failure (n = 19; 46.3%), irreversible graft dysfunction (n = 9; 22.0%), postcardiotomy acute heart failure (n = 5; 12.2%), acute myocardial infarction (n = 4; 9.8%), and acute graft rejection (n = 4; 9.8%).Results. Twenty-seven (65.9%) patients had cardiac arrest in the intensive care unit (ICU) and 14 (34.1%) outside ICU. The interval between femoral artery puncture and ECPR initiation was 4-17 (9 ± 5) minutes, while that between cardiopulmonary resuscitation (CPR) initiation and peripheral VA-ECMO was 26 ± 9 minutes. Atonic seizure developed in 11 (26.8%) of 41 patients while receiving VA-ECMO. Of the 41 patients, 30 (73.2%) had irreversible brain damage. Four (9.8%) patients were discharged from the hospital without neurological or multiple organ dysfunction. In 26 (63.4%) patients (10 (38.5%) women and 16 (61.5%) men) aged 14 to 63 (40.7 ± 15.8) years, ECPR and subsequent treatment resulted in survival to HT while receiving VA-ECMO (duration 1-11 (4.0 [1.5; 5.0]) days). The age of the heart donor (6 (23.1%) women and 20 (76.9%) men) was 44.0 ± 9.9 years, the cumulative Eurotransplant Heart Donor Score was 16.9 ± 2.7, the Donor Risk Index was 6.3 ± 1.5, and the estimated incidence of severe primary graft dysfunction (RADIAL scale) was 15.4 ± 3.7%. Graft ischemia lasted for 188 ± 72 (170.0 [141.25; 185.0]) minutes. Five (19.2%) recipients developed severe dysfunction, which required continuation of peripheral VA-ECMO in the postperfusion period. The cause of death (n = 4; 15.3%) in the early post-HT period was irreversible multiple organ dysfunction.Conclusion. In-hospital survival after emergency HT in recipients who underwent ECPR before transplantation is 84.7%.

Purpose: Centers with high-volume of heart transplantation (HT) demonstrate superior early and long-term posttransplant outcomes. Achievement of high-volume of heart transplantation may be associated with a large number of high risk recipients and using hearts from marginal donors that may have an ambiguous effect on heart transplant center's efficacy. Purpose of the study was to analyze pretransplant heart recipient's characteristics, donor's parameters, immediate and long-term results in a very high annual HT volume center.

Heart transplantation remains the gold standard treatment for end-stage heart failure. Lifelong immunosuppressive and adjuvant therapy requires constant medical follow-up in order to optimize treatment regimens and increase the adherence of heart recipients to treatment.Objective: to study and adapt a method for systematic assessment of the complexity of treatment regimen using the MRCI index, and its link to long-term prognosis in heart recipients.Materials and methods. Results of the study were obtained by analyzing the data of heart recipients observed at the Consultative & Diagnostic Department, Shumakov National Medical Research Center of Transplantology and Artificial Organs (Shumakov Center). The Medication Regimen Complexity Index (MRCI) was used to assess drug therapy. In our study, polypharmacy was defined as taking five or more medications, and high-risk polypharmacy was defined as the use of more than eight medications. The heart recipients were divided into two groups based on how many medications they received daily.Results. The study included patients observed at the Consultative & Diagnostic Department, Shumakov Center from January 2008 to December 2017. The number of drugs taken by the patient at year 5 of follow-up was 9.2 ± 4.2. During the conducted data analysis, the mean total MRCI score was 48.72 ± 19.15 (from 32 to 70); medications used to treat comorbidities accounted for 42.9% of the total MRCI score, and immunosuppressive therapy accounted for 28.7%. The total MRCI score in the high-risk polypharmacy group was 58.49 ± 17.41; medications used to treat comorbidities accounted for 50.27% of the total MRCI score. The analysis revealed a correlation between the total MRCI score and the frequency of hospitalizations.Conclusions. Patient adherence to prescribed treatment is a predictor of favorable prognosis of event-free long-term survival, but low adherence and therapeutic inertness are associated with decreased quality of life, more frequent hospitalizations and higher risk of adverse events. With proper outpatient follow-up of this patient cohort, there were no significant differences in survival in the polypharmacy and high-risk polypharmacy group.

Heart transplantation (HT) with extremely prolonged (>6 hours) graft ischemia is associated with severe cardiac graft dysfunction. The high efficiency of prophylactic (preoperative initiation) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to prevent severe hemodynamic disorders during cardiac surgery has been demonstrated. Objective: to determine the effect of prophylactic VA-ECMO on the perioperative period in HT with an expected graft ischemia >6 hours. Materials and methods. Thirty-eight recipients (33 (86.8%) males and 5 (13.2%) females), age 11–66 (44.7 ± 12.0) years (median 48.0 years) were examined. Pre-transplant mechanical circulatory support (MCS) using peripheral VA-ECMO was applied in 15 (39.5%) recipients, in 6 of whom by prophylactic technique. The recipients (n = 38) were divided into 3 groups: 1) «no pre-HT VA-ECMO» (n = 23); 2) «pre-HT VA-ECMO» (n = 9) – pre-transplant VA-ECMO as a bridge to HT; 3) «prophylactic VA-ECMO» (n = 6). Results. In «prophylactic VA-ECMO» group, extracorporeal circulation (ECC) (94.0 [85.5; 102.8] min) and reperfusion time (20.0 [18.3; 27.6] min) were shorter (p < 0.05) compared to «no pre-HT VA-ECMO» (161.0 [122; 191.5] and 60.0 [55.3; 70.5] min) and «pre-HT VA-ECMO» (127.0 [117; 150.3] and 35.0 [27.8; 48.8] min) groups. The vasoactive-inotropic score was lower (p < 0.05) in «pre-HT VA-ECMO» and «prophylactic VAECMO» groups compared to recipients in «no pre-HT VA-ECMO» group, 12.1 [11.2; 14.0] and 12.5 [11.7; 14.8] vs. 16.0 [15.0; 18.5], respectively. The groups did not differ in terms of incidence of severe primary dysfunction. The «pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups were characterized by shorter duration of mechanical ventilation (MV) compared with «no pre-HT VA-ECMO» group (11.7 [10.0; 16.5] and 12.7 [11.3; 18.4], respectively, vs. 14.5 [13.0; 19.3]). The «no pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups did not differ in the need for postoperative MST, 21.7% and 16.7%, respectively. The groups did not differ in terms of length of stay in the intensive care unit (ICU) and in-hospital mortality – 0% («prophylactic VA-ECMO») and 8.7% («no pre-HT VA-ECMO») and 11.1% («pre-HT VA-ECMO»), respectively. Conclusion. Prophylactic VA-ECMO in HT with extremely prolonged cardiac graft ischemia reduces ECC duration, reperfusion period, postoperative mechanical ventilation period, and the need for inotropic therapy.

Objective: comparative analysis of long-term outcomes following heart transplantation (HT) with prolonged and short cold ischemia. Materials and methods. We analyzed the data of 29 orthotopic HT with > 4 hours of cold ischemia. The transplant surgery was performed at Meshalkin National Medical Research Center between 2013 and the present time. Organs were obtained from donors from other regions. The control group consisted of 29 HTs with cold ischemia < 4 hours, performed in the same period. The minimum distance between the transplant center and the donor base was about 250 km (Barnaul); the maximum distance was about 850 km (Krasnoyarsk). Recipient survival and postoperative peculiarities were analyzed. Results. In-hospital survival in the prolonged cold ischemia group was 89.7% (n = 26) with 3 deaths (10.3%). In the second group (< 240 min), in-hospital survival was 79.3% (n = 23) with 6 (20.7%) deaths. The Kaplan-Meier survival analysis showed no difference between the groups (Log-Rank Test, P 1/4 0.59). In addition, cold ischemia time did not increase the risk of graft rejection and the risk of transplant coronary artery disease (TCAD). Conclusion. HT with cold ischemia > 4 hours did not have worse outcomes than in short graft ischemia. This provides grounds for further accumulation of experience in the use of heart donors from remote locations.

Federation In certain categories of patients with end-stage heart failure (HF), short-term mechanical circulatory support (MSC) is successfully used as a mechanical «bridge» to heart transplantation (HTx). In predominantly left-ventricular (LV) dysfunction, the use of isolated coronary artery bypass, especially amidst high pulmonary hypertension (PH), seems to be a more physiological method of short-term MSC. Objective: to present the results of a series of clinical cases of the use of percutaneous left ventricular assist device (pLVAD) before HTx in potential recipients with predominantly LV dysfunction and concomitant high PH. Materials and methods . Three potential heart recipients with predominantly left-sided HF and high pre-transplant PH (pulmonary vascular resistance, PVR, 4.7–6.6 Wood units) who required MSC due to progression of hemodynamic disorders were included in the study. A standard venous extracorporeal membrane oxygenation (ECMO) cannula (26 F) was used for percutaneous left atrial-femoral artery (LA–FA) bypass. The cannula was passed from the transfemoral route through the interatrial septum into the left atrial cavity. A paracorporeal centrifugal pump provided blood injection through a standard arterial ECMO cannula (15 F). Results. pLVAD unloaded the left ventricle effectively (PCWP reduced from 27–32 to 15–20 mmHg), reduced pre-transplant PH (mean pulmonary artery pressure (mPAP) reduced from 45–53 to 28–33 mmHg) and improved systemic hemodynamics (cardiac index (CI) increased from 1.8–1.9 to 2.1–2.6 l/min/m 2 and mean arterial pressure (mAP) from 56–59 to 70–75 mmHg). All these created the prerequisites for subsequent successful HTx. Against the background of pLVAD, transpulmonary pressure gradient (TPG) decreased from 15–25 to 13–15 mmHg, and PVR decreased from 4.7–6.6 to 2.7–3.4 Wood units. pLVAD flow rate was 2.9–3.8 L/min or 1.38–1.83 L/min/m 2 at 4700–7100 rpm. pLVAD duration ranged from 4 (n = 1) to 7 (n = 2) days. All patients underwent successful HTx. Conclusion. pLVAD is a highly effective method of short-term MSC in potential recipients with predominantly LV dysfunction and concomitant high PH, leading to rapid regression of the dysfunction against the background of left ventricular unloading. This short-term MSC technique can be successfully realized using standard ECMO cannulas and centrifugal pumps of any modification, without requiring additional special equipment.

Implantable left ventricular assist device (LVAD) is a state-of-the-art treatment for adults and children with end-stage heart failure. The early and late period after LVAD implantation can be severely complicated. Right ventricular failure (RVF) still remains a common complication after LVAD implantation. RVF is the cause of reduced post-implant survival. We suggest that an additional temporary or permanent right ventricular assist device (RVAD) is an effective treatment for LVAD-associated RVF. In this clinical case report, we describe the medical history of a pediatric patient (14 years old) with severe heart failure (PediMACS Level 1) against a background of dilated cardiomyopathy. The patient required peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) prior to urgent LVAD (HM3) implantation. In the early post-LVAD implantation (1 POD) period, the patient presented with hemodynamic and echocardiographic events of acute RVF that was resistant to drug therapy (inotropic/vasopressor support, iNO) and required mechanical circulatory support (MCS) with a preoperatively implanted VA-ECMO. In the LVAD-associated RVF scenario, VA-ECMO as a means of total cardiac bypass is a non-physiological MCS method and, therefore, undesirable. In this clinical situation, our solution was to use a paracorporeal centrifugal blood pump for temporary right heart support. A RVAD was assembled using percutaneous cannulation in two sites and a modification of the pre-existing VA-ECMO circuit. For RVAD, we used an ECMO cannula previously installed through the femoral vein (26 F) and added a reverse venous cannula (22 F) through the right internal jugular vein into the pulmonary trunk. To facilitate the passage of the return cannula into the pulmonary artery, we used a contralateral sheath (6 F, 40 cm) and an Amplatz Super Stiff guidewire under radiological control. The oxygenator was removed from the circuit on day 2 of RVAD. Central hemodynamics (reduction in right atrial pressure (RAP) to 10 mm Hg, increase in pulmonary capillary wedge pressure (PCWP) to 14 mm Hg), as well as right ventricular (RV) and left ventricular (LV) volume characteristics all improved. These observations allowed us to optimize the performance of the implantable LVAD (increase in flow rate to 4.2 l/min or 2.1 l/min/m 2 ). The duration of paracorporeal RVAD after LVAD implantation was 7 days with an average flow rate of 2.3 ± 0.2 l/min. Postoperative treatment in the intensive care unit (ICU) lasted for 15 days. The patient was discharged from the hospital on postoperative day 34.

Heart transplantation (HT) is considered the optimal therapy for end-stage heart failure. In recent years, the number of operations performed has been growing, which has led to a rise in the number of heart transplant recipients requiring outpatient follow-up. Objective: to evaluate the effectiveness of the model of dual personalized follow-up of heart transplant recipients in the consultative and diagnostic department of Shumakov National Medical Research Center of Transplantology and Artificial Organs. Materials and methods . The study included 1,436 patients under outpatient follow-up from January 2008 to December 2022. Recipient data, results of laboratory and instrumental examination methods, nature and frequency of complications at different follow-up periods were analyzed. Results : At the time of discharge from the hospital, 98.7% of patients had received triple-drug immunosuppressive therapy; 6 months later, methylprednisolone was discontinued in 72.2% of recipients. Mean tacrolimus level during the 1-year follow-up was 8.7 ± 2.7 ng/mL; in the period from 1 to 5 years of followup, the mean was 5.1 ± 2.4 ng/mL. At year 1 after transplantation, 23 (1.7%) recipients had been converted to everolimus; by the end of year 5 of follow-up, the number had increased to 8.6%. The most frequently detected complications during outpatient follow-up were: hypertension (48.65%), post-transplant diabetes mellitus (7.24%), nephropathy (35.97%), and malignant neoplasms (4.2%). Recipient survival, excluding in-hospital mortality, was 96.5%; and 88.0% at year 1 and 5 of follow-up, respectively. Conclusion : The dual personalized approach model for outpatient follow-up and treatment of heart transplant recipients will improve recipient survival and quality of life in the long-term post-HT period.

Chronic heart failure (CHF) against the background of congenital heart disease, mostly in early childhood, or various forms of cardiomyopathies, more common in teenage age, represents an important cause of morbidity and mortality in the pediatric population [1, 2]. Due to the increase in the number of patients suffering from refractory end-stage CHF over the last two decades, and the current shortage of donor organs in pediatric practice, the issue of long-term mechanical circulatory support (MCS) is becoming increasingly a pressing problem. Patient management is a multidisciplinary task, since prolonged use of anticoagulant and antiplatelet therapy to prevent ventricular thrombosis has potentially life-threatening complications - acute hemorrhagic stroke and bleeding of varying severity.

Amidst the shortage in viable donor hearts, the use of hearts from expanded criteria donors, including those with prolonged ischemic time, remains one of the real ways to increase the donor pool and number of heart transplantations (HTx) performed. The study included 38 recipients (33 (86.8%) men and 5 (13.2%) women) aged 11 to 66 (44.7 ± 12.0 years, median 48.0 years), who underwent primary (n = 37; 97.4%) or repeat (n = 1; 2.6%) HTx (retransplantation). Donor hearts (n = 38) with ischemic time ranged from 362 (6 hours 2 minutes) to 571 (9 hours 31 minutes) or 407 ± 52 minutes (median 400 minutes). In 33 (86.8%) of 38 recipients, the early posttransplant period was characterized by satisfactory initial graft function. Five (13.1%) recipients developed severe primary graft dysfunction, requiring post-transplant venoarterial extracorporeal membrane oxygenation (VA-ECMO) (n = 4; 10.5%) or prolongation of pre-transplant VA-ECMO within 8 days of HTx (n = 1; 2.6%). In-hospital mortality was 7.9% (n = 3). Thirty-five (92.1%) of 38 recipients were discharged from the hospital. Three recipients died in the post-hospital period at day 734, 944, and 2146 after HTx. Thirty-two (84.2%) of the 38 recipients remained alive at the end of the study. Our own experience shows that HTx from donors with prolonged ischemic time could be effective.

Primary cardiac sarcoma is a rapidly progressive, aggressive cardiac tumor that is very rare in the general population. Conservative treatment for this tumor is not very effective. The only effective treatment is radical surgical removal of the malignancy. However, if sarcoma removal cannot be performed, heart transplantation (HT) becomes the only treatment option. The median survival of heart recipients with preoperative cardiac sarcoma is 8.5 months. Globally, such operations are performed in a small number of cases. This paper presents the first experience of HT for a patient with primary cardiac sarcoma in the Russian Federation.

As the survival rate of cardiac recipients improves, higher incidence of malignancy in the late postoperative period becomes essential for their prognosis. Immunosuppressive therapy is one of the key prerequisites for successful transplantation. However, long-term use of immunosuppressive agents increases the incidence of malignant tumors compared to the general population. The risk of their development after organ transplantation increases by 2–4 times compared to the general population. For patients who have undergone transplantation since 2000, the risk of developing malignant neoplasms 1–5 years after surgery is estimated at 10–12%. Timely comprehensive examination of patients, development of new immunosuppression schemes, treatment of those predisposing to the development of malignant neoplasms and giving up harmful habits will reduce the risk of malignant tumors and help diagnose these serious complications at an early stage, which, in turn, will increase the life expectancy of solid organ (particularly the heart) recipients.

Objective: to present our own experience of heart transplantation in a patient with persistent left superior vena cava (PLSVC). A clinical case of successful orthotopic heart transplantation using the biatrial technique in a patient with PLSVC drainage into the right atrium is presented. The clinical effect achieved as a result of the treatment fully justifies the chosen surgical tactics and allows us to recommend the proposed tactics for treatment of such a rare anomaly. Conclusion. The clinical effect achieved as a result of the treatment fully justifies the chosen surgical tactics and allows us to recommend the proposed tactics for treatment of such a rare anomaly.

Kidney injury in cardiac transplant recipients is one of the most severe complications affecting both short- and long-term transplant outcomes. The need for renal replacement therapy (RRT) is determined not only and not so much by the degree of renal dysfunction, as by the need for correction of fluid balance and metabolic disorders. These circumstances are associated with the specificity of extracorporeal renal replacement therapy in donor heart recipients. In this review, we discuss the problems of early versus delayed initiation of RRT, anticoagulation and vascular access, advantages and disadvantages of continuous and intermittent techniques. Special attention is paid to chronic kidney injury and peculiarities of kidney transplantation in heart recipients.

Kidney injury in heart transplant recipients is of a complex nature and bears the features of all types of cardiorenal interaction impairment. Pre-transplant renal dysfunction, perioperative acute kidney injury, as well as factors associated with graft and immunosuppression, determine the prevalence and severity of kidney pathology in this group of patients. This review examines the pathophysiology of kidney dysfunction in heart failure, the epidemiology, and criteria for acute kidney injury.

Mechanical circulatory support (MCS) is the only way to save a life for heart transplant candidates and to decrease of waiting list mortality. The choice between short- or long-term pretransplant MCS depends on of type and severity of CHF. One of the most frequently used methods of temporary MSC before orthotopic heart transplantation (OHTx) is veno-arterial extracorporeal membrane oxygenation (VA ECMO). The aim of this study was to analyze own experience of peripheral VA ECMO (pVA ECMO) in heart transplant candidates needed in urgent HT METHODS: This study included 182 pts [160 (87.9%) men and 22 (12.1%) female, age 43±1.2 yrs] supported with pVA ECMO in the period from 01. 01. 2013 to 31. 12. 2017 or 23.2% from all waiting list (n=786) RESULTS: During VA ECMO, 16 (8.8%) of the 182 pts died. In most pts [n=13 (81.3%)] multiorgan failure/sepsis were the cause of death. One hundred and sixty-six (91.2%) pts were successfully bridged to OHTx or 27.9% from all heart transplant recipients (n=594) (2013-2017 yrs). The duration of pVA ECMO before OHTx (n=166) was 5.8±3.2 days. One hundred and forty-three (86.1%) from 166 pts were discharged to home. Post-transplant survival among heart transplant recipient with pre-transplant MCS by pVA ECMO was in comparison with recipients without pretransplant MCS [84.2% vs. 90.1% (6 months), 83.3% vs.91.8% (1 years), 75.1% vs. 86.1% (2 years), 74.2% vs. 85.8% (3 years), 72.3% vs. 84.7% (4 years), 72.3% vs. 83.5% (5 years) respectively (P<0.0001)] CONCLUSION: pVA ECMO is a useful tool of treatment of patients with INTERMACS profile 1/2. Results of OHTx at recipients bridged with VA ECMO are less successful that recipients without pre-transplant MCS. VA ECMO should be considered as a direct bridge to OHTx in conditions of limited financial resources of health care and high availability of donor's hearts.

We herein present our initial report from «ROKKOR-recipient», a national multicenter observational study. The prevalence, risk factors, clinical manifestations and outcomes of the novel coronavirus disease 2019 (COVID-19) in solid organ transplant recipients receiving immunosuppressive therapy were investigated. The study enrolled 251 COVID-19 patients (220 kidney recipients, 7 liver recipients, 1 liver-kidney recipient, and 23 heart recipients). The subjects came from 20 regions in Russia. The symptoms, clinical presentation, imaging and lab test results, therapy and outcomes of COVID-19 were described. It was established that solid organ transplant recipients with COVID-19 have a higher risk of developing adverse events. Predictors of adverse events include associated cardiovascular diseases, pulmonary diseases, diabetes, and kidney failure. Symptoms of the disease include dyspnea, rash and catarrhal signs, as well as initial low blood oxygen saturation (SpO2 <92%), leukocytosis (white blood cell count >10 × 109/L), elevated creatinine levels (>130 μmol/L) and a marked decrease in glomerular filtration rate, requiring hemodialysis. Performing organ transplant surgery in COVID-19 does not increase the risk of adverse events but could save the lives of waitlisted terminally ill patients.