Optimal Pharmacologic and Non-pharmacologic Management of Cardiac Transplant Candidates: Approaches to Be Considered Prior to Transplant Evaluation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006

Critical care therapies pre- and post-heart transplant and their impact: Analysis from the Pediatric Cardiac Critical Care Consortium

BACKGROUND

Few studies highlighting the critical care management of patients after heart HTx (HTx) have been published to date. This analysis provides a contemporary representation of pre- and post-HTx critical care in various patient cohorts and outlines the impact of intensive care unit (ICU) therapies on outcomes.

METHODS

Data from PC4 Collaborative Registry were analyzed for pediatric patients undergoing HTx between August 2014 and April 2022.

RESULTS

A total of 1877 HTx in 1857 patients were reported from 42 centers; 56.5% had congenital heart disease (CHD). Patients with CHD were younger, smaller, more likely male, White race, and publicly insured. CHD patients had higher need for catheterization, increased likelihood of inotropic support and mechanical ventilation and lower VAD rates. Their operative courses were significant for longer bypass and cross-clamp times. Postoperatively, CHD patients required more CPR , utilized more ICU therapies and had higher hospital mortality (7.8% vs. 1.8% for non-CHD patients, p<0.0001). Longer cardiopulmonary bypass, longer deep hypothermic circulatory arrest times and delayed sternal closure were independent risk factors for hospital mortality. Lastly, center transplant volume but not surgical volume was associated with transplant outcomes.

CONCLUSIONS

A diagnosis of CHD before HTx is associated with a greater use of ICU-specific therapies compared non-CHD cohort. Operative factors, particularly in patients with CHD, are independently associated with higher hospital mortality as was low transplant volume at the center. The study provides basis for further investigating ICU and operative factors that can be modified to improve transplant outcomes.

Multimodal Prehabilitation in Heart Transplant Recipients Improves Short-Term Post-Transplant Outcomes without Increasing Costs

(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Palliative Care for Patients With Advanced Heart Disease

Over the past 2 decades, the discipline of palliative care has evolved and expanded such that it is now the standard of care for a variety of acute and chronic processes. Although there are recommendations encouraging incorporation of palliative care into the routine management of patients with chronic cardiac processes, such as congestive heart failure, implementation has been challenging, and nowhere more so than in the cardiac surgical population. However, as the boundaries of surgical care have expanded to include progressively more complex cases, increasing attention has been given to the integration of palliative care into their management. In this review article, the authors describe the existing evidence for palliative care team involvement in patients with non-operative and surgical cardiac diseases and examine future directions for growth in this field.

Comparison of Brachial Vein Versus Internal Jugular Vein Approach for Access to the Right Side of the Heart With or Without Myocardial Biopsy

Right heart catheterization (RHC) and endomyocardial biopsy are mainstay procedures for patients with heart failure and heart transplantation. Approaches are predominantly neck (internal jugular) or leg (femoral vein). We describe a novel arm (brachial/basilica vein) approach. Over 5.5 years, 1,130 right-sided cardiac procedures in 276 patients were analyzed retrospectively and divided into either neck or arm approach. Comparative analyses of procedural success, time, safety, efficacy, and cost were performed. Patient preference was assessed for those who had both neck and arm approaches. In patients receiving RHC (174 neck and 121 arm cases) and in those receiving RHC + biopsy (594 neck and 141 arm cases), mean elapsed and fluoroscopic times (minutes), respectively, were 60 ± 20 versus 62 ± 19 and 3.43 ± 3.8 versus 4.99 ± 5.2 (RHC neck vs arm, respectively), and 55 ± 19 versus 63 ± 17 and 4.14 ± 3.4 versus 5.22 ± 2.6 (RHC + biopsy neck vs arm, respectively). Procedural complications were low (n = 7, 0.6%) and restricted to the neck approach. Patients surveyed preferred the arm approach. In conclusion, RHC and endomyocardial biopsy through the brachial vein can be performed safely, timely, effectively, and at equivalent cost compared with a neck approach. We advocate that an arm approach be the preferred method for these procedures.

A single German center experience with intermittent inotropes for patients on the high-urgent heart transplant waiting list

AIM

Currently, more than 900 patients with end-stage heart failure are listed for heart transplantation in Germany. All patients on the Eurotransplant high-urgent status (HU) have to be treated in intensive care units and have to be relisted every 8 weeks. Long-term continuous inotropes are associated with tachyphylaxia, arrhythmias and even increased mortality. In this retrospective analysis, we report our single center experience with HU patients treated with intermittent inotropes as a bridging therapy.

METHODS AND RESULTS

117 consecutive adult HU candidates were treated at our intensive care heart failure unit between 2008 and 2013, of whom 14 patients (12 %) were stabilized and delisted during follow-up. In the remaining 103 patients (age 42 ± 15 years), different inotropes (dobutamine, milrinone, adrenaline, noradrenaline, levosimendan) were administered based on the patient's specific characteristics. After initial recompensation, patients were weaned from inotropes as soon as possible. Thereafter, intermittent inotropes (over 3-4 days) were given as a predefined weekly (until 2011) or 8 weekly regimen (from 2011 to 2013). In 57 % of these patients, additional regimen-independent inotropic support was necessary due to hemodynamic instabilities. Fourteen patients (14 %) needed a left- or biventricular assist device; 14 patients (14 %) died while waiting and 87 (84 %) received heart transplants after 87 ± 91 days. Cumulative 3 and 12 months survival of all 103 patients was 75 and 67 %, respectively.

CONCLUSION

Intermittent inotropes in HU patients are an adequate strategy as a bridge to transplant; the necessity for assist devices was low. These data provide the basis for a prospective multicenter trial of intermittent inotropes in patients on the HU waiting list.

Melatonin synergized with cyclosporine A improves cardiac allograft survival by suppressing inflammation and apoptosis

Melatonin, a widespread physiological mediator, has been demonstrated to exhibit a dose‑dependent immunoregulatory effect in vitro and in vivo, including mediating physiological circadian rhythms, neutralizing free radicals and exerting antisenescence actions. In the present study, the efficacy and mechanism of melatonin alone or in combination with cyclosporine (CsA) in prolonging heart transplantation survival was examined. Daily treatment with melatonin (200 mg/kg/day) through a gavage, significantly prolonged the survival of cardiac grafts (mean survival time, 13.4±2.4 days; n=7; P<0.0001) compared with the untreated controls (5.8±1.2 days; n=7). When CsA (5 mg/kg/day) was co‑administered with melatonin (50 mg/kg/day), the survival rate improved (31.6±2.4 days; n=7; P<0.001), compared with that achieved by only 20 mg/kg/day CsA (22±2.8 days; n=7). As expected, melatonin significantly alleviated the inflammatory response and apoptosis as determined by TdT‑mediated dUTP‑biotin nick end labeling assay (P<0.05). Further analysis demonstrated that melatonin significantly reduced p65 activation and the release of inflammatory factors. Therefore, these findings indicate that melatonin in combination with CsA protected the cardiac allograft by inhibiting inflammation‑induced apoptosis. These results provide evidence for a novel therapeutic approach for future immunosuppressive agents in organ transplantation.

Inotropes do not increase mortality in advanced heart failure

Inotrope use is one of the most controversial topics in the management of heart failure. While the heart failure community utilizes them and recognizes the state of inotrope dependency, retrospective analyses and registry data have overwhelmingly suggested high mortality, which is logically to be expected given the advanced disease states of those requiring their use. Currently, there is a relative paucity of randomized control trials due to the ethical dilemma of creating control groups by withholding inotropes from patients who require them. Nonetheless, results of such trials have been mixed. Many were also performed with agents no longer in use, on patients without an indication for inotropes, or at a time before automatic cardio-defibrillators were recommended for primary prevention. Thus, their results may not be generalizable to current clinical practice. In this review, we discuss current indications for inotrope use, specifically dobutamine and milrinone, depicting their mechanisms of action, delineating their patterns of use in clinical practice, defining the state of inotrope dependency, and ultimately examining the literature to ascertain whether evidence is sufficient to support the current view that these agents increase mortality in patients with heart failure. Our conclusion is that the evidence is insufficient to link inotropes and increased mortality in low output heart failure.

Surgical treatment of functional mitral regurgitation in dilated cardiomyopathy

Functional mitral regurgitation is a significant complication of end-stage cardiomyopathy. Dysfunction of one or more components of the mitral valve apparatus occurs in 39-74% and affects almost all heart failure patients. Survival is decreased in subjects with more than mild mitral regurgitation irrespective of the aetiology of heart failure. The goal of treating functional mitral regurgitation is to slow or reverse ventricular remodelling, improve symptoms and functional class, decrease the frequency of hospitalization for congestive heart failure, slow progression to advanced heart failure (time to transplant) and improve survival. This article reviews the role of mitral valve surgery in patients with heart failure and dilated cardiomyopathy.

INTERMACS profiles of advanced heart failure: the current picture

BACKGROUND

The current classification of patients with New York Heart Association Class IV symptoms does not offer adequate description to allow optimal selection of patients for the current options of medical and pacing therapies, cardiac transplantation and mechanical circulatory support.

METHODS

Seven clinical profiles and an arrhythmia modifier were developed and implemented into the first year of data collection for the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The INTERMACS Coordinators' Council provided ongoing feedback regarding the characterization of patients receiving implantable devices.

RESULTS

The definition of 7 clinical profiles revealed that 80% of current devices are being used in the 2 profiles with the highest levels of clinical compromise. The INTERMACS Coordinators' Council helped to identify gaps in the characterization of hospitalized patients on temporary assist devices and of homebound patients with resting symptoms, which has led to revised definitions of Profile 3 and 4 and the addition of 2 new modifiers, for temporary circulatory support devices in the hospital, and for frequent rehospitalization of patients at home.

CONCLUSIONS

Patients considered for mechanical circulatory support can now be classified using the 7 profiles plus 3 modifiers developed through INTERMACS. Further understanding these profiles and their impact on outcome should help to better select patients and therapies in the advanced stages of disease.

Are hemodynamic parameters predictors of mortality?

This article addresses a question that the authors consider to be somewhat rhetorical: are hemodynamic parameters predictors of mortality? It reviews the specific hemodynamic abnormalities and pathophysiologic consequences distinctive to the patient who has decompensation and addresses the data that implicate abnormal hemodynamics as a treatment target associated with increased mortality. The focus is on patients who have decompensated heart failure, defined as left ventricular systolic dysfunction and an acute, subacute, or gradual worsening of symptoms while receiving optimal medical therapy.

Prognostic ability of resting periodic breathing and ventilatory variation in closely matched patients with heart failure

PURPOSE

Periodic breathing (PB), characterized by waxing and waning oscillations of ventilation, has been reported in some patients with heart failure. Although PB is usually assessed in sleeping patients, PB has also been observed in awake patients. We tested the hypothesis that PB in awake, resting patients with heart failure predicts mortality.

METHODS

Resting gas exchange data were collected in consecutive, awake patients with heart failure referred for possible cardiac transplantation. Periodic breathing was defined as oscillations of resting ventilation, that is, 30% or more during 2 consecutive cycles. Each PB patient was matched to a comparison patient by age, gender, heart failure etiology, peak oxygen consumption, peak respiratory exchange ratio, and ventilatory efficiency slope.

RESULTS

Forty-four of 355 patients met the criteria for PB and were matched to 44 comparison patients. During an average follow-up of 4.9 +/- 0.1 years, 30 patients with PB (68%) versus 23 comparisons (52%) died or were transplanted urgently (P = NS). However, among the 88 PB patients and comparisons, ventilatory variation was an independent predictor of mortality by Cox regression analysis (P = .004). Resting ventilatory variation increased the explained variation in mortality by 44%, from 16% to 23%, in a mortality model that included ventilatory efficiency slope, peak oxygen consumption, left ventricular ejection fraction, systolic blood pressure, sex, age, heart rate, and etiology.

CONCLUSION

Resting ventilatory variation independently and powerfully predicted mortality in this cohort of patients with heart failure.

Assisting the failing heart

Anesthesiologists increasingly encounter patients who have a spectrum of heart failure ranging from stable chronic heart failure to acute heart failure to cardiogenic shock. Improved medical therapy has increased the survival of patients who have chronic heart failure but not of patients who have acute heart failure. New surgical techniques and mechanical devices may offer alternatives to certain patients who have refractory heart failure This article provides an overview of established and newer pharmacologic and nonpharmacologic therapies and surgical interventions to manage patients who have heart failure, including the perioperative management of heart transplantation and ventricular assist devices.

Insomnia and chronic heart failure

Insomnia is highly prevalent in patients with chronic disease including chronic heart failure (CHF) and is a significant contributing factor to fatigue and poor quality of life. The pathophysiology of CHF often leads to fatigue, due to nocturnal symptoms causing sleep disruption, including cough, orthopnea, paroxysmal nocturnal dyspnea, and nocturia. Inadequate cardiac function may lead to hypoxemia or poor perfusion of the cerebrum, skeletal muscle, or visceral body organs, which result in organ dysfunction or failure and may contribute to fatigue. Sleep disturbances negatively affect all dimensions of quality of life and is related to increased risk of comorbidities, including depression. This article reviews insomnia in CHF, cardiac medication side-effects related to sleep disturbances, and treatment options.

Psychosocial and behavioural factors in heart transplant candidates – an overview

Mortality among heart transplant (HTX) candidates remains high. This review of the literature shows that psychosocial characteristics like depression, social isolation and coping strategies contribute to morbidity and mortality in heart failure (HF) patients, and may also be relevant to the prognosis of HTX candidates. Based on the research to date, physical activity favourably affects subjective and objective parameters not only in HF patients, but also in HTX candidates. Depression is prevalent among HTX candidates, especially in ischaemic patients, and seems to be related to earlier transplantation. Findings on the effects of depression on pretransplant mortality are conflicting. Not much is known concerning social isolation, coping, nutrition, or weight loss in this patient group. Identification of modifiable psychosocial and behavioural variables related to clinical status in this patient group is clearly needed and will aid the development of behavioural interventions to supplement medical therapies.

[Heart failure in 2006]

This article are summarizes the most relevant articles in the field of heart failure including epidemiology, diagnostic and therapeutic issues. Therapy includes drugs, cardiac resinchronization therapy, automatic implantable defibrillator, heart transplantation and cell therapy. Stem cell therapy is feasible and short term data indicates it is safe. However there are unresolved concerns on arrhythmias, restenosis and efficacy. At this point experts recommend that medium-sized randomized controlled trials, using surrogate endpoints, should be carried out to establish the efficacy and safety of this form of treatment.