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Al-Adhami A, Avtaar Singh SS, De SD, Singh R, Panjrath G, Shah A, Dalzell JR, Schroder J, Al-Attar N. Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma. Curr Probl Cardiol 2021; 47:100941. [PMID: 34404551 DOI: 10.1016/j.cpcardiol.2021.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow.
| | - Sudeep Das De
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, Virginia
| | - Gurusher Panjrath
- Heart Failure and Mechanical Circulatory Support Program, George Washington University Hospital, Washington, DC
| | - Amit Shah
- Advanced Heart Failure and Cardiac Transplant Unit, Fiona Stanley Hospital, Perth, Australia
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Jacob Schroder
- Heart Transplantation Program, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow
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Immohr MB, Akhyari P, Boettger C, Erbel S, Westenfeld R, Scheiber D, Tudorache I, Aubin H, Lichtenberg A, Boeken U. Levosimendan for Treatment of Primary Graft Dysfunction After Heart Transplantation: Optimal Timing of Application. EXP CLIN TRANSPLANT 2021; 19:473-480. [PMID: 33877035 DOI: 10.6002/ect.2020.0342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Primary graft dysfunction remains a serious problem after heart transplant. Pharmacological treatment with the calcium sensitizer levosimendan may be an additive treatment for primary graft dysfunction. MATERIALS AND METHODS Patients undergoing heart transplant between 2010 and 2020 were retrospectively reviewed and divided depending on postoperative treatment with (n = 41) or without (n = 109) levosimendan. Recipients who received levosi mendan were further divided with regard to timing of levosimendan application (early group: started ≤48 hours posttransplant [n = 23]; late group: started >48 hours posttransplant [n = 18]). RESULTS Patients who received levosimendan treatment displayed a remarkable incidence (87.8%) of postoperative primary graft dysfunction with need for venoarterial extracorporeal membrane oxygenation and therefore often presented with perioperative morbidity. Patient with early application of levosimendan showed significantly decreased duration of venoarterial extracorporeal membrane oxygenation support (5.1 ± 3.5 days vs 12.6 ± 9.3 days in those with late application; P < .01) and decreased mortality during venoarterial extracorporeal membrane oxygenation support (0.0% vs 33.3% in early vs late group; P < .01). In addition, compared with patients with late levosimendan application, patients with early application needed fewer blood transfusions (P < .05), had shorter ventilation times (279 ± 235 vs 428 ± 293 h; P = .03), and showed a trend of reduced incidence of postoperative renal failure (69.6% vs 94.4%; P = .06). Moreover, survival analyses indicated an increased survival for patients with early start of levosimendan therapy within the first 48 hours after heart transplant (P = .09). CONCLUSIONS Pharmacotherapy with levosimendan may be a promising additive in the treatment of primary graft dysfunction after heart transplant. With administration of levosimendan within the first 48 hours posttransplant, rates of successful weaning from venoarterial extracorporeal membrane oxygenation and outcomes after heart transplant were shown to increase.
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Affiliation(s)
- Moritz Benjamin Immohr
- From the Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Abstract
Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland.
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland.
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland.
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
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Subramani S, Aldrich A, Dwarakanath S, Sugawara A, Hanada S. Early Graft Dysfunction Following Heart Transplant: Prevention and Management. Semin Cardiothorac Vasc Anesth 2019; 24:24-33. [DOI: 10.1177/1089253219867694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heart transplant can be considered as the “gold standard” treatment for end-stage heart failure, with nearly 5.7 million adults in the United States carrying a diagnosis of heart failure. According to the International Society for Heart and Lung Transplantation registry, nearly 3300 orthotopic heart transplants were performed in 2016 in North America. In spite of significant improvements in overall perioperative care of heart transplant recipients for the past few decades, the risk of 30-day mortality remains 5% to 10%, primarily related to early failure of the allograft. Early graft dysfunction (EGD) occurs within 24 hours after transplant, manifesting as left ventricular dysfunction, right ventricular dysfunction, or biventricular dysfunction. EGD is further classified into primary and secondary graft dysfunction. This review focus on describing overall incidences of EGD, potential risk factors associated with EGD, perioperative preventive measures, and various management options.
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Shen T, Huh MH, Czer LS, Vaidya A, Esmailian F, Kobashigawa JA, Nurok M. Controversies in the Postoperative Management of the Critically Ill Heart Transplant Patient. Anesth Analg 2019; 129:1023-1033. [PMID: 31162160 DOI: 10.1213/ane.0000000000004220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heart transplant recipients are susceptible to a number of complications in the immediate postoperative period. Despite advances in surgical techniques, mechanical circulatory support (MCS), and immunosuppression, evidence supporting optimal management strategies of the critically ill transplant patient is lacking on many fronts. This review identifies some of these controversies with the aim of stimulating further discussion and development into these gray areas.
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Affiliation(s)
- Tao Shen
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Lawrence S Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Ajay Vaidya
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Jon A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Nurok
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
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Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is common early postheart transplantation; however, use of standardized definitions remains inconsistent. This review focuses on understanding the incidence, classification, risk factors, and management of PGD. RECENT FINDINGS The incidence and mortality of PGD in heart transplant varies considerably in the published literature ranging from 1.0% to 31% and 3% to 75%, respectively. There is also considerable variation in management strategies with current data favoring early intervention. SUMMARY PGD in heart transplantation remains a challenging problem associated with significant mortality and morbidity. There is need for a consistent and accessible definition to better define associated risk factors and optimize management strategies.
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Kobashigawa J, Zuckermann A, Macdonald P, Leprince P, Esmailian F, Luu M, Mancini D, Patel J, Razi R, Reichenspurner H, Russell S, Segovia J, Smedira N, Stehlik J, Wagner F. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant 2014; 33:327-40. [DOI: 10.1016/j.healun.2014.02.027] [Citation(s) in RCA: 307] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 02/28/2014] [Indexed: 10/25/2022] Open
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Barisin S, Djuzel V, Barisin A, Rudez I. Levosimendan reverses right-heart failure in a 51-year-old patient after heart transplantation. Wien Klin Wochenschr 2014; 126:495-9. [PMID: 24652017 DOI: 10.1007/s00508-014-0528-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 02/18/2014] [Indexed: 11/30/2022]
Abstract
Primary graft failure in the early postoperative period after heart transplantation, remains a main cause of a poor outcome. Current treatment options include pharmacological (catecholamines and phosphodiesterase inhibitors) and mechanical assist device support. Pharmacological support with catecholamines is related to elevated myocardial oxygen consumption and regional hypoperfusion leading to organ damage. On the other hand, levosimendan, as a calcium-sensitizing agent increases cardiac contractility without altering intracellular Ca(2+) levels and increase in oxygen demand. We present a case of a 51-year-old man, who was suffering from acute right-heart failure in the early postoperative period after heart transplantation. As a rescue therapy at the late stage of a low cardiac output state, levosimendan was started as continuous infusion at 0.1 μg/kg/min for 12 h and thereafter, at 0.2 μg/kg/min for the following 36 h. Levosimendan demonstrated an advanced pharmacological option as was portrayed in this case, where the right ventricle was under a prolonged severe depression and acutely overloaded after heart transplantation.
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Affiliation(s)
- Stjepan Barisin
- Clinical Department of Cardiovascular Anesthesia and Intensive Care, University Department of Anesthesiology, Resuscitation and Intensive Care, Dubrava University Hospital, Av. G. Suska 6, 10000, Zagreb, Croatia,
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Toller W, Algotsson L, Guarracino F, Hörmann C, Knotzer J, Lehmann A, Rajek A, Salmenperä M, Schirmer U, Tritapepe L, Weis F, Landoni G. Perioperative use of levosimendan: best practice in operative settings. J Cardiothorac Vasc Anesth 2012; 27:361-6. [PMID: 22658687 DOI: 10.1053/j.jvca.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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