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Journal of the American College of... Jun 2023Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of... (Review)
Review
Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode.
Topics: Humans; Arrhythmias, Cardiac; Anti-Arrhythmia Agents; Defibrillators, Implantable; Heart Transplantation; Catheter Ablation; Tachycardia, Ventricular
PubMed: 37257955
DOI: 10.1016/j.jacc.2023.03.424 -
Multimedia Manual of Cardiothoracic... Jul 2023An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of...
An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of durable mechanical circulation support, a small number of patients will be considered for a heart retransplant. In this video tutorial, we describe the strategy and technique for patients who have already received an orthotopic heart transplant and who undergo a cardiac retransplant with a modified bicaval anastomosis technique.
Topics: Humans; Reoperation; Heart Transplantation; Anastomosis, Surgical
PubMed: 37470829
DOI: 10.1510/mmcts.2023.043 -
Journal of Clinical Medicine Jan 2024Heart transplantation (HTx) remains the last therapeutic resort for patients with advanced heart failure. The present work is a clinically focused review discussing... (Review)
Review
Heart transplantation (HTx) remains the last therapeutic resort for patients with advanced heart failure. The present work is a clinically focused review discussing current issues in heart transplantation. Several factors have been associated with the outcome of HTx, such as ABO and HLA compatibility, graft size, ischemic time, age, infections, and the cause of death, as well as imaging and laboratory tests. In 2018, UNOS changed the organ allocation policy for HTx. The aim of this change was to prioritize patients with a more severe clinical condition resulting in a reduction in mortality of people on the waiting list. Advanced heart failure and resistant angina are among the main indications of HTx, whereas active infection, peripheral vascular disease, malignancies, and increased body mass index (BMI) are important contraindications. The main complications of HTx include graft rejection, graft angiopathy, primary graft failure, infection, neoplasms, and retransplantation. Recent advances in the field of HTx include the first two porcine-to-human xenotransplantations, the inclusion of hepatitis C donors, donation after circulatory death, novel monitoring for acute cellular rejection and antibody-mediated rejection, and advances in donor heart preservation and transportation. Lastly, novel immunosuppression therapies such as daratumumab, belatacept, IL 6 directed therapy, and IgG endopeptidase have shown promising results.
PubMed: 38256691
DOI: 10.3390/jcm13020558 -
Transplant International : Official... 2024
Topics: Humans; Immunosuppressive Agents; Organ Transplantation; Clinical Trials as Topic; Graft Rejection
PubMed: 38736987
DOI: 10.3389/ti.2024.13111 -
Journal of the American College of... Jun 2023
Topics: Humans; Heart Transplantation
PubMed: 37316115
DOI: 10.1016/j.jacc.2023.04.020 -
The New England Journal of Medicine Nov 2023Hemodynamic instability and myocardial dysfunction are major factors preventing the transplantation of hearts from organ donors after brain death. Intravenous... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Hemodynamic instability and myocardial dysfunction are major factors preventing the transplantation of hearts from organ donors after brain death. Intravenous levothyroxine is widely used in donor care, on the basis of observational data suggesting that more organs may be transplanted from donors who receive hormonal supplementation.
METHODS
In this trial involving 15 organ-procurement organizations in the United States, we randomly assigned hemodynamically unstable potential heart donors within 24 hours after declaration of death according to neurologic criteria to open-label infusion of intravenous levothyroxine (30 μg per hour for a minimum of 12 hours) or saline placebo. The primary outcome was transplantation of the donor heart; graft survival at 30 days after transplantation was a prespecified recipient safety outcome. Secondary outcomes included weaning from vasopressor therapy, donor ejection fraction, and number of organs transplanted per donor.
RESULTS
Of the 852 brain-dead donors who underwent randomization, 838 were included in the primary analysis: 419 in the levothyroxine group and 419 in the saline group. Hearts were transplanted from 230 donors (54.9%) in the levothyroxine group and 223 (53.2%) in the saline group (adjusted risk ratio, 1.01; 95% confidence interval [CI], 0.97 to 1.07; P = 0.57). Graft survival at 30 days occurred in 224 hearts (97.4%) transplanted from donors assigned to receive levothyroxine and 213 hearts (95.5%) transplanted from donors assigned to receive saline (difference, 1.9 percentage points; 95% CI, -2.3 to 6.0; P<0.001 for noninferiority at a margin of 6 percentage points). There were no substantial between-group differences in weaning from vasopressor therapy, ejection fraction on echocardiography, or organs transplanted per donor, but more cases of severe hypertension and tachycardia occurred in the levothyroxine group than in the saline group.
CONCLUSIONS
In hemodynamically unstable brain-dead potential heart donors, intravenous levothyroxine infusion did not result in significantly more hearts being transplanted than saline infusion. (Funded by Mid-America Transplant and others; ClinicalTrials.gov number, NCT04415658.).
Topics: Humans; Brain; Brain Death; Heart Transplantation; Thyroxine; Tissue and Organ Procurement; Tissue Donors; Administration, Intravenous; Hemodynamics
PubMed: 38048188
DOI: 10.1056/NEJMoa2305969