Donor Cross match Date 4 ℃ T-cell4 ℃ B-cell37 ℃ T-cell37 ℃ B-cell Anti-HLA class I Ab Anti-HLA class I I Ab Flow PRA Class I Flow PRA Class II 2012-7-12 1:2 Positive 1:16 Positive 1:1 Positive 1:16 Positive Negative 2012-7-19 Positive 2012-7-20 14:33 1:8 Positive 1:32 Positive 1:2 Positive 1:32 Positive 98.9674.47 2012-7-20 20:41 Negative1:16 Positive Negative1:32 Positive 2012-8-6 16:44 1:32 Positive 2012-8-15 99.7471.47 2012-8-29 1:1 Positive 1:8 Positive 1:1 Positive 1:4 Positive
Treatment Course in 5CVI 2012/07/14 ECMO+CAVH, on HTx waiting list, PRA(+) 2012/07/25 Start Desensitization Protocol 7/25 Rituximab 200 mg iv stat with solu-medrol 40 mg st 7/26 DFPP(2A) with IVIG 7/26, 7/28, 7/30 8/1~14 DFPP (4A) with IVIG (QW2,5) 8 courses
Treatment Course in 5CVI 2012/07/11-8/30: Waiting for Heart Transplantation (ECMO) ‧ Coagulopathy DFPP + IVIG for desensitization low fibrinogen, bleeding Thrombus formation s/p emergent evacuation *4 PRA(+) VT DC shock (7/29, 8/27,8/28)
2012/08/30 LVAD implantation OP Method: LVAD THORATEC implantation V cannula: beveled tip against septim through LV apex A cannula: 14mm graft end-to-side anastomosis to AsAo; then wrapped by 20mm Hemashield vascular graft.
The decrease of patient blood volume was induced by an oncotic pressure drop due to albumin loss and often resulted in a pressure drop.
ECMO + DFPP
Intraoperative plasmapheresis and Cellcept induction Peri-operative alemtuzumab(Campath-1H) and plasmapheresis for high-PRA positive lymphocyte crossmatch heart transplant: a strategy to shorten left ventricular device support. – Department of surgery, University of Texas Medical Branch, Galveston. – J Heart Lung Transplant. 2008 Sep;27(9): 1036-9. Mortality and morbidity in pre-sensitized pediatric heart transplant recipients with a positive donor crossmatch utilizing peri-operative plasmapheresis and cytolytic therapy. – Department of Pediatrics, Washington University school of Medicine. – J Heart Lung Transplant. 2007 Sep;26(9): 876-82. Pediatric cardiac transplantation in children with high panel reactive antibody. – The Congenital Heart institute of Florida, All children’s Hospital, University of South Florida. – Ann Thorac Surg. 2004 Nov;78(5):1703-9
Protocol 3-volume exchange in 60-100 min, depending on the patient’s body size. Repaid removal of calcium and heparin sulfate during pheresis. The timing of the institution of CPB and pheresis is determined by the expected arrival of the donor heart.
Ann Thorac Surg 2011;92:1428-34
NTUH Plasma exchange during CPB
EvafluxPore sizeAlbumin sc IgG sc HDL sc IgM sc LDL 2A 0.01 ㎛ 0.620.190.1500 3A 0.02 ㎛ 0.70.350.2200 4A 0.03 ㎛ 0.850.550.500 5A 0.03 ㎛ (?) 0.920.850.830.10.02 移除目標為 IgG: 2A 或 3A (can remove Immunoglobulins while allowing Albumin to be returned) 移除目標為 IgM: 4A 或 5A 移除目標為 LDL: 5A (can remove LDL while allowing Albumin and HDL to be returned)
4/18 plasma exchange in OR
LVAD (Thoratec Heartmate VE) Pulsatile, LV assist Only. Fixed rate / Chamber filled (asynchrony) – Initiated with flow 2.2L/min/m 2, LAP 10-15mmHg Bridge to Heart Transplantation.
Manual Of Perioperative Care In Adult Cardiac Surgery Ch11 p.479
Contraindication Reasonable chance of recovery? – Age, medical condition, RV function, – Comorbidities ( neurologic, pulmonary, renal, hepatic) – Other medical issues ( infection, vascular disease, DM…)
Post-LVAD management Adequate tissue perfusion – Assessed by mixed Venous oxygen saturation Decrease myocardial demand – Vasoactive medication only for RV function or increased SVR to keep MAP>75mmHg – “vasodilatory shock”
Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial; N=280. The 1-year survival after LVAD implantation was 56%; in-hospital mortality after LVAD surgery was 27%. – The most important determinants: poor nutrition hematological abnormalities end-organ or right ventricular dysfunction lack of inotropic support Circulation. 2007 Jul 31;116(5):497-505. Epub 2007 Jul 16
Preoperative RV dysfunction correlated well with postoperative worsening RV dysfunction. – deviation of interventricular septum towards the LV, which eliminates the septal contribution to right heart contractility. Neragi-Miandoab et al. Journal of Cardiothoracic Surgery 2012, 7:60a
Operative mortality of 46% for a score > 5. 12% for a score to <=5. J Thorac Cardiovasc Surg 2003;125:855-62
Back to our patient and Questions Pre-LVAD status: – prolonged ECMO support end organ damage? – profound coagulopathy – PRA(+) Increase peri-operative mortality