Frequently the only therapy for primary graft- and right heart failure, as well as low output syndrome from acute of chronic rejection, is implantation of a mechanical circulatory support system, until recompensation or retransplantation. At our institution, mechanical assist devices were implanted in 25 heart recipients for a cute rejection (n=9), primary graft failure (n=7), acute right heart failure (n=7), and chronic rejection with low output syndrome (n=2). Patients (pts) with primary graft failure (n=3) received an intraaortic balloon pump (IABP), one pt an IABP plus Abiomed-System for left ventricular support, one pt the Thoratec-System for biventricular support. Patients with right heart failure (RHF) received the Biomedicus centrifugal pump for right ventricular support. Nine pts suffered from acute rejection. Six pts received an IABP, one the Biomedicus as femoro-femoral bypass, one the Abiomed-System for biventricular support, two the Thoratec-System for biventricular support and two within this group switched from the Biomedicus pump to the Thoratec-System for biventricular support. Patients with chronic graft failure (n=2) received the Novacor-System (LVAD) for left ventricular support, one received a Tojobo-System and an oxygenator for biventricular support post coronary artery bypass surgery. Support time ranged from 0.5-h to 73 days. Five pts were weaned. Two (8%) of 25 pts were retransplanted, 18 (72%) died in spite of mechanical support from multiple organ failure. The use of a mechanical assist device after heart transplantation is encouraging only in the case of early right heart failure, as well as primary and chronic graft failure. In view of the poor results, the use of mechanical assist devices should not be recommended in the case of heart failure caused by acute rejection.
Based on our limited experience, cardiac allografts from donors exposed to different kinds of poisons can be transplanted in selected cases. If the donor organ is not hemodynamically compromised, showing regular filling pressures on low or mild inotropic support just before explantation, and if there are no electrocardiographic changes in combination with elevation of the transaminases, cardiac allograft transplantation seems to be a safe and life-saving procedure.
In our experience, it is possible to increase the cardiac donor pool by accepting allografts from donors, preferably female, > or =60 years of age in selected cases without a coronary angiogram, if hemodynamic parameters are in a normal range on mild-to-moderate inotropic support. We do not recommend cardiac allografts from donors > or =60 if there are signs of coronary insufficiency in the electrocardiogram, if left ventricle filling pressures are above normal on mild-to-moderate inotropic support and optimum hemodynamic management, or if there are signs of segmental dysfunction or mitral insufficiency >I in the echocardiogram.
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