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BackgroundRecent advances in ultrasound strain imaging facilitate more precise monitoring of subtle myocardial changes and thus may allow for more appropriate assessment of myocardium after orthotopic heart transplantation (OHT). This study aimed to explore longitudinal left ventricular (LV) and right ventricular (RV) function by speckle-tracking echocardiography (STE) during a 12-month follow-up period in relation to acute cellular rejection (ACR) degree ≥2R and the response to intense immunosuppressive therapy with intravenous steroids.Material/MethodsForty-five adult heart transplant recipients were prospectively assessed at a single center from January 2016 until June 2017. Echocardiography was performed serially at baseline and together with routine biopsies at 2 weeks and 1, 2, 3, 6, 9, and 12 months after OHT. Changes in graft function were evaluated using STE before and during ACR and in the resolving period of ACR.ResultsA total of 220 pairs of biopsy specimens and strain recordings were analyzed. Moderate ACR was seen in 30 biopsies (13.6%). In the serial assessment, longitudinal strain parameters of the LV (global and 4-, 2-, 3-chamber longitudinal strain) and RV (global and free wall longitudinal strain) were decreased at baseline and improved significantly (P<0.001) within 12 months after OHT. The degree of improvement was not influenced by ACR. There were no significant differences in circumferential, radial, or longitudinal strain rate, or mechanical dyssynchrony. Reduced LV and RV longitudinal strain was related to ACR degree 2R and increased significantly (P<0.0005) during 3 days of intravenous methylprednisolone therapy.ConclusionsUsing the STE technique, we have documented an acute improvement in mechanical myocardial function following ACR steroid therapy and a progressive recovery of LV and RV longitudinal function during the first year after OHT.

Left ventricular assist device (LVAD) thrombosis remains a dreadful complication of mechanical circulatory support, with an incidence of 8–12% depending on the pump type and patient’s comorbidities. Fibrinolysis may be considered early in pump thrombosis, but when contraindicated a pump exchange remains the only alternative. This short report documents an emergency LVAD exchange in a 55-year-old man who underwent LVAD (HeartWare Inc) implantation in 2013 as a bridge to transplantation. Four months after the initial surgery, he suffered from a hemorrhagic stroke despite properly managed anticoagulation. On February 17th, 2017 he was re-admitted with LVAD pump thrombosis. As fibrinolysis was contraindicated, an emergency pump exchange was performed via a limited thoracic incision in order to minimize surgical trauma, reduce intraoperative complications and facilitate immediate post-operative recovery. This report documents the very first LVAD pump exchange as well as the first one performed via a minimally invasive approach in Poland.

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A 37-year-old female with non-compaction cardiomyopathy and history of mitral valve replacement in 2015 (Carpentier-Edwards Perimount 29 mm) was admitted to the cardiac emergency department in a tertiary centre due to rapidly progressing decompensation of chronic heart failure. The patient had a history of recurrent hospitalisations and was on an active transplant list. Marked symptoms and signs of pulmonary and peripheral congestion were visible. Echocardiography revealed left ventricular ejection fraction (LVEF) of 10%, left ventricle diameter 63/60 mm and right ventricle 33 mm with tricuspid annular plane systolic excursion of 11 mm. Despite intensive medical management (diuretics and inotropic support) the patient progressed to cardiogenic shock. A temporary mechanical circulatory support -an Impella CP ® (Abiomed, USA) -was percutaneously inserted via the right femoral artery (Fig. 1A), generating up to 4 L/min of flow. Inotropic agents were gradually reduced, as the patient's clinical and haemodynamic condition improved. Appropriate anticoagulation was achieved with unfractionated heparin titrated to activated partial thromboplastin time of 60-80 s. Despite careful repositioning of the Impella CP, clear evidence of haemolysis and the subsequent haemolytic anaemia was observed 24 h later. An attempt to wean the Impella's support was made, but failed. The patient was qualified to an emergency upgrade to long-term mechanical ventricular support and transferred to our centre. On the fifth day, a less-invasive, sternum-sparing left ventricular assist device (LVAD) implantation was performed (Fig. 1B). Via a left anterolateral thoracotomy, the HeartMate 3™ LVAD as well as its outflow graft -connecting the pump with the ascending aorta -were placed extrapericardially (Fig. 2), to minimise the risk associated with pericardial dissection. A reversed T-upper mini-sternotomy was used to anastomose the outflow-graft to the ascending aorta. The Impella CP was surgically removed after completion of the LVAD procedure. However, a thrombectomy with a surgical reconstruction of the right femoral artery was necessary. The partially thrombosed rotor of the Impella was found on inspection of the pump. The patient was extubated 8 h later with minimal inotropic support and transferred to an intermediate care unit two days later. Improvement of LVEF to 20% as well as liver and renal function was observed. Resolution of haemolysis was immediate. We report here the first successful bridging with an Impella CP to less invasive LVAD implantation in a Polish patient with cardiogenic shock refractory to intensive medical therapy. This case confirms that the Impella CP is safe and effective for temporary stabilisation of a failing heart, allowing for subsequent upgrade for mechanical circulatory support. Minimally invasive, video-assisted LVAD implantation provides a safe option in patients after cardiac surgical procedures and allows for anastomosis of the outflow graft with the ascending aorta. The patient is at home in overall very ...

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Background Oxidative stress is a cause of cardiac diseases and contribute to apoptosis, cardiac remodeling, cardiac growth and repair. The end-stage heart failure (HF) is associated with ischemia-reperfusion, increased neurohumoral activity, cytokine stimulation and presence of inflammatory cells. Above factors are stimuli which generate free radicals and can induce oxidative stress in the heart and cause damage to essential myocardial structures and function. However, the role of oxidative stress in end-stage HF has not been fully understood. Purpose This study aimed to evaluate the prognostic value of the oxidative stress markers in ambulatory patients with end-stage HF awaiting heart transplantation (HT) during a 1.5 year follow-up period. Method The study was a prospective analysis of 85 optimally treated adult patients with end-stage HF, who were added to the HT waiting list at the Cardiology Department between 2015 and 2016. At the time of enrollment to the study routine laboratory tests, cardiopulmonary exercise test, echocardiography, spirometry and right heart catheterization were performed in all patients. During right heart catheterization, 10 ml of coronary sinus blood was additionally collected to determine total oxidant status (TOS) and total antioxidant capacity (TAC) levels. TOS and TAC were measured by Erel's method. The endpoint was all-cause mortality during a 1.5 years follow-up. The Medical University of Silesia's local Institutional Review Board approved the study protocol, and all patients provided informed consent. Results Median age of the patients was 53.0 (43.0–56.0) years and 90.6% of them were male. During the observation period, the mortality rate was 40%. The area under the receiver operating characteristics (ROC) curves indicated an acceptable discriminatory power of TAC (AUC: 0.780 [CI: 0.677–0.883]; sensitivity 56%, and specificity 90%); and excellent power of TOS (AUC: 0.9530 [CI: 0.9279–0.9781]; sensitivity 88%, and specificity 94%) for 1.5 years mortality. Patients with a low TAC level (≤1.10) had a significantly worse 1.5-year survival compared to the group with a high TAC level (&gt;1.10) (1.5 year survival: 20.8% versus 75.4%; (long rank p&lt;0.001). Similarly, patients with a high TOS level (≥3.11) had a significantly worse survival compared to the group with a low TOS level (&lt;3.11) (1.5- year survival: 9.1% versus 92.3%; p&lt;0.001). Conclusion TAC with acceptable prognostic power and TOS with excellent prognostic power allows assessment of the prognosis in end-stage HF during a 1.5 year follow-up period. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice, Poland

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