Publications by authors named "Pedro Catarino"

47 Publications

Long-term outcomes after heart transplantation using ex vivo allograft perfusion in standard risk donors: A single-center experience.

Clin Transplant 2022 Jan 14:e14591. Epub 2022 Jan 14.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Introduction: The Organ Care System (OCS) is an ex vivo perfusion platform for donor heart preservation. Short/mid-term post-transplant outcomes after its use are comparable to standard cold storage (CS). We evaluated long-term outcomes following its use.

Methods: Between 2011 and 2013, 38 patients from a single center were randomized as a part of the PROCEED II trial to receive allografts preserved with CS (n = 19) or OCS (n = 19). Endpoints included 8-year survival, survival free from graft-related deaths, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejections.

Results: Eight-year survival was 57.9% in the OCS group and 73.7% in the CS group (p = .24). Freedom from CAV was 89.5% in the OCS group and 67.8% in the CS group (p = .13). Freedom from NF-MACE was 89.5% in the OCS group and 67.5% in the CS group (p = .14). Eight-year survival free from graft-related death was equivalent between the two groups (84.2% vs. 84.2%, p = .93). No differences in rejection episodes were observed (all p > .5).

Conclusions: In select patients receiving OCS preserved allografts, late post-transplant survival trended lower than those transplanted with an allograft preserved with CS. This is based on a small single-center series, and larger numbers are needed to confirm these findings.
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http://dx.doi.org/10.1111/ctr.14591DOI Listing
January 2022

Non- heart-lung transplantation: doing less may prove to be worth it.

J Thorac Dis 2021 Oct;13(10):5579-5581

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

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http://dx.doi.org/10.21037/jtd-21-1490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575818PMC
October 2021

Contemporary Left Ventricular Assist Device Outcomes in an Aging Population: An STS INTERMACS Analysis.

J Am Coll Cardiol 2021 08;78(9):883-894

Kirklin Institute for Research in Surgical Outcomes (KIRSO), Department Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Background: Survival, functional outcomes, and quality of life after left ventricular assist device (LVAD) are ill-defined in elderly patients, and with new-generation devices.

Objectives: This study sought to evaluate survival, functional outcomes, and quality of life after LVAD in contemporary practice.

Methods: Adults receiving durable LVADs between January 1, 2010, and March 1, 2020, were identified from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database. The primary outcome was adjusted survival; secondary outcomes included quality of life rated using a visual analogue scale (where 0 represents "worst health" and 100 "best health"); 6-minute walk distance; stroke; device malfunction; and rehospitalization, stratified by patient age. Median follow-up was 15 months (IQR: 6-32 months).

Results: The cohort comprised 68.9% (n = 16,808) patients aged <65 years, 26.3% (n = 6,418) patients aged 65-75 years, and 4.8% (n = 1,182) patients aged >75 years, who were predominantly male (n = 19,119, 78%) and on destination therapy (n = 12,425, 51%). Competing outcomes analysis demonstrated mortality (70% CIs) of 34% (33%-34%), 54% (54%-55%), and 66% (64%-68%) for patients aged <65, 65-75, and >75 years, respectively, which improved during the study in patients aged >75 years. Newer-generation devices were associated with reduced late mortality (HR: 0.35; 95% CI: 0.25-0.49). Stroke, device malfunction or thrombosis, and rehospitalizations decreased with increasing age (all P < 0.01). Median 6-minute walk distance increased from 0 feet (IQR: 0-665 feet) to 1,065 feet (IQR: 642-1,313 feet) (P < 0.001), and quality of life improved from 40 (IQR: 15-60) to 75 (IQR: 60-90) (P < 0.001) after LVAD in all age groups.

Conclusions: In elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.
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http://dx.doi.org/10.1016/j.jacc.2021.06.035DOI Listing
August 2021

Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms.

BMJ Open 2021 03 4;11(3):e043323. Epub 2021 Mar 4.

Cardiac Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK.

Objective: To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA).

Design: Systematic review and meta-analysis DATA SOURCES: MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020.

Eligibility Criteria For Selective Studies: All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately.

Data Extraction And Synthesis: Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively.

Results: Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG.

Conclusions: There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA.

Prospero Registration Number: CRD42017054565.
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http://dx.doi.org/10.1136/bmjopen-2020-043323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934769PMC
March 2021

Commentary: The importance of surgical case volume in the transcatheter era.

J Thorac Cardiovasc Surg 2020 Jul 25. Epub 2020 Jul 25.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.076DOI Listing
July 2020

COVID-19 patient with coronary thrombosis supported with ECMO and Impella 5.0 ventricular assist device: a case report.

Eur Heart J Case Rep 2020 Dec 20;4(6):1-6. Epub 2020 Nov 20.

Royal Papworth Hospital, Cambridge CB2 0AY, UK.

Background: COVID-19 can present with cardiovascular complications.

Case Summary: We present a case report of a 43-year-old previously fit patient who suffered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with thrombosis of the coronary arteries causing acute myocardial infarction. These were treated with coronary stenting during which the patient suffered cardiac arrest. He was supported with automated chest compressions followed by peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). No immediate recovery of the myocardial function was observed and, after insufficient venting of the left ventricle was diagnosed, an Impella 5 pump was implanted. The cardiovascular function recovered sufficiently and ECMO was explanted and inotropic infusions discontinued. Due to SARS-CoV-2 pulmonary infection, hypoxia became resistant to conventional mechanical ventilation and the patient was nursed prone overnight. After initial recovery of respiratory function, the patient received a tracheostomy and was allowed to wake up. Following a short period of agitation his neurological function recovered completely. During the third week of recovery, progressive multisystem dysfunction, possibly related to COVID-19, developed into multiorgan failure, and the patient died.

Discussion: We believe that this is the first case report of coronary thrombosis related to COVID-19. Despite the negative outcome in this patient, we suggest that complex patients may in the future benefit from advanced cardiovascular support, and may even be nursed safely in the prone position with Impella devices.
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http://dx.doi.org/10.1093/ehjcr/ytaa342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717226PMC
December 2020

Neuroprotection and the Aorta: One System, One Artery, One Expectation, One Team.

J Cardiothorac Vasc Anesth 2021 04 17;35(4):1189-1191. Epub 2020 Dec 17.

Department of Critical Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Birmingham Acute Care Research, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2020.12.020DOI Listing
April 2021

Insertion technique for the Impella 5.0 heart pump in the COVID-19 era.

Multimed Man Cardiothorac Surg 2020 Dec 23;2020. Epub 2020 Dec 23.

Department of Transplantation Royal Papworth Hospital NHS Foundation Trust Cambridge, United Kingdom.

We describe the insertion of the Impella 5.0, a peripherally placed mechanical cardiovascular microaxial pump, in a patient with ischemic left ventricular dysfunction. The Impella is a 7 Fr device capable of achieving a flow of 4.0-5.0 L/min; its use necessitates an open arterial cut-down. A subclavicular incision is used to access the right or left axillary artery. A 10-mm tube graft is anastomosed to the artery through which the Impella 5.0 is inserted. The device traverses the tube graft and is advanced via the aorta, across the aortic valve, to its final position (inflow toward the ventricular apex and outflow above the aorta). The device may remain in situ for 10 days until recovery or until further supports are instituted. Our goal is to demonstrate the insertion of the Impella 5.0 device in a patient with cardiogenic shock whose situation was further complicated by coronavirus disease 2019.
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http://dx.doi.org/10.1510/mmcts.2020.078DOI Listing
December 2020

Size matching in heart transplantation: Is predicted heart mass the optimal method in a United Kingdom cohort?

Clin Transplant 2021 03 29;35(3):e14192. Epub 2020 Dec 29.

Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.

Predicted heart mass (PHM) equations have been proposed as an alternative method for size matching in heart transplantation. We assessed association between donor-recipient size mismatch, defined using PHM equations, and survival post-heart transplant in the United Kingdom. Data from all adult patients who received a heart transplant between 1995 and 2017 were obtained from the United Kingdom Transplant Registry. PHM was calculated using published equations. Primary outcome was 1-year survival post-heart transplantation. Recipients of undersized organs had reduced 1-year survival (HR 1.31, 95% CI 1.03-1.67, p = .03). Oversizing had no impact on survival (HR 0.99, 95% CI 0.78-1.26, p = .96). Gender mismatching had no impact on survival in the cohort matched by PHM (HR 1.12, 95% CI 0.86-1.47, p = .4). In recipients without pulmonary hypertension, undersizing by PHM had no impact on 1-year survival (HR 0.95, 95% CI 0.61-1.49, p = .83). In recipients with pulmonary hypertension, oversizing donor RV by using PHM RV equation (PHM ) results in improved survival at 1 year (HR 0.65, 95% CI 0.5-0.83, p = .001). In conclusion, receiving an organ undersized by PHM was associated with decreased 1-year survival. Subgroup analyses demonstrated that undersizing only impacted survival in recipients with pulmonary hypertension and that these recipients had improved outcomes if they received an organ with an RV oversized by >10% by PHM .
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http://dx.doi.org/10.1111/ctr.14192DOI Listing
March 2021

Commentary: How long can you go with del Nido?

J Thorac Cardiovasc Surg 2020 Oct 27. Epub 2020 Oct 27.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.076DOI Listing
October 2020

A 5-year single-center early experience of heart transplantation from donation after circulatory-determined death donors.

J Heart Lung Transplant 2020 12 3;39(12):1463-1475. Epub 2020 Oct 3.

Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom. Electronic address:

Background: In an effort to address the increasing demand for heart transplantation within the United Kingdom (UK), we established a clinical program of heart transplantation from donation after circulatory-determined death (DCD) donors in 2015. After 5 years, we report the clinical early outcomes and impact of the program.

Methods: This is a single-center, retrospective, matched, observational cohort study comparing outcomes of hearts transplanted from DCD donors from March 1, 2015 to February 29, 2020 with those from matched donation after brain death (DBD) donors at Royal Papworth Hospital (RPH) (Cambridge, UK). DCD hearts were either retrieved using thoracoabdominal normothermic regional perfusion or the direct procurement and perfusion technique. All DBD hearts were procured using standard cold static storage. The primary outcomes were recipient 30-day and 1-year survival.

Results: During the 5-year study, DCD heart donation increased overall heart transplant activity by 48% (79 for DCD and 164 for DBD). There was no difference in survival at 30 days (97% for DCD vs 99% for DBD, p = 1.00) or 1 year (91% for DCD vs 89% for DBD, p = 0.72). There was no difference in the length of stay in the intensive care unit (7 for DCD vs 6 for DBD days, p = 0.24) or in the hospital (24 for DCD vs 25 for DBD days, p = 0.84).

Conclusions: DCD heart donation increased overall heart transplant activity at RPH by 48%, with no difference in 30-day or 1-year survival in comparison with conventional DBD heart transplantations. DCD heart donation is set to make a dramatic difference in the number of patients who can benefit from heart transplantation.
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http://dx.doi.org/10.1016/j.healun.2020.10.001DOI Listing
December 2020

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study.

Medicine (Baltimore) 2020 Nov;99(46):e22427

Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK.

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.
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http://dx.doi.org/10.1097/MD.0000000000022427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668481PMC
November 2020

Combined heart-lung transplantation from a donation after circulatory death donor.

J Heart Lung Transplant 2020 12 20;39(12):1366-1371. Epub 2020 Aug 20.

Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom. Electronic address:

Combined heart-lung transplantation is the optimal treatment option for many patients with end-stage heart failure and fixed severe pulmonary hypertension. It offers the only possibility of long-term survival and a return to a normal quality of life. Unfortunately, it is rarely performed because of donor organ allocation policies. We present the case of a critically ill 24-year-old man, who after waiting for >100 days in-hospital on the urgent transplant list, deteriorated further and underwent the first successful heart-lung transplant with organs from a donation after circulatory death.
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http://dx.doi.org/10.1016/j.healun.2020.08.007DOI Listing
December 2020

Transcatheter aortic valve implantation in patients with a left ventricular assist device: a word of caution.

Eur J Cardiothorac Surg 2020 12;58(6):1309-1310

Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.

We describe a patient with a HeartMate 3 left ventricular assist device in whom we attempted transcatheter aortic valve implantation for severe aortic regurgitation. The valve migrated into the left ventricle and lodged on the left ventricular assist device inflow cannula. Caution should be exercised when considering the use of transcatheter aortic valve implantation in patients with an implanted left ventricular assist device, with pure aortic regurgitation.
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http://dx.doi.org/10.1093/ejcts/ezaa237DOI Listing
December 2020

Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes.

J Thorac Dis 2020 May;12(5):2426-2434

Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK.

Background: Vasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx.

Methods: Patients undergoing LVAD explant followed by HTx from 01/2013-12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 μg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database.

Results: During the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% 100% P=0.99) and 1-year (67.7% 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period.

Conclusions: Vasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.
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http://dx.doi.org/10.21037/jtd.2020.03.53DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330418PMC
May 2020

Spontaneous diaphragmatic rupture as a complication following lung transplantation.

Am J Transplant 2020 06 8;20(6):1744-1747. Epub 2020 Mar 8.

Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK.

Spontaneous diaphragm rupture is a rare but potentially life-threatening condition, requiring urgent surgical intervention. Here we present two patients who developed spontaneous right hemidiaphragm rupture with abdominal visceral herniation into the thoracic cavity several days following bilateral lung transplantation, as an unusual complication. Both patients' surgeries were performed through bilateral anterior thoracotomies and were uneventful. There may be an association with this complication and patients suffering with emphysema, typically receiving donor lungs smaller than their native lungs, and with significant pretransplant exposure to steroids, factors that when combined may contribute to an increased risk of spontaneous diaphragmatic rupture in the absence of a significant precipitant. If a similar clinical picture is seen, teams managing lung transplant recipients should be aware of this potential complication and recognize the need for urgent intervention.
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http://dx.doi.org/10.1111/ajt.15824DOI Listing
June 2020

Validation of Cardiovascular Magnetic Resonance-Derived Equation for Predicted Left Ventricular Mass Using the UK Biobank Imaging Cohort: Tool for Donor-Recipient Size Matching.

Circ Heart Fail 2019 12 6;12(12):e006362. Epub 2019 Dec 6.

William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, United Kingdom (K.F., J.A.C., S.E.P.).

Background: Current guidance from International Society for Heart and Lung Transplantation recommends using body weight for donor-recipient size matching for heart transplantation. However, recent studies have shown that predicted heart mass, using body weight, height, age, and sex, may represent a better method of size matching. We aim to validate a cardiovascular magnetic resonance (CMR)-derived equation for predicted left ventricular mass (LVM) in a cohort of normal individuals in the United Kingdom.

Methods: This observational study was conducted in 5065 middle-aged (44-77 years old) UK Biobank participants who underwent CMR imaging in 2014 to 2015. Individuals with cancer diagnosis in the previous 12 months or history of cardiovascular disease were excluded. Predicted LVM was calculated based on participants' sex, height, and weight recorded at the time of imaging. Correlation analyses were performed between the predicted LVM and the LVM obtained from manual contouring of CMR cine images. The analysis included 3398 participants (age 61.5±7.5 years, 47.8% males).

Results: Predicted LVM was considerably higher than CMR-derived LVM (mean±SD of 138.8±28.9 g versus 86.3±20.9 g). However, there was a strong correlation between the 2 measurements (Spearman correlation coefficient 0.802, <0.0001).

Conclusions: Predicted LVM calculated using a CMR-derived equation that incorporates height, weight, and sex has a strong correlation with CMR LVM in large cohort of normal individuals in the United Kingdom. Our findings suggest that predicted heart mass equations may be a valid tool for donor-recipient size matching for heart transplantation in the United Kingdom.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6922072PMC
December 2019

Donation after circulatory death in lung transplantation-five-year follow-up from ISHLT Registry.

J Heart Lung Transplant 2019 12;38(12):1235-1245

University of Toronto, Toronto, Ontario, Canada.

Background: This study aimed to examine intermediate-term outcomes of lung transplantation (LTx) recipients from donors after circulatory death (DCD).

Methods: We examined the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry data for patients transplanted between January 2003 and June 2017 at 22 centers in North America, Europe, and Australia participating in the DCD Registry. The distribution of continuous variables was summarized as median and interquartile range (IQR) values. Wilcoxon rank sum test was used to compare distribution of continuous variables and chi-square or Fisher's exact test for categorical variables. Kaplan-Meier survival rates after LTx from January 2003 to June 2016 were compared between DCD-III (Maastricht category III withdrawal of life-sustaining therapy [WLST]) only and donors after brain death (DBD) using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model.

Results: The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD lung transplants with complete data. DCD-III comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx performed each year increased from 0.6% in 2003 to 13.5% in 2016. DCD donor management included extubation in 91%, intravenous heparin in 53% and pre-transplant normothermic ex vivo donor lung perfusion in 15%. The median time interval from WLST to cardiac arrest was 15 minutes (IQR: 11-22 minutes) and to cold flush 32 minutes (IQR: 26-41minutes). Compared with DBD, donor age was higher in DCD-III donors (46 years [IQR: 34-55] vs 40 years [IQR: 24-52]), bilateral LTx was performed more often (88.3% vs 76.6%), and more recipients had chronic obstructive pulmonary disease and emphysema as their transplant indication. Five-year survival rates were comparable (63% vs 61%, p = 0.72). In multivariable analysis, recipient and donor ages, indication diagnosis, procedure type (single vs bilateral and double LTx), and transplant era (2003-2009 vs 2010-2016) were independently associated with survival (p < 0.001), but donor type was not (DCD-III vs DBD; hazard ratio, 1.04 [0.90-1.19], p = 0.61).

Conclusion: This ISHLT DCD Registry report with 5-year follow-up demonstrated similar favorable long-term survival in DCD-III and DBD lung donor recipients at 22 experienced centers globally. These data indicate that more extensive use of DCD-LTx would increase donor organ availability and may reduce waiting list mortality.
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http://dx.doi.org/10.1016/j.healun.2019.09.007DOI Listing
December 2019

The potential of heart transplantation from donation after circulatory death donors within the United Kingdom.

J Heart Lung Transplant 2019 08 29;38(8):872-874. Epub 2019 Apr 29.

Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.

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http://dx.doi.org/10.1016/j.healun.2019.04.007DOI Listing
August 2019

Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation.

J Cardiothorac Vasc Anesth 2020 Feb 16;34(2):374-382. Epub 2019 May 16.

Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom. Electronic address:

Objectives: The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes.

Design: A retrospective case series.

Setting: A tertiary referral cardiothoracic transplantation center.

Participants And Interventions: Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central).

Measurements And Main Results: All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%.

Conclusions: The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.
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http://dx.doi.org/10.1053/j.jvca.2019.05.012DOI Listing
February 2020

Reflection From UK Aortic Group: Frozen Elephant Trunk Technique as Optimal Solution in Type A Acute Aortic Dissection.

Semin Thorac Cardiovasc Surg 2019 Winter;31(4):686-690. Epub 2019 Apr 10.

University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.
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http://dx.doi.org/10.1053/j.semtcvs.2019.03.010DOI Listing
January 2020

Catastrophic sickling crisis in patient undergoing cardiac transplantation with sickle cell trait.

Am J Transplant 2019 08 30;19(8):2378-2382. Epub 2019 Apr 30.

Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.

There is debate in the literature regarding management of patients with sickle cell trait (SCT) undergoing cardiac surgery, since it is recognized that cardiopulmonary bypass presents many precipitating risk factors for a sickling crisis. Despite this, many report successful outcomes without any modification to perioperative management. A 49-year-old woman with SCT (HbS 38%) with postpartum cardiomyopathy underwent cardiac transplantation. The patient was cooled to 34.0°C and retrograde cold blood cardioplegia was infused continuously. The cold ischemic time was 219 minutes and warm ischemic time 46 minutes. After weaning from bypass, she developed global cardiac dysfunction requiring veno-arterial extracorporeal membrane oxygenation. The circuit suddenly stopped, requiring emergency reinstitution of bypass; the circuit had clotted. Transesophageal-echocardiogram revealed thrombus within the left atrium and ventricle. There was no recovery of cardiac function and the patient developed multiorgan failure. At postmortem there was extensive myocardial infarction with evidence of widespread catastrophic intravascular red-cell sickling. This case highlights the danger of complacency in patients with SCT, offering a learning opportunity for the cardiothoracic community to highlight the most serious complication that can occur in this group of patients. We have learned that SCT and cardiac surgery is not a benign combination.
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http://dx.doi.org/10.1111/ajt.15379DOI Listing
August 2019

Three consecutive cases of fatal intraoperative intracardiac thrombosis associated with the initiation of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin.

Perfusion 2019 07 2;34(5):417-421. Epub 2019 Feb 2.

1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK.

Central venoarterial extracorporeal membrane oxygenation has been used since the 1970s to support patients with cardiogenic shock following cardiac surgery. Despite this, in-hospital mortality is still high, and although rare, thrombus within the cardiac chambers or within the extracorporeal membrane oxygenation circuit is often fatal. Aprotinin is an antifibrinolytic available in Europe and Canada, though not currently in the United States. Due to historical safety concerns, use of aprotinin is generally limited and is commonly reserved for patients with the highest bleeding risk. Given the limited availability of aprotinin over the last decade, it is not surprising to find a complete absence of literature describing the use of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin. We present three consecutive cases of rapid fatal intraoperative intracardiac thrombosis associated with post-cardiotomy central venoarterial extracorporeal membrane oxygenation in patients receiving aprotinin.
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http://dx.doi.org/10.1177/0267659119826822DOI Listing
July 2019

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement.

J Thorac Cardiovasc Surg 2018 12 4;156(6):2124-2132.e31. Epub 2018 Jun 4.

London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.

Objective: Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR.

Methods: This pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population.

Results: In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR, 0.874; 95% confidence interval [CI], 0.668-1.143; P = .3246) or time to fitness for discharge (HR, 0.907; 95% CI, 0.688-1.197; P value = .4914). During a mean follow-up of 760 days (745 days for the MS group and 777 days for the FS group), 12 patients (10%) in the MS group and 7 patients (7%) in the FS group died (HR, 1.871; 95% CI, 0.723-4.844; P = .1966). Average extra cost for MS was £1714 during the first 12 months after AVR.

Conclusions: Compared with FS for AVR, MS did not result in shorter hospital stay, faster recovery, or improved survival and was not cost-effective. The MS approach is not superior to FS for performing AVR.
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http://dx.doi.org/10.1016/j.jtcvs.2018.05.057DOI Listing
December 2018

Branched Thoraco-Abdominal Aortic Aneurysm Repair with Branch Access Through a Transapical Left Ventricular Approach.

Cardiovasc Intervent Radiol 2018 Aug 27;41(8):1274-1279. Epub 2018 Apr 27.

Interventional Radiology, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK.

Branched thoracic aortic aneurysm repair requires arterial access from above the diaphragm in order to insert the visceral branches. This is routinely performed from the subclavian, axillary or carotid arteries and less commonly direct thoracic aorta puncture. The left ventricular apex is an alternative access route which is commonly used for percutaneous aortic valve replacement and rarely used for EVAR, FEVAR and TEVAR access. Here we describe two patients for which the left ventricular apex was the most suitable available access to the visceral branches during a branched thoracic aortic aneurysm repair. This access should be considered as an alternative approach if conventional arterial access is not available.
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http://dx.doi.org/10.1007/s00270-018-1973-5DOI Listing
August 2018

Outcome after heart transplantation from donation after circulatory-determined death donors.

J Heart Lung Transplant 2017 Dec 24;36(12):1311-1318. Epub 2017 Oct 24.

Department of Transplantation, Papworth Hospital National Health Service Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom. Electronic address:

Background: The requirement for heart transplantation is increasing, vastly outgrowing the supply of hearts available from donation after brain death (DBD) donors. Transplanting hearts after donation after circulatory-determined death (DCD) may be a viable additive alternative to DBD donors. This study compared outcomes from the largest single-center experience of DCD heart transplantation against matched DBD heart transplants.

Methods: DCD hearts were retrieved using normothermic regional perfusion (NRP) or direct procurement and perfusion (DPP). During NRP, perfusion was restored to the arrested heart within the donor with the exclusion of the cerebral circulation, whereas DPP hearts were removed directly. All hearts were maintained on machine perfusion during transportation. A retrospective cohort of DBD heart transplants, matched for donor and recipient characteristics, was used as a comparison group. The primary outcome measure of this study (set by the United Kingdom regulatory body) was 90-day survival.

Results: There were 28 DCD heart transplants performed during the 25-month study period. Survival at 90 days was not significantly different between DCD and matched DBD transplant recipients (DCD, 92%; DBD, 96%; p = 1.0). Hospital length of stay, treated rejection episodes, allograft function, and 1-year survival (DCD, 86%; DBD, 88%; p = 0.98) were comparable between groups. The method of retrieval (NRP or DPP) was not associated with a difference in outcome.

Conclusions: These results suggest that heart transplantation from DCD heart donation provides comparable short-term outcomes to traditional DBD heart transplants and can serve to increase heart transplant activity in well-selected patients.
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http://dx.doi.org/10.1016/j.healun.2017.10.021DOI Listing
December 2017

Use of Intraaortic Balloon Pumps in Acute Type A Aortic Dissection.

Ann Thorac Surg 2017 Oct;104(4):e321-e322

Cardiac Surgery Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom.

Cardiac failure may occur after repair of type A aortic dissections and contributes significantly to mortality. The use of an intraaortic balloon pump (IABP) for circulatory support in these patients is traditionally considered contraindicated because of concerns over extension of the residual dissection flap or aortic rupture. We propose that the use of an IABP may be appropriate and safe to improve cardiac function in patients after type A dissection repair. The two cases presented here contribute to increasing the body of evidence to support the appropriate use of IABP in these patients.
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http://dx.doi.org/10.1016/j.athoracsur.2017.05.079DOI Listing
October 2017

The ETTAA study protocol: a UK-wide observational study of 'Effective Treatments for Thoracic Aortic Aneurysm'.

BMJ Open 2015 Jun 2;5(6):e008147. Epub 2015 Jun 2.

Papworth Hospital, Cambridge, UK.

Introduction: Chronic thoracic aortic aneurysm (CTAA) affecting the arch or descending aorta is an indolent but life-threatening condition with a rising prevalence as the UK population ages. Treatment may be in the form of open surgical repair (OSR) surgery, endovascular stent grafting (ESG) or best medical therapy (BMT). Currently, there is no consensus on the best management strategy, and no UK-specific economic studies that assess outcomes beyond the chosen procedure, but this is required in the context of greater demand for treatment and limited National Health Service (NHS) resources.

Methods And Analysis: This is a prospective, multicentre observational study with statistical and economic modelling of patients with CTAA affecting the arch or descending aorta. We aim to gain an understanding of how treatments are currently chosen, and to determine the clinical effectiveness and cost-effectiveness of the three available treatment strategies (BMT, ESG and OSR). This will be achieved by: (1) following consecutive patients who are referred to the teams collaborating in this proposal and collecting data regarding quality of life (QoL), medical events and hospital stays over a maximum of 5 years; (2) statistical analysis of the comparative effectiveness of the three treatments; and (3) economic modelling of the comparative cost-effectiveness of the three treatments. Primary study outcomes are: aneurysm growth, QoL, freedom from reintervention, freedom from death or permanent neurological injury, incremental cost per quality-adjusted life year gained.

Ethics And Dissemination: The study will generate an evidence base to guide patients and clinicians to determine the indications and timing of treatment, as well as informing healthcare decision-makers about which treatments the NHS should provide. The study has achieved ethical approval and will be disseminated primarily in the form of a Health Technology Assessment monograph at its completion.

Trial Registration Number: ISRCTN04044627.
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http://dx.doi.org/10.1136/bmjopen-2015-008147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458682PMC
June 2015
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