Gareth Parry

Background: Delaying onset and early recognition of CLAD are clinically relevant strategic targets in lung transplantation. Flow volume (FV) curves provide a simple easy visual indicator of early/persistent allograft injury and scalloping on FV loop in particular is a marker of small airway obstruction which is characteristic of CLAD-BOS. Aims and objectives: To study if early scalloping on FV loop at 3 months post-transplant can predict onset of CLAD-BOS at 1 year post transplant and influence frequency of acute cellular rejection (ACR) or survival. Methodology: This is a non-interventional retrospective study involving all patients who underwent bilateral lung transplantation from 2012-2015 at Freeman Hospital, Newcastle Upon Tyne, UK. Serial post-transplant monitoring data were reviewed. Spirometry at 3 months post lung transplant, FV loop, incidence of ACR, BOS and long term survival post transplant were recorded and analyzed. Results: 156 subjects-93 males (59.6%) who underwent bilateral lung transplantation were included. 42 (27%) subjects demonstrated scalloping of FV loop at 3 months. Subjects with scalloping of FV loop have significant higher incidence of BOS at 1 & 2 year (16.7% & 26.2%) compared to those without scalloping (5.3% & 8%), p=0.023 & 0.002 respectively. Kaplan-Meier survival analysis estimates shorter median survival in subjects with scalloping (7.56 years versus 8.9 years), p=0.222. There is no significant correlation between scalloping of FV loop and number of ACR’s at 1 year. Conclusions: Early detection of scalloping on FV loop is clinically relevant and increases incidence of CLAD-BOS.

Although left ventricular assist device (LVAD) improves functional capacity, on average LVAD patients are unable to achieve the aerobic capacity of normal healthy subjects or mild heart failure patients. The aim of this study was to examine if markers of right ventricular (RV) function influence maximal exercise capacity. This was a single-center prospective study that enrolled 20 consecutive HeartWare ventricular assist device patients who were admitted at the Freeman Hospital (Newcastle upon Tyne, United Kingdom) for a heart transplant assessment from August 2017 to October 2018. Mean peak oxygen consumption (Peak VO₂) was 14.0 ± 5.0 ml/kg/min, and mean peak age and gender-adjusted percent predicted oxygen consumption (%VO₂) was 40.0% ± 11.5%. Patients were subdivided into two groups based on the median peak VO₂, so each group consisted of 10 patients (50%). Right-sided and pulmonary pressures were consistently higher in the group with poorer exercise tolerance. Patients with poor exercise tolerance (peak VO₂ below the median) had higher right atrial pressures at rest (10.6 ± 6.4 vs. 4.3 mmHg ± 3.2; p = 0.02) and the increase with passive leg raising was significantly greater than those with preserved exercise tolerance (peak VO₂ above the median). Patients with poor functional capacity also had greater RV dimensions (4.4 cm ± 0.5 vs. 3.7 cm ± 0.5; p = 0.02) and a higher incidence of significant tricuspid regurgitation (moderate or severe tricuspid regurgitation in five patients in the poor exercise capacity group vs. none in the preserved exercise capacity group; p = 0.03). In conclusion, echocardiographic and hemodynamic markers of RV dysfunction discriminate between preserved and nonpreserved exercise capacity in HeartWare ventricular assist device patients.

Orthotopic heart transplantation (OHT) is the “gold standard” treatment for patients with end-stage heart failure, with approximately 5000 transplants performed each year worldwide. Heart transplantation survival rates have progressively improved at all time points, despite an increase in donor and recipient age and comorbidity and greater recipient urgency; according to the registry of the International Society of Heart and Lung Transplantation (ISHLT), the median survival of patients posttransplantation is currently 12.2 years. Long-term survival is sub-optimal, and outcomes after OHT remain constrained by the development of acute rejection and cardiac allograft vasculopathy (CAV). Moreover, donor organs are in short supply, making optimal organ utilization an ongoing priority. For these reasons, substantial interest continues to exist in identifying factors portending increased survival and improved organ utilization.

Management of adults with failing Fontan physiology poses many challenges, especially as transplantation offers the only realistic alternative to palliative care. We present the first combined heart and liver transplant performed in Europe, for a late survivor of single ventricle palliation with the Fontan circulation. In addition to the conventional medical and surgical challenges posed, we highlight the management of the associated multi-organ failure with focus on the liver and novel strategies for assessment and optimization.

To manage myocardial recovery in patients with the HeartWare left ventricular assist device (HVAD), we describe a minimally invasive approach (decommissioning) that involves disconnecting the driveline and occluding the outflow tract through a small left thoracotomy incision, leaving the device in situ, in conjunction with optimal medical therapies and comprehensive assessment of left ventricular recovery. Nine patients (all male, 37 ± 12 years, all nonischemic dilated cardiomyopathy) had an HVAD implanted for 766 ± 343 days. When left ventricular function improved to mild impairment by echocardiography, patients underwent assessment at reduced flow (2578 ± 148 to 1822 ± 67 rpm) with documentation of compensated right heart hemodynamics and ejection fraction 52 ± 8%. Eight of nine patients underwent decommissioning, and 1 patient had a hybrid procedure of percutaneous occlusion of outflow graft and surgical division of driveline. Two patients died postoperatively at 413 days (sepsis) and 810 days (heart failure). In conclusion, in selected patients with nonischemic dilated cardiomyopathy, a prolonged period of HVAD support in conjunction with heart failure medications can lead to recovery of left ventricular function. Surgical decommissioning is then an option to remove these patients from support. These patients are, however, not cured and remain at risk for future deterioration in ventricular function and infections.