Dogan Emre Sert

Purpose: The conventional triple immunosuppressive regimen administered following heart transplantation typically comprises a calcineurin inhibitor, an antiproliferative agent, and corticosteroids. Everolimus has emerged as a viable alternative to calcineurin inhibitors. This study aims to evaluate the immunosuppressive efficacy and adverse effect profile of everolimus when introduced after the first post-transplant year, in comparison to continued calcineurin inhibitor therapy. Methods: A retrospective analysis was conducted on 90 heart transplant recipients under regular follow up. Patients were categorized into two groups: those who maintained calcineurin inhibitor therapy beyond the first year post-transplant ( n = 45), and those who transitioned to everolimus after the first year ( n = 45). The groups were compared in terms of rejection incidence and side effects. Results: Following the treatment modification, the everolimus group showed a significant improvement in serum urea and creatinine levels ( p < 0.05). Rejection rates after the first year were found to be similar between the two groups. Conclusion: Everolimus provides effective immunosuppression with a lower rate of side effects.It demonstrates a favorable impact on renal function without increasing the risk of rejection.The first year may be recommended as the optimal timing, considering both safe wound healing and the risk of rejection.

Incidence and clinical implications of aortic root thrombosis in LVAD patients: A single-center experience - Turkish Journal of Thoracic and Cardiovascular Surgery

Amaç: Bu çalışmada beyin ölümü gerçekleşen hastalarda organ bağışının seyrini araştırmak, organ bağışından organ nakline kadar olan aşamaları incelemek, kullanılmayan veya reddedilen vericilerin nedenlerini ortaya çıkarmak ve çözüm önerileri ortaya konması amaçlandı. Gereç ve Yöntemler: Ocak 2015-Aralık 2016 tarihleri arasında, aile izinleri olan tüm kadavra bağışçılarının Sağlık Bakanlığı Ulusal Koordinasyon Merkezi Başkanlığı arşivlerindeki donör kayıt verilerini inceledik. Donör adaylarının demografik verileri, yoğun bakım kalış süresindeki verileri ve donör olarak kullanılmama nedenleri incelendi. Sonuçlar: 985 donör incelendi; %65'i erkek, ortalama yaş 47.5 (0-96) idi ve donörlerin %65'inde nörolojik nedenlerle beyin ölümü gerçekleşmişti. Ortalama beyin ölümü rapor süresi 5.4 ± 9.3 (1-169) gündü. Donörlerin 169’unda (%17.1) enfeksiyon tespit edildi. Ortalama yoğun bakımda kalış süresi 8,55 ± 4,42 (2-38) gündü. Donörlerin sadece 159’undan (%16,2) kalp grefti alındı. 495 (%50,2) donör tıbbi nedenlerle reddedildi, 64 (%6,5) donör, alıcı merkezler tarafından reddedildiği için kalp nakli için uygun değildi. Potansiyel bağışçıların %20'sinde kalp bağışı için aile onayı alınmadı. Aile onayı olmayan bağışçıların %70'i 65 yaşın altındaydı ve %67'sinin greft olarak kalp kullanımından kaçınmak için herhangi bir tıbbi sorunu yoktu. Kalp onayı olmayan donörlerde greft olarak karaciğer kullanım oranı %71, böbrek için kullanım oranı %70 idi. Sonuç: Beyin ölümü tanısından donörlerin bakımına kadar olan süreci yürütecek ve yönlendirecek organ nakli ekiplerine ihtiyacımız vardır.

Postoperative 3D thorax computed tomographic scan image of the patient.

Background/Aims: In this study, the results of patients who had orthotopic heart transplantation (OHT) in acute rejection who admitted to our clinic with decompensated heart failure and who could not undergo endomyocardial biopsy (EMB) were evaluated. Methods: The study included 27 patients who underwent OHT in our clinic between December 1998 and November 2021, who admitted with acute rejection causing decompensated heart failure during follow-up, and who could not undergo EMB and administered IV pulse steroid plus plasmapheresis. Demographics of patients, peri-treatment left ventricular functions, survival rates and causes of mortality were analyzed. Results: 19 (70.4%) were male and mean age was 28.7 ± 14.7 (range: 3-54). After OHT, overall survival rates were 92.6%, 77.6%, and 69.4% at 1st, 3rd and 5th year respectively. During the follow-up, the survival rates of patients who presented with decompensated heart failure and given pulse steroid plus plasmapheresis were 70.4%, 58.8%, and 53.4% at 1st, 3rd and 5th year respectively after plasmapheresis. Median rejection time after transplant was 19 months (range 0-113 months). Pre-, and post-treatment left ventricle ejection fractions were 25.11% ± 11.1%, and 52.14% ± 13.4% respectively (p<0.05). The leading causes of mortality were pneumonia causing sepsis (5/13 patients). Conclusions: In acute rejection patients with decompensated heart failure in whom EMB is not possible, administration of plasmapheresis in addition to IV pulse steroid therapy may have a positive effect on survival in this patient group. Özet Amaç: Bu çalışmada ortotopik kalp nakli (OHT) yapılan, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile kliniğimize başvuran ve endomiyokardiyal biyopsi (EMB) yapılamayan hastaların sonuçları değerlendirildi. Yöntemler: Çalışmaya Aralık 1998-Kasım 2021 tarihleri arasında kliniğimizde OHT yapılıp, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile başvuran ve EMB uygulanamayan, IV pulse steroid + plazmaferez uygulanan 27 hasta dahil edildi. Hastaların demografik özellikleri, tedavi öncesi sol ventrikül fonksiyonları, sağkalım oranları ve mortalite nedenleri analiz edildi. Bulgular: Hastaların 19'u (%70.4) erkekti ve yaş ortalaması 28.7 ± 14.7 (3-54) idi. OHT sonrası genel sağkalım oranları 1., 3. ve 5. yılda sırasıyla %92.6, %77.6 ve %69.4 idi. İzlemde dekompanze kalp yetmezliği ile başvuran ve pulse steroid + plazmaferez uygulanan hastaların plazmaferez sonrası 1., 3. ve 5. yılda sağkalım oranları sırasıyla %70.4, %58.8 ve %53.4 idi. Nakil sonrası median rejeksiyon süresi 19 aydı (0-113 ay). Tedavi öncesi ve sonrası sol ventrikül ejeksiyon fraksiyonları sırasıyla %25.11±%11.1 ve %52.14±%13.4 idi (p<0.05). Mortalitenin önde gelen nedeni ise sepsise neden olan pnömoni (5/13 hasta) idi. Sonuç: EMB'nin yapılmasının mümkün olmadığı dekompanze kalp yetmezliği olan akut rejeksiyon hastalarında, IV pulse steroid tedavisine ek olarak plazmaferez uygulanması sağkalımı olumlu etkileyebilir.

Heart transplant is in high demand, but the wait list exceeds 6 months in Turkey. Until a donor heart can be procured, venoarterial extracorporeal membrane oxygenation is an important support option to bridge patients on the wait list or as a rescue therapy for patients with right ventricular failure after implant of left ventricular assist device; it is less expensive than other options, provides benefits such as simple percutaneous insertion, and requires neither sternotomy nor biventricular and respiratory support. We present a case of a patient bridged to transplant with 5 months of extracorporeal membrane oxygenation support.

Background Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Prediction of this clinical situation in LVAD patients with different clinical scores is still an enigma. The aim of this study is to analyze the predictive power of clinical parameters and risk scores and their combinations to discriminate RVF after LVAD implantation. Methods A retrospective, single center review of 71 patients who underwent continuous flow‐LVAD implantation between September 2013 and September 2016, was performed. RVF was defined as need for RVAD and/or administration of inotropic agents more than 14 days after LVAD implantation. Patients with and without RVF were divided into two groups and predictive power of the nine parameters (tricuspid annular plane systolic excursion (TAPSE), Michigan score, Pennsylvania score, central venous pressure/pulmonary artery wedge pressure ratio (CVP/PCWP), and right ventricular stroke work index, pulmonary artery pulsatility index, CRITT score, ALMA score, European registry for patients with mechanical circulatory support (EUROMACS) right heart failure model and their combinations were analyzed to predict postoperative RVF. Results Of 71 patients, 21 had RVF after implantation. For the variables that can be used to discriminate between RVF and non‐RVF groups, the diagnostic performance of the best cut‐off points and tests was obtained using receiver operating characteristic (ROC) curve analysis. Discrimination analysis was performed to determine the combinations of tests. For all single risk scores and parameters; the area under the ROC curve (AUC) was below 0.7 which is considered to be a poor level of discrimination except EUROMACS score (AUC: 0.789, P < .001) and CRITT score (AUC: 0.739, P = .004). AUC for the combination of TAPSE and Pennsylvania score was 0.722, combination of Michigan and Pennsylvania scores represented AUC of 0.732 in the analysis. The combination of TAPSE + Pennsylvania score was found to have the highest sensitivity (85%), whereas TAPSE + Michigan score + CVP/PCWP appeared as the most specific (97%) combination. Conclusion EUROMACS and CRITT scores predict RVF with high discrimination after LVAD implantation. Although, no other single test predicts RVF ideally, combination of risk scores and parameters discriminate RVF acceptably.

Purpose Continuous flow intracorporeal left ventricular assist devices (CF‐LVAD) are used more frequently in pediatric population. One of the major complications of CF‐LVAD is cerebrovascular events(CVE). Limited information is available on this complication in pediatric patients. We hereby present our experience on CVE in children under CF‐LVAD support in our institution. Methods A retrospective, single center review of 21 patients younger than 19 years of age who underwent CF‐LVAD implantation between June 2014 and September 2018 was performed. Patients on biventricular support and extracorporeal device were excluded. Cerebrovascular accidents‐ischemic or hemorrhagic‐were investigated. CVE was confirmed by brain computed tomographic scan. Results Of twenty‐one pediatric patients, 11 was male. Mean BSA was 1.05±0.41 m² and mean age was 11.05±4.07 years. Dilated cardiomyopathy was the leading cause of heart failure. The patients were implanted HeartWare hVAD (n=19), Heartmate II (n=1) and Heartmate III (n=1). Mean support time was 421±448(18‐1460) days. Target international normalized ratio was between 2.5‐3.0. Nine(43%) patients underwent transplantation, 1 patient recovered with subsequent device explantation. Four(17%) patients were still on support. One patient(5%) died in early postoperative period and 6(28%) patients died on VAD support after mean duration of 194 days. There were overall 5 cerebral hemorrhagic strokes in 4 patients(0.2 events per patient‐year). CVA occurred between 250 and 1320 days(mean 600 days). No ischemic stroke was documented. Only one(20%) patient died after hemorrhagic stroke; other 3 patients recovered and were discharged from the hospital with minor sequelaes. Conclusion Incidence of CVE in children on CF‐LVAD is relatively low compared with adults on VAD and severity of stroke is milder than adult population.