What have we learnt 50 years after the first Fontan procedure?
The Fontan procedure is often the only definitive palliative surgical option for patients with a variety of complex CHD sharing in common, a single, dominant ventricle. In recent decades, imaging and therapeutic improvement have played a crucial role in those patients in whom many complications can hamper their life. After 50 years from the first procedure, heart transplantation remains the only definitive treatment for those with a failing Fontan circulation.
Triple-organ transplants are rare, challenging operations necessitated by multi-organ failure. The difficulty of matching patients with a prospective donor, as well as the high level of complexity and coordination involved, prevents most transplant centers from performing these procedures, leaving patients who are in need of a triple-organ transplant searching for willing centers or opting for palliative care. We assessed the trends in frequency of various triple-organ transplants involving the heart over the last three decades by exploring the UNOS database.
AbstractIntravenous inotropic therapy can be used in patients with advanced heart failure, as palliative therapy or as a bridge to cardiac transplantation or mechanical circulatory support, as well as in cardiogenic shock. Their use is limited to increasing cardiac output in low cardiac output states and reducing ventricular filling pressures to alleviate patient symptoms and improve functional class. Many advanced heart failure patients have sinus tachycardia as a compensatory mechanism to maintain cardiac output. However, excessive sinus tachycardia caused by intravenous inotropes can increase myocardial oxygen consumpti...
As techniques for corrective and palliative surgery in congenital heart disease improve, the number of patients surviving to become adults with congenital heart disease (ACHD) has increased. A significant proportion of these patients will progress to develop advanced heart failure, the symptoms of which vary, complicating prediction of life expectancy. Unlike acquired heart failure, there is a lack of evidence-based treatments with which to relieve symptoms and prolong survival. As a result, a number of ACHD patients will proceed to heart transplantation.
We describe our palliative surgical strategy in a symptomatic teenager. A 16-year-old girl, with a recent diagnosis of severe suprasystemic pulmonary hypertension, with severe right ventricular dysfunction, presented with syncope and World Health Organization functional class 4 symptoms. Blood and imaging work up revealed changes suggestive of pulmonary veno-occlusive disease. She failed to improve with oral pulmonary vasodilators and was listed for heart and lung transplant. Pending the transplant, a 10-mm handmade valved tube graft was placed between descending thoracic aorta and the proximal left pulmonary artery, on ca...
End-stage heart failure that is refractory to medical therapy constitutes 5% of total heart failure population but has profound effects on quality of life with dismal survival1. Palliative options with or without ionotropic therapies remained the only route for majority of these patients, with only few eligible for orthotropic heart transplant. The advent of durable left ventricular assist devices (LVADs) changed this paradigm after showing drastically improved outcomes, and are now widely accepted therapeutic options for eligible patients2-4.
End-stage heart failure that is refractory to medical therapy constitutes 5% of total heart failure population but has profound effects on quality of life with dismal survival.1 Palliative options with or without ionotropic therapies remained the only route for majority of these patients, with only few eligible for orthotropic heart transplant. The advent of durable left ventricular assist devices (LVADs) changed this paradigm after showing drastically improved outcomes, and are now widely accepted therapeutic options for eligible patients.
Patients with heart failure (HF) requiring advanced therapies (AT) or palliative inotropes have been well described in the literature, but less is known regarding their earlier clinical course. Patients started on inotropes may be appropriate candidates for AT, yet do not always receive timely evaluations. Given the high mortality associated with end stage HF, we investigated the clinical characteristics and outcomes of HF patients after initiation of inotrope therapy.
Long-term, continuous intravenous inotropic support (CIIS) is frequently initiated for palliation of symptoms related to advanced heart failure (AHF) in patients who are not eligible for heart transplantation or mechanical circulatory support (MCS). Although the use of CIIS has increased in prevalence over the past decade, robust data regarding quality of life (QOL) outcomes in these patients are lacking. We wished to describe healthcare utilization and QOL outcomes in patients on palliative CIIS.
Risk factors such as diabetes mellitus (DM) have been associated with increased risk of mortality in patients with heart failure (HF). Obesity in diabetic patients worsens outcomes. However, there appears to be an obesity paradox in which stable HF patients with higher body mass index (BMI) have better survival. We sought to evaluate the association of DM and BMI with mortality in patients with end stage HF on palliative inotropic therapy.
Cardiac allograft vasculopathy (CAV) is one of the leading causes of late mortality among heart transplant recipients. Retransplantation, although considered the only definitive therapy, is not a feasible option for most patients. Percutaneous coronary intervention (PCI) with drug eluting stents (DES) or bare metal stents (BMS) has become a palliative, more accessible therapy. We conducted a systematic review and meta-analysis to investigate clinical outcomes of DES vs BMS.