Canadian Cardiac Transplant Network Status Review 2021
Canadian Cardiac Transplant Network
Status 4 Review
2021
Status 4 Cases Vancouver
Case 1: VJ
•
54 yo F, NICM, LVEF <20%, s/p MV repair, ICD
•
cPRA 87%
•
Given worsening symptoms listed status 4S Oct 15, 2020
•
The clerk entered her as status 4 instead of status 4S by mistake and
this was corrected within 4 hrs
•
She was eventually transplanted as a status 4S (imported heart)
Case 2: EM
•
39 yo F, transferred from outside with hospital with cardiogenic shock
•
VF arrest, AKI ->CRRT and IHD -> ECMO Nov 14, 20
•
Normal coronary angiogram
•
EmBx revealed Giant cell myocarditis
•
Treated with Steroids, azathioprine, and cyclosporine
•
Listed Status 4 while on ECMO
•
Improved hemodynamically and from VT perspective, decannulated Nov 23
rd
and deslited
•
Treated with po amiodarone
•
LVEF improved to 54%
•
Subsequently she developed DRESS from septra
•
ICD implanted
•
Discharged Mar 2
nd
2021 to rehab facility
Case 3: SR
•
55 yo female, acute myocarditis
•
8/2020 – flu like illness and ?PE, treated with IV heparin in peripheral
hospital
•
Developed HITT with thrombosis and embolism to head, hands and
feet requiring thrombectomy
•
Echo showed bivent dysfunction, likely from acute viral myocarditis
•
Milrinone dependent and transferred to St. Paul’s
•
8
/30/2020 – VT/VF arrest on ward and was placed on VA ECMO
•
Managed on Argatroban
Case 3: SR
•
9/3/20 - Unable to wean and converted to HVAD LVAD (off pump
implant with bivirudin) as a bridge to transplant or recovery
•
Complicated course in hospital (digits amputation, VAP with trach,
ischemic gut with resection and colostomy, fungemia, reversal of
colostomy…..)
•
2/19/20201 - Discharged home
•
Repeat echo and invasive cath confirmed myocardial recovery on
optimal medical therapy
•
5/25/21 - Admitted elective for total LVAD explant (fungemia)
•
5/27/21 - Uneventful OR
Case 3: SR
•
POD 1 - worsening RHF requiring temporary RVAD
•
POD 2 - developed LV failure with severe MR, converted to central
ECMO
•
Listed for S4 heart
•
5/30 – Transplanted
•
Long recovery and discharged 7/3/21
•
Home and doing well
Case 4: DV
•
55 y/o male with late presentation inf STEMI
•
June 17/21 – PCI to RCA, progressive HF, TTE showed VSR
•
June 18 – surgical VSR repair
•
June 24 – discharged home
•
July 4 – wound infection, left pleural and pericardial effiusion
•
July 14 – hypotension, repeat echo showed large pericardial effusion
•
To OR for pericardial drainage and sternal dehiscence, found to have
contained LV rupture, repaired. Off CPB on high doses of pressors and
intropes
Case 4: DV
•
July 15 – placed on VA ECMO
•
Seen by Tx team, not a candidate for durable VAD
•
Considered for S4 listing
•
Delisted due to sepsis, ischemic leg requiring amputation
•
July 25 - Weaned from ECMO
•
Transferred to general ICU
•
Developed recurrent sepsis and died 2 months later in ICU
UAH (Edmonton)
Status 4 Listings
CCTN September 2020 – August 2021
UAH Summary (Sept 2020-Aug 2021)
•
Status 4 listed patients: 2
•
Transplanted: 1
•
Not transplanted/Deceased: 1
S.H.
•
25F with Familial (Desmin Gene) Cardiomyopathy with progressive BiV
failure and recurrent VT
•
Brief Clinical Summary
•
2019: Presented with HF
•
Congestive and Low output symptoms
•
LVEF 25% with moderate RV hypokinesis
•
Started on GDMT
•
Fall 2020: Deterioration
•
Worsening symptoms including VT
•
LVEF 15% with akinetic RV and RV thrombus – started on OAC
•
Dec 3, 2020:
Status 1
•
Jan -Mar 2021:
Status 2
•
Repeated admissions for ADHF and ICD shocks for frequent, recurrent VT
•
cMRi showed RV thrombus resolved
S.H. (Continued)
•
Mar - April, 2021:
Status 0
•
LVAD implant (HM3) + C-Mag RVAD
•
Failed RVAD wean attempts due to recurrent VT – Multiple AAs with no improvement
and VT ablation not an option as per EP
•
Positive HIT screen but negative SRA so safe to expose to heparin as per Hematology
•
Continued recurrent VT – multiple daily episodes
•
April 8, 2021:
Status 4 (LVAD and RV failure/VT on t-MCS)
•
April 9, 2021: Transplanted
•
May 4, 2021: Discharged in good condition
A.S.
•
55F with AMI and urgent CABG
Cardiac arrest post-op requiring t-MCS (VA-
ECMO)
•
Brief Clinical Summary
•
Oct – Dec 2020 – AMI and post-op arrest
•
Urgent CABG with post-op arrest
VA-ECMO for severe BiV failure
•
BiVAD C-Mag with oxygenator (oxygenator removed after 2 weeks)
•
Cath showed loss of SVG to RCA (PCI not option as diffuse, severe native disease of small RCA)
•
Failed multiple RVAD wean attempts
•
Recurrent GI bleeds initially but eventually resolved with holding anticoagulation
•
Dec 24, 2020:
Status 4 (t-MCS not a candidate for durable VAD due to severe RVF)
•
HTx work up and listing
•
cPRA 100% with strong Class I & II Abs
•
Jan 4, 2021:
Status 0
•
CVA with initial left sided hemiparesis with early improvement
•
Jan 15, 2021:
Status 4
•
PT assessment cleared her for listing again
A.S. (Continued)
•
Jan 26, 2021:
Status 0
•
MSSA Infection
•
Feb 4, 2021:
Status 4
•
Infection cleared
•
Multidisciplinary meeting and discussion re: likelihood of transplant in view of cPRA (100%) and poor
candidate for desensitization (very strong Class I and II abs)
•
Agreed to reassess candidacy weekly
•
February 27-March 9
•
Team and family discussion re: no acceptable offers during Status 4 listing period
•
Agreed to continue Status 4 but as per family wishes to proceed with
BiVAD one –way wean
,
understanding that if she deteriorated she would not be a HTx candidate
•
RVAD C-Mag weaned off
•
Mar 10, 2021:
Status 0
•
LVAD C-Mag off with IABP and ino-pressor support
•
Mar 15, 2021: Deceased
•
Intractable Cardiogenic Shock
Winnipeg: 1 patient, 1 month
•
59-year-old gentleman who has known ischemic cardiomyopathy and
post HeartMate 3 LVAD, listed Status 4 for 1 month in the setting of
refractory GI bleeds after national consensus achieved
•
Status 4 August 20 2021, no further bleeding on thalidomide and
downgraded to Status 3 Sept 21
st
.
•
Units PRBC total 79 and met criteria for Status 4 based on number
and units , absence on contributing factors and extensive
investigations
•
Was an outpatient at time of listing (this may be a point of
discussion)
•
Units and investigations listed on next slide
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Admission April with balloon enteroscopy
•
June 18th to June 28th, 7 units of packed RBCs. balloon enteroscopy on June
23
rd
, his INR on admission had only been 2.5. He was discharged on a higher dose
of octreotide at 30 mg monthly.
•
July 7
th
- July 26th. INR on admission was 4.5, 23 units of packed RBCs; even when
his INR was down to 1.1, he had ongoing bleeding. balloon enteroscopy on July
21
st
. His octreotide was discontinued and thalidomide 50 mg at h.s. was
instituted.
•
University of Toronto
Adult Transplant Program: Status 4 Review
NS
•
51 M, police officer
•
Aug 2020
: diagnosed with ischemic CMP, LVEF 25%, NYHA 1, being medically optimized
prior to CABG
•
Oct 22, 2020
: presented with pre-syncope and polymorphic VT
•
Oct 27, 2020
: 5V CABG + aneurysm repair
•
Oct 29, 2020
: POD#2, developed VT storm, multiple morphologies, escalating inotrope
requirements
•
Cannulated centrally for ECMO as bridge to decision (biVAD, vs transplant)
•
No suitable substrate amenable to ablation
•
Oct 30, 2020
: decision made to list Status 4
•
Oct 31, 2020
: suitable donor available, transplant
•
Nov 14, 2020
: discharged from hospital with uneventful course
•
Continues to do well
SR
•
32 M, familial CMP (brother was transplanted a few months prior)
•
Feb 14, 2021
: worsening HF as an outpatient, admitted locally and then transferred to TGH with fevers, worsening
hemodynamic status
•
Underwent Impella (R. axilla) as bridge to decision; significant pulm HTN, unknown source of fever
•
March 2, 2021:
Infectious/rheumatologic work up negative. Probable drug fever. Upgraded to Heartware HVAD;
no RVAD required
•
March 8, 2021
:Developed cholangitis, tamponade with chest re-opening; sternal OR swabs +ve for Candida
albicans
•
March 22, 2021
: further recovery and discharge home (on antifungal)
•
March 25, 2021
: recurrent fevers, low flow alarms, repeat sternal wound swab +ve for Candida and E. fecaelis
•
CT chest imaging showed mycotic pseudoaneurysm at outflow cannula anastomosis
•
March 26, 2021
: Taken back to OR for repair of pseudoaneurysm, reconstruction of ascending aorta; ID opinion
that source control would be infeasible (persistent fungal mediastinitis)
•
March 27, 2021
: Listed status 4
•
April 8, 2021
: suitable local donor available; transplanted
•
April 22, 2021
: discharged from hospital and continues to do well with no further admissions
PR
•
70 M, longstanding dilated CMP, no other comorbidities
•
Listed for transplant early 2020
•
Progressive decline as an outpatient, became inotrope dependent
•
Dec 8, 2020
underwent BTC HeartMate 3 for worsening pulmonary HTN, INTERMACS III
•
3 months post LVAD, had recovered very well, and repeat hemodynamics were acceptable for transplant.
•
April 29, 2021
: Listed status 3 as an outpatient
•
Over next 3 weeks, developed recurrent episodes of VT/VT storm with 2 admissions for ICD shocks; 3
rd
admission to CVICU for incessant VT and ICD shocks, refractory to medical therapy, not amenable to ablation
•
May 25, 2021:
listed status 4 (fulfilled criteria for arrhythmic VAD complication)
•
May 27, 2021:
Transplanted with suitable donor
•
Developed severe PGD requiring CMAG bivad support
•
Progressive recovery, complicated by episode of AV block, fungemia; eventually discharged to rehab hospital
June 20, 2021.
•
Now doing well
MJ
•
29 F, dilated CMP (familial)
•
2019-2021
: Recurrent admissions to CCU with acute HF, requiring inotropes
•
June-Aug 2021
: Long admission and unable to wean milrinone, listed status 3 for transplant.
•
Debate about BTT VAD due to marginal RV function and patient reluctance
•
Discharged home on milrinone
•
Aug 6, 2021
: Readmitted with worsening congestion and rapid hemodynamic deterioration
•
Aug 10, 2021:
Underwent HM 3 implant, INTERMACS 2
•
POD#1-6 - worsening hemodynamics/low flows
•
Aug 16, 2021
: CMAG RVAD inserted
•
Aug 22
nd
listed status 4
•
Recurrent bleeding, tamponade with multiple sternal re-openings
•
Unable to wean support, unable to anticoagulated
•
Remained extubated, mobile/ambulatory, unsensitized
•
Sept 24,2021
: suitable donor offer and transplanted
•
Sept 24 – Oct 2, 2021
: progressed very well with good graft function. Prior to discharge,
developed sudden headache, decreased LOC and was found to have massive intracranial
hemorrhage. No surgical option. Declared brain dead and passed away back in CVICU
UOHI Status 4
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Managed in Hull for longstanding familial cardiomyopathy with severe biventricular systolic dysfunction
•
April 12: hospitalized in Hull for gallstone pancreatitis and heart failure decompensation
•
May 3: transfer to UOHI in cardiogenic shock on IABP post failed inotrope wean
•
May 5: ongoing haemodynamic deterioration requiring VA-ECMO support and intubation.
•
May 6: listed status 4 for heart transplant
•
May 9: Heart transplant. Complicated post op course with severe RV failure requiring inopressor support for
1 month, AKI requiring dialysis (CCRT followed by hemodialysis), pneumonia, delirium, bilateral IJ
thrombosis, CHB (PPM June 4) and prolonged 1 month ICU stay
•
June 29: transfer to Hull for physical rehabilitation
•
Jul 23: diagnosed with left panendopthalmitis while at Hull inpatient rehabilitation
•
Jul 29: transfer to UOHI for management of disseminated aspergillus: b
lood culture positive, lung lesions,
infected PPM, tricsupid valve vegetation, sternal wound infection, RIJ pseudoanuerysm infection.
Treated
with antifungals/antimicrobials, PPM explant (Aug 4).
•
Sep 13: TTE showing w
orsening TV vegetation encasing the septal TV leaflet with severe TR and satellite RA
lesions, moderate RV dysfunction
•
Sep 15: deemed to have no surgical options due to comorbid state with medical treatment being non-
curative. Palliative care involved with subsequent decision to continue with medical treatment (including
antimicrobials, dialysis) but not for ICU/intubation/CPR
•
Oct 13: passed away following progressive clinical deterioration.
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Dr Normand Racine
Medical Director,
Heart Transplant & Ventricular Assist Device Program
Montreal Heart Institute
Université de Montréal
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2020-10-23: 27 F Congenital CMP: Turner Syndrome with post-cardiotomy
Cardiogenic Shock per ROSS and Konnu procedure. Persistent biventricular
Failure per-op.: ECMO implanted in OR. ABO: O+
•
PMHx:
•
Turner Syndrome
•
Congenital CMP : Severe congenital Aortic Stenosis
•
Remained on Ventilator
•
LVEF 10-15% 24 h post-op: Milri / Dobutamine high doses
/ Epinephrine drip
•
Unable to wean ECMO
•
2020-10-17: LISTED STATUS 4 (day 4 post-op).
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2020-10-30: TRANSPLANTED
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2020-12-11: Discharged home.
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ALIVE and doing very well
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M 43
GR A+; 91 Kg 168 cm
•
2020-11-18: Isch CMP transferred from another hospital in cardiogenic shock post
NSTEMI, Large Apical thrombus (20x22 mm) + 3Vx disease + Severe Mitral Regurg.
LVEF 15-20%. RVEF: N.
•
2020-11-26: Recurrent NSTEMI with NS-VT
•
2020-11-30: Recurrent VF early am prior to OR
•
2020-11-30: CABG + MVR : required ECMO per-op
•
Required multiple Vasopressors high doses (Levo-Adren-Vaso-Milri), Dialysis
•
Lactates 7.4
•
2020-12-02: Urgent LISTING status 4 Intubated, Vasopressors, Malignant
arrhythmias)
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2020-12-07: TRANSPLANTED
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Long convalescence
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HOME, Doing well
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M 50. ABO: Gr B+ 102 kg. 175 cm
•
2019-06: Severe Bicuspic Ao St
enosis: ROSS + Asc Ao Replacement
•
Known Congenital Hypofibrinogenemia syndrome
•
2020-12-14: Transferred from another Hospital for AF + Left Main Emboli :
Anterior STEMI c Cardiogenic shock : CPR
•
Remained hospitalized with Severe residual LV dysfct 10-15% ; Inotropes
dependant (INTERMACS 3).
•
2020-12-23 LISTED STATUS 3.5
•
2020-01-21 : SUDDEN HEMODYN decompensation : LEVO + LISTED STATUS 4
•
2020-01-21: TOTAL Heart: CardioWest
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2021-01-30: Cardiac Transplantation
•
2021-02-19: D/C home. ALIVE Doing well.
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M 65. Gr A- 89 Kg 168 cm
•
2021-03-02 : transferred from another hospital: INF STEMI with late
presentation. PPCI-RCA + IABP + Intubated VSD detected.
•
Remained hemodynamically unstable: VASOPRESSORS, Low output
•
Severe RV dysfunction post-PPCI.
•
2021-03-03: Surgical Repair of VSD + ECMO VA
•
2021-03-04: Residual VSD & RV dysfct ; Rising PRESSORS support.
•
2021-03-05: LISTED Status 4
•
2021-03-05: Transplanted from Hepatitis C (+) donor: Ab(+) NAT (-)
•
2021-03-19: D/C home. ALIVE Doing very well
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M 22. Gr A+ 84 Kg 178 cm
•
2021-02-12 Transferred from another hospital. Decompensated Biventricular
HF with LOW Output.
•
Dx: Non-compaction CMP, Thrombus APEX LV (10mm); LVEF 10-15% MR 2+
with Moderate RV dysfct and TR 3+
•
Milrinone initiated ; failed weaning. Levophed added
•
2021-02-16: Worsening HF
•
2021-02-19: LISTING Statut 3.5
•
2021-02-20: Cardiogenic shock; MR 4/4 –
>
ECMO-VA (INTERMACS 3)
•
2021-02-20: LISTING Statut 4
•
2021-03-02: ECMO removed. LV Centrimag implanted
•
2021-03-03: TRANSPLANTED.
•
2021-03-19: D
/C home ALIVE. Doing very well
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M 51. Gr A+ 79 Kg 167 cm
•
2021-02-26 Transferred from another hospital : Cardiogenic shock
Isch CMP; LVEF 10% with Apical thrombus.
Milrinone dependent since Feb 19.
•
2021-03-10: CABG (RCA) + Tricuspid Annular Valvuloplasty + HeartMate-3
•
2021-03-21: Arrhythmic storm uncontrollable despite Amio + Xylo IV
drips: LISTED Status 4 transiently ad 03-31.
•
Subsequently stabilized.
•
2021-04-28: D/C home. ALIVE.
•
Presently on HOLD for Tx: awaiting GI investigation prior to relisting.
MUHC
Oct 2021
Status 4 presentation
Patient Mr. B
•
29 yo man
•
Presents to “spoke” hospital in shock.
•
Heart biopsy shows fibrosis
•
History of amphetamine abuse
•
Echo severe BiV failure, swan-ganz shows very high CVP vs wedge
•
Deteriorates despite inotropes, transferred in shock and gets ECMO
on arrival
•
Impella implanted for LV unloading
Patient Mr. B (continued)
•
ECMO unweanable
•
Patient extubated and able to have discussion
•
Concerns about prior durg use, but very strong family support and
patient cooperation
•
In view of BiV failure as per standard criteria, listed for transplant as
felt to not be suitable LVAD candidate
•
Transplanted, doing well – has not resumed any consumption of
amphetamines
Patient Mr. P
•
56 yo man
•
Presented to “spoke” hospital with out of hospital arrest with STEMI
•
Cath showed LM culprit with underlying 3v disease and very poor LV
function, LM PCI
•
Transferred in shock for ECMO support
•
Neuro recovery
•
Drop in platelets with suspected HITs
•
ECMO unweanable and due to HITs suspicion was felt to be high risk ofor
LVAD and was listed for transplant
•
Head bleed within days of listing, deactivated for transplant and palliated.
Patient Mr. M
•
Known RV dysplasia with poor RV function and LV poor function due
to non-specific CMY
•
Issues of recurrent Ventricular arrhythmias despite several ablations
and had been on the heart transplant wait list
•
Presented to transplant recently worse with BIV failure and recurrent
intractable Vtach and severe hemodynamic compromise
•
In view of BiV failure and known RV dysplasia was placed on BIV
support with CentriMAG
•
Listed as status 4 and waiting for heart
Status 4 CCTN
2020-2021
Institut Universitaire de Cardiologie et de Pneumologie de Québec
Quebec city
Patient RB
•
68 years old male
•
No medical issue and still working full time
•
Massive anterior infarct 2/03/2021, fibrinolytic therapy failure,
rescue angioplasty and stents LAD followed by stents CX (second
procedure), LVEF 30%
•
Chest pain back home, hospitalised local center 7/03/2021
•
Sent back to IUCPQ 11/03
•
Cath lab 11/03 : extensive stents thrombosis on proximal LAD and
CX, angioplasty and stent of LAD + intra aortic ballon pump for
cardiogenic shock
•
ECMO for refractory cardiogenic shock 11/03, LVEF 5-10%
•
Electrical storm 14/03 and intubation
•
Severe biventricular failure with no potential for improvement
•
Not a candidate for LVAD (active ventricular arythmia with severe RV
failure)
Patient RB (suite)
•
Listed status 4 for heart transplant 15/03 : creatinine 226, bilirubine 15, ALT 85,
INR 1,3 lungs clear, neurological status ok (can obey to orders)
•
Heart transplant on 19/03
•
Good hemodynamics and graft function and but massive ischemic stroke post op
with oedema and hemorragic transformation, died on 20/03
Pediatrics
CCTN Status 4 Review
Stollery Children’s Hospital
Edmonton, Alberta
SJ 13 years
•
Emery Dreifuss Muscular Dystrophy
•
Dilated cardiomyopathy, recurrent ventricular tachycardia
•
LVAD Heartware cannulation, June 13, 2020
•
Listed Status 3.5 September 2, 2020 after elective recovery period
•
Changed to status 3 September 9, 2020 (discharge from hospital)
•
Changed to Status 4 December 30, 2020 for VAD complication of ongoing MRSA VAD cannula
infection needing repeat surgical revision without resolution.
•
Transplanted January 3, 2021
•
Alive and well
VN – 2 years
•
Hypoplastic left heart syndrome
•
1 week: Norwood Sano, residual ascending aorta obstruction
•
6 months: balloon angioplasty of the ascending aorta
•
7 months: Glenn anastomosis and reconstruction of the ascending aorta by injury to
the left common carotid artery repaired with patch plasty.
•
20 months: sever RV-dysfunction and heart failure presentation. Berlin Heart
implantation and associated Fontan completion (extracardiac, fenestrated)
•
20 months
- sever hemolysis and pump revision
•
Status 4 from initial listing April 15, 2021 for paracorporeal VAD in single
ventricle patient
•
VAD erosion with rapid exsanguination and clamping of cannulas,
CPR and ECMO cannulation August 8, 2021
•
Severe ischemic intestinal injury, multi organ failure
•
Deceased August 9, 2021 following withdrawal of care
RSL 10 months
•
Restrictive cardiomyopathy – VT/VF arrest
•
July 23, 2021 ECMO Cannulation at BCCH
•
Transfer to U of A, transplant work-up
•
July 29, 2021 BiVAD cannulation, Berlin Heart Cannula and initial Pedimag
support
•
August 3, 2021 switch to Berlin Heart BiVAD
•
August 9, 2021 listing Status 4: paracorporeal VAD <8 (10)kg and <1 year
of age (at listing: weight 7.1kg, age 7 months)
•
Actively listed status 4
JL 8 months
•
Mixed cardiomyopathy with restrictive physiology – deterioration on full heart
failure medication
•
Transferred from inpatient stay at BCCH with circulatory arrest on transport,
receiving CPR on transport and cannulated to V/A ECMO within 30 minutes of
admission August 10, 2021
•
August 13, 2021 LVAD cannulation with Berlin Heart Cannulas and initial
Pedimag support
•
August 24, 2021 Switch to Berlin Heart LVAD
•
August 26, 2021 Status 4 listing: paracorporeal VAD <8 (10) kg or <1 year of age
(at listing weight: 6Kg, age 6 months)
•
Actively listed status 4
SickKids Status 4 – Case#1 - 2021
•
24/03 (5 mos)
: Admitted to CCCU in acute decompensated HF. Dx
DCM
(ACTN2 mutation).
•
5-9/04
: Tx assessment
•
09/04 (6 mos)
: Listed Status 4. Milrinone 1.0; 24 HR CPAP; TPN and
significant sedation
(melatonin, quetiapine, clonidine, chloral)
. Plan for VAD
(2 other Berlins in house so had to arrange for another IKUS)
•
15/04
: Berlin heart (10 mL) LVAD implantation. Wt 4.8 kg.
•
19/10 (1 yr)
: Remains listed Status 4 = Wt 7.8 kg.
SickKids Status 4 – Case #2 - 2021
•
17/2 (NB)
: 36 wk Twin, IUGR. PATr/IVS with RVDCC. LV dysfunction.
Wt 1.69 kg. Decision to wait until 2 kg if survived to offer
intervention. PGEs, milrinone, nipride, phenotolamine, PPV.
•
16/3
: bilateral PABs
•
9/4
: bilateral PAB tightening (poor weight gain, Qp:Qs 2.44:1)
•
25/05-09/06 (3 mos)
: Tx assessment.
•
PPV-dependent, PGEs, milrinone, TPN/Tube feeds
•
09/06 (4 mos)
: listed Status 4. Wt. 3.44 kg. Reassess at 5 kg for
BDCPC.
•
21/09 (7 mos)
:
Delisted
. BDCPC. Wt. 5.565 kg.
SickKids Status 4 – Case #3
•
20/09/
20
(3 mos)
: CCCU w acute decompensated heart failure. DCM.
•
CPAP, milrinone, diuretics. Wt. 4.3 kg.
•
7-9/10
: Tx assessment. Listed Status 4. Wt. 4.5 kg.
•
19/10
: I&V, sedated. Family counseling/deciding about VAD.
•
28/10 (4 mos):
Berlin LVAD (10 mL). Wt. 4.67 kg.
•
9/12 (6 mos):
pump change for clot
•
01/04 (9.5 mos): Listing hold
for social concerns. CAS involved.
•
07/04
: Improved fxn by Echo.
•
13/04
: Encouraging VAD weaning trial.
•
14/04:
Cath with good hemodynamics
•
20/4/
21
(10 mos): Delisted.
VAD explant and PA band (50% systemic RV)
•
19/10 (15 mos):
stable outpatient on oral meds; mod red LV fxn
Status 4 – St. Justine
TQ112384 MT
•
6 mo girl, Group 0, Weight 6kg
•
Diagnosed with DCM with EF 10% at presentation. Large LV thrombus
(volume estimated 1/3 of the LV volume)
•
Admitted to the ICU for tracheal intubation, inotropic support
•
Work-up for heart transplant including cerebral MRI and extensive
coagulation panel (antithrombine, prot C and S, anticardiolipine, lupus,
anti B2) : negative
•
Listed on Nov 19
th
status 4, ABO incompatible
•
Epinephrine, milrinone, levosimendan, feeding intolerance, endotracheal
intubation; 2 milrinone weaning failures
TQ112384 MT
•
Nov 15
th
low cardiac output, urosepsis E coli
•
Nov 18
th
frequent premature ventricular contractions
•
Nov 21
st
right hemiparesia : 3 small frontal foci on MRI
•
Nov 29
th
S. epidermidis sepsis, low cardiac output
•
Cardiac transplantation Dec 1
st
ABO incompatible (Donor B, recipient 0)
•
Seizures on POD1 : right subdural hematoma
•
Further improvement. Discharged home.
TQ112328 JL
•
18yo girl, Group A, Weight 56 kg
•
Diagnosed with LV non compaction-restrictive cardiomyopathy, abnormal
coronaries (filiform), myocardial ischemia, and ASD at 12yo.
•
Admitted to the ICU Jan 2020 with acute ischemia - NYHA 3
•
Work-up for heart transplant including cath showing normal pulmonary
pressures and PVR : listed st 3
•
Deterioration on Oct 23
rd
with ischemia, VT and SVT. Intubation.
Amiodarone. Listed st 4, Oct 23
rd
TQ112328 JL
•
ICD Oct 25th
•
Perforation of the right ventricle : surgery Oct 26
th
for removal and
reposition of the RV probe and surgical suture of the wound at the RV
apex
•
Downgraded status 3 on Oct 28
th
•
On amiodarone, metoprolol, diltiazem
•
OHT on Jan 28
th
2021
•
Postop : GI bleeding and hemoglobin drop (Hgb 6g/dl), SVT
•
Currently doing fine
3321349 ESP
•
8 yo girl, group 0, WT = 24 kg
•
Aortic stenosis, hypoplastic aorta, large multiple VSDs with significant dysfunction
•
s/p Norwood/BTS - progression of the biventricular systolic dysfunction, s/p BDG 7 mo,
s/p ECF 5 yo (non-fenestrated)
•
Redo 3 weeks after Fontan operation, RPA compression by the conduit. Multiple right
pulmonary embolisms. Persistent systolic dysfunction
•
LPA stenosis, s/p percutaneous angioplasty, bilateral veno-venous collaterals coiled
•
Progression of the biventricular dysfunction, leading to ICU admission in Jan 2020 with
an LVEF 12%
•
Chronic renal failure, creatinine clearance 59ml/min/m2, Right hydronephrosis
•
Pre diabetes
•
Pre transplantation work up : high Fontan pressure 12-13mmHg, multiple venous
collaterals from hepatic veins to pulmonary veins which could not be embolized.
3321349 ESP
•
PRA Class 1 34% Class 2 65% (rituxan-IVIG on the waiting list)
•
Listed on Feb 10 status 3
•
ICU stay : progressive deterioration with worsening of dyspnea. Increase in ascites : s/p
punction (3l) without significant improvement in symptoms. Increase in GI intolerance despite
maximal therapy. Deterioration of renal function. Increase in milrinone and epinephrine
•
Listed status 4 on March 4
th
– ongoing discussion at this time regarding VAD implantation
•
OHT March 7
th,
positive crossmatch B7
•
Postoperative:
- bleeding +++
- acute renal failure
- subdural haematoma, cerebral microbleeds
- Extensive thrombus left arm
Desensitization protocol, humoral rejection grade 2 diagnosed at biopsy 1 month post
transplantation
Discharged home, no rejection since April, doing fine
3344290 ALT
•
15 do girl, group 0, weight 3.3 Kg
•
Postnatal diagnosis : biventricular dilated cardiomyopathy, large VSD
•
Normal pregnancy, postnatal respiratory distress
•
Admitted DOL1 in the ICU, tracheal intubation
•
DOL9 : feeding intolerance, suspicion of necrotizing enterocolitis, NPO,
improvement
•
July 17
th
listed status 4
•
July 19
th
: acute renal failure
•
July 26t
h
: necrotizing enterocolitis despite NPO, GI perforation
•
Withdrawal from transplantation list July 26th
•
Deceased July 27th
3296070 EA
•
1yo boy. Weight 6.4kg. Group O.
•
Prenatal diagnosis of AV block and myocardiopathy (mother positive SSA
antibodies, Sjogren syndrome)
•
Premature birth by c-section 32 + 5 days, BW 1520g. Apgar 6-8-9.
Pacemaker at 1mo (1 RV probe). Upgrade of the PM Nov 2020 (atrial
probe). LVEF improved from 20 to 45%. Extensive fibroelastosis.
Discharged home.
•
LV failure Feb 2021, May : triple chamber pacemaker (resynchronization
therapy) without LV function improvement. Intubated. Inotropic IV
support.
•
Listed May 12
nd
status 4
•
Gradual deterioration with worsening perfusion (SVO2 25-27, altered
mental status – reintubated and introduction of low-dose epinephrine)
3296070 EA
•
LVAD (Berlin Heart) implanted on 05/18, right ventricular dysfunction
slowly improving, extubation, slow decrease in inotropic support
•
Several episodes of positive hemocultures, chronic effusion of the left
Berlin canula
•
June : significant upper GI bleed - transfusion
•
August 25
th
: extensive IVC thrombus (piccline in the femoral vein), renal
failure. Partial
thrombectomy
in the cath lab, multiple venous collaterals
RV support increased (inotropes, NO).
•
October 2021: severe septic shock : S epidermidis sepsis. PET-scan shows
deep infection left canula, 8th rib erosion and osteomyelitis; on clavulin
and micafungin
The Canadian Cardiac Transplant Network Status Review 2021 provides a detailed overview of cardiac transplant programs across various provinces in Canada from 2016 to 2021. The report includes data on the number of cases, hospitals involved, and referral centers, showcasing the trends in cardiac transplant activities over the years. Additionally, the report highlights specific cases of patients who underwent heart transplants in different hospitals, detailing their medical histories and outcomes.
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Presentation Transcript
Canadian Cardiac Transplant Network Status 4 Review 2021
Program 2016-17 2017-18 2018-19 2019-20 2020-21 BC: BC Children's Hospital 1 1 3 0 0 BC: St. Paul 's Hospital 4 0 3 7 4 AB: University of Alberta Hospital - Adult 4 0 0 0 0 AB: University of Alberta Hospital (Referral centre unknown) - Adult 0 3 0 6 2 AB: University of Alberta Hospital - Ped 5 2 0 4 1 AB: University of Alberta Hospital (Referral centre unknown) - Ped 0 1 4 6 3 AB: Foothills Medical Centre referrals to UAH 3 1 1 1 0 MB: Health Sciences Centre referrals to UAH 3 0 0 1 1 SK: St. Paul s Hospital referrals to UAH 0 1 0 0 0 ON: London Health Sciences Centre 4 1 1 3 0 ON: Hospital for Sick Children 7 7 6 1 3 ON: Toronto General Hospital 10 6 5 5 4 ON: University of Ottawa Heart Institute 6 0 3 1 1 QC: H pital Ste-Justine 5+1 6* 3 1 5 QC: Institut de Cardiologie de Montr al 2 7 5 9 6 8 adult (no ped) QC: Royal Victoria Hospital 3 9 3 3 QC: Institut Universitaire De Cardiologie 8 5 4 0 1 QC: Total 18+1 27 20 13 15 NS: Queen Elizabeth II Health Sciences Centre 1 1 0 0 0 Total 67 51 46 48 35
Case 1: VJ 54 yo F, NICM, LVEF <20%, s/p MV repair, ICD cPRA 87% Given worsening symptoms listed status 4S Oct 15, 2020 The clerk entered her as status 4 instead of status 4S by mistake and this was corrected within 4 hrs She was eventually transplanted as a status 4S (imported heart)
Case 2: EM 39 yo F, transferred from outside with hospital with cardiogenic shock VF arrest, AKI ->CRRT and IHD -> ECMO Nov 14, 20 Normal coronary angiogram EmBx revealed Giant cell myocarditis Treated with Steroids, azathioprine, and cyclosporine Listed Status 4 while on ECMO Improved hemodynamically and from VT perspective, decannulated Nov 23rd and deslited Treated with po amiodarone LVEF improved to 54% Subsequently she developed DRESS from septra ICD implanted Discharged Mar 2nd 2021 to rehab facility
Case 3: SR 55 yo female, acute myocarditis 8/2020 flu like illness and ?PE, treated with IV heparin in peripheral hospital Developed HITT with thrombosis and embolism to head, hands and feet requiring thrombectomy Echo showed bivent dysfunction, likely from acute viral myocarditis Milrinone dependent and transferred to St. Paul s 8/30/2020 VT/VF arrest on ward and was placed on VA ECMO Managed on Argatroban
Case 3: SR 9/3/20 - Unable to wean and converted to HVAD LVAD (off pump implant with bivirudin) as a bridge to transplant or recovery Complicated course in hospital (digits amputation, VAP with trach, ischemic gut with resection and colostomy, fungemia, reversal of colostomy ..) 2/19/20201 - Discharged home Repeat echo and invasive cath confirmed myocardial recovery on optimal medical therapy 5/25/21 - Admitted elective for total LVAD explant (fungemia) 5/27/21 - Uneventful OR
Case 3: SR POD 1 - worsening RHF requiring temporary RVAD POD 2 - developed LV failure with severe MR, converted to central ECMO Listed for S4 heart 5/30 Transplanted Long recovery and discharged 7/3/21 Home and doing well
Case 4: DV 55 y/o male with late presentation inf STEMI June 17/21 PCI to RCA, progressive HF, TTE showed VSR June 18 surgical VSR repair June 24 discharged home July 4 wound infection, left pleural and pericardial effiusion July 14 hypotension, repeat echo showed large pericardial effusion To OR for pericardial drainage and sternal dehiscence, found to have contained LV rupture, repaired. Off CPB on high doses of pressors and intropes
Case 4: DV July 15 placed on VA ECMO Seen by Tx team, not a candidate for durable VAD Considered for S4 listing Delisted due to sepsis, ischemic leg requiring amputation July 25 - Weaned from ECMO Transferred to general ICU Developed recurrent sepsis and died 2 months later in ICU
UAH (Edmonton) Status 4 Listings CCTN September 2020 August 2021
UAH Summary (Sept 2020-Aug 2021) Status 4 listed patients: 2 Transplanted: 1 Not transplanted/Deceased: 1
S.H. 25F with Familial (Desmin Gene) Cardiomyopathy with progressive BiV failure and recurrent VT Brief Clinical Summary 2019: Presented with HF Congestive and Low output symptoms LVEF 25% with moderate RV hypokinesis Started on GDMT Fall 2020: Deterioration Worsening symptoms including VT LVEF 15% with akinetic RV and RV thrombus started on OAC Dec 3, 2020: Status 1 Jan -Mar 2021: Status 2 Repeated admissions for ADHF and ICD shocks for frequent, recurrent VT cMRi showed RV thrombus resolved
S.H. (Continued) Mar - April, 2021: Status 0 LVAD implant (HM3) + C-Mag RVAD Failed RVAD wean attempts due to recurrent VT Multiple AAs with no improvement and VT ablation not an option as per EP Positive HIT screen but negative SRA so safe to expose to heparin as per Hematology Continued recurrent VT multiple daily episodes April 8, 2021: Status 4 (LVAD and RV failure/VT on t-MCS) April 9, 2021: Transplanted May 4, 2021: Discharged in good condition
A.S. 55F with AMI and urgent CABG Cardiac arrest post-op requiring t-MCS (VA- ECMO) Brief Clinical Summary Oct Dec 2020 AMI and post-op arrest Urgent CABG with post-op arrest VA-ECMO for severe BiV failure BiVAD C-Mag with oxygenator (oxygenator removed after 2 weeks) Cath showed loss of SVG to RCA (PCI not option as diffuse, severe native disease of small RCA) Failed multiple RVAD wean attempts Recurrent GI bleeds initially but eventually resolved with holding anticoagulation Dec 24, 2020: Status 4 (t-MCS not a candidate for durable VAD due to severe RVF) HTx work up and listing cPRA 100% with strong Class I & II Abs Jan 4, 2021: Status 0 CVA with initial left sided hemiparesis with early improvement Jan 15, 2021: Status 4 PT assessment cleared her for listing again
A.S. (Continued) Jan 26, 2021: Status 0 MSSA Infection Feb 4, 2021: Status 4 Infection cleared Multidisciplinary meeting and discussion re: likelihood of transplant in view of cPRA (100%) and poor candidate for desensitization (very strong Class I and II abs) Agreed to reassess candidacy weekly February 27-March 9 Team and family discussion re: no acceptable offers during Status 4 listing period Agreed to continue Status 4 but as per family wishes to proceed with BiVAD one way wean, understanding that if she deteriorated she would not be a HTx candidate RVAD C-Mag weaned off Mar 10, 2021: Status 0 LVAD C-Mag off with IABP and ino-pressor support Mar 15, 2021: Deceased Intractable Cardiogenic Shock
Winnipeg: 1 patient, 1 month 59-year-old gentleman who has known ischemic cardiomyopathy and post HeartMate 3 LVAD, listed Status 4 for 1 month in the setting of refractory GI bleeds after national consensus achieved Status 4 August 20 2021, no further bleeding on thalidomide and downgraded to Status 3 Sept 21st. Units PRBC total 79 and met criteria for Status 4 based on number and units , absence on contributing factors and extensive investigations Was an outpatient at time of listing (this may be a point of discussion) Units and investigations listed on next slide
Admission April with balloon enteroscopy June 18th to June 28th, 7 units of packed RBCs. balloon enteroscopy on June 23rd, his INR on admission had only been 2.5. He was discharged on a higher dose of octreotide at 30 mg monthly. July 7th- July 26th. INR on admission was 4.5, 23 units of packed RBCs; even when his INR was down to 1.1, he had ongoing bleeding. balloon enteroscopy on July 21st. His octreotide was discontinued and thalidomide 50 mg at h.s. was instituted.
University of Toronto Adult Transplant Program: Status 4 Review
NS 51 M, police officer Aug 2020: diagnosed with ischemic CMP, LVEF 25%, NYHA 1, being medically optimized prior to CABG Oct 22, 2020: presented with pre-syncope and polymorphic VT Oct 27, 2020: 5V CABG + aneurysm repair Oct 29, 2020: POD#2, developed VT storm, multiple morphologies, escalating inotrope requirements Cannulated centrally for ECMO as bridge to decision (biVAD, vs transplant) No suitable substrate amenable to ablation Oct 30, 2020: decision made to list Status 4 Oct 31, 2020: suitable donor available, transplant Nov 14, 2020: discharged from hospital with uneventful course Continues to do well
SR 32 M, familial CMP (brother was transplanted a few months prior) Feb 14, 2021: worsening HF as an outpatient, admitted locally and then transferred to TGH with fevers, worsening hemodynamic status Underwent Impella (R. axilla) as bridge to decision; significant pulm HTN, unknown source of fever March 2, 2021: Infectious/rheumatologic work up negative. Probable drug fever. Upgraded to Heartware HVAD; no RVAD required March 8, 2021 :Developed cholangitis, tamponade with chest re-opening; sternal OR swabs +ve for Candida albicans March 22, 2021: further recovery and discharge home (on antifungal) March 25, 2021: recurrent fevers, low flow alarms, repeat sternal wound swab +ve for Candida and E. fecaelis CT chest imaging showed mycotic pseudoaneurysm at outflow cannula anastomosis March 26, 2021: Taken back to OR for repair of pseudoaneurysm, reconstruction of ascending aorta; ID opinion that source control would be infeasible (persistent fungal mediastinitis) March 27, 2021: Listed status 4 April 8, 2021: suitable local donor available; transplanted April 22, 2021: discharged from hospital and continues to do well with no further admissions
PR 70 M, longstanding dilated CMP, no other comorbidities Listed for transplant early 2020 Progressive decline as an outpatient, became inotrope dependent Dec 8, 2020 underwent BTC HeartMate 3 for worsening pulmonary HTN, INTERMACS III 3 months post LVAD, had recovered very well, and repeat hemodynamics were acceptable for transplant. April 29, 2021: Listed status 3 as an outpatient Over next 3 weeks, developed recurrent episodes of VT/VT storm with 2 admissions for ICD shocks; 3rd admission to CVICU for incessant VT and ICD shocks, refractory to medical therapy, not amenable to ablation May 25, 2021: listed status 4 (fulfilled criteria for arrhythmic VAD complication) May 27, 2021: Transplanted with suitable donor Developed severe PGD requiring CMAG bivad support Progressive recovery, complicated by episode of AV block, fungemia; eventually discharged to rehab hospital June 20, 2021. Now doing well
MJ 29 F, dilated CMP (familial) 2019-2021: Recurrent admissions to CCU with acute HF, requiring inotropes June-Aug 2021: Long admission and unable to wean milrinone, listed status 3 for transplant. Debate about BTT VAD due to marginal RV function and patient reluctance Discharged home on milrinone Aug 6, 2021: Readmitted with worsening congestion and rapid hemodynamic deterioration Aug 10, 2021: Underwent HM 3 implant, INTERMACS 2 POD#1-6 - worsening hemodynamics/low flows Aug 16, 2021: CMAG RVAD inserted Aug 22nd listed status 4 Recurrent bleeding, tamponade with multiple sternal re-openings Unable to wean support, unable to anticoagulated Remained extubated, mobile/ambulatory, unsensitized Sept 24,2021: suitable donor offer and transplanted Sept 24 Oct 2, 2021: progressed very well with good graft function. Prior to discharge, developed sudden headache, decreased LOC and was found to have massive intracranial hemorrhage. No surgical option. Declared brain dead and passed away back in CVICU
JP 44 male, familial cardiomyopathy JP 44 male, familial cardiomyopathy Managed in Hull for longstanding familial cardiomyopathy with severe biventricular systolic dysfunction April 12: hospitalized in Hull for gallstone pancreatitis and heart failure decompensation May 3: transfer to UOHI in cardiogenic shock on IABP post failed inotrope wean May 5: ongoing haemodynamic deterioration requiring VA-ECMO support and intubation. May 6: listed status 4 for heart transplant May 9: Heart transplant. Complicated post op course with severe RV failure requiring inopressor support for 1 month, AKI requiring dialysis (CCRT followed by hemodialysis), pneumonia, delirium, bilateral IJ thrombosis, CHB (PPM June 4) and prolonged 1 month ICU stay June 29: transfer to Hull for physical rehabilitation Jul 23: diagnosed with left panendopthalmitis while at Hull inpatient rehabilitation Jul 29: transfer to UOHI for management of disseminated aspergillus: blood culture positive, lung lesions, infected PPM, tricsupid valve vegetation, sternal wound infection, RIJ pseudoanuerysm infection. Treated with antifungals/antimicrobials, PPM explant (Aug 4). Sep 13: TTE showing worsening TV vegetation encasing the septal TV leaflet with severe TR and satellite RA lesions, moderate RV dysfunction Sep 15: deemed to have no surgical options due to comorbid state with medical treatment being non- curative. Palliative care involved with subsequent decision to continue with medical treatment (including antimicrobials, dialysis) but not for ICU/intubation/CPR Oct 13: passed away following progressive clinical deterioration.
CCTN CCTN AGM Status 4 Status 4 AGM Dr Normand Racine Medical Director, Heart Transplant & Ventricular Assist Device Program Montreal Heart Institute Universit de Montr al
CASE no 1 (TQ 112324) CASE no 1 (TQ 112324) 2020-10-23: 27 F Congenital CMP: Turner Syndrome with post-cardiotomy Cardiogenic Shock per ROSS and Konnu procedure. Persistent biventricular Failure per-op.: ECMO implanted in OR. ABO: O+ PMHx: Turner Syndrome Congenital CMP : Severe congenital Aortic Stenosis Remained on Ventilator LVEF 10-15% 24 h post-op: Milri / Dobutamine high doses / Epinephrine drip Unable to wean ECMO 2020-10-17: LISTED STATUS 4 (day 4 post-op). 2020-10-30: TRANSPLANTED 2020-12-11: Discharged home. ALIVE and doing very well
CASE no 2 (TQ 112404) CASE no 2 (TQ 112404) M 43 GR A+; 91 Kg 168 cm 2020-11-18: Isch CMP transferred from another hospital in cardiogenic shock post NSTEMI, Large Apical thrombus (20x22 mm) + 3Vx disease + Severe Mitral Regurg. LVEF 15-20%. RVEF: N. 2020-11-26: Recurrent NSTEMI with NS-VT 2020-11-30: Recurrent VF early am prior to OR 2020-11-30: CABG + MVR : required ECMO per-op Required multiple Vasopressors high doses (Levo-Adren-Vaso-Milri), Dialysis Lactates 7.4 2020-12-02: Urgent LISTING status 4 Intubated, Vasopressors, Malignant arrhythmias) 2020-12-07: TRANSPLANTED Long convalescence HOME, Doing well
CASE no 3 (TQ 112463) CASE no 3 (TQ 112463) M 50. ABO: Gr B+ 102 kg. 175 cm 2019-06: Severe Bicuspic Ao Stenosis: ROSS + Asc Ao Replacement Known Congenital Hypofibrinogenemia syndrome 2020-12-14: Transferred from another Hospital for AF + Left Main Emboli : Anterior STEMI c Cardiogenic shock : CPR Remained hospitalized with Severe residual LV dysfct 10-15% ; Inotropes dependant (INTERMACS 3). 2020-12-23 LISTED STATUS 3.5 2020-01-21 : SUDDEN HEMODYN decompensation : LEVO + LISTED STATUS 4 2020-01-21: TOTAL Heart: CardioWest 2021-01-30: Cardiac Transplantation 2021-02-19: D/C home. ALIVE Doing well.
CASE no 4 (TQ 112607) CASE no 4 (TQ 112607) M 65. Gr A- 89 Kg 168 cm 2021-03-02 : transferred from another hospital: INF STEMI with late presentation. PPCI-RCA + IABP + Intubated VSD detected. Remained hemodynamically unstable: VASOPRESSORS, Low output Severe RV dysfunction post-PPCI. 2021-03-03: Surgical Repair of VSD + ECMO VA 2021-03-04: Residual VSD & RV dysfct ; Rising PRESSORS support. 2021-03-05: LISTED Status 4 2021-03-05: Transplanted from Hepatitis C (+) donor: Ab(+) NAT (-) 2021-03-19: D/C home. ALIVE Doing very well
CASE no 5 (TQ 112569) CASE no 5 (TQ 112569) M 22. Gr A+ 84 Kg 178 cm 2021-02-12 Transferred from another hospital. Decompensated Biventricular HF with LOW Output. Dx: Non-compaction CMP, Thrombus APEX LV (10mm); LVEF 10-15% MR 2+ with Moderate RV dysfct and TR 3+ Milrinone initiated ; failed weaning. Levophed added 2021-02-16: Worsening HF 2021-02-19: LISTING Statut 3.5 2021-02-20: Cardiogenic shock; MR 4/4 > ECMO-VA (INTERMACS 3) 2021-02-20: LISTING Statut 4 2021-03-02: ECMO removed. LV Centrimag implanted 2021-03-03: TRANSPLANTED. 2021-03-19: D/C home ALIVE. Doing very well
CASE no 5 (TQ 112569) M 51. Gr A+ 79 Kg 167 cm 2021-02-26 Transferred from another hospital : Cardiogenic shock Isch CMP; LVEF 10% with Apical thrombus. Milrinone dependent since Feb 19. 2021-03-10: CABG (RCA) + Tricuspid Annular Valvuloplasty + HeartMate-3 2021-03-21: Arrhythmic storm uncontrollable despite Amio + Xylo IV drips: LISTED Status 4 transiently ad 03-31. Subsequently stabilized. 2021-04-28: D/C home. ALIVE. Presently on HOLD for Tx: awaiting GI investigation prior to relisting.
MUHC Oct 2021 Status 4 presentation
Patient Mr. B 29 yo man Presents to spoke hospital in shock. Heart biopsy shows fibrosis History of amphetamine abuse Echo severe BiV failure, swan-ganz shows very high CVP vs wedge Deteriorates despite inotropes, transferred in shock and gets ECMO on arrival Impella implanted for LV unloading
Patient Mr. B (continued) ECMO unweanable Patient extubated and able to have discussion Concerns about prior durg use, but very strong family support and patient cooperation In view of BiV failure as per standard criteria, listed for transplant as felt to not be suitable LVAD candidate Transplanted, doing well has not resumed any consumption of amphetamines
Patient Mr. P 56 yo man Presented to spoke hospital with out of hospital arrest with STEMI Cath showed LM culprit with underlying 3v disease and very poor LV function, LM PCI Transferred in shock for ECMO support Neuro recovery Drop in platelets with suspected HITs ECMO unweanable and due to HITs suspicion was felt to be high risk ofor LVAD and was listed for transplant Head bleed within days of listing, deactivated for transplant and palliated.
Patient Mr. M Known RV dysplasia with poor RV function and LV poor function due to non-specific CMY Issues of recurrent Ventricular arrhythmias despite several ablations and had been on the heart transplant wait list Presented to transplant recently worse with BIV failure and recurrent intractable Vtach and severe hemodynamic compromise In view of BiV failure and known RV dysplasia was placed on BIV support with CentriMAG Listed as status 4 and waiting for heart
Status 4 CCTN 2020-2021 Institut Universitaire de Cardiologie et de Pneumologie de Qu bec Quebec city
Patient RB 68 years old male No medical issue and still working full time Massive anterior infarct 2/03/2021, fibrinolytic therapy failure, rescue angioplasty and stents LAD followed by stents CX (second procedure), LVEF 30% Chest pain back home, hospitalised local center 7/03/2021 Sent back to IUCPQ 11/03 Cath lab 11/03 : extensive stents thrombosis on proximal LAD and CX, angioplasty and stent of LAD + intra aortic ballon pump for cardiogenic shock ECMO for refractory cardiogenic shock 11/03, LVEF 5-10% Electrical storm 14/03 and intubation Severe biventricular failure with no potential for improvement Not a candidate for LVAD (active ventricular arythmia with severe RV failure)
Patient RB (suite) Listed status 4 for heart transplant 15/03 : creatinine 226, bilirubine 15, ALT 85, INR 1,3 lungs clear, neurological status ok (can obey to orders) Heart transplant on 19/03 Good hemodynamics and graft function and but massive ischemic stroke post op with oedema and hemorragic transformation, died on 20/03
CCTN Status 4 Review Stollery Children s Hospital Edmonton, Alberta
SJ 13 years Emery Dreifuss Muscular Dystrophy Dilated cardiomyopathy, recurrent ventricular tachycardia LVAD Heartware cannulation, June 13, 2020 Listed Status 3.5 September 2, 2020 after elective recovery period Changed to status 3 September 9, 2020 (discharge from hospital) Changed to Status 4 December 30, 2020 for VAD complication of ongoing MRSA VAD cannula infection needing repeat surgical revision without resolution. Transplanted January 3, 2021 Alive and well
VN 2 years Hypoplastic left heart syndrome 1 week: Norwood Sano, residual ascending aorta obstruction 6 months: balloon angioplasty of the ascending aorta 7 months: Glenn anastomosis and reconstruction of the ascending aorta by injury to the left common carotid artery repaired with patch plasty. 20 months: sever RV-dysfunction and heart failure presentation. Berlin Heart implantation and associated Fontan completion (extracardiac, fenestrated) 20 months- sever hemolysis and pump revision Status 4 from initial listing April 15, 2021 for paracorporeal VAD in single ventricle patient VAD erosion with rapid exsanguination and clamping of cannulas, CPR and ECMO cannulation August 8, 2021 Severe ischemic intestinal injury, multi organ failure Deceased August 9, 2021 following withdrawal of care
RSL 10 months Restrictive cardiomyopathy VT/VF arrest July 23, 2021 ECMO Cannulation at BCCH Transfer to U of A, transplant work-up July 29, 2021 BiVAD cannulation, Berlin Heart Cannula and initial Pedimag support August 3, 2021 switch to Berlin Heart BiVAD August 9, 2021 listing Status 4: paracorporeal VAD <8 (10)kg and <1 year of age (at listing: weight 7.1kg, age 7 months) Actively listed status 4
JL 8 months Mixed cardiomyopathy with restrictive physiology deterioration on full heart failure medication Transferred from inpatient stay at BCCH with circulatory arrest on transport, receiving CPR on transport and cannulated to V/A ECMO within 30 minutes of admission August 10, 2021 August 13, 2021 LVAD cannulation with Berlin Heart Cannulas and initial Pedimag support August 24, 2021 Switch to Berlin Heart LVAD August 26, 2021 Status 4 listing: paracorporeal VAD <8 (10) kg or <1 year of age (at listing weight: 6Kg, age 6 months) Actively listed status 4
SickKids Status 4 Case#1 - 2021 24/03 (5 mos): Admitted to CCCU in acute decompensated HF. Dx DCM (ACTN2 mutation). 5-9/04: Tx assessment 09/04 (6 mos): Listed Status 4. Milrinone 1.0; 24 HR CPAP; TPN and significant sedation (melatonin, quetiapine, clonidine, chloral). Plan for VAD (2 other Berlins in house so had to arrange for another IKUS) 15/04: Berlin heart (10 mL) LVAD implantation. Wt 4.8 kg. 19/10 (1 yr): Remains listed Status 4 = Wt 7.8 kg.
SickKids Status 4 Case #2 - 2021 17/2 (NB): 36 wk Twin, IUGR. PATr/IVS with RVDCC. LV dysfunction. Wt 1.69 kg. Decision to wait until 2 kg if survived to offer intervention. PGEs, milrinone, nipride, phenotolamine, PPV. 16/3: bilateral PABs 9/4: bilateral PAB tightening (poor weight gain, Qp:Qs 2.44:1) 25/05-09/06 (3 mos): Tx assessment. PPV-dependent, PGEs, milrinone, TPN/Tube feeds 09/06 (4 mos): listed Status 4. Wt. 3.44 kg. Reassess at 5 kg for BDCPC. 21/09 (7 mos): Delisted. BDCPC. Wt. 5.565 kg.
SickKids Status 4 Case #3 20/09/20 (3 mos): CCCU w acute decompensated heart failure. DCM. CPAP, milrinone, diuretics. Wt. 4.3 kg. 7-9/10: Tx assessment. Listed Status 4. Wt. 4.5 kg. 19/10: I&V, sedated. Family counseling/deciding about VAD. 28/10 (4 mos): Berlin LVAD (10 mL). Wt. 4.67 kg. 9/12 (6 mos): pump change for clot 01/04 (9.5 mos): Listing hold for social concerns. CAS involved. 07/04: Improved fxn by Echo. 13/04: Encouraging VAD weaning trial. 14/04: Cath with good hemodynamics 20/4/21 (10 mos): Delisted. VAD explant and PA band (50% systemic RV) 19/10 (15 mos): stable outpatient on oral meds; mod red LV fxn
