Παρουσίαση Περιστατικού Καρδιακή Ανεπάρκεια Τελικού Σταδίου. Αγγελική Γκουζιούτα Καρδιολόγος Μονάδα Καρδιακής Ανεπάρκειας και Μεταµοσχεύσεων ΩΚΚ

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1 Παρουσίαση Περιστατικού Καρδιακή Ανεπάρκεια Τελικού Σταδίου Αγγελική Γκουζιούτα Καρδιολόγος Μονάδα Καρδιακής Ανεπάρκειας και Μεταµοσχεύσεων ΩΚΚ

2 Ο Ασθενής Aνδρας 18 ετών Μυοκαρδίτιδα σε ηλικία 3 ετών (Coxsackie virus) Καλή ανάπτυξη και ελεύθερο καρδιολογικό ιστορικό σε αναφερόµενους τακτικούς ελέγχους έως και πριν 3 έτη. Αναφερόµενη ήπια δυσλειτουργία αριστερής κοιλίας λόγω ήπιας ανεπάρκειας της Μιτροειδούς Βαλβίδος

3 Φοιτητής Δύσπνοια Προσπαθείας NYHA II-IIβ Προσυγκοπτικό Επεισόδιο και Οιδήµατα κάτω άκρων Νοσηλεία σε Καρδιολογική Κλινική Σοβαρή ανεπάρκεια Μιτροειδούς Βαλβίδος και επηρεασµένη Λειτουργικότητα αριστερής κοιλίας Παραποµπή στο ΩΚΚ για επιδιόρθωση Μιτροειδούς και Τριγλώχινος Βαλβίδος.

4 CxR ΜΕΘ ΚΔ

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7 ABG p H : p CO2 : 18.9 mmhg p O2 :78.9 mmhg SaO2:89.3% Lac :5.3 mmol/l Base (Ecf)c : -8.9 mmol/l

8 Ωνάσειο Δεξιός Καθετηριασµός Βιοψία Μυοκαρδίου Ra:32 mm Hg RV:49/38 mm Hg Pa:48/34/41 mmhg PCWP:38 mm Hg CO:2.9 l/min CI:1.56 l/min/m² Ao:80/70/60 mmhg Βιοψία ; Αρνητική για µυοκαρδίτιδα.διάχυτη ίνωση.

9 ΜΕΘ IABP και ινότροπα 1 ο βράδυ ΜΕΘ/ΚΔ,VT-VF arrest Εργώδης Ανάνηψη >55 min Αποκατάσταση ρυθµού και χαµηλή κατδιακή παροχή Κλήση καρδιοχειρουργών Λόγω της παρατεταµένης ανάνηψης VAD ως BTD/BTT. 2 ECMO ΠΔΜΕΘΚΧ Levitronix (High Risk CABG)

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11 Impella The Impella 2.5 is a minimally invasive, catheter-based cardiac assist device that is delivered through a 13 Fr sheath via the common femoral artery, and is placed retrograde across the aortic valve into the LV. A revolving pump rotates at a maximum speed of 51,000 rpm, drawing blood out of the LV and ejecting it into the ascending aorta beyond the end of the pump. The 13 Fr Impella device provides up to 2.5 L/min of forward flow from the LV into the systemic circulation. The Impella reduces myocardial workload and myocardial oxygen consumption, with concomitant increases in cardiac output, coronary perfusion, and end-organ perfusion.

12 ] Impella is now included in five sets of clinical practice guidelines:1) 2011 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/ Society for Coronary Angiography Interventions (SCAI) guidelines for Percutaneous Coronary Intervention, JACC 2011; 2) 2013 ACCF/AHA Guidelines for the Management of ST- Elevation Myocardial Infarction, Circulation 2012; 3) 2013 ACCF/AHA guidelines for the Management of Heart Failure, Journal of American College of Cardiology 2013; 4) 2012 AHA guidelines for mechanical circulatory support, Circulation 2012; and 5) 2013 International Society for Heart & Lung Transplantation (ISHLT) guidelines for Mechanical Circulatory Support, The Journal of Heart and Lung Transplantation 2013

13 Πολυοργανική Ανεπάρκεια PRISMA Αδυναµία διατήρησης σταθερής καρδιακής παροχής Παθολογική Νευρολογική Εξέταση Μεταφορά στην ΜΕΘ/ΚΧ για υποστήριξη µε Impella RVAD Αιµορραγική Διάθεση και ανοιχτό στέρνο

14 Επιπλοκές LDH : 4,802 U/L Bilirubin to 5.6 mg/dl Haptoglobin level was Αιµοκάθαρση Μεταγγίσεις µε RPC/FFP/NOVO VII Αγγειοχειρουργική Εκτίµηση Νέκρωση και Σύνδροµο Διαµερίσµατος. 2 εβδοµάδες µετά την εισαγωγή BiVAD ως BTD

15 BiVAD

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17 EXCOR EXCOR Adult - The Paracorporeal Ventricular Assist DeviceEXCOR is a paracorporeal, pulsatile ventricular assist device, or VAD for short. Paracorporeal means that the actual blood pumps are located outside of the body, and are connected to the heart and blood vessels via cannulae. EXCOR can be used to support one ventricle (left-sided / LVAD or right-sided / RVAD) or both ventricles (bilateral / BVAD). The system is used successfully as short, medium and long-term cardiac support. EXCOR is often used as a bridge until heart transplantation is performed or the heart has recovered. EXCOR has also been used as an alternative to a heart transplant in some patients.since its first use in 1987, roughly 3,600 patients have been supported with the device. The longest period of use so far has been five years.the wide product range covers blood pumps of various sizes and types, as well as a variety of cannulas. Consequently, all clinical needs can be fulfilled and patients of all sizes treated. For the initial period in hospital, the stationary driving unit Ikus can be used. Adolescent and adult patients can also be supported by the EXCOR mobile driving system.

18 BiVAD Εργώδης εµφύτευση λόγω αιµορραγικής διάθεσης Πολυµεταγγιζόµενος ασθενής Παρατεταµένη Νοσηλεία στην ΜΕΘΚΧ µε feeding tube /τραχειοστοµία/αιµοκάθαρση / Σταδιακή και βασανιστική αποκατάσταση και µεταφορά στην Κλινική µετά από 2 µήνες παραµονή σε ΜΕΘ. Εξιτήριο 4 µήνες µετά

19 BiVAD-BTT Προµεταµοσχευτικός Ελεγχος Καχεξία Ενταξη στην Λίστα για ΜΤΧ Καρδιάς 8 µήνες µετά. Συνολικά 15 εισαγωγές ως επί εµπύρετης λοίµωξης µε εστία το χερουργικό τραύµα και θετικές αιµοκαλλιέργειες. Klebsiella pneumoniae /MSSA.

20 HLA specific antibodies 11/08/08

21 HLA specific antibodies 22/09/08

22 C4d deposition 11/08/08

23 C4d deposition 22/09/08

24 On Thu, 10/9/08, Rose, Marlene L <marlene.rose@imperial.ac.uk> wrote: From: Rose, Marlene L <marlene.rose@imperial.ac.uk>subject: RE: C4d Luminex+ DSATo: degiannis@yahoo.comcc: J.Smith@rbht.nhs.uk Date: Thursday, October 9, 2008, 5:30 PM Dear Dr Degiannis Please see the attached report regarding the specificities and C4d binding properties of the serum of your young patient. This report was compiled by Dr John Smith, my Head of Tissue Typing. We used single antigen beads and Luminex to define HLA specificities. This patiens is highly sensitised with antibodies to MHC class I and class II antigens. Not all the sera fix C4d. In our centre, we will not transplant patients in the presence of detectable antibodies to donor specific HLA antigens (either class I or class II), - even if they do not fix C4d.Looking at the multiple antigen specificities you have, it may be difficult to find donors who lack these antigens. However, I would suggest analysing the single antigen reports provided with regard to negative reactivity with the aim to produce a list of acceptable mismatches. Anything blue or less is negative. Obviously, you will have your own criteria and your own ideas about this. This probably has not told you anything you did not know already! Please let me know if you wish to continue to discuss these patients. Kind regards Marlene Rose

25 Αδυναµία ΜΤΧ λόγω ευαισθητοποιήσης του ασθενούς Προσπάθεια απευαισθητοποίησης µε ανοσοκατασταλτικά και συνεδρίες πλασµαφαίρεσης Θετικό crossmatch σε 5 αξιολογήσεις

26 ΜΤΧ Καρδιάς Μετά από 905 ηµέρες µηχανικής υποστήριξης

27 I am sure you remember that last September I contacted you with an interesting case of a heart due to positive T and B cell crossmatches (Patient&#039;s). Eventually after three more unsuccessful attempts (positive crossmatches) and on and off on plasmapheresis, the patient&#039;s Class I PRA fell (ranging from 95% to 20%, occasionally), but his Class II PRA remained high (60-90% ). On June 10, an appropriate heart was found for this patient and since the donor was in the Athens area, we had the luxury of performing a prospective crossmatch and a virtual crossmatch. The patient, at that particular moment, had no HLA antibodies against the donor. Class I and II antigens, his T cell crossmatch was negative, whereas his B cell crossmatch was positive (however, significantly less positive than the 5 previous attempts). The chief transplant surgeon, decided, taking into consideration the long stay of the patient on BiVAD (more than two years), that this was an opportunity to transplant him and the patient received the heart graft on the evening of June 10..

28 The patient, after 4 days, is hemodynamically stable and in very good condition and the only problem is that he is developing (progressively) anti-dr4 and anti-dr16 antibodies (which were the donor&#039;s Class II antibodies, MFIs on June 14 exceeding 7000), despite undergoing daily plasmapheresis. The patient still after 4 days is on ATG which will be discontinued today and on day 3 he started receiving cyclosporine, which on June 14 was switched to tacrolimus.

29 Συνεδρίες ανοσοπροσρόφησης µετά την ΜΤΧ καρδιάς Αεπιθετική Ανοσοκαταστολή µε Στεροειδή,ATG,FK,MMF. 1µήνα µετά εξιτήριο. Νο anti-donor Class Ι/ II antibodies. Antibody titres dissappeared 15 days post-transplant without major intevention.

30 6 χρόνια µετά