Research Spotlight

Hassan, M.F. (2020). “Tissue “valve-over-valve” implantation in previous mechanical Bentall.” J Card Surg Aug 13. [Epub ahead of print.].

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The authors present a case report about the elective replacement of a mechanical Bentall with a bioprosthetic valve. The authors describe a technique whereby the mechanical valve is “broken” off its mechanism and the new valve is sutured in the old cuff.

Cravedi, P., Schold, J.D., Safa, K., Kates, O.S., Elfadawy, N., Mannon, R.B., Shah, M.B., Hammond, S.P., Avery, R., Guerrero Miranda, C., Riella, L.V., Jowsey-Gregoire, S., Akalin, E., Camirand, G., Alegre, M.L. and Azzi, J. (2020). “The COVID-19 Pandemic: A community approach.” Clin Transplant Aug 6;e14059. [Epub ahead of print.].

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An unprecedented global pandemic caused by a novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has quickly overwhelmed the health care systems worldwide. While there is an absence of consensus among the community in how to manage solid organ transplant recipients and donors, a platform provided by the American Society of Transplantation online community “Outstanding Questions in Transplantation”, hosted a collaborative multicenter, multinational discussions to share knowledge in a rapidly evolving global situation. Here, we present a summary of the discussion in addition to the latest published literature

Gong, T. and Hall, S. (2020). “Considerations and experience driving expansion of combined heart-liver transplantation.” Curr Opin Organ Transplant Aug 10. [Epub ahead of print.].

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PURPOSE OF REVIEW: Heart transplantation concomitant with a liver transplant may be warranted when end-stage heart failure results in irreversible liver failure. Previously reported outcomes have been excellent yet the specific immunoprotective role of the liver allograft is not known. We review the current literature about the immunologic benefit for combined heart and liver transplantation (CHLT). RECENT FINDINGS: The total number of combined heart and liver transplants continues to increase and accounts for approximately 25 cases per year. Familial amyloid polyneuropathy with cardiac cirrhosis is the most common indication for CHLT while adult congenital heart disease (CHD) with associated cirrhosis is increasing in frequency. The majority of recent registry data suggest a statistically equivalent to modestly improved survival advantage for CHLT compared with isolated heart transplantation. Direct mechanisms accounting for this survival advantage are not proven, but combined heart and liver transplants experience lower rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV). SUMMARY: Combined heart and liver transplants remain a small percentage of the total heart transplants worldwide, but the majority of recent literature confirms the safety and viability of this option for patients with end-stage heart and liver disease. Equivalent to modestly improved survival outcomes, lower rates of acute cardiac rejection and CAV warrant further investigation into the liver allograft’s immunoprotective effect on the transplanted heart. The key mechanisms of tolerogenicity have important implications for surgical technique and immunosuppression requirements. Future directions include development of criteria for heart-liver transplant candidacy and identification of equitable allocation protocols.

Dixon, A.L., McCully, B.H., Rick, E.A., Dewey, E., Farrell, D.H., Morrison, L.J., McMullan, J., Robinson, B.R.H., Callum, J., Tibbs, B., Dries, D.J., Jui, J., Gandhi, R.R., Garrett, J.S., Weisfeldt, M.L., Wade, C.E., Aufderheide, T.P., Frascone, R.J., Tallon, J.M., Kannas, D., Williams, C., Rowell, S.E., Schreiber, M.A., McKnight, B., Meier, E.N., May, S., Sheehan, K., Bulger, E.M., Idris, A.H., Christenson, J., Bosarge, P.L., Colella, M.R., Johannigman, J., Cotton, B.A., Richmond, N.J., Zielinski, M.D., Schlamp, R., Klein, L., Rizoli, S., Gamber, M., Fleming, M., Hwang, J., Vincent, L.E., Hendrickson, A., Simonson, R., Klotz, P., Ferrara, M., Sopko, G. and Witham, W. (2020). “TXA Administration in the Field Does Not Affect Admission TEG after Traumatic Brain Injury.” J Trauma Acute Care Surg Aug 28. [Epub ahead of print.].

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BACKGROUND: No FDA-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI. METHODS: Data were extracted from a placebo-controlled clinical trial in which patients ≥15 years old with TBI (Glascow Coma Scale 3-12) and systolic blood pressure ≥90 mmHg were randomized prehospital to receive placebo bolus/placebo infusion (Placebo), 1 gram (g) TXA bolus/1g TXA infusion (Bolus Maintenance [BM]); or 2g TXA bolus/placebo infusion (Bolus Only [BO]). TEG was performed and coagulation measures including prothrombin time (PT), activated partial thromboplastin time (aPTT), international ratio (INR), fibrinogen, D-dimer, plasmin anti-plasmin (PAP), thrombin anti-thrombin (TAT), tissue plasminogen activator (tPA), and plasminogen activator inhibitor-1 (PAI-1) were quantified at admission and six hours later. RESULTS: Of 966 patients receiving study drug, 700 had labs drawn at admission and six hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p>0.05). No differences between PT, aPTT, INR, fibrinogen, TAT, tPA, and PAI-1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at six hours (p<0.001). Concentrations of PAP were less in TXA treatment groups than placebo on admission (p<0.001) and six hours (p=0.02). No differences in D-dimer and PAP were observed between BM and BO. CONCLUSION: While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared to placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and six hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo. LEVEL OF EVIDENCE: III; Diagnostic.

Gamino, L.A., Sewell, K.W., Prosser-Dodds, L. and Hogan, N.S. (2020). “Intuitive and Instrumental Grief: A Study of the Reliability and Validity of the Grief Pattern Inventory.” Omega (Westport) 81(4): 532-550.

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A convenience sample of 209 participants completed the Grief Pattern Inventory (GPI) together with the Hogan Grief Reaction Checklist (HGRC), the Integration of Stressful Life Events Scale (ISLES), and the Myers-Briggs Type Indicator (MBTI). Alpha coefficients of the GPI’s intuitive and instrumental subscales were improved by eliminating low-performing items and empirically reassigning items from the GPI dissonant subscale. The two modified scales showed a near zero intercorrelation indicating they were independent constructs in this sample, a conclusion further verified by factor analysis. Both styles correlated with distress measures from the HGRC and correlated negatively with adaptation indicators from the ISLES, though the findings were stronger for intuitive grievers. MBTI findings revealed that intuitive grievers endorsed significantly more “feeling” in how processing occurs while grievers who preferred sensing/thinking functions more often identified with the instrumental grief pattern. Implications of these findings for scholars and clinicians are discussed.