Ann Thorac Surg 2009;88:1324-1326. doi:10.1016/j.athoracsur.2009.02.056
© 2009 The Society of Thoracic Surgeons
Case Reports
Simultaneous Heart and Kidney Transplantation After Bridging With The CardioWest Total Artificial Heart
Dawn E. Jaroszewski, MD, MBA*,
Christopher C. Pierce, MS, CCP,
Linda L. Staley, NP,
Raymond Wong, PhD, CCP,
Robert R. Scott, MD,
Eric E. Steidley, MD,
Radha S. Gopalan, MD,
Patrick DeValeria, MD,
Louis Lanza, MD,
David Mulligan, MD,
Francisco A. Arabia, MD, MBA
Department of Transplants, Mayo Clinic Arizona, Phoenix, Arizona
Accepted for publication February 16, 2009.
* Address correspondence to Dr Jaroszewski, Mayo Clinic Arizona, Department of Tansplant, 5777 E Mayo Blvd, Phoenix, AZ 85054 (Email: jaroszewski.dawn{at}mayo.edu).
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Abstract
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End-stage renal failure is often considered a relative contraindication for total artificial heart implantation due to the increased risk of mortality after transplantation. We report the successful treatment of a patient having heart and renal failure with the CardioWest (SynCardia Inc, Tucson, AZ) total artificial heart for bridge-to-cardiac transplantation of a heart and kidney.
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Introduction
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The CardioWest (SynCardia Inc, Tucson, AZ) total artificial heart (TAH-t) is a bridge-to-cardiac transplantation approved by the United States Food and Drug Administration. Patients requiring the TAH-t are at high risk for imminent death from irreversible biventricular cardiac failure. End-stage renal failure is often considered a relative contraindication for TAH-t implantation. Preoperative renal failure is one of the major risk factors for mortality in isolated heart transplantation [1]. Despite this factor, satisfactory short-term and long-term results have been achieved with simultaneous heart and kidney transplantation from a single donor [2–5]. Here we present what we believe is the first published case of simultaneous heart and kidney transplantation after bridging with the CardioWest (SynCardia Inc) TAH-t.
A 63-year-old man, with a body surface area of 2.23 m2, who had a history of ischemic cardiomyopathy, status postmyocardial infarction, and coronary artery bypass grafting 18 years prior was transferred from an outside hospital in decompensated heart failure. He had evidence of heart and renal dysfunction with a B-type natriuretic peptide > 1,810 pmol/L and serum creatinine (CR) of 2.0 mg/dL. Inotropic support with low-dose milrinone was initiated as well as 10 L of fluid removal by ultrafiltration. He continued to deteriorate during the following 2 weeks and experienced ventricular arrythmias requiring multiple cardioversions. Dialysis was initiated for anuria. Placement of an intra-aortic balloon pump and maximization of multiple inotropes failed to reverse his decline.
The patient was emergently taken to the operating room for placement of the CardioWest TAH-t. A redo sternotomy was performed. On bi-caval cardiopulmonary bypass, a cardiectomy was performed by removing the ventricle 1 cm above the atrioventricular groove. The tricuspid and mitral valves were removed, leaving the annulus. The aorta and the pulmonary artery were divided and separated. Then the CardioWest Quick-Connects (SynCardia Inc) were sutured to the ventricular muscle rim, and the pulmonary artery and aortic conduits were anastomosed as previously described [6, 7]. The ventricles were connected, the air was removed, and prosthetic heart pumping was initiated. Transesophageal echocardiogram confirmed flows without compression of the pulmonary veins. The patient was weaned off cardiopulmonary bypass without difficulty.
The patient was extubated 48 hours later and heparin anticoagulation was initiated on postoperative day (POD) 1. On POD 5, warfarin was introduced, and on POD 6, aspirin and dipyridamole were started. Initiation of anti-platelet therapy was delayed from our usual protocol of POD 2 due to a low platelet count that recovered by POD 6. Heparin was subsequently discontinued when a therapeutic warfarin level was achieved. Using thromboelastography, aspirin, warfarin, and dipyridamole were administered and adjusted to maintain adequate anticoagulation. Postoperative recovery was complicated by mediastinal bleeding and tamponade on POD 12, which required a return to the operating room and evacuation of hematoma. Despite adequate cardiac outputs, the renal function of the patient did not recover, and he continued to require dialysis. This was performed through a tunneled catheter in the jugular vein. The renal transplantation team was intimately involved in the evaluation of renal function. The patient underwent ultrasound and biopsy of the kidney with pathologic findings consistent with end-stage renal disease secondary to hypertensive nephropathy and chronic hypoperfusion. Despite the hope of renal recovery with a seemingly low serum CR initially, this patient demonstrated significant chronic damage histopathologically, making the likelihood of renal recovery under postoperative calcineurin inhibitor immunosuppression exceedingly unlikely. Furthermore, the time on the TAH-t, restoring normal cardiac output to the kidneys, failed to produce any renal function, confirming the findings on the renal biopsy. Knowing the immunologic benefit from receiving both organs from the same donor and the high mortality of performing a heart transplant with continued hemodialysis postoperatively, it was believed that a combined heart kidney transplant would be in this patient's best interest. The patient continued with rehabilitation and recovery with the exception of his renal function (Fig 1).
When the patient was adequately rehabilitated, he was listed for simultaneous heart and kidney transplantation. After 62 days of TAH-t support the patient underwent orthotopic heart transplant. Subsequent to reversal of heparin for cardiopulmonary bypass, the kidney transplant was performed. Postoperative immunosuppression consisted of thymoglobulin (1.5 mg/kg for 3 days) and methylprednisolone (3 additional doses every 8 hours). Mycophenolate mofetil (1,250 mg daily) was also begun on POD 1. Tacrolimus (1 mg twice daily) was initiated on POD 2. These were continued on a daily basis and adjusted for optimal levels. The patient was discharged home 16 days later with both grafts in good function without evidence of rejection and a CR of 1.1 mg/dL. Cardiac rejection was monitored by surveillance endomyocardial biopsies commencing on POD 7. For kidneys, rejection was generally monitored by noninvasive means, including serum CR levels.
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Comment
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We report the successful treatment of a patient with decompensated heart failure and renal failure with the CardioWest TAH-t for bridge-to-transplant of a heart and kidney. While on TAH-t support, aggressive dialysis and ultrafiltration treatment regimens are facilitated by the circulatory control afforded by biventricular replacement. Acute renal insufficiency can often be reversed with the improved renal perfusion provided by the TAH-t. When this type of improvement is absent, it demonstrates the possibility of a positive outcome with simultaneous heart and kidney transplantation, as in this case study. Many times it is difficult to assess whether renal function can and will recover, despite TAH-t, and consideration for biopsy of the native kidney to assess degree of renal parenchymal damage can be helpful in deciding if a patient should be listed for combined heart-kidney transplant.
The CardioWest TAH-t is a pneumatic, implantable system that totally replaces the failing ventricles. It has been used worldwide as a bridge-to-heart transplantation. Patient selection is considered essential for a good outcome with the TAH-t [8]. An assumed requirement of minimal end-organ damage has excluded some patients with end-stage renal failure. This assumed requirement may have contributed to previous multivariate analysis results showing that serum CR and blood urea nitrogen did not influence the survival of patients bridged with the CardioWest TAH-t [7].
The risks of increased morbidity for performing simultaneous heart and renal transplantation stem mainly from the extended surgical procedure duration. Furthermore, there are risks to the patient, including the risk of wasting a donor kidney if the renal transplant procedure is cancelled due to acute cardiac graft dysfunction or extended bleeding complications. Postoperative bleeding control can be especially challenging in a TAH-t or other cardiac assist-device bridged patient.
Simultaneous transplantation from the same donor provides a significant advantage due to the limitation in antigenic exposure. The issues of immunosuppression were discussed and agreed to by both the heart and kidney transplant teams. The cardiac protocol is used with careful monitoring of kidney function. Initiation of calcineurin inhibitors is initially delayed. Achieving peak therapeutic calcineurin levels may be delayed as well, based on the induction therapy used. Heart rejections are treated according to standard protocol-based fashion, again with careful attention paid to renal function regarding calcineurin inhibitors. Immunosuppression adjustments are mainly made according to the requirement for cardiac allograft survival, which is usually more than adequate for the kidney.
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References
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- Taylor DO, Edwards LB, Boucek MM, et al. International Society for Heart and Lung Transplantation Registry of International Society for Heart and Lung Transplantation: twenty-third official adult transplantation report — 2006 J Heart Lung Transplant 2006;25:869-879.[Medline]
- Bruschi G, Busnach G, Colombo T, et al. Long-term follow-up simultaneous heart and kidney transplantation with single donor allografts Ann Thorac Surg 2007;84:522-527.[Abstract/Free Full Text]
- Trachiotis GD, Vega JD, Johnston TS, et al. Ten-year follow-up in patients with combined heart and kidney transplantation J Thorac Cardiovasc Surg 2003;126:2065-2071.[Abstract/Free Full Text]
- Luckraz H, Parameshwar J, Charman SC, et al. Short-and long-term outcomes of combined cardiac and renal transplantation with allografts from single donor J Heart Lung Transplant 2003;22:1318-1322.[Medline]
- Leeser DB, Jeevanandam V, Furukawa S, et al. Simultaneous heart and kidney transplantation in patients with end-stage heart and renal failure Am J Transplant 2001;1:89-92.[Medline]
- Arabia FA, Copeland JG, Pavie A, Smith RG. Implantation technique for the CardioWest total artificial heart Ann Thorac Surg 1999;68:698-704.[Abstract/Free Full Text]
- Copeland JG, Arabia FA, Tsau PH, et al. Total artificial hearts: Bridge to transplantation Cardiology Clinics 2003;21:101-113.[Medline]
- Copeland J, Smith R, Bose R, et al. Risk factor analysis for bridge to transplantation with the CardioWest Total Artificial Heart Ann Thorac Surg 2008;85:1639-1645.[Abstract/Free Full Text]
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Abstract
Introduction
= number of dialysis sessions per week; 
= amount of fluid removed each week.)