A new study projects significant reductions in postoperative complications and substantial cost savings through the implementation of a system-wide preoperative nutrition programme.
The American Heart Association and American College of Cardiology have jointly published an updated guideline for managing cardiovascular risks in patients undergoing noncardiac surgery, reflecting a decade of new evidence since the last update in 2014.
Hani Najm, M.D., who led the heart surgery team, inserts an IV line in the foetus’s right arm to deliver fluids and medications as needed. — courtesy Cleveland Clinic
A multidisciplinary team of Cleveland Clinic and Cleveland Clinic Children’s doctors and nurses performed a rare and complex lifesaving foetal surgery to remove a tumour attached to the heart of a 26-week-old foetus.
Few studies about the rare condition – an intrapericardial teratoma with foetal hydrops (i.e., fluid accumulation) evolving to foetal heart failure – have been reported in medical journals. “Only one previous incidence of continued pregnancy and delivery after foetal intrapericardial teratoma resection is documented in the world’s medical literature,” said Darrell Cass, M.D., director of Cleveland Clinic’s Fetal Surgery and Fetal Care Center. “As far as we know, Cleveland Clinic is the second academic medical centre in the world to have performed this foetal surgery successfully with continued pregnancy and delivery.”
During the procedure in May, surgeons successfully removed the malignant tumour, which had been compressing the left side of the foetus’ heart and impairing circulation, leading to fluid accumulation around the heart and other organs of the foetus.
The surgery included paediatric and congenital heart surgeons, a paediatric cardiologist, obstetric and paediatric anaesthesiologists, and a maternal-foetal medicine specialist.
— courtesy Cleveland Clinic
Following the operation, the mother and foetus recovered well with no complications and no sign of tumour recurrence during prenatal check-ups. On July 13, at 36 weeks and two days, a baby boy was delivered near full term by Caesarean section. Both mother and baby are doing well.
“I am very proud of our talented congenital heart surgery and foetal surgery teams that integrated seamlessly to successfully perform a complex lifesaving foetal surgery,” said Dr. Cass. “This tumour was growing rapidly in the exact wrong spot. It was compressing the heart of the foetus, causing fluid accumulation, and we started seeing signs that the cardiac function was deteriorating. We needed to act quickly and decisively to rescue the foetus.”
To perform this foetal surgery, Dr. Cass led a team that included paediatric and congenital heart surgeons Hani Najm, M.D., and Alistair Phillips, M.D.; paediatric cardiologist Francine Erenberg, M.D.; obstetric and paediatric anaesthesiologists McCallum Hoyt, M.D., Tara Hata, M.D., Yael Dahan, M.D.; and maternal-foetal medicine specialist, Amanda Kalan, M.D., who provided the mother’s care, including delivery of the newborn baby boy 10 weeks after the foetal surgery.
See the animation of the foetal intrapericardial teratoma resection
https://youtu.be/v-kOveNbbio
Once the mother was anesthetized with an approach to provide the safest environment for the foetal heart surgery to be successful, a Caesarean section-like incision was made to expose the mother’s uterus. Ultrasound was used to carefully locate the placenta and foetus, and best location for entry. The uterus was then opened about 12 cm, and the arms of the foetus were brought out to expose the chest.
Dr. Najm, who led the heart surgery team, inserted an IV line in a blood vessel of the foetus’s right arm to deliver fluids and medications as needed. Then, he carefully opened the chest and pericardium, and removed the tumour from the beating foetal heart. “As soon as the tumour was removed, the compression of the left atrium disappeared, and there was a nice blood flow that was almost back to normal,” said Dr. Najm.
Following the completion of the foetal heart surgery, the chest of the foetus was closed and the foetus was positioned back in the uterus. The uterus was then closed, followed by closure of the mother’s abdomen. The surgery lasted 3 ½ hours.
Rylan Harrison Drinnon was born on July 13 to Sam and Dave Drinnon.
Both mother and foetus recovered well following the surgery. The foetus’s cardiac function immediately improved, and the foetus stayed in the womb for the remainder of the pregnancy. Ten weeks later, the baby was born.
“Such an innovative foetal surgery provides hope to other families who may receive a similar devastating diagnosis,” said Dr. Najm, chair of Pediatric and Congenital Heart Surgery at Cleveland Clinic Children’s. “Clinical teams from Cleveland Clinic and Cleveland Clinic Children’s are consistently collaborating and remain dedicated to innovation and teamwork to ensure our patients of all ages can feel safe when entrusting their care to us.”
Moving forward, the infant’s healthcare team will monitor his heart health and check that there are no signs of tumour recurrence. In the future, the child will likely need surgery to reposition together his sternum that did not properly heal in utero.
“In this case, time was of the essence,” said Dr. Cass. “Shortly after the patient arrived at Cleveland Clinic, imaging tests showed that the tumour kept growing and the foetus’s heart function was deteriorating. It is important to acknowledge the whole care team. This family’s maternal foetal medicine specialist accurately diagnosed the condition and reached out to us because of our expertise in foetal care and treatment.”
Bartley P. Griffith, MD and the patient, David Bennett — University of Maryland School of Medicine
In a major medical breakthrough, a man in the United States has received a heart from a genetically modified pig in a successful transplant.
The 57-year-old man, David Bennett, who was not eligible for a routine heart transplant, opted for the experimental surgical procedure, saying: “It was either die or do this transplant. I want to live. I know it’s a shot in the dark, but it’s my last choice.”
The eight-hour surgery took place on Friday 7 January and at the time of this publication, the patient was reportedly doing well.
The historic surgery was conducted by a team lead by Bartley P. Griffith, MD, and Muhammad M. Mohiuddin, MD, at the University of Maryland Medicine.
This experimental transplant procedure shows that a genetically-modified animal heart can function like a human heart without immediate rejection by the body and has major implications for the future of transplant surgery.
The U.S. Food and Drug Administration granted emergency authorization for the surgery on New Year’s Eve through its expanded access (compassionate use) provision. It is used when an experimental medical product, in this case the genetically-modified pig’s heart, is the only option available for a patient faced with a serious or life-threatening medical condition.
Dr Griffith, who is the Thomas E. and Alice Marie Hales Distinguished Professor in Transplant Surgery at University of Maryland School of Medicine (UMSOM), commented: “This was a breakthrough surgery and brings us one step closer to solving the organ shortage crisis. There are simply not enough donor human hearts available to meet the long list of potential recipients. We are proceeding cautiously, but we are also optimistic that this first-in-the-world surgery will provide an important new option for patients in the future.”
Prior to transplant, the heart from the genetically modified pig is removed from a machine perfusion device to keep it preserved until surgery — University of Maryland School of Medicine
Dr Mohiuddin, Professor of Surgery at UMSOM is considered one of the world’s foremost experts on transplanting animal organs, known as xenotransplantation. He established the Xenotransplantation Program five years ago with Dr. Griffith at UMSOM.
“This is the culmination of years of highly complicated research to hone this technique in animals with survival times that have reached beyond nine months. The FDA used our data and data on the experimental pig to authorize the transplant in an end-stage heart disease patient who had no other treatment options,” Dr Mohiuddin said. “The successful procedure provided valuable information to help the medical community improve this potentially life-saving method in future patients.”
The genetically modified pig was provided by Revivicor, a regenerative medicine company based in Blacksburg, Virginia, US.
Three genes – responsible for rapid antibody-mediated rejection of pig organs by humans – were knocked out in the donor pig. Six human genes responsible for immune acceptance of the pig heart were inserted into the genome. Lastly, one additional gene in the pig was knocked out to prevent excessive growth of the pig heart tissue.
The transplant surgical team was lead by Bartley P. Griffith, MD, and Muhammad M. Mohiuddin, MD. — University of Maryland School of Medicine
Dr. Mohiuddin, Dr. Griffith, and their research team have spent the past five years perfecting the surgical technique for transplantation of pig hearts into non-human primates.
“As a cardiothoracic surgeon who does lung transplants, this is an amazing moment in the history of our field. Decades of research here at Maryland and elsewhere have gone into this achievement. This has the potential to revolutionize the field of transplantation by eventually eliminating the organ shortage crisis,” said Christine Lau, MD, MBA the Dr. Robert W. Buxton Professor and Chair of the Department of Surgery at UMSOM and Surgeon-in-Chief at UMMC. “This is a continuation of steps to making xenotransplantation a life-saving reality for patients in need.”
The New York Times quoted Dr. Griffith as saying he first broached the experimental treatment in mid-December. It was a “memorable” and “pretty strange” conversation.
“I said, ‘We can’t give you a human heart; you don’t qualify. But maybe we can use one from an animal, a pig,” Dr. Griffith recalled. “It’s never been done before, but we think we can do it.’”
“I wasn’t sure he was understanding me,” Dr. Griffith added. “Then he said, ‘Well, will I oink?’”
Organs from genetically modified pigs have been the focus of much of the research in xenotransplantation, in part because of physiologic similarities between pigs, human, and nonhuman primates.
UMSOM received $15.7 million sponsored research grant to evaluate Revivicor genetically-modified pig ‘UHearts’ in baboon studies.
Bartley Griffith, MD, performs the historic transplant — University of Maryland School of Medicine
A new experimental drug made by Kiniksa Pharmaceuticals, along with conventional anti-rejection drugs, which are designed to suppress the immune system and prevent the body from rejecting the foreign organ, were used in the procedure.
Bruce Jarrell, MD, President of the University of Maryland, Baltimore, who himself is a transplant surgeon, recalled: “Dr. Griffith and I began as organ transplant surgeons when it was in its infancy. Back then, it was the dream of every transplant surgeon, myself included, to achieve xenotransplantation and it is now personally gratifying to me to see this long-sought goal clearly in view. It is a spectacular achievement.”
A 14-year-old boy has received a living liver donation from his elder brother at Cleveland Clinic Abu Dhabi, an integral part of Mubadala Health, becoming the youngest patient to undergo the operation in the hospital’s history.
Montasir Elfatih Mohyeldin Taha was diagnosed with biliary atresia in infancy, a condition where the bile ducts outside the liver fail to form during fetal development, not allowing the bile to reach the small intestine where it helps in the digestion of fat. At 10 months, he had to undergo the Kasai procedure, which is done to connect a loop of small bowel directly to the liver so that the bile can drain into it. Montasir’s doctors back home in Sudan knew that it was only a matter of time before he would have to undergo a liver transplant, an inevitable consequence for most children who have this procedure.
Earlier this year, Montasir’s symptoms and blood tests revealed that he had started developing liver failure and was suffering from portal hypertension, an increase in the pressure within the vein that carries blood from the digestive organs to the liver, resulting in varicose veins in his esophagus. Seeing the high risk of potential complications, his doctors in Sudan recommended that he undergo a liver transplant at Cleveland Clinic Abu Dhabi.
Dr. Luis Campos, the Director of Liver Transplant and Hepatobiliary at Cleveland Clinic Abu Dhabi, who was part of the interdisciplinary team that cared for Montasir, says this was one of the most complex living donor liver transplant surgeries that they have performed at the hospital.
“There were additional nuances that had to be taken into consideration because of his age, which made it even more challenging. Factors such as height and weight impact the surgery and after-care, and determine the dose of immunosuppressive medication during and after the transplant. There is also a risk of other infectious complications in pediatric liver transplant that do not apply to adult surgeries,” says Dr. Campos.
The multidisciplinary medical team at Cleveland Clinic Abu Dhabi studied the case and evaluated Montasir’s mother and brother for a match in February. After careful discussion with colleagues in the US-based Cleveland Clinic, doctors here decided that his sibling would be a more suitable match.
“My little brother needed me. I was very relieved when I was told that I can help be the cure to his illness. This was one of the easiest decisions that I have had to make,” says Khalifa Elfatih Mohyeldin Taha. “My father passed away six months back and as the eldest son in the family, it was my responsibility to save him.”
Dr. Shiva Kumar, the Chair of Gastroenterology and Hepatology in the Digestive Disease Institute at Cleveland Clinic Abu Dhabi, who was also part of the patient’s care team, says one of the biggest challenges during Montasir’s transplant was posed by the young patient’s Kasai procedure.
“While the Kasai procedure is commonly performed to prolong the need for a liver transplant in children, this is a major operation and makes the transplant more challenging to perform,” says Dr. Kumar.
“However, the surgeries of both brothers were successful and without complications. Montasir received a left lobe graft from his brother. This is a smaller portion of the liver than if we were transplanting a right lobe graft. This makes it a safer operation for the donor and helps them recover faster.”
The brothers are on their way to a full recovery. Khalifa is back to his normal life now while the Cleveland Clinic Abu Dhabi care team is monitoring Montasir’s immunosuppressive regimen, which he will be on for the rest of his life.
Khalifa says he could not contain his joy when he was told that the surgery was a success. “The best part of my transplant journey was to see that Montasir’s body had accepted the new organ. My family and I are very grateful to the care team at Cleveland Clinic Abu Dhabi for saving my brother’s life.”
He also hopes that more people consider organ donation. “The feeling of giving a chance to someone to live a normal life is incomparable. Seeing the result of your donation will fill you with contentment.”
In May 2020, a team led by thoracic surgeon Konrad Hoetzenecker of the Department of Surgery of MedUni Vienna and Vienna General Hospital performed a lung transplant on a 44-year-old patient who had been seriously ill with Covid-19, making her the first patient in Europe to receive a lung transplant for this indication. The Vienna lung transplantation programme now plays a leading role in an international consortium comprising experts from the USA, Europe and Asia. Based on the expertise from Vienna, approximately 40 transplants have now been carried out on Covid-19 patients throughout the world.
In a study published in The Lancet Respiratory Medicine, the consortium has now proposed the first general selection criteria for lung transplantation in Covid-19 patients.
“We have collated the first experiences in the world of performing lung transplants on Covid-19 patients. It is clear that such a complex intervention should only be considered for patients who, by virtue of their age and good general health, have a good chance of recovery with new lungs,” explaindc Konrad Hoetzenecker, Head of the lung transplantation programme at MedUni Vienna and Vienna General Hospital. The Vienna team performs around 100 lung transplants a year, making it one of the largest programmes in the world, alongside Toronto, Cleveland and Hanover.
Candidates for a lung transplant
The following factors were established as criteria for potential transplantation: exhaustion of all conservative treatment options, no recovery of the Covid-19-damaged lungs despite at least four weeks of ventilation/ECMO, evidence of advanced and irreversible lung damage in several consecutive CT scans, age below 65 and no relevant comorbidities. In addition to this, candidates for a lung transplant must be in good physical condition and have a good chance of complete physical rehabilitation following the transplant.
“These guidelines can be applied worldwide for making a sound selection of patients who are suitable for a lung transplant following a Covid-19 infection,” according to a statement released by MedUni Vienna.
The surgical team at MedUni Vienna and Vienna General Hospital has meanwhile carried out 12 lung transplantations on Covid-19 patients, demonstrating that even the most seriously ill patients, who would otherwise die, can survive with a lung transplant.
Patient No. 1
In March 2020, patient number one suffered total pulmonary failure as a result of Covid-19, so that artificial ventilation was no longer possible. She could only be kept alive by the circulation pump. At the time of the transplant, the PCR test showed that virus particles were still present but were no longer infectious. The MedUni Vienna/Vienna General Hospital thoracic surgeons and surgical team managed to replace the patient’s completely destroyed lungs with new donor lungs.
Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.
The Lancet Respiratory Medicine, 2021
https://doi.org/10.1016/S2213-2600(21)00077-1
https://www.sciencedirect.com/science/article/pii/S2213260021000771
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