151
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The Interaction of Amiodarone and Continuous-flow Left Ventricular Assist Device Use in Risk of Severe Primary Graft Dysfunction Following Heart Transplantation. Transplant Direct 2022; 8:e1281. [PMID: 35047663 PMCID: PMC8759622 DOI: 10.1097/txd.0000000000001281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Primary graft dysfunction (PGD) increases morbidity and mortality after heart transplant. Here we investigated (1) the association of continuous-flow left ventricular assist device (CF-LVAD), amiodarone, and severe PGD and (2) the safety of amiodarone discontinuation in CF-LVAD patients. Methods. Retrospective, single-center study of heart transplant recipients was conducted to investigate the association of risk factors and severe PGD. Patients were grouped into 4 groups based on the presence (denoted +) or absence (denoted –) of amiodarone and CF-LVAD. Prospective amiodarone discontinuation was undertaken to investigate its safety in a cohort of CF-LVAD patients. Study endpoints were severe PGD and recurrence of arrhythmia. Results. Severe PGD was strongly associated with CF-LVAD and amiodarone use, and its prevalence is highest if both risk factors were present (CF-LVAD–/amiodarone – 1.5%, CF-LVAD –/amiodarone+ 4.5%, CF-LVAD+/amiodarone – 7.1%, CF-LVAD+/amiodarone+ 21.8%; P < 0.01). The product of every 1-y additional CF-LVAD support by every 100 mg amiodarone was associated with severe PGD (adjusted odds ratio, 1.43; 95% confidence interval, 1.15-1.78; P < 0.01). Amiodarone was prospectively discontinued in 28 CF-LVAD patients. Of them, 6 patients had recurrence of arrhythmia requiring treatment or heart failure admission. There were no deaths. Nine patients in whom amiodarone had been discontinued had heart transplants with no severe PGD. Conclusions. Amiodarone and CF-LVAD were independently associated with severe PGD. The combination of both risk factors was associated with a higher prevalence of severe PGD. Amiodarone discontinuation was associated with recurrence of arrhythmia in 6 CF-LVAD patients. There was no mortality associated with amiodarone discontinuation.
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152
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Bitargil M, Haddad O, Pham SM, Goswami RM, Patel PC, Jacob S, El‐Sayed Ahmed MM, Leoni Moreno JC, Yip DS, Landolfo K, Sareyyupoglu B. Controlled temperatures in cold preservation provides safe heart transplantation results. J Card Surg 2022; 37:732-738. [DOI: 10.1111/jocs.16243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Macit Bitargil
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
| | - Osama Haddad
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
| | - Si M. Pham
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
| | - Rohan M. Goswami
- Department of Transplantation Mayo Clinic Hospital Jacksonville Florida USA
| | - Parag C. Patel
- Department of Transplantation Mayo Clinic Hospital Jacksonville Florida USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
| | | | | | - Daniel S. Yip
- Department of Transplantation Mayo Clinic Hospital Jacksonville Florida USA
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery Mayo Clinic Hospital Jacksonville Florida USA
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153
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Perez-Gutierrez A, Siddiqi U, Kim G, Rangrass G, Kacha A, Jeevanandam V, Becker Y, Potter L, Fung J, Baker TB. Combined heart-liver-kidney transplant: The university of chicago medicine experience. Clin Transplant 2022; 36:e14586. [PMID: 35041226 DOI: 10.1111/ctr.14586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 11/27/2022]
Abstract
Until recently, combined heart-liver-kidney transplantation was considered too complex or too high-risk an option for patients with end-stage heart failure who present with advanced liver and kidney failure as well. The objective of this paper is to present our institution's best practices for successfully executing this highly challenging operation. At our institution, referral patterns are most often initiated through the cardiac team. Determinants of successful outcomes include diligent multidisciplinary patient selection, detailed perioperative planning, and choreographed care transition and coordination among all transplant teams. The surgery proceeds in three distinct phases with three different teams, linked seamlessly in planned handoffs. The selection and perioperative care are executed with determined collaboration of all of the invested care teams. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Umar Siddiqi
- Section of Cardiac Surgery, University of Chicago, Chicago, IL
| | - Gene Kim
- Department of Cardiology, University of Chicago, Chicago, IL
| | - Govind Rangrass
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Aalok Kacha
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | | | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL
| | - Lisa Potter
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL
| | - John Fung
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL
| | - Talia B Baker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL
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154
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Cardiac Allograft Injuries: A Review of Approaches to a Common Dilemma, With Emphasis on Emerging Techniques. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:123-135. [PMID: 36262796 PMCID: PMC9383355 DOI: 10.36628/ijhf.2021.0042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/15/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022]
Abstract
Clinical features of allograft injury are often unreliable, and context within the transplant journey is key. In the setting of post-transplant allograft dysfunction, the choice of initial investigation depends on clinical assessment and history. One of the major considerations is the time post transplantation in helping to decide a likely cause for allograft injury. Immediately post transplantation, it is important to consider donor factors (including donor demographics as well as immunological match), ischaemic times, surgical issues as well as early rejection. Clinical suspicion needs to remain high with variable presentations, including haemodynamic instability, arrhythmia, as well as left ventricular dysfunction. Symptoms of allograft dysfunction may include dyspnoea, exertional intolerance, dizziness / lightheadedness, palpitations, as well as right or left heart failure. In the coming weeks and months, endomyocardial biopsy and blood-based biomarkers may be helpful including high sensitivity troponin and donor-derived cell-free DNA. Molecular markers for rejection are hopeful, and may also be useful in non-ischaemic causes of allograft dysfunction. Screening remains important late post heart transplant due to variety of signs associated with rejection (early) and lack of typical anginal symptoms (later). New imaging modalities - especially cardiac magnetic resonance imaging, have been shown to be useful for assessing cause of allograft dysfunction including ischemia, infarction and rejection.
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155
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Rodriguez ER, Santos-Martins C, Tan CD. Pathology of cardiac transplantation. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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156
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Batchelor RJ, Wong N, Liu DH, Chua C, William J, Tee SL, Sata Y, Bergin P, Hare J, Leet A, Taylor AJ, Patel HC, Burrell A, McGiffin D, Kaye DM. Vasoplegia Following Orthotopic Heart Transplantation: Prevalence, Predictors and Clinical Outcomes. J Card Fail 2021; 28:617-626. [PMID: 34974975 DOI: 10.1016/j.cardfail.2021.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/03/2021] [Accepted: 11/22/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients undergoing heart transplant are at high risk for postoperative vasoplegia. Despite its frequency and association with poor clinical outcomes, there remains no consensus definition for vasoplegia, and the predisposing risk factors for vasoplegia remain unclear. Accordingly, the aim of this study was to evaluate the prevalence, predictors, and clinical outcomes associated with vasoplegia in a contemporary cohort of patients undergoing heart transplantation. METHODS This was a retrospective cohort study of patients undergoing heart transplantation from January 2015 to December 2019. A binary definition of vasoplegia of a cardiac index of 2.5 L/min/m2 or greater and requirement for norepinephrine (≥5 µg/min), epinephrine (≥4 µg/min), or vasopressin (≥1 unit/h) to maintain a mean arterial blood pressure of 65 mm Hg, for 6 consecutive hours during the first 48 hours postoperatively, was used in determining prevalence. Given the relatively low threshold for the binary definition of vasoplegia, patients were divided into tertiles based on their cumulative vasopressor requirement in the 48 hours following transplant. Outcomes included all-cause mortality, intubation time, intensive care unit length of stay, and length of total hospitalization. RESULTS After exclusion of patients with primary cardiogenic shock, major bleeding, or overt sepsis, data were collected on 95 eligible patients. By binary definition, vasoplegia incidence was 66.3%. We separately stratified by actual vasopressor requirement tertile (high, intermediate, low). Stratified by tertile, patients with vasoplegia were older (52.7 ± 10.2 vs 46.8 ± 12.7 vs 44.4 ± 11.3 years, P = .02), with higher rates of chronic kidney disease (18.8% vs 32.3% vs 3.1%, P = .01) and were more likely to have been transplanted from left ventricular assist device support (n = 42) (62.5% vs 32.3% vs 37.5%, P = .03). Cardiopulmonary bypass time was prolonged in those that developed vasoplegia (155 min [interquartile range 135-193] vs 131 min [interquartile range 117-152] vs 116 min [interquartile range 102-155], P = .003). Intubation time and length of intensive care unit and hospital stay were significantly increased in those that developed vasoplegia; however, this difference did not translate to a significant increase in all-cause mortality at 30 days or 1 year. CONCLUSIONS Vasoplegia occurs at a high rate after heart transplantation. Older age, chronic kidney disease, mechanical circulatory support, and prolonged bypass time are all associated with vasoplegia; however, this study did not demonstrate an associated increase in all-cause mortality LAY SUMMARY: Patients undergoing heart transplantation are at high risk of vasoplegia, a condition defined by low blood pressure despite normal heart function. We found that vasoplegia was common after heart transplant, occurring in 60%-70% of patients after heart transplant after excluding those with other causes for low blood pressure. Factors implicated included age, poor kidney function, prolonged cardiopulmonary bypass time and preoperative left ventricular assist device support. We found no increased risk of death in patients with vasoplegia despite longer lengths of stay in intensive care and in hospital.
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Affiliation(s)
- Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | | | - Clara Chua
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Su Ling Tee
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Yusuke Sata
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Peter Bergin
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - James Hare
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Angeline Leet
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hitesh C Patel
- Department of Cardiology, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Heart Failure Research, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Aidan Burrell
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Heart Failure Research, Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - David McGiffin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Heart Failure Research, Baker Heart and Diabetes Institute, Melbourne, Australia.
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157
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See Hoe LE, Wildi K, Obonyo NG, Bartnikowski N, McDonald C, Sato K, Heinsar S, Engkilde-Pedersen S, Diab S, Passmore MR, Wells MA, Boon AC, Esguerra A, Platts DG, James L, Bouquet M, Hyslop K, Shuker T, Ainola C, Colombo SM, Wilson ES, Millar JE, Malfertheiner MV, Reid JD, O'Neill H, Livingstone S, Abbate G, Sato N, He T, von Bahr V, Rozencwajg S, Byrne L, Pimenta LP, Marshall L, Nair L, Tung JP, Chan J, Haqqani H, Molenaar P, Li Bassi G, Suen JY, McGiffin DC, Fraser JF. A clinically relevant sheep model of orthotopic heart transplantation 24 h after donor brainstem death. Intensive Care Med Exp 2021; 9:60. [PMID: 34950993 PMCID: PMC8702587 DOI: 10.1186/s40635-021-00425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Heart transplantation (HTx) from brainstem dead (BSD) donors is the gold-standard therapy for severe/end-stage cardiac disease, but is limited by a global donor heart shortage. Consequently, innovative solutions to increase donor heart availability and utilisation are rapidly expanding. Clinically relevant preclinical models are essential for evaluating interventions for human translation, yet few exist that accurately mimic all key HTx components, incorporating injuries beginning in the donor, through to the recipient. To enable future assessment of novel perfusion technologies in our research program, we thus aimed to develop a clinically relevant sheep model of HTx following 24 h of donor BSD.
Methods BSD donors (vs. sham neurological injury, 4/group) were hemodynamically supported and monitored for 24 h, followed by heart preservation with cold static storage. Bicaval orthotopic HTx was performed in matched recipients, who were weaned from cardiopulmonary bypass (CPB), and monitored for 6 h. Donor and recipient blood were assayed for inflammatory and cardiac injury markers, and cardiac function was assessed using echocardiography. Repeated measurements between the two different groups during the study observation period were assessed by mixed ANOVA for repeated measures.
Results Brainstem death caused an immediate catecholaminergic hemodynamic response (mean arterial pressure, p = 0.09), systemic inflammation (IL-6 - p = 0.025, IL-8 - p = 0.002) and cardiac injury (cardiac troponin I, p = 0.048), requiring vasopressor support (vasopressor dependency index, VDI, p = 0.023), with normalisation of biomarkers and physiology over 24 h. All hearts were weaned from CPB and monitored for 6 h post-HTx, except one (sham) recipient that died 2 h post-HTx. Hemodynamic (VDI - p = 0.592, heart rate - p = 0.747) and metabolic (blood lactate, p = 0.546) parameters post-HTx were comparable between groups, despite the observed physiological perturbations that occurred during donor BSD. All p values denote interaction among groups and time in the ANOVA for repeated measures. Conclusions We have successfully developed an ovine HTx model following 24 h of donor BSD. After 6 h of critical care management post-HTx, there were no differences between groups, despite evident hemodynamic perturbations, systemic inflammation, and cardiac injury observed during donor BSD. This preclinical model provides a platform for critical assessment of injury development pre- and post-HTx, and novel therapeutic evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00425-4.
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Affiliation(s)
- Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia. .,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia. .,School of Pharmacy and Medical Sciences, Griffith University, Southport, QLD, Australia.
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Wellcome Trust Centre for Global Health Research, Imperial College London, London, UK.,Initiative to Develop African Research Leaders (IDeAL), Kilifi, Kenya
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Charles McDonald
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Second Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Sanne Engkilde-Pedersen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia
| | - Sara Diab
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matthew A Wells
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Pharmacy and Medical Sciences, Griffith University, Southport, QLD, Australia
| | - Ai-Ching Boon
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Arlanna Esguerra
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia
| | - David G Platts
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lynnette James
- Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mahe Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kieran Hyslop
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Tristan Shuker
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Sebastiano M Colombo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Emily S Wilson
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Maximillian V Malfertheiner
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Janice D Reid
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Hollier O'Neill
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Samantha Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gabriella Abbate
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Ting He
- Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Viktor von Bahr
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Pitié-Salpêtrière University Hospital, Paris, France
| | - Liam Byrne
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,The Canberra Hospital Intensive Care, Garran, ACT, Australia.,Australia National University, Canberra, ACT, Australia
| | - Leticia P Pimenta
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Lachlan Marshall
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - Lawrie Nair
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - John-Paul Tung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jonathan Chan
- Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Southport, QLD, Australia
| | - Haris Haqqani
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - Peter Molenaar
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - David C McGiffin
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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158
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Masarone D, Kittleson M, Gravino R, Valente F, Petraio A, Pacileo G. The Role of Echocardiography in the Management of Heart Transplant Recipients. Diagnostics (Basel) 2021; 11:diagnostics11122338. [PMID: 34943575 PMCID: PMC8699946 DOI: 10.3390/diagnostics11122338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/29/2021] [Accepted: 12/09/2021] [Indexed: 01/30/2023] Open
Abstract
Transthoracic echocardiography is the primary non-invasive modality for the investigation of heart transplant recipients. It is a versatile tool that provides comprehensive information on cardiac structure and function. Echocardiography is also helpful in diagnosing primary graft dysfunction and evaluating the effectiveness of therapeutic approaches for this condition. In acute rejection, echocardiography is useful with suspected cellular or antibody-mediated rejection, with findings confirmed and quantified by endomyocardial biopsy. For identifying chronic rejection, ultrasound has a more significant role and, in some specific patients (e.g., patients with renal failure), it may offer a role comparable to coronary angiography to identify cardiac allograft vasculopathy. This review highlights the usefulness of echocardiography in evaluating normal graft function and its role in the management of heart transplant recipients.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (R.G.); (F.V.); (G.P.)
- Correspondence:
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA 90048, USA;
| | - Rita Gravino
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (R.G.); (F.V.); (G.P.)
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (R.G.); (F.V.); (G.P.)
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplantology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy;
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (R.G.); (F.V.); (G.P.)
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159
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Immohr MB, Lichtenberg A, Akhyari P, Boeken U. Multimodal temporary mechanically circulatory assistance for primary graft dysfunction after heart transplantation: a case report. Eur Heart J Case Rep 2021; 5:ytab501. [PMID: 34926987 PMCID: PMC8677403 DOI: 10.1093/ehjcr/ytab501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/06/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022]
Abstract
Background Primary graft dysfunction (PGD) remains a serious complication after heart transplantation (HTx). Although there is no therapy available, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a bailout strategy in selected cases. Especially in patients with severe biventricular failure, chances of survival remain poor. Case summary Here, we report a case of a 56-year-old patient suffering from severe PGD after HTx with biventricular failure (ejection fraction < 20%) who was successfully bridged to recovery of the donor graft by temporary multimodal mechanically circulatory assistance by combining both, VA-ECMO and a microaxial pump (Impella®, Abiomed, Inc., Danvers, MA, USA), a concept also referred as ECMELLA. During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications with need for four re-thoracotomies and temporary open chest situation. Nevertheless, ventricular function recovered and the patient could be weaned from mechanical circulatory support after 12 days. During follow-up, the patient recovered and was successfully discharged. After the following rehabilitation, the patient now shows no persistent signs of heart failure with normal biventricular function of the cardiac graft. Discussion ECMELLA may offer a therapeutic option for patients with severe PGD after HTx. Special awareness and further studies addressing targeted anticoagulation strategies for patients on dual-mechanical support are needed to diminish the incidence of bleeding complications.
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Affiliation(s)
- Moritz B Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
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SOMETHING EVIL THIS WAY COMES: Proteomic Profiling Identifies CLEC4C Expression as a Novel Biomarker of Primary Graft Dysfunction After Heart Transplantation. J Heart Lung Transplant 2021; 41:269-270. [DOI: 10.1016/j.healun.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 11/24/2022] Open
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Primary graft dysfunction in heart transplantation: How to recognize it, when to institute extracorporeal membrane oxygenation, and outcomes. JTCVS OPEN 2021; 8:128-133. [PMID: 36004187 PMCID: PMC9390270 DOI: 10.1016/j.xjon.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/04/2021] [Indexed: 11/19/2022]
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Cardoso B, Kelecsenyi A, Smith J, Jansen K, De Rita F, Nassar MS, Coats L. Improving outcomes for transplantation in failing Fontan—what is the next target? JTCVS OPEN 2021; 8:565-573. [PMID: 36004059 PMCID: PMC9390714 DOI: 10.1016/j.xjon.2021.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022]
Abstract
Objective To identify the key contributors to postoperative mortality in patients undergoing orthotopic heart transplantation (OHT) for late Fontan failure. Methods This retrospective review of failing Fontan patients who underwent OHT in our tertiary care center between 2007 and 2019 included adult patients with congenital heart disease and single ventricle physiology who were palliated with a Fontan circulation for >1 year. We excluded patients undergoing combined heart-liver transplantation. Results The study cohort comprised 31 patients, including 18 males (58.1%), with a mean weight of 58.4 kg, median age at Fontan of 6.9 years (interquartile range [IQR], 2-38 years), and a median age at OHT of 27.1 years (IQR, 16.7-53.3). Almost all (93.5%) of the patients were in New York Heart Association class III-IV, and the majority (74.2%) were in Interagency Registry for Mechanically Assisted Circulatory Support class 3. Overall survival at 30 days, 1 year, and 5 years after OHT was 81%, 71%, and 67%, respectively. Major intraoperative bleeding was associated with increased mortality after OHT (odds ratio, 30; 95% confidence interval, 2.8-322; P = .002). Neither preoperative systemic ventricular function nor the development of primary graft dysfunction (PGD) was significantly associated with postoperative death. Nevertheless, PGD determined significant morbidity of this population. Conclusions In our cohort, major intraoperative bleeding was the key factor associated with mortality after OHT for late Fontan failure. Novel strategies for the prevention and management of postoperative bleeding will improve outcomes in this group of patients.
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Affiliation(s)
- Barbara Cardoso
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Address for reprints: Barbara Cardoso, MD, Paediatric Heart Unit, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, United Kingdom.
| | - Andras Kelecsenyi
- Department of Anaesthesia, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jonathan Smith
- Department of Anaesthesia, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Congenital Heart Disease Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katrijn Jansen
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Congenital Heart Disease Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Congenital Heart Disease Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mohamed Samy Nassar
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Congenital Heart Disease Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Department of Cardiothoracic Surgery, Alexandria University, Alexandria, Egypt
| | - Louise Coats
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Congenital Heart Disease Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Post-transplantation outcomes of sensitized patients receiving durable mechanical circulatory support. J Heart Lung Transplant 2021; 41:365-372. [PMID: 34895990 DOI: 10.1016/j.healun.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 09/14/2021] [Accepted: 11/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients. METHODS Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR). RESULTS Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01). CONCLUSIONS Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations.
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Endocrine Management and Hormone Replacement Therapy in Cardiac Donor Management: A Retrospective Observational Study. Transplant Proc 2021; 53:2807-2815. [PMID: 34756710 DOI: 10.1016/j.transproceed.2021.08.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/27/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pituitary dysfunction after brainstem death can cause various hormone deficiencies in potential heart donors. The aim of this study was to evaluate the relationship between hormone replacement therapy (HRT; including antidiuretic hormone analog, thyroid hormone, and methylprednisolone) in heart donors and the recipients' outcomes after heart transplantation (HTx). METHODS We retrospectively analyzed HTxs performed between January 2012 and October 2018. Donor and recipient characteristics were retrieved with a focus on endocrine parameters and HRT. The primary outcome was primary graft dysfunction (PGD). Secondary outcomes were the 30-day and 2-year mortality of the recipients. Univariate and multivariate Cox regression analyses were applied. RESULTS The study included 297 HTxs. PGD occurred in 56 recipients (18.9%). In the multivariable Cox analysis, methylprednisolone and thyroxine treatment in donors were associated with a lower odds for PGD (odds ratio [OR], 0.43; 95% CI, 0.19-1.01; P = .052; and OR,: 0.34; 95% CI, 0.15-0.76; P = .009, respectively). In multivariate analysis, thyroxine treatment in donors was associated with a lower odds of PGD (OR, 0.38; 95% CI, 0.17-0.86; P = .020). Donor thyroxine supplementation also had a beneficial effect on recipients' 2-year survival (OR, 0.53; 95% CI, 0.29-0.96; P = .036). CONCLUSIONS Combined thyroxine and methylprednisolone treatment could be a protective factor against PGD. Thyroxine administration was associated with better 2-year survival in recipients.
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Jernryd V, Metzsch C, Andersson B, Smith JG, Nilsson J. Myocardial injury biomarkers at point of care for early identification of primary graft dysfunction after heart transplantation. Clin Transplant 2021; 36:e14526. [PMID: 34738670 DOI: 10.1111/ctr.14526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/20/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Primary graft dysfunction (PGD) is a leading cause of 30-day mortality following heart transplantation, and early intervention in PGD may correlate to improved survival. Our analysis aimed to determine the feasibility of measuring cardiac biomarkers from the donor heart in the early phase for use as a predictor of PGD. METHODS Blood samples from the coronary sinus were obtained at the time of transplantation in hearts preserved by cold static storage. The samples were analyzed for CK-MB and cTnI with a point-of-care method. The primary outcome was severe PGD or the need for veno-arterial extracorporeal membrane oxygenation within 7 days, referred to as severe graft dysfunction. RESULTS Of the total cohort (n = 63), eight patients (13%) were diagnosed with severe graft dysfunction within 7 days. Patients with high CK-MB had an increased risk for severe graft dysfunction with unadjusted Odds Ratio (OR) of 4.5 (95%CI .96-21.11 P = .057) and adjusted OR of 7.4 (95%CI 1.13-48.46, P = .037. Similar but non significant trends were observed for cTnI. CONCLUSION By measuring CK-MB from the coronary effluent in the donor heart, it may be possible to identify patients at increased risk for severe PGD after heart transplantation.
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Affiliation(s)
- Victoria Jernryd
- Department of Clinical Sciences Lund, Cardiothoracic surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Carsten Metzsch
- Department of Clinical Sciences Lund, Cardiothoracic surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - J Gustav Smith
- Clinical Sciences Lund, Cardiology, Lund University and Skane University Hospital, Lund, Sweden.,Wallenberg Center for Molecular Medicine and Lund University Diabetes Center, Lund University, Lund, Sweden.,The Wallenberg Laboratory/Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University and the Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic surgery, Lund University and Skane University Hospital, Lund, Sweden.,Department of Translational Medicine, Cardiothoracic surgery and bioinformatics, Lund University and Skane University Hospital, Lund, Sweden
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M'Pembele R, Roth S, Stroda A, Buse GL, Sixt SU, Westenfeld R, Polzin A, Rellecke P, Tudorache I, Hollmann MW, Aubin H, Akhyari P, Lichtenberg A, Huhn R, Boeken U. Life impact of VA-ECMO due to primary graft dysfunction in patients after orthotopic heart transplantation. ESC Heart Fail 2021; 9:695-703. [PMID: 34734490 PMCID: PMC8788039 DOI: 10.1002/ehf2.13686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/01/2021] [Accepted: 10/09/2021] [Indexed: 12/04/2022] Open
Abstract
Aims Primary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) until graft recovery. Long‐term mortality of patients weaned from VA‐ECMO after HTX is comparable with non‐ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient‐centred outcome in HTX patients at 1 year after surgery. Methods and results This retrospective single‐centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA‐ECMO due to PGD. VA‐ECMO and non‐VA‐ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA‐ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15–0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA‐ECMO and non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27–1.90; P = 0.48]. DAOH were significantly higher in non‐ECMO patients compared with VA‐ECMO patients and patients weaned from VA‐ECMO [non‐ECMO vs. VA‐ECMO: median 310 (inter‐quartile range 277–327) days vs. 243 (0–288) days; P < 0.0001; non‐ECMO vs. VA‐ECMO (weaned): 310 (277–327) days vs. 253 (208–299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables. Conclusions Despite similar survival rates, VA‐ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient‐centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients.
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Affiliation(s)
- René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stephan U Sixt
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Rellecke
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Amsterdam, The Netherlands
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Noly PE, Hébert M, Lamarche Y, Cortes JR, Mauduit M, Verhoye JP, Voisine P, Flécher E, Carrier M. Use of extracorporeal membrane oxygenation for heart graft dysfunction in adults: incidence, risk factors and outcomes in a multicentric study. Can J Surg 2021; 64:E567-E577. [PMID: 34728522 PMCID: PMC8565882 DOI: 10.1503/cjs.021319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 11/20/2022] Open
Abstract
Background: The decision about whether to use venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiac graft dysfunction (GD) is usually made on a case-by-case basis and is guided by the team’s experience. We aimed to determine the incidence of VA-ECMO use after heart transplantation (HT), to assess early- and long-term outcomes and to assess risk factors for the need for VA-ECMO and early mortality in these patients. Methods: We included adults who underwent heart transplantation at 3 cardiac centres who met the most recent International Society for Heart and Lung Transplantation definition of graft dysfunction (GD) over a 10-year period. Pre-transplant, intraoperative and posttransplant characteristics of the heart recipients as well as donor characteristics were analyzed and compared among recipients with GD treated with and without VA-ECMO. Results: There were 135 patients with GD in this study, of whom 66 were treated with VA-ECMO and 69 were not. The mean follow-up averaged 81.2 months (standard deviation 36 mo, range 0–184 mo); follow-up was complete in 100% of patients. The overall incidence of GD (30%) and of VA-ECMO use increased over the study period. We did not identify any predictive pre-transplantation factors for VA-ECMO use, but patients who required VA-ECMO had higher serum lactate levels and higher inotropes doses after HT. The overall survival rates were 83% and 42% at 1 year and 78% and 40% at 5 years among patients who received only medical treatment and those who received VA-ECMO, respectively. Delayed initiation of VA-ECMO and postoperative bleeding were strongly associated with increased in-hospital mortality. Conclusion: The incidence of GD increased over the study period, and the need for VA-ECMO among patients with GD remains difficult to predict. In-hospital mortality decreased over time but remained high among patients who required VA-ECMO, especially among patients with delayed initiation of VA-ECMO.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Michel Carrier
- From the Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Que. (Noly, Hébert, Lamarche, Carrier); the Department of Cardiac Surgery, Quebec Heart and Lung Institute, Université Laval, Québec, Que. (Cortes, Voisine); and the Department of Thoracic and Cardiovascular Surgery, Rennes Hospital, University of Rennes 1, Rennes, France (Mauduit, Verhoye, Flécher)
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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169
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Kasturi S, Kumaran T, Shetty V, Punnen J, Subramanya S, Raghuraman B, Parachuri VR, Shetty DP. Oversized donor heart transplantation-clinical experience with an underestimated problem. Indian J Thorac Cardiovasc Surg 2021; 37:631-638. [PMID: 34776661 PMCID: PMC8546007 DOI: 10.1007/s12055-021-01200-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Heart transplantation is the definitive treatment for end-stage heart failure. With respect to donor-recipient size matching, the problems with undersized heart transplantation have been widely discussed, but there is a paucity of information on oversized transplants due to the presumed advantage of large hearts. We intend to share our center's experience with oversized heart transplantation and its associated problems which would help to expand the knowledge on oversized cardiac allografts. METHODS Patients who underwent isolated heart transplantation at our hospital between March 1, 2008, and March 1, 2020, were included. For adults, a donor-recipient predicted heart mass percentage difference exceeding 30% and for children, a donor-recipient weight ratio < 0.8 and > 2.0 was considered a mismatch. We collected data from the in-patient medical records and analyzed the in-hospital outcomes and survival post-transplant among various other parameters. RESULTS Out of the 43 patients included in this study, 32 (74.4%) patients received a matched heart and 11 (25.6%) patients received oversized hearts. None of the patients received an undersized heart. The in-hospital mortality rate of oversized transplants was 18.2% whereas that of matched transplants was 9.4% (p = 0.432). The post-operative characteristics and 1-year survival were comparable between the groups. We encountered problems specific to oversizing in 5 of the 11 patients (45.4%) which are discussed. CONCLUSION With the liberalization of donor criteria to overcome organ shortage, oversized heart transplantation poses certain unique challenges, which when efficiently managed offers acceptable outcomes.
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Affiliation(s)
- Srikanth Kasturi
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Thiruthani Kumaran
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
- Consultant Cardiothoracic and Heart Transplant Surgeon, Narayana Institute of Cardiac Sciences, 258/A, Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Varun Shetty
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Julius Punnen
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Shashiraj Subramanya
- Department of Cardiology, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Bagirath Raghuraman
- Department of Cardiology, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Venkat Rao Parachuri
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
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Schramm R, Zittermann A, Fuchs U, Fleischhauer J, Costard-Jäckle A, Ruiz-Cano M, Krenz LA, Fox H, Götte J, Günther SPW, Wlost S, Rojas SV, Hakim-Meibodi K, Morshuis M, Gummert JF. Donor-recipient risk assessment tools in heart transplant recipients: the Bad Oeynhausen experience. ESC Heart Fail 2021; 8:4843-4851. [PMID: 34704397 PMCID: PMC8712925 DOI: 10.1002/ehf2.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS Some risk assessment tools have been developed to categorize mortality risk in heart transplant recipients, but it is unclear whether these tools can be used interchangeable in different transplant regions. METHODS AND RESULTS We performed a retrospective single-centre study in 1049 adult German heart transplant recipients under jurisdiction of Eurotransplant. Univariable and multivariable Cox regression analysis was used to generate a risk scoring system. C-statistics were used to compare our score with a US score and a French score regarding their ability to discriminate between 1 year survivors and non-survivors within our study cohort. Of 38 parameters assessed, seven recipient-specific parameters [age, height, dilated cardiomyopathy (DCM), ischaemic cardiomyopathy (ICM), total bilirubin, extracorporeal membrane oxygenation (ECMO), and biventricular assist device/total artificial heart (BVAD/TAH) implant], one donor-specific parameter (cold ischaemic time), and one recipient-independent and donor-independent other parameter (late transplant era) were statistically significant in predicting 1 year mortality. The initial score was generated by using the regression coefficients from the multivariable analysis as follows: 1.70 * ln age - 4.0 * ln height - 0.9 * diagnosis (= 1 if diagnosis = DCM) - 0.67 * diagnosis (= 1 if diagnosis = ICM) + 0.33 * ln total bilirubin + 1.74 * ln cold ischaemic time + 0.98 * mechanical circulatory support (MCS) implant (= 1 if MCS implant = ECMO) + 0.47 * MCS implant (= 1 of MCS implant = BVAD/TAH) - 0.66 * transplant era (= 1 if transplant era = 2017-2018). The initial score was converted into the Bad Oeynhausen (BO) score as a positive integer variable by means of the following formula: BO score = (initial score + 8) * 3. In patients scoring 2 to <7 points (n = 112), 7 to <11 points (n = 580), 11 to <15 points (n = 339), and 15 to 20 points (n = 18), 1 year survival was 93.1%, 84.2%, 66.9%, and 27.8%, respectively. The c-index of our score was 0.73 [95% confidence interval (CI): 0.69-0.77]. Values were in our cohort for the US and French scores 0.66 (95% CI: 0.62-0.70) and 0.63 (95% CI: 0.59-0.67), respectively. CONCLUSIONS Data indicate that our score, but also risk assessment tools from other transplant regions, may be used as a reliable support for risk-adjusted organ allocation and potentially help to improve outcomes in heart transplantation. Further developments will have to include as yet unaccounted risk factors for even more reliable predictions.
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Affiliation(s)
- Rene Schramm
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Armin Zittermann
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Uwe Fuchs
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Jan Fleischhauer
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Angelika Costard-Jäckle
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Maria Ruiz-Cano
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Luminata-Adriana Krenz
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Henrik Fox
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Julia Götte
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Sabina P W Günther
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Stefan Wlost
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Sebastian V Rojas
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Kavous Hakim-Meibodi
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Michiel Morshuis
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Jan F Gummert
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
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Immohr MB, Aubin H, Erbel-Khurtsidze S, Dalyanoglu H, Bruno RR, Westenfeld R, Tudorache I, Akhyari P, Boeken U, Lichtenberg A. Impact of pretransplant left ventricular assist device support duration on outcome after heart transplantation. Interact Cardiovasc Thorac Surg 2021; 34:462-469. [PMID: 34647129 PMCID: PMC8860434 DOI: 10.1093/icvts/ivab265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/19/2021] [Accepted: 08/27/2021] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Heart transplantation after left ventricular assist device (LVAD) implantation remains challenging. It is still unclear whether its support duration impacts the outcome after transplantation.
METHODS All patients undergoing heart transplantation between 2010 and 2021 at a single department after previous left ventricular assistance were retrospectively reviewed and divided into 4 different study groups with regard to the duration of LVAD support to examine the impact on the postoperative morbidity and mortality. RESULTS A total of n = 198 patients were included and assigned to the 4 study groups (group 1: <90 days, n = 14; group 2: 90 days to 1 year, n = 31; group 3: 1–2 years, n = 29; group 4: >2 years, n = 24). Although there were no differences between the 4 groups concerning relevant mismatch between the recipients and donors, the incidence of primary graft dysfunction was numerically increased in patients with the shortest support duration, and also those patients with >1 year of support (group 1: 35.7%, group 2: 25.8%, group 3: 41.4%, group 4: 37.5%, P = 0.63). The incidence of acute graft rejection was by trend increased in patients of group 1 (group 1: 28.6%, group 2: 3.3%, group 3: 7.1%, group 4: 12.5%, P = 0.06). Duration of LVAD support did not impact on perioperative adverse events (infections, P = 0.79; acute kidney injury, P = 0.85; neurological events, P = 0.74; thoracic bleeding, P = 0.61), neither on postoperative survival (1-year survival: group 1: 78.6%, group 2: 66.7%, group 3: 80.0%, group 4: 72.7%, P = 0.74). CONCLUSION We cannot identify a significant impact of the duration of pretransplant LVAD support on postoperative outcome; therefore, we cannot recommend a certain timeframe for transplantation of LVAD patients.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sophiko Erbel-Khurtsidze
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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172
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Qamar A, Zhao J, Xu L, McLeod P, Huang X, Jiang J, Liu W, Haig A, Zhang ZX. Cyclophilin D Regulates the Nuclear Translocation of AIF, Cardiac Endothelial Cell Necroptosis and Murine Cardiac Transplant Injury. Int J Mol Sci 2021; 22:11038. [PMID: 34681708 PMCID: PMC8540562 DOI: 10.3390/ijms222011038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/23/2021] [Accepted: 10/08/2021] [Indexed: 12/26/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) is an inevitable consequence of organ transplant procedure and associated with acute and chronic organ rejection in transplantation. IRI leads to various forms of programmed cell death, which worsens tissue damage and accelerates transplant rejection. We recently demonstrated that necroptosis participates in murine cardiac microvascular endothelial cell (MVEC) death and murine cardiac transplant rejection. However, MVEC death under a more complex IRI model has not been studied. In this study, we found that simulating IRI conditions in vitro by hypoxia, reoxygenation and treatment with inflammatory cytokines induced necroptosis in MVECs. Interestingly, the apoptosis-inducing factor (AIF) translocated to the nucleus during MVEC necroptosis, which is regulated by the mitochondrial permeability molecule cyclophilin D (CypD). Furthermore, CypD deficiency in donor cardiac grafts inhibited AIF translocation and mitigated graft IRI and rejection (n = 7; p = 0.002). Our studies indicate that CypD and AIF play significant roles in MVEC necroptosis and cardiac transplant rejection following IRI. Targeting CypD and its downstream AIF may be a plausible approach to inhibit IRI-caused cardiac damage and improve transplant survival.
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Affiliation(s)
- Adnan Qamar
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
| | - Jianqi Zhao
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
- Department of Rheumatology and Immunology, The First Hospital of Jilin University, 3808 Jiefang Road, Changchun 130021, China
| | - Laura Xu
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
| | - Patrick McLeod
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
| | - Xuyan Huang
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
| | - Jifu Jiang
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
| | - Weihua Liu
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
| | - Aaron Haig
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
| | - Zhu-Xu Zhang
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, B4-231, 339 Windermere Road, London, ON N6A 5A5, Canada; (A.Q.); (J.Z.); (L.X.); (P.M.); (X.H.); (J.J.)
- Department of Pathology, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada; (W.L.); (A.H.)
- Multi-Organ Transplant Program, London Health Sciences Centre, London, ON N6A 5A5, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON N6A 3K7, Canada
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173
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Kędziora A, Piątek J, Hymczak H, Wasilewski G, Guzik B, Drwiła R, Kapelak B, Sobczyk D, Konstanty-Kalandyk J, Wierzbicki K. Early postoperative hemodynamic instability after heart transplantation - incidence and metabolic indicators. BMC Anesthesiol 2021; 21:236. [PMID: 34600476 PMCID: PMC8487161 DOI: 10.1186/s12871-021-01455-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/23/2021] [Indexed: 12/28/2022] Open
Abstract
Background Primary graft dysfunction (PGD) is the main cause of death in the first 30 days after heart transplantation (HTX), accounting for approximately 40% of mortality. The study’s primary aim was to assess the incidence of PGD, following the International Society for Heart and Lung Transplantation consensus, and to compare it with the incidence of significant postoperative hypotension despite administration of high-dose inotropes and vasoconstrictors. The secondary aim of the study was to determine changes in biochemical markers that accompany the phenomenon. Methods Forty-five patients who underwent HTX between 2010 and 2015 were enrolled in this study, and detailed hemodynamic and metabolic data from the first 48 postoperative hours were collected and analyzed. Hemodynamic instability was defined as significant postoperative hypotension (mean arterial pressure (MAP) < 60 mmHg) combined with a high inotrope score (> 10). Data for long-term mortality were obtained from the population registration office. Results PGD incidence was relatively low (17.8%); however, hemodynamic instability was common (40%). Among unstable patients, MAP was insufficient for end-organ perfusion (51.4 ± 9.5 mmHg) but no decrease in left ventricular function was observed (cardiac index, 2.65 ± 0.6 l/min/m2; left ventricular ejection fraction, 52.9 ± 15.5%). Within this group, mean systemic vascular resistance index (961 ± 288 dyn*s*m2/cm5) was low despite receiving high doses of vasoactive agent (norepinephrine 0.21 (0.06-0.27) μg/kg/min during first 24 h postoperatively and 0.21 (0.01-0.27) μg/kg/min during next 24 h postoperatively). After HTX, serum lactate levels were initially significantly higher in patients with hemodynamic instability (p = 0.002); however, impaired lactate clearance was not observed (p = 0.366), and lactate levels normalized within the first 24 h postoperatively. Postoperative hemodynamic instability altered the long-term outcome and increased 5-year mortality after HTX (p = 0.034). Conclusions Hemodynamic instability is a more common phenomenon than PGD. Only early postoperative serum lactate levels correspond with hemodynamic instability following HTX. Postoperative hemodynamic instability is associated with poor long-term survival among HTX recipients.
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Affiliation(s)
- Anna Kędziora
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland. .,Jagiellonian University Medical College, Krakow, Poland.
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland
| | - Hubert Hymczak
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, Krakow, Poland.,Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Grzegorz Wasilewski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland
| | - Bartłomiej Guzik
- Jagiellonian University Medical College, Krakow, Poland.,Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Rafał Drwiła
- Jagiellonian University Medical College, Krakow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland.,Jagiellonian University Medical College, Krakow, Poland
| | - Dorota Sobczyk
- Jagiellonian University Medical College, Krakow, Poland.,Department of Cardiac and Vascular Diseases, John Paul II Hospital, Kraków, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland.,Jagiellonian University Medical College, Krakow, Poland
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, 80 Pradnicka St., 31-202, Krakow, Poland.,Jagiellonian University Medical College, Krakow, Poland
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174
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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175
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Huang F, Yang R, Xiao Z, Xie Y, Lin X, Zhu P, Zhou P, Lu J, Zheng S. Targeting Ferroptosis to Treat Cardiovascular Diseases: A New Continent to Be Explored. Front Cell Dev Biol 2021; 9:737971. [PMID: 34527678 PMCID: PMC8435746 DOI: 10.3389/fcell.2021.737971] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/02/2021] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular diseases, including cardiomyopathy, myocardial infarction, myocardial ischemia/reperfusion injury, heart failure, vascular injury, stroke, and arrhythmia, are correlated with cardiac and vascular cell death. Ferroptosis is a novel form of non-apoptotic regulated cell death which is characterized by an iron-driven accumulation of lethal lipid hydroperoxides. The initiation and execution of ferroptosis are under the control of several mechanisms, including iron metabolism, glutamine metabolism, and lipid peroxidation. Recently, emerging evidence has demonstrated that ferroptosis can play an essential role in the development of various cardiovascular diseases. Recent researches have shown the ferroptosis inhibitors, iron chelators, genetic manipulations, and antioxidants can alleviate myocardial injury by blocking ferroptosis pathway. In this review, we systematically described the mechanisms of ferroptosis and discussed the role of ferroptosis as a novel therapeutic strategy in the treatment of cardiovascular diseases.
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Affiliation(s)
- Fangze Huang
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ronghua Yang
- Department of Burn Surgery, The First People's Hospital of Foshan, Foshan, China
| | - Zezhou Xiao
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Xie
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xuefeng Lin
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Zhu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Lu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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176
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Smith DE, Kon ZN, Carillo JA, Chen S, Gidea CG, Piper GL, Reyentovich A, Montgomery RA, Galloway AC, Moazami N. Early experience with donation after circulatory death heart transplantation using normothermic regional perfusion in the United States. J Thorac Cardiovasc Surg 2021; 164:557-568.e1. [PMID: 34728084 DOI: 10.1016/j.jtcvs.2021.07.059] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/05/2021] [Accepted: 07/15/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This pilot study sought to evaluate the feasibility of our donation after circulatory death (DCD) heart transplantation protocol using cardiopulmonary bypass (CPB) for normothermic regional reperfusion (NRP). METHODS Suitable local DCD candidates were transferred to our institution. Life support was withdrawn in the operating room (OR). On declaration of circulatory death, sternotomy was performed, and the aortic arch vessels were ligated. CPB was initiated with left ventricular venting. The heart was reperfused, with correction of any metabolic abnormalities. CPB was weaned, and cardiac function was assessed at 30-minute intervals. If accepted, the heart was procured with cold preservation and transplanted into recipients in a nearby OR. RESULTS Between January 2020 and January 2021, a total of 8 DCD heart transplants were performed: 6 isolated hearts, 1 heart-lung, and 1 combined heart and kidney. All donor hearts were successfully resuscitated and weaned from CPB without inotropic support. Average lactate and potassium levels decreased from 9.39 ± 1.47 mmol/L to 7.20 ± 0.13 mmol/L and 7.49 ± 1.32 mmol/L to 4.36 ± 0.67 mmol/L, respectively. Post-transplantation, the heart-lung transplant recipient required venoarterial extracorporeal membrane oxygenation for primary lung graft dysfunction but was decannulated on postoperative day 3 and recovered uneventfully. All other recipients required minimal inotropic support without mechanical circulatory support. Survival was 100% with a median follow-up of 304 days (interquartile range, 105-371 days). CONCLUSIONS DCD heart transplantation outcomes have been excellent. Our DCD protocol is adoptable for more widespread use and will increase donor heart availability in the United States.
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Affiliation(s)
- Deane E Smith
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY.
| | - Zachary N Kon
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Julius A Carillo
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY
| | - Stacey Chen
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY
| | - Claudia G Gidea
- Division of Cardiology, New York University Langone Health, New York, NY
| | - Greta L Piper
- Department of Surgery, New York University Langone Health, New York, NY
| | - Alex Reyentovich
- Division of Cardiology, New York University Langone Health, New York, NY
| | - Robert A Montgomery
- Department of Surgery, New York University Langone Health, New York, NY; Transplant Institute, New York University Langone Health, New York, NY
| | - Aubrey C Galloway
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY
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Pretransplant Right Ventricular Dysfunction Is Associated With Increased Mortality After Heart Transplantation: A Hard Inheritance to Overcome. J Card Fail 2021; 28:259-269. [PMID: 34509597 DOI: 10.1016/j.cardfail.2021.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Right ventricular dysfunction (RVD) is a major issue in patients with advanced heart failure because it precludes the implantation of left ventricular assist device, usually leaving heart transplantation (HTx) as the only available treatment option. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating information of right ventricular function and of pulmonary circulation. Our aim is to evaluate the association of preoperative RVD, hemodynamically defined as a low PAPi, with post-HTx survival. METHODS AND RESULTS Consecutive adult HTx recipient at 2 Italian transplant centers between 2000 and 2018 with available data on pre-HTx right heart catheterization were included retrospectively. RVD was defined as a value of PAPi lower than the 25th percentile of the study population. The association of RVD with the 1-year post-HTx mortality and other secondary end points were evaluated. Multivariate logistic regression was used to adjust for clinical and hemodynamic variables. Analyses stratified by pulmonary vascular resistance (PVR) status (≥3 Woods units vs <3 Woods units) were also performed. Among 657 HTx recipients (female 31.1%, age 53 ± 11 years), patients with pre-HTx RVD (PAPi of <1.68) had significantly lower 1-year survival rates (77.8% vs 87.1%, P = .005), also after adjusting for estimated glomerular filtration rate, total bilirubin, PVR, serum sodium, inotropes, and mechanical circulatory support at HTx (hazard ratio 2.0, 95% confidence interval, 1.3-3.1). RVD was also associated with post-HTx renal replacement therapy (hazard ratio 2.0, 95% confidence interval 1.05-3.30) and primary graft dysfunction (hazard ratio 1.7, , 95% confidence interval 1.02-3.30). When stratifying patients by estimated PVR status, RVD was associated with worse 1-year survival among patients with normal PVR (76.9% vs 88.3%, P = .003), but not in those with increased PVR (78.6% vs 83.2%, P = .49). CONCLUSIONS Preoperative RVD, evaluated through PAPi, is associated with mortality and morbidity after HTx, providing incremental prognostic value over traditional clinical and hemodynamic parameters.
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Lei I, Huang W, Ward PA, Pober JS, Tellides G, Ailawadi G, Pagani FD, Landstrom AP, Wang Z, Mortensen RM, Cascalho M, Platt J, Eugene Chen Y, Lam HYK, Tang PC. Differential inflammatory responses of the native left and right ventricle associated with donor heart preservation. Physiol Rep 2021; 9:e15004. [PMID: 34435466 PMCID: PMC8387788 DOI: 10.14814/phy2.15004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Dysfunction and inflammation of hearts subjected to cold ischemic preservation may differ between left and right ventricles, suggesting distinct strategies for amelioration. METHODS AND RESULTS Explanted murine hearts subjected to cold ischemia for 0, 4, or 8 h in preservation solution were assessed for function during 60 min of warm perfusion and then analyzed for cell death and inflammation by immunohistochemistry and western blotting and total RNA sequencing. Increased cold ischemic times led to greater left ventricle (LV) dysfunction compared to right ventricle (RV). The LV experienced greater cell death assessed by TUNEL+ cells and cleaved caspase-3 expression (n = 4). While IL-6 protein levels were upregulated in both LV and RV, IL-1β, TNFα, IL-10, and MyD88 were disproportionately increased in the LV. Inflammasome components (NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3), adaptor molecule apoptosis-associated speck-like protein containing a CARD (ASC), cleaved caspase-1) and products (cleaved IL-1β and gasdermin D) were also more upregulated in the LV. Pathway analysis of RNA sequencing showed increased signaling related to tumor necrosis factor, interferon, and innate immunity with ex-vivo ischemia, but no significant differences were found between the LV and RV. Human donor hearts showed comparable inflammatory responses to cold ischemia with greater LV increases of TNFα, IL-10, and inflammasomes (n = 3). CONCLUSIONS Mouse hearts subjected to cold ischemia showed time-dependent contractile dysfunction and increased cell death, inflammatory cytokine expression and inflammasome expression that are greater in the LV than RV. However, IL-6 protein elevations and altered transcriptional profiles were similar in both ventricles. Similar changes are observed in human hearts.
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Affiliation(s)
- Ienglam Lei
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Wei Huang
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Peter A. Ward
- Department of PathologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Jordan S. Pober
- Department of ImmunobiologyYale UniversityNew HavenConnecticutUSA
| | | | - Gorav Ailawadi
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Francis D. Pagani
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | | | - Zhong Wang
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Richard M. Mortensen
- Department of Internal MedicineUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Marilia Cascalho
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Jeffrey Platt
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Yuqing Eugene Chen
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | | | - Paul C. Tang
- Department of Cardiac SurgeryUniversity of Michigan Frankel Cardiovascular CenterAnn ArborMichiganUSA
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179
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Parajuli S, Karim AS, Muth BL, Leverson GE, Yang Q, Dhingra R, Smith JW, Foley DP, Mandelbrot DA. Risk factors and outcomes for delayed kidney graft function in simultaneous heart and kidney transplant recipients: A UNOS/OPTN database analysis. Am J Transplant 2021; 21:3005-3013. [PMID: 33565674 DOI: 10.1111/ajt.16535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/04/2021] [Accepted: 01/31/2021] [Indexed: 01/25/2023]
Abstract
There are no prior studies assessing the risk factors and outcomes for kidney delayed graft function (K-DGF) in simultaneous heart and kidney (SHK) transplant recipients. Using the OPTN/UNOS database, we sought to identify risk factors associated with the development of K-DGF in this unique population, as well as outcomes associated with K-DGF. A total of 1161 SHK transplanted between 1998 and 2018 were included in the analysis, of which 311 (27%) were in the K-DGF (+) group and 850 in the K-DGF (-) group. In the multivariable analysis, history of pretransplant dialysis (OR: 3.95; 95% CI: 2.94 to 5.29; p < .001) was significantly associated with the development of K-DGF, as was donor death from cerebrovascular accident and longer cold ischemia time of either organ. SHK recipients with K-DGF had increased mortality (HR: 1.99; 95% CI: 1.52 to 2.60; p < .001) and death censored kidney graft failure (HR: 3.51; 95% CI: 2.29 to 5.36; p < .001) in the multivariable analysis. Similar outcomes were obtained when limiting our study to 2008-2018. Similar to kidney-only recipients, K-DGF in SHK recipients is associated with worse outcomes. Careful matching of recipients and donors, as well as peri-operative management, may help reduce the risk of K-DGF and the associated detrimental effects.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Aos S Karim
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Brenda L Muth
- Division of Nephrology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Glen E Leverson
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Qiuyu Yang
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Ravi Dhingra
- Division of Cardiovascular Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Jason W Smith
- Division of Cardiothoracic Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - David P Foley
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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180
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Peled Y, Messer S, Large SR, Kittleson MM. Donation after Circulatory Death: Extending the Boundaries of this New Frontier. J Heart Lung Transplant 2021; 40:1419-1421. [PMID: 34429239 DOI: 10.1016/j.healun.2021.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Simon Messer
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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181
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Truby LK, Kwee LC, Agarwal R, Grass E, DeVore AD, Patel CB, Chen D, Schroder JN, Bowles D, Milano CA, Shah SH, Holley CL. Proteomic profiling identifies CLEC4C expression as a novel biomarker of primary graft dysfunction after heart transplantation. J Heart Lung Transplant 2021; 40:1589-1598. [PMID: 34511330 DOI: 10.1016/j.healun.2021.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Clinical models to identify patients at high risk of primary graft dysfunction (PGD) after heart transplantation (HT) are limited, and the underlying pathophysiology of this common post-transplant complication remains poorly understood. We sought to identify whether pre-transplant levels of circulating proteins reporting on immune activation and inflammation are associated with incident PGD. METHODS The study population consisted of 219 adult heart transplant recipients identified between 2016 and 2020 at Duke University Medical Center, randomly divided into derivation (n = 131) and validation (n = 88) sets. PGD was defined using modified ISHLT criteria. Proteomic profiling was performed using Olink panels (n = 354 proteins) with serum samples collected immediately prior to transplantation. Association between normalized relative protein expression and PGD was tested using univariate and multivariable (recipient age, creatinine, mechanical circulatory support, and sex; donor age; ischemic time) models. Significant proteins identified in the derivation set (p < 0.05 in univariate models), were then tested in the validation set. Pathway enrichment analysis was used to test candidate biological processes. The predictive performance of proteins was compared to that of the RADIAL score. RESULTS Nine proteins were associated with PGD in univariate models in the derivation set. Of these, only CLEC4C remained associated with PGD in the validation set after Bonferroni correction (OR [95% CI] = 3.04 [1.74,5.82], p = 2.8 × 10-4). Patterns of association were consistent for CLEC4C in analyses stratified by biventricular/left ventricular and isolated right ventricular PGD. Pathway analysis identified interferon-alpha response and C-type lectin signaling as significantly enriched biologic processes. The RADIAL score was a poor predictor of PGD (AUC = 0.55). CLEC4C alone (AUC = 0.66, p = 0.048) and in combination with the clinical covariates from the multivariable model (AUC = 0.69, p = 0.018) improved discrimination for the primary outcome. CONCLUSIONS Pre-transplantation circulating levels of CLEC4C, a protein marker of plasmacytoid dendritic cells (pDCs), may identify HT recipients at risk for PGD. Further studies are needed to better understand the potential role pDCs and the innate immune response in PGD.
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Affiliation(s)
- Lauren K Truby
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Lydia Coulter Kwee
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Richa Agarwal
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth Grass
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Dongfeng Chen
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn Bowles
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Svati H Shah
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Christopher L Holley
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
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182
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de la Rosa AL, Singer-Englar T, Tompkins RO, Patel JK, Kobashigawa JA, Kittleson MM. Advanced heart failure and heart transplantation in adult congenital heart disease in the current era. Clin Transplant 2021; 35:e14451. [PMID: 34365682 DOI: 10.1111/ctr.14451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) may undergo heart transplantation (HTx) despite increased risk of poor short-term outcomes due to factors including surgical complexity and antibody sensitization. We assessed the clinical characteristics and outcomes of patients with ACHD in the current era referred for HTx at a single high-volume transplant center. METHODS From 2010-2020, 37 ACHD patients were evaluated for HTx. ACHD HTx recipients were compared to non-ACHD HTx recipients matched for age, sex, listing status, and prior cardiac surgery. RESULTS Of the 37 patients with ACHD, 8 (21.6%) were declined for HTx. Of 29 ACHD patients listed, 19 (65.5%) underwent HTx. Compared with non-ACHD HTx controls, the ACHD HTx recipients had more treated cellular (21.1% vs 15.8%, p = 0.010) and antibody-mediated (15.8% vs 10.5%, p = 0.033) rejection. There was no difference in hospital readmission or allograft vasculopathy at 1 year. There was a nonsignificant higher 1-year mortality in ACHD HTx recipients (21.1% vs 7.9%, p = 0.21). CONCLUSION At a high-volume transplant center, ACHD patients undergoing HTx appear to have a marginally higher risk of rejection, but no significant increase in 1-year mortality. With careful selection and management, HTx for patients with ACHD may be feasible in the current era. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Angelo L de la Rosa
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tahli Singer-Englar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rose O Tompkins
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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183
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Lechiancole A, DE Manna ND, Vendramin I, Sponga S, Livi U. Contemporary contribution of cardiac surgery for the treatment of cardiomyopathies and pericardial diseases. Minerva Cardiol Angiol 2021; 70:258-272. [PMID: 34338489 DOI: 10.23736/s2724-5683.21.05801-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiomyopathy refers to a spectrum of heterogeneous myocardial disorders characterized by morphological and structural alterations leading eventually to heart failure, by affecting cardiac filling and/or the cardiac systolic function. Heart transplantation is currently the gold standard surgical treatment for patients with heart failure, with a median survival in adults of 12 years according to international registries. However, the limited available donor pool does not allow its extensive employment. For this reason, mechanical circulatory supports are increasingly used, and in the short term are becoming as possible alternatives to heart transplantation, owing to improved technologies and increased biocompatibility. However, long-term outcomes of mechanical assist devices are still burdened with a high rate of adverse events. Conventional surgical treatments could be still considered as alternatives to heart replacement treatment when tailored both on patient clinical conditions and etiology of cardiac diseases. In particular, among patients affected by ischemic cardiomyopathy, coronary artery bypass grafting has proven to improve survival when associated to optimal medical treatment, and surgical ventricular restoration might be considered as a valid treatment in particular cases. Correction of functional mitral valve regurgitation by mitral annuloplasty, which aims to restore left ventricular geometry, has not demonstrated unambiguous results, and outcomes of this procedure are still controversial. Pericardial pathology becomes of surgical interest when it is responsible for a reduced filling capacity of the heart chambers, which can develop acutely (cardiac tamponade) or chronically (as in the case of constrictive pericarditis). This review focuses on the different surgical approaches that could be adopted to treat patients with heart failure and pericardial diseases.
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Affiliation(s)
| | - Nunzio D DE Manna
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Sandro Sponga
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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184
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Venema CS, Erasmus ME, Mariani M, Voors AA, Damman K. Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation. Clin Transplant 2021; 35:e14347. [PMID: 33969543 PMCID: PMC8519078 DOI: 10.1111/ctr.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice. METHODS Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality. RESULTS The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2 = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12). CONCLUSION High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.
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Affiliation(s)
- Constantijn S. Venema
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Michiel E. Erasmus
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Massimo Mariani
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Adriaan A. Voors
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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185
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Baran DA, Lansinger J, Long A, Herre JM, Yehya A, Sawey EJ, Badiye AP, Old W, Copeland J, Stelling K, Copeland H. Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety. Circ Heart Fail 2021; 14:e007433. [PMID: 34315226 PMCID: PMC8366767 DOI: 10.1161/circheartfailure.120.007433] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history. Methods: The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors. Results: The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001). Conclusions: Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.
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Affiliation(s)
- David A Baran
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Justin Lansinger
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Ashleigh Long
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - John M Herre
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Amin Yehya
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Edward J Sawey
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Amit P Badiye
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Wayne Old
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | | | - Kelly Stelling
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
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186
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Edwards S, Allen S, Sidebotham D. Anaesthesia for heart transplantation. BJA Educ 2021; 21:284-291. [PMID: 34306729 DOI: 10.1016/j.bjae.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- S Edwards
- Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - S Allen
- Auckland City Hospital, Auckland, New Zealand
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187
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Al-Adhami A, Avtaar Singh SS, De SD, Singh R, Panjrath G, Shah A, Dalzell JR, Schroder J, Al-Attar N. Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma. Curr Probl Cardiol 2021; 47:100941. [PMID: 34404551 DOI: 10.1016/j.cpcardiol.2021.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow.
| | - Sudeep Das De
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, Virginia
| | - Gurusher Panjrath
- Heart Failure and Mechanical Circulatory Support Program, George Washington University Hospital, Washington, DC
| | - Amit Shah
- Advanced Heart Failure and Cardiac Transplant Unit, Fiona Stanley Hospital, Perth, Australia
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Jacob Schroder
- Heart Transplantation Program, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow
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188
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Sponga S, Benedetti G, de Manna ND, Ferrara V, Vendramin I, Lechiancole A, Maiani M, Nalon S, Nalli C, Di Nora C, Bortolotti U, Livi U. Heart transplant outcomes in patients with mechanical circulatory support: cold storage versus normothermic perfusion organ preservation. Interact Cardiovasc Thorac Surg 2021; 32:476-482. [PMID: 33221874 DOI: 10.1093/icvts/ivaa280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Patients with mechanical circulatory support bridged to a heart transplant (HTx) are at higher risk of postoperative graft dysfunction. In this subset, a mode of graft preservation that shortens graft ischaemia should be beneficial. METHODS The outcomes of 38 patients on mechanical circulatory support (extracorporeal life support, left ventricular assist device and biventricular assist device) who received a HTx between 2015 and 2020 were analysed according to the method of graft preservation: cold storage (CS) group, 24 (63%) or ex vivo perfusion (EVP) group, 14 (37%). RESULTS The median age was 57 (range 30-73) vs 64 (35-75) years (P = 0.10); 88% were men (P = 0.28); extracorporeal life support was more frequent in the CS group (54% vs 36%; P = 0.27) versus left ventricular and biventricular assist devices in the EVP group (46% vs 64%; P = 0.27). Clamping time was shorter in the EVP group (P < 0.001) and ischaemic time >4 h was higher in the CS group (P = 0.01). Thirty-day mortality was 13% (0-27%) in the CS group and 0% (P = 0.28) in the EVP group. A significantly lower primary graft failure [7% (0-23%) vs 42% (20-63%); P = 0.03] was observed in the EVP group. Survival at 1 year was 79 ± 8% (63-95%) in the CS group and 84 ± 10% (64-104%) in the EVP group (P = 0.95). CONCLUSIONS Our results support the use of ex vivo graft perfusion in patients on mechanical circulatory support as a bridge to a HTx. This technique, by shortening graft ischaemic time, seems to improve post-HTx outcomes.
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Affiliation(s)
- Sandro Sponga
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | | | - Veronica Ferrara
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | - Massimo Maiani
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Sandro Nalon
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Chiara Nalli
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Concetta Di Nora
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Uberto Bortolotti
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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189
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Redd MA, Scheuer SE, Saez NJ, Yoshikawa Y, Chiu HS, Gao L, Hicks M, Villanueva JE, Joshi Y, Chow CY, Cuellar-Partida G, Peart JN, See Hoe LE, Chen X, Sun Y, Suen JY, Hatch RJ, Rollo B, Xia D, Alzubaidi MAH, Maljevic S, Quaife-Ryan GA, Hudson JE, Porrello ER, White MY, Cordwell SJ, Fraser JF, Petrou S, Reichelt ME, Thomas WG, King GF, Macdonald PS, Palpant NJ. Therapeutic Inhibition of Acid Sensing Ion Channel 1a Recovers Heart Function After Ischemia-Reperfusion Injury. Circulation 2021; 144:947-960. [PMID: 34264749 DOI: 10.1161/circulationaha.121.054360] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Ischemia-reperfusion injury (IRI) is one of the major risk factors implicated in morbidity and mortality associated with cardiovascular disease. During cardiac ischemia, the build-up of acidic metabolites results in decreased intracellular and extracellular pH that can reach as low as 6.0-6.5. The resulting tissue acidosis exacerbates ischemic injury and significantly impacts cardiac function. Methods: We used genetic and pharmacological methods to investigate the role of acid sensing ion channel 1a (ASIC1a) in cardiac IRI at the cellular and whole organ level. Human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs) as well as ex vivo and in vivo models of IRI were used to test the efficacy of ASIC1a inhibitors as pre- and post-conditioning therapeutic agents. Results: Analysis of human complex trait genetics indicate that variants in the ASIC1 genetic locus are significantly associated with cardiac and cerebrovascular ischemic injuries. Using hiPSC-CMs in vitro and murine ex vivo heart models, we demonstrate that genetic ablation of ASIC1a improves cardiomyocyte viability after acute IRI. Therapeutic blockade of ASIC1a using specific and potent pharmacological inhibitors recapitulates this cardioprotective effect. We used an in vivo model of myocardial infarction (MI) and two models of ex vivo donor heart procurement and storage as clinical models to show that ASIC1a inhibition improves post-IRI cardiac viability. Use of ASIC1a inhibitors as pre- or post-conditioning agents provided equivalent cardioprotection to benchmark drugs, including the sodium-hydrogen exchange inhibitor zoniporide. At the cellular and whole organ level, we show that acute exposure to ASIC1a inhibitors has no impact on cardiac ion channels regulating baseline electromechanical coupling and physiological performance. Conclusions: Collectively, our data provide compelling evidence for a novel pharmacological strategy involving ASIC1a blockade as a cardioprotective therapy to improve the viability of hearts subjected to IRI.
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Affiliation(s)
- Meredith A Redd
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
| | - Sarah E Scheuer
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Natalie J Saez
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science (N.J.S., G.F.K.), The University of Queensland, St Lucia, Australia
| | - Yusuke Yoshikawa
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Han Sheng Chiu
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Ling Gao
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
| | - Mark Hicks
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Department of Pharmacology (M.H.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Jeanette E Villanueva
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Yashutosh Joshi
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Chun Yuen Chow
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Gabriel Cuellar-Partida
- The University of Queensland Diamantina Institute, Faculty of Medicine and Translational Research Institute, Woolloongabba, Australia (G.C.-P.)
| | - Jason N Peart
- School of Medical Science, Griffith University, Southport, Australia (J.N.P.)
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Xiaoli Chen
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Yuliangzi Sun
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Robert J Hatch
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Ben Rollo
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Di Xia
- Genome Innovation Hub (D.X.), The University of Queensland, St Lucia, Australia
| | - Mubarak A H Alzubaidi
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Snezana Maljevic
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | | | - James E Hudson
- QIMR Berghofer Medical Research Institute, Brisbane, Australia (G.A.Q.-R., J.E.H.)
| | - Enzo R Porrello
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Australia (E.R.P.)
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, Australia (E.R.P.)
| | - Melanie Y White
- School of Medical Sciences, School of Life and Environmental Sciences, and Charles Perkins Centre, The University of Sydney, Sydney, Australia (M.Y.W., S.J.C.)
| | - Stuart J Cordwell
- School of Medical Sciences, School of Life and Environmental Sciences, and Charles Perkins Centre, The University of Sydney, Sydney, Australia (M.Y.W., S.J.C.)
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Steven Petrou
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Melissa E Reichelt
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Walter G Thomas
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Glenn F King
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science (N.J.S., G.F.K.), The University of Queensland, St Lucia, Australia
| | - Peter S Macdonald
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Nathan J Palpant
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
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190
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Atik FA, Couto CDF, de Souza SEM, Biondi RS, da Silva AHM, Vilela MF, Barzilai VS, Cardoso HSS, Ulhoa MB. Outcomes of Orthotopic Heart Transplantation in the Setting of Acute Kidney Injury and Renal Replacement Therapy. J Cardiothorac Vasc Anesth 2021; 36:437-443. [PMID: 34362644 DOI: 10.1053/j.jvca.2021.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Heart transplantation in the setting of renal insufficiency is controversial. The objective of this study was to perform a descriptive analysis of patients who underwent orthotopic heart transplantation and renal replacement therapy (RRT) due to acute kidney injury (AKI). DESIGN An observational cohort study with retrospective data collection. SETTING A tertiary care hospital. PARTICIPANTS Fifty-one patients underwent orthotopic heart transplantation with cardiogenic shock under inotrope dependence, with nine patients having preoperative RRT and 42 patients not having preoperative RRT. INTERVENTIONS There were no interventions. MEASUREMENTS AND MAIN RESULTS Hospital mortality occurred in eight (15.6%) patients. Although there were no significant differences between the study groups (preoperative RRT 33.3% v controls 11.9%, p = 0.1), this study was underpowered to detect differences in mortality. Dialysis also was required in 52.4% of patients who were not on preoperative RRT. All survivors had full recovery of kidney function with similar timing after transplant (18.5 days v 15 days, p = 0.75). Actuarial survival was 82.4%, 76.5%, and 66.5% at six months, one year, and five years, respectively. A cold ischemic time greater than 180 minutes (hazard ratio [HR] 4.37 95% confidence interval [CI] 1.51-12.6; p = 0.006) and pretransplant RRT (HR = 7.19 95% CI 1.13-45.7; p = 0.04) were independent predictors of long-term mortality. CONCLUSIONS In a health system with limited funding and availability of mechanical circulatory support, heart transplantation in the setting of AKI, RRT, and low Interagency Registry for Mechanically Assisted Circulatory Support profile was associated with important hospital mortality. Among hospital survivors, however, all patients had full renal recovery and by 25 months there was no difference in mortality between those who required preoperative RRT and those who did not.
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Affiliation(s)
- Fernando A Atik
- Instituto de Cardiologia do Distrito Federal, Brazil; University of Brasilia, Brasilia, DF, Brazil.
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191
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Giangreco NP, Lebreton G, Restaino S, Jane Farr M, Zorn E, Colombo PC, Patel J, Levine R, Truby L, Soni RK, Leprince P, Kobashigawa J, Tatonetti NP, Fine BM. Plasma kallikrein predicts primary graft dysfunction after heart transplant. J Heart Lung Transplant 2021; 40:1199-1211. [PMID: 34330603 DOI: 10.1016/j.healun.2021.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/21/2021] [Accepted: 07/01/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early mortality after heart transplant. Pre-transplant predictors of PGD remain elusive and its etiology remains unclear. METHODS Microvesicles were isolated from 88 pre-transplant serum samples and underwent proteomic evaluation using TMT mass spectrometry. Monte Carlo cross validation (MCCV) was used to predict the occurrence of severe PGD after transplant using recipient pre-transplant clinical characteristics and serum microvesicle proteomic data. Putative biological functions and pathways were assessed using gene set enrichment analysis (GSEA) within the MCCV prediction methodology. RESULTS Using our MCCV prediction methodology, decreased levels of plasma kallikrein (KLKB1), a critical regulator of the kinin-kallikrein system, was the most predictive factor identified for PGD (AUROC 0.6444 [0.6293, 0.6655]; odds 0.1959 [0.0592, 0.3663]. Furthermore, a predictive panel combining KLKB1 with inotrope therapy achieved peak performance (AUROC 0.7181 [0.7020, 0.7372]) across and within (AUROCs of 0.66-0.78) each cohort. A classifier utilizing KLKB1 and inotrope therapy outperforms existing composite scores by more than 50 percent. The diagnostic utility of the classifier was validated on 65 consecutive transplant patients, resulting in an AUROC of 0.71 and a negative predictive value of 0.92-0.96. Differential expression analysis revealed a enrichment in inflammatory and immune pathways prior to PGD. CONCLUSIONS Pre-transplant level of KLKB1 is a robust predictor of post-transplant PGD. The combination with pre-transplant inotrope therapy enhances the prediction of PGD compared to pre-transplant KLKB1 levels alone and the resulting classifier equation validates within a prospective validation cohort. Inflammation and immune pathway enrichment characterize the pre-transplant proteomic signature predictive of PGD.
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Affiliation(s)
- Nicholas P Giangreco
- Departments of Systems Biology, Biomedical Informatics, and Medicine, Columbia University, New York, New York
| | - Guillaume Lebreton
- Chirurgie Thoracique et Cardiovasculaire, Pitiíe-Salpetriere University Hospital, Paris, France
| | - Susan Restaino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Mary Jane Farr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Emmanuel Zorn
- Center for Translational Immunology, Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Jignesh Patel
- Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Ryan Levine
- Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Lauren Truby
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Rajesh Kumar Soni
- Proteomics and Macromolecular Crystallography Shared Resource, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Pascal Leprince
- Chirurgie Thoracique et Cardiovasculaire, Pitiíe-Salpetriere University Hospital, Paris, France
| | - Jon Kobashigawa
- Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Nicholas P Tatonetti
- Departments of Systems Biology, Biomedical Informatics, and Medicine, Columbia University, New York, New York; Institute for Genomic Medicine, Columbia University, New York, New York
| | - Barry M Fine
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
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192
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Hoffman JRH, McMaster WG, Rali AS, Rahaman Z, Balsara K, Absi T, Levack M, Brinkley M, Menachem J, Punnoose L, Sacks S, Wigger M, Zalawadiya S, Stevenson L, Schlendorf K, Lindenfeld J, Shah AS. Early US experience with cardiac donation after circulatory death (DCD) using normothermic regional perfusion. J Heart Lung Transplant 2021; 40:1408-1418. [PMID: 34334301 DOI: 10.1016/j.healun.2021.06.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts from DCD donors. METHODS Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval. RESULTS The mean age of the DCD donors was 23 ± 7 years and average time on TA-NRP was 56 ± 8 minutes. Total ischemic time was 183 ± 31 minutes and distance from transplant center was 373 ± 203 nautical miles. Recipient age was 55 ± 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days. CONCLUSIONS Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aniket S Rali
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynn Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Suzanne Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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193
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Hoffman JRH, Larson EE, Rahaman Z, Absi T, Levack M, Balsara KR, McMaster W, Brinkley M, Menachem JN, Punnoose LR, Sacks SB, Wigger MA, Zalawadiya SK, Stevenson LW, Schlendorf KH, Lindenfeld J, Shah AS. Impact of increased donor distances following adult heart allocation system changes: A single center review of 1-year outcomes. J Card Surg 2021; 36:3619-3628. [PMID: 34235763 DOI: 10.1111/jocs.15795] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. METHODS In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. RESULTS A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006). CONCLUSIONS Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emilee E Larson
- Section of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn R Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark A Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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194
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Hess NR, Hickey GW, Sultan I, Wang Y, Kilic A. Impact of various sizing metrics on female donor to male recipient heart transplant outcomes. J Card Surg 2021; 36:3242-3249. [PMID: 34231256 DOI: 10.1111/jocs.15748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study evaluated the impact of various sizing metrics on outcomes of female donor to male recipient orthotopic heart transplantation (OHT). METHODS We queried the United Network of Organ Sharing database to analyze all isolated, primary adult OHTs from January 1, 2010 to January 20, 020. Patients were stratified by donor-recipient sex pairing. Logistic regression was used to investigate risk-adjusted effects of current size matching criteria (weight ratio, body mass index [BMI] ratio, predicted heart mass [pHM] ratio) on 1-year posttransplant mortality. Kaplan-Meier analysis was used to compare posttransplant survival among cohorts. RESULTS A total of 22,450 patients were analyzed, of which 3019 (13.4%) underwent female-to-male transplantation. Of sex-matched pairs, female-to-male donation had the lowest proportion of undersized hearts using weight and BMI ratio metrics (10.5% and 5.2%) but had the highest proportion of undersizing using pHM metrics (48.1%) (all p < 0.001). Female-to-male recipients had the lowest rate of unadjusted 1-year survival (90.0%, p = 0.0169), and increased hazards of mortality after risk adjustment (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.01-1.36, p = 0.034). Undersizing using pHM (donor-recipient ratio <0.85) was the only metric found to be associated in increased mortality after risk adjustment (OR: 1.32, 95% CI: 1.02-1.71, p = 0.035). CONCLUSION Female-to-male heart transplantation has the worst survival of all sex-matching combinations. Although female donors in this cohort are appropriately sized using traditional metrics, half are under-sized using pHM. This, combined with its strong association with mortality, underscores the importance of routine pHM assessment when evaluating female donors for male recipients.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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195
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Nazario RDA, Goldraich LA, Hastenteufel LCT, Santos ABS, Carrion L, Clausell N. Donor-recipient predicted heart mass ratio and right ventricular-pulmonary arterial coupling in heart transplant. Eur J Cardiothorac Surg 2021; 59:847-854. [PMID: 33860318 DOI: 10.1093/ejcts/ezaa391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/20/2020] [Accepted: 09/24/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Right ventricular-pulmonary arterial (RV-PA) coupling interactions are largely unexplored in heart transplant patients. The outcome of this study was RV-PA coupling at 7 and 30 days after heart transplant and its association with donor-recipient size matching. METHODS Clinical, echocardiographic and haemodynamic data from a retrospective cohort of heart transplant recipients and respective donors were reviewed. Coupling between RV-PA was examined by assessing the RV fractional area change and pulmonary artery systolic pressure ratio. Donor-recipient size matching was assessed by the predicted heart mass (PHM) ratio, and groups with a PHM ratio <1 and ≥1 were compared. RESULTS Forty-four heart transplant recipients were included in this study (50 years, 57% male sex). Postoperative RV-PA coupling improved from 7 to 30 days (RV fractional area change/pulmonary artery systolic pressure 0.9 ± 0.3 vs 1.2 ± 0.3; P < 0.001). A positive association was found between an adequate PHM ratio and improvement of RV fractional area change/pulmonary artery systolic pressure at 30 days, independent of graft ischaemic time and pre-existent pulmonary hypertension (B coefficient 0.54; 95% confidence interval 0.11-0.97; P = 0.016; adjusted R2 = 0.24). CONCLUSIONS These findings highlight the role of PHM as a metric to help donor selection and suggest its impact in RV-PA coupling interactions post-heart transplant.
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Affiliation(s)
- Raffaela de Almeida Nazario
- Division of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.,Graduate Studies Program on Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Livia Adams Goldraich
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Angela B S Santos
- Graduate Studies Program on Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciana Carrion
- Division of Cardiology, Hospital Nossa Senhora da Conceição, Porto Alegre, Rio Grande do Sul, Brazil
| | - Nadine Clausell
- Graduate Studies Program on Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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196
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Anguela-Calvet L, Moreno-Gonzalez G, Sbraga F, Gonzalez-Costello J, Tsui S, Oliver-Juan E. Heart Donation From Donors After Controlled Circulatory Death. Transplantation 2021; 105:1482-1491. [PMID: 33208694 DOI: 10.1097/tp.0000000000003545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The gold-standard therapy for advanced-stage heart failure is cardiac transplantation. Since the first heart transplant in 1967, the majority of hearts transplanted came from brain death donors. Nevertheless, in recent years, the option of donation after circulatory death (DCD) is gaining importance to increase donor pool. Currently, heart-transplant programs using controlled donation after circulatory death (cDCD) have been implemented in the United Kingdom, Belgium, Australia, United States of America, and, recently, in Spain. In this article, we performed a concise review of the literature in heart cDCD; we summarize the pathophysiology involved in ischemia and reperfusion injury during this process, the different techniques of heart retrieval in cDCD donors, and the strategies that can be used to minimize the damage during retrieval and until transplantation. Heart transplant using DCD hearts is in continuous improvement and must be implemented in experienced cardiac transplant centers.
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Affiliation(s)
- Laura Anguela-Calvet
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Gabriel Moreno-Gonzalez
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Fabrizio Sbraga
- Cardiac Surgery Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jose Gonzalez-Costello
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Advance Heart Failure and Cardiac Transplantation Unit, Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Steven Tsui
- Cardiothoracic Surgery Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Eva Oliver-Juan
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
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197
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Sathianathan S, Bhat G, Dowling R. Vasoplegia from Continuous Flow Left Ventricular Assist Devices. Curr Cardiol Rep 2021; 23:101. [PMID: 34196837 DOI: 10.1007/s11886-021-01534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The contribution of continuous flow left ventricular assist devices (c-LVAD) to vasoplegic syndrome and postoperative outcomes after orthotopic heart transplant (OHT) is contested in the literature. A standardized definition of vasoplegic syndrome (VS) is needed to better recognize and manage vasoplegic shock. RECENT FINDINGS Vasoplegic syndrome occurs after orthotopic heart transplant more frequently than after other surgeries requiring cardiopulmonary bypass. c-LVADs lead to small vessel endothelial dysfunction and desensitized adrenal receptors; however, their contribution to the development of vasoplegia is debated in clinical studies. Pulsatility may mitigate vascular dysfunction resulting from long-term continuous flow, and should be further explored in the clinical setting when considering risk factors for vasoplegic syndrome. The incidence of vasoplegic syndrome after orthotopic heart transplant is rising with the increasing use of c-LVAD bridge to therapy. Robust clinical studies are needed to advance our understanding and approach to mitigating VS after OHT.
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Affiliation(s)
- Shyama Sathianathan
- School of Medicine, Penn State College of Medicine, 500 University Dr, Hershey, PA, 17033, USA.
| | - Geetha Bhat
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Robert Dowling
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
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198
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Singh TP, Profita EL, Rycus P, Thiagarajan R, Gauvreau K. Risk Factors for Severe Primary Graft Dysfunction in Infants Following Heart Transplant. J Am Heart Assoc 2021; 10:e021082. [PMID: 34184543 PMCID: PMC8403271 DOI: 10.1161/jaha.121.021082] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Previous studies suggest that infant heart transplant (HT) recipients are at higher risk of developing severe primary graft dysfunction (PGD) than older children. We sought to identify risk factors for developing severe PGD in infant HT recipients. Methods and Results We identified all HT recipients aged <1 year in the United States during 1996 to 2015 using the Organ Procurement and Transplant Network database. We linked their data to ELSO (Extracorporeal Life Support Organization) registry data to identify those with severe PGD, defined by initiation of extracorporeal membrane oxygenation support for PGD within 2 days following HT. We used multivariable logistic regression to assess risk factors for developing severe PGD. Of 1718 infants analyzed, 600 (35%) were <90 days old and 1079 (63%) had congenital heart disease. Overall, 134 (7.8%) developed severe PGD; 95 (71%) were initiated on extracorporeal membrane oxygenation support on the day of HT, 34 (25%) the next day, and 5 (4%) the following day. In adjusted analysis, recipient congenital heart disease, extracorporeal membrane oxygenation, or biventricular assist device support at transplant, recipient blood type AB, donor‐recipient weight ratio <0.9, and graft ischemic time ≥4 hours were independently associated with developing severe PGD whereas left ventricular assist device support at HT was not. One‐year graft survival was 48% in infants with severe PGD versus 87% without severe PGD. Conclusions Infant HT recipients with severe PGD have poor graft survival. Although some recipient‐level risk factors are nonmodifiable, avoiding modifiable risk factors may mitigate further risk in infants at high risk of developing severe PGD.
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Affiliation(s)
- Tajinder P Singh
- Department of Cardiology Boston Children's Hospital Boston MA.,Department of Pediatrics Harvard Medical School Boston MA
| | | | - Peter Rycus
- Extracorporeal Life Support Organization Registry Ann Arbor MI
| | - Ravi Thiagarajan
- Department of Cardiology Boston Children's Hospital Boston MA.,Department of Pediatrics Harvard Medical School Boston MA
| | - Kimberlee Gauvreau
- Department of Cardiology Boston Children's Hospital Boston MA.,Department of Biostatistics Harvard School of Public Health Boston MA
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199
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Lim HS, Ranasinghe A, Quinn D, Chue CD, Mascaro J. Pathophysiology of severe primary graft dysfunction in orthotopic heart transplantation. Clin Transplant 2021; 35:e14398. [PMID: 34176143 DOI: 10.1111/ctr.14398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/15/2021] [Accepted: 06/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A series of insults on the donor heart result in pathophysiological changes that manifest as primary graft dysfunction (PGD) post-orthotopic heart transplantation. The objectives of this study were: (i) describe the pathophysiology of severe PGD using an established cardiovascular model; and (ii) the evolution of the pathophysiology during recovery from severe PGD. METHODS Hemodynamic data from 20 consecutive patients with severe PGD (need for mechanical circulatory support, MCS) at baseline (T0), 6 h (T6) and "recovery" (explant of support), and 20 consecutive patients without severe PGD were used to model the pathophysiology using the cardiovascular model described by Burkhoff and Dickstein. RESULTS There was a progressive (from T0 to T6) up- and leftward shift in the diastolic pressure-volume relationship, especially of the right ventricle (RV), resulting in reduced capacitance. RV end-systolic elastance (Ees) was significantly elevated in severe PGD but preload-recruitable stroke work (PRSW) was significantly lower compared to patients without severe PGD. "Recovery" (after liberation from MCS) was associated with improvement in RV Ees, chamber capacitance and PRSW, although they remained significantly lower than patients without severe PGD. CONCLUSION Severe PGD of the dominant right heart failure phenotype is characterized by reduced chamber capacitance, increased "stiffness" and impaired contractility. Complete normalization was not required for successful weaning of MCS.
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Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aaron Ranasinghe
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Quinn
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin D Chue
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jorge Mascaro
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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200
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Tokavanich N, Sinphurmsukskul S, Kongruttanachok N, Thammanatsakul K, Sritangsirikul S, Ariyachaipanich A, Ongcharit P, Siwamogsatham S, Boonyaratavej S, Puwanant S. Circulating growth differentiation factor-15 as a novel biomarker in heart transplant. ESC Heart Fail 2021; 8:3279-3285. [PMID: 34110100 PMCID: PMC8318448 DOI: 10.1002/ehf2.13471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/20/2021] [Accepted: 06/01/2021] [Indexed: 12/19/2022] Open
Abstract
Aims This study aimed to examine (i) whether circulating growth differentiation factor‐15 (GDF‐15) is associated with acute cellular cardiac allograft rejection (ACR); (ii) a longitudinal trend of GDF‐15 after heart transplantation; and (iii) the prognostic value of GDF‐15 in predicting a composite outcome of severe primary graft dysfunction (PGD) and 30 day mortality post‐transplant. Methods and results Serum samples were collected before heart transplantation and at every endomyocardial biopsy (EMB) post‐heart transplantation in de novo transplant patients. A total of 60 post‐transplant serum samples were matched to the corresponding EMBs. Seven (12%) were considered International Society for Heart Lung Transplantation Grade 1R ACR, and one (2%) was identified as Grade 2R ACR. GDF‐15 levels in patients with ACR were not different from those in the non‐rejection group (6230 vs. 6125 pg/mL, P = 0.27). GDF‐15 concentration gradually decreased from 8757 pg/mL pre‐transplant to 5203 pg/mL at 4 weeks post‐transplant. The composite adverse outcome of PGD and 30 day mortality was significantly associated with increased post‐operative GDF‐15 (odds ratio: 40; 95% confidence interval: 2.01–794.27; P = 0.005) and high inotrope score post‐transplant (odds ratio: 18; 95% confidence interval: 1.22–250.35; P = 0.01). Conclusions Circulating GDF‐15 concentration was markedly elevated in patients with end‐stage heart failure and decreased after heart transplantation. GDF‐15 was significantly associated with post‐transplant PGD and mortality. A lack of association between ACR and GDF‐15 did not support routine use of GDF‐15 as a biomarker to detect ACR. However, GDF‐15 may be potentially useful to determine heart transplant recipients at high risk for adverse post‐transplant outcomes. We suggest that GDF‐15 levels in recipient serum can provide risk stratification for severe PGD including death during post‐operative period. This novel biomarker may serve to inform and guide timely interventions against severe PGD and adverse outcomes during the first 4 weeks after transplantation. Further studies to support the utility of GDF‐15 in heart transplantation are required.
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Affiliation(s)
- Nithi Tokavanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand
| | - Supanee Sinphurmsukskul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Narisorn Kongruttanachok
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanokwan Thammanatsakul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Supaporn Sritangsirikul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Aekarach Ariyachaipanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Pat Ongcharit
- Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand.,Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Chula Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
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