1
|
Venkata Devarakonda B, Kumar S, Tiwari N, Ameta N, Singh S. Ambulatory milrinone therapy as a bridge to heart transplantation. Med J Armed Forces India 2023; 79:726-728. [PMID: 37981937 PMCID: PMC10654362 DOI: 10.1016/j.mjafi.2023.08.014] [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: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 11/21/2023] Open
Abstract
Inotrope therapy for patients with advanced heart failure awaiting a heart transplant or ventricular assist device has been reported to facilitate hospital discharge. We report the case of a 46-year-old man with advanced heart failure (Stage D), initially found unsuitable for a heart transplant due to high pulmonary vascular resistance (PVR) was placed on ambulatory Milrinone therapy leading to significant improvement in PVR. He underwent a successful orthotopic heart transplant.
Collapse
Affiliation(s)
- Bhargava Venkata Devarakonda
- Associate Professor (Anaesthesia) & Cardiothoracic Anaesthesiologist, Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Sameer Kumar
- Head & Consultant (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Nikhil Tiwari
- Consultant (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Nihar Ameta
- Assistant Professor (Anaesthesia) & Caradiothoracic Anaesthesiologist, Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Saurabh Singh
- Senior Advisor (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| |
Collapse
|
2
|
Oehler D, Oehler H, Sigetti D, Immohr MB, Böttger C, Bruno RR, Haschemi J, Aubin H, Horn P, Westenfeld R, Bönner F, Akhyari P, Kelm M, Lichtenberg A, Boeken U. Early Postoperative Neurologic Events Are Associated With Worse Outcome and Fatal Midterm Survival After Adult Heart Transplantation. J Am Heart Assoc 2023; 12:e029957. [PMID: 37548172 PMCID: PMC10492937 DOI: 10.1161/jaha.123.029957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023]
Abstract
Background Neurologic events during primary stay in heart transplant (HTx) recipients may be associated with reduced outcome and survival, which we aim to explore with the current study. Methods and Results We screened and included all patients undergoing HTx in our center between September 2010 and December 2022 (n=268) and checked for the occurrence of neurologic events within their index stay. Neurologic events were defined as ischemic stroke, hemorrhage, hypoxic ischemic injury, or acute symptomatic neurologic dysfunction without central nervous system injury. The cohort was then divided into recipients with (n=33) and without (n=235) neurologic events after HTx. Using a multivariable Cox regression model, the association of neurologic events after HTx and survival was assessed. Recipients with neurologic events displayed a longer intensive care unit stay (30 versus 16 days; P=0.009), longer mechanical ventilation (192 versus 48 hours; P<0.001), and higher need for blood transfusion, and need for hemodialysis after HTx was substantially higher (81% versus 55%; P=0.01). Resternotomy (36% versus 26%; P=0.05) and mechanical life support (extracorporeal life support) after HTx (46% versus 24%; P=0.02) were also significantly higher in patients with neurologic events. Covariable-adjusted multivariable Cox regression analysis revealed a significant independent association of neurologic events and increased 30-day (hazard ratio [HR], 2.5 [95% CI, 1.0-6.0]; P=0.049), 1-year (HR, 2.2 [95% CI, 1.1-4.3]; P=0.019), and overall (HR, 2.5 [95% CI, 1.5-4.2]; P<0.001) mortality after HTx and reduced Kaplan-Meier survival up to 5 years after HTx (P<0.001). Conclusions Neurologic events after HTx were strongly and independently associated with worse postoperative outcome and reduced survival up to 5 years after HTx.
Collapse
Affiliation(s)
- Daniel Oehler
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hannah Oehler
- Department of NeurologyHeidelberg UniversityHeidelbergGermany
| | - Dennis Sigetti
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | | | - Charlotte Böttger
- Department of Diagnostic and Interventional RadiologyHeinrich‐Heine UniversityDuesseldorfGermany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Jafer Haschemi
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hug Aubin
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Patrick Horn
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Florian Bönner
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Payam Akhyari
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Artur Lichtenberg
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Udo Boeken
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| |
Collapse
|
3
|
Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
Collapse
Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
| |
Collapse
|
4
|
Tao R, Hess TM, Kuchnia A, Hermsen J, Raza F, Dhingra R. Association of Size Matching Using Predicted Heart Mass With Mortality in Heart Transplant Recipients With Obesity or High Pulmonary Vascular Resistance. JAMA Netw Open 2023; 6:e2319191. [PMID: 37351886 PMCID: PMC10290246 DOI: 10.1001/jamanetworkopen.2023.19191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/04/2023] [Indexed: 06/24/2023] Open
Abstract
Importance Pretransplant obesity and higher pulmonary vascular resistance (PVR) are risk factors for death after heart transplant. However, it remains unclear whether appropriate donor-to-recipient size matching using predicted heart mass (PHM) is associated with lower risk. Objective To investigate the association of size matching using PHM with risk of death posttransplant among patients with obesity and/or higher PVR. Design, Setting, and Participants All adult patients (>18 years) who underwent heart transplant between 2003 and 2022 with available information using the United Network for Organ Sharing cohort database. Multivariable Cox models and multivariable-adjusted spline curves were used to examine the risk of death posttransplant with PHM matching. Data were analyzed from October 2022 to March 2023. Exposure Recipient's body mass index (BMI) in categories (<18.0 [underweight], 18.1-24.9 [normal weight, reference], 25.0-29.9 [overweight], 30.0-34.9 [obese 1], 35-39.9 [obese 2], and ≥40.0 [obese 3]) and recipient's pretransplant PVR in categories of less than 4 (29 061 participants), 4 to 6 (2842 participants), and more than 6 Wood units (968 participants); and less than 3 (24 950 participants), 3 to 5 (6115 participants), and 5 or more (1806 participants) Wood units. Main Outcome All-cause death posttransplant on follow-up. Results The mean (SD) age of the cohort of 37 712 was 52.8 (12.8) years, 27 976 (74%) were male, 25 342 were non-Hispanic White (68.0%), 7664 were Black (20.4%), and 3139 were Hispanic or Latino (8.5%). A total of 12 413 recipients (32.9%) had a normal BMI, 13 849 (36.7%) had overweight, and 10 814 (28.7%) had obesity. On follow-up (median [IQR] 5.05 [0-19.4] years), 12 785 recipients (3046 female) died. For patients with normal weight, overweight, or obese 2, receiving a PHM-undermatched heart was associated with an increased risk of death (normal weight hazard ratio [HR], 1.20; 95% CI, 1.07-1.34; overweight HR, 1.12; 95% CI, 1.02-1.23; and obese 2 HR, 1.07; 95% CI, 1.01-1.14). Moreover, patients with higher pretransplant PVR who received an undermatched heart had a higher risk of death posttransplant in multivariable-adjusted spline curves in graded fashion until appropriately matched. In contrast, risk of death among patients receiving a PHM-overmatched heart did not differ from the appropriately matched group, including in recipients with an elevated pretransplant PVR. Conclusion and Relevance In this cohort study, undermatching donor-to-recipient size according to PHM was associated with higher posttransplant mortality, specifically in patients with normal weight, overweight, or class II obesity and in patients with elevated pretransplant PVR. Overmatching donor-to-recipient size was not associated with posttransplant survival.
Collapse
Affiliation(s)
- Ran Tao
- Department of Medicine, University of Wisconsin-Madison, Madison
| | - Timothy M. Hess
- Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison
| | - Adam Kuchnia
- Department of Nutritional Sciences, College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison
| | - Joshua Hermsen
- Division of Cardiothoracic Surgery, University of Wisconsin-Madison, Madison
| | - Farhan Raza
- Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison
| | - Ravi Dhingra
- Division of Cardiovascular Medicine, University of Wisconsin-Madison, Madison
| |
Collapse
|
5
|
Frequency, Risk Factors, and Clinical Outcomes of Late-Onset Atrial Flutter in Patients after Heart Transplantation. J Cardiovasc Dev Dis 2022; 9:jcdd9100337. [PMID: 36286289 PMCID: PMC9604694 DOI: 10.3390/jcdd9100337] [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: 09/11/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 11/23/2022] Open
Abstract
Aims: Atrial flutter (AFL) is a common late-onset complication after heart transplantation (HTX) and is associated with worse clinical outcomes. Methods: This study investigated the frequency, risk factors, and outcomes of late-onset post-transplant AFL. We analyzed 639 adult patients undergoing HTX at the Heidelberg Heart Center between 1989 and 2019. Patients were stratified by diagnosis and type of late-onset post-transplant AFL (>90 days after HTX). Results: A total of 55 patients (8.6%) were diagnosed with late-onset post-transplant AFL, 30 had typical AFL (54.5%) and 25 had atypical AFL (45.5%). Patients with AFL were younger at HTX (p = 0.028), received more biatrial anastomosis (p = 0.001), and presented with moderate or severe tricuspid regurgitation (56.4%). Typical AFL was associated with graft rejection (p = 0.016), whereas atypical AFL was associated with coronary artery disease (p = 0.028) and stent implantation (p = 0.042). Patients with atypical AFL showed a higher all-cause 1-year mortality (p = 0.010) along with a higher rate of graft failure after diagnosis of AFL (p = 0.023). Recurrence of AFL was high (83.6%). Patients with catheter ablation after AFL recurrence had a higher 1-year freedom from AFL (p = 0.003). Conclusions: Patients with late-onset post-transplant AFL were younger at HTX, received more biatrial anastomosis, and showed a higher rate of moderate or severe tricuspid regurgitation. Typical AFL was associated with graft rejection, whereas atypical AFL was associated with myocardial ischemia, graft failure, and mortality. Catheter ablation represents a viable option to avoid further episodes of late-onset AFL after HTX.
Collapse
|
6
|
Outcome and Midterm Survival after Heart Transplantation Is Independent from Donor Length of Stay in the Intensive Care Unit. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071053. [PMID: 35888141 PMCID: PMC9325071 DOI: 10.3390/life12071053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/10/2022] [Accepted: 07/10/2022] [Indexed: 11/17/2022]
Abstract
Prolonged treatment of organ donors in the intensive care unit (ICU) may be associated with complications influencing the outcome after heart transplantation (HTx). We therefore aim to explore the potential impact of the donor length of stay (LOS) in the ICU on outcomes in our cohort. We included all patients undergoing HTx in our center between September 2010 and April 2022 (n = 241). Recipients were divided around the median into three groups regarding their donor LOS in the ICU: 0 to 3 days (≤50th percentile, n = 92), 4 to 7 days (50th–75th percentile, n = 80), and ≥8 days (≥75th percentile, n = 69). Donor LOS in the ICU ranged between 0 and 155 days (median 4, IQR 3–8 days). No association between the LOS in the ICU and survival after HTx was observed (AUC for overall survival 0.514). Neither the Kaplan–Meier survival analysis up to 5 years after HTx (Log-Rank p = 0.789) nor group comparisons showed significant differences. Baseline recipient characteristics were comparable between the groups, while the donor baselines differed in some parameters, such as less cardiopulmonary resuscitation prior to HTx in those with a prolonged LOS. However, regarding the recipients’ peri- and postoperative parameters, the groups did not differ in all of the assessed parameters. Thus, in this retrospective analysis, although the donors differed in baseline parameters, the donor LOS in the ICU was not associated with altered recipient survival or outcome after HTx.
Collapse
|
7
|
Rivinius R, Gralla C, Helmschrott M, Darche FF, Ehlermann P, Bruckner T, Sommer W, Warnecke G, Kopf S, Szendroedi J, Frey N, Kihm LP. Pre-transplant Type 2 Diabetes Mellitus Is Associated With Higher Graft Failure and Increased 5-Year Mortality After Heart Transplantation. Front Cardiovasc Med 2022; 9:890359. [PMID: 35757347 PMCID: PMC9218221 DOI: 10.3389/fcvm.2022.890359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022] Open
Abstract
Aims Cardiac transplant recipients often suffer from type 2 diabetes mellitus (T2DM) but its influence on graft failure and post-transplant mortality remains unknown. The aim of this study was to investigate the long-term effects of pre-transplant T2DM in patients after heart transplantation (HTX). Methods This study included a total of 376 adult patients who received HTX at Heidelberg Heart Center between 01/01/2000 and 01/10/2016. HTX recipients were stratified by diagnosis of T2DM at the time of HTX. Patients with T2DM were further subdivided by hemoglobin A1c (HbA1c ≥ 7.0%). Analysis included donor and recipient data, immunosuppressive drugs, concomitant medications, post-transplant mortality, and causes of death. Five-year post-transplant mortality was further assessed by multivariate analysis (Cox regression) and Kaplan–Meier estimator. Results About one-third of all HTX recipients had T2DM (121 of 376 [32.2%]). Patients with T2DM showed an increased 5-year post-transplant mortality (41.3% versus 29.8%; P = 0.027) and had a higher percentage of death due to graft failure (14.9% versus 7.8%; P = 0.035). Multivariate analysis showed T2DM (HR: 1.563; 95% CI: 1.053–2.319; P = 0.027) as an independent risk factor for 5-year mortality after HTX. Kaplan–Meier analysis showed a significantly better 5-year post-transplant survival of patients with T2DM and a HbA1c < 7.0% than patients with T2DM and a HbA1c ≥ 7.0% (68.7% versus 46.3%; P = 0.008) emphasizing the clinical relevance of a well-controlled T2DM in HTX recipients. Conclusion Pre-transplant T2DM is associated with higher graft failure and increased 5-year mortality after HTX.
Collapse
Affiliation(s)
- Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
- Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research, Heidelberg, Germany
- *Correspondence: Rasmus Rivinius,
| | - Carolin Gralla
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabrice F. Darche
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
- Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
- Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research, Heidelberg, Germany
| | - Tom Bruckner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
- Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research, Heidelberg, Germany
| | - Lars P. Kihm
- Department of Internal Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| |
Collapse
|
8
|
Oehler D, Bruno RR, Holst HT, Aubin H, Tudorache I, Akhyari P, Westenfeld R, Kelm M, Lichtenberg A, Boeken U. Ischemic Versus Nonischemic Recipient Indication Does Not Impact Outcome After Heart Transplantation. EXP CLIN TRANSPLANT 2022; 20:580-584. [DOI: 10.6002/ect.2022.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Heil KM, Helmschrott M, Darche FF, Bruckner T, Ehlermann P, Kreusser MM, Doesch AO, Sommer W, Warnecke G, Frey N, Rivinius R. Risk Factors, Treatment and Prognosis of Patients with Lung Cancer after Heart Transplantation. Life (Basel) 2021; 11:life11121344. [PMID: 34947875 PMCID: PMC8707242 DOI: 10.3390/life11121344] [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: 11/01/2021] [Revised: 11/21/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022] Open
Abstract
Long-term survival after heart transplantation (HTX) is impacted by adverse effects of immunosuppressive pharmacotherapy, and post-transplant lung cancer is a common occurrence. This study aimed to examine the risk factors, treatment, and prognosis of patients with post-transplant lung cancer. We included 625 adult patients who received HTX at Heidelberg Heart Center between 1989 and 2018. Patients were stratified by diagnosis and staging of lung cancer after HTX. Analysis comprised donor and recipient characteristics, medications including immunosuppressive drugs, and survival after diagnosis of lung cancer. A total of 41 patients (6.6%) were diagnosed with lung cancer after HTX, 13 patients received curative care and 28 patients had palliative care. Mean time from HTX until diagnosis of lung cancer was 8.6 ± 4.0 years and 1.8 ± 2.7 years from diagnosis of lung cancer until last follow-up. Twenty-four patients (58.5%) were switched to an mTOR-inhibitor after diagnosis of lung cancer. Multivariate analysis showed recipient age (HR: 1.05; CI: 1.01-1.10; p = 0.02), COPD (HR: 3.72; CI: 1.88-7.37; p < 0.01), and history of smoking (HR: 20.39; CI: 2.73-152.13; p < 0.01) as risk factors for post-transplant lung cancer. Patients in stages I and II had a significantly better 1-year (100.0% versus 3.6%), 2-year (69.2% versus 0.0%), and 5-year survival (53.8% versus 0.0%) than patients in stages III and IV (p < 0.01). Given the poor prognosis of late-stage post-transplant lung cancer, routine reassessment of current smoking status, providing smoking cessation support, and intensified lung cancer screening in high-risk HTX recipients are advisable.
Collapse
Affiliation(s)
- Karsten M. Heil
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
| | - Fabrice F. Darche
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Michael M. Kreusser
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Andreas O. Doesch
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- Department of Pneumology and Oncology, Asklepios Hospital, 36433 Bad Salzungen, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (W.S.); (G.W.)
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (W.S.); (G.W.)
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.M.H.); (M.H.); (F.F.D.); (P.E.); (M.M.K.); (A.O.D.); (N.F.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-56-8676; Fax: +49-6221-56-5515
| |
Collapse
|
10
|
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.
Collapse
|
11
|
Darche FF, Helmschrott M, Rahm AK, Thomas D, Schweizer PA, Bruckner T, Ehlermann P, Kreusser MM, Warnecke G, Frey N, Rivinius R. Atrial fibrillation before heart transplantation is a risk factor for post-transplant atrial fibrillation and mortality. ESC Heart Fail 2021; 8:4265-4277. [PMID: 34453484 PMCID: PMC8497346 DOI: 10.1002/ehf2.13552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/14/2021] [Accepted: 07/26/2021] [Indexed: 01/10/2023] Open
Abstract
AIMS Atrial fibrillation (AF) after heart transplantation (HTX) is associated with worse clinical outcomes. The current study aimed to analyse the association between AF before HTX and AF within 30 days after HTX. METHODS AND RESULTS This study included 639 adults who received HTX at Heidelberg Heart Center. Patients were subdivided into four groups depending on the status of AF before and after HTX. Analyses comprised recipient and donor data, medication, echocardiographic features, permanent pacemaker implantation, stroke, and mortality after HTX. Three hundred thirty-two patients (52.0%) had neither AF before nor after HTX, 15 patients (2.3%) had no AF before HTX but showed AF after HTX, 219 patients (34.3%) showed AF before HTX but had no AF after HTX, and 73 patients (11.4%) had AF before and after HTX. Patients with AF before and after HTX had a higher 1 year post-transplant mortality (39.7%) than patients without AF before or after HTX (18.1%, P < 0.01). Secondary outcomes showed a higher percentage of enlarged atria, ventricular dysfunction, mitral regurgitation, 1-year stroke, and 1-year permanent pacemaker implantation in patients with AF before and after HTX. Multivariate analysis revealed a six-fold elevated risk for post-transplant AF in patients with AF before HTX (hazard ratio: 6.59, confidence interval: 3.72-11.65; P < 0.01). Further risk factors for post-transplant AF were higher donor age and prolonged ischaemic time, whereas total orthotopic HTX was associated with a two-fold lower risk for post-transplant AF. CONCLUSIONS Atrial fibrillation before HTX is a risk factor for post-transplant AF, permanent pacemaker implantation, and mortality after HTX.
Collapse
Affiliation(s)
- Fabrice F Darche
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Ann-Kathrin Rahm
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Patrick A Schweizer
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| |
Collapse
|
12
|
Transcatheter mitral valve repair may increase eligibility for heart transplant listing in patients with end-stage heart failure and severe secondary mitral regurgitation. Int J Cardiol 2021; 338:72-78. [PMID: 34157353 DOI: 10.1016/j.ijcard.2021.06.031] [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: 10/12/2020] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Heart transplantation remains the gold standard for treatment of patients with end-stage heart failure and severely reduced ejection fraction (HFrEF). An increased pulmonary vascular resistance (PVR), which is often prevalent in HFrEF patients with secondary mitral regurgitation (SMR), limits the eligibility for transplantation. Therefore, we evaluated whether transcatheter mitral valve repair (TMVr) improves pulmonary circulatory hemodynamics and increases the eligibility for transplantation in end-stage HFrEF patients with severe SMR. METHODS We retrospectively analysed the hemodynamics by right heart catheterization (RHC) as well as laboratory and clinical outcomes of end-stage HFrEF patients with SMR that underwent TMVr. RESULTS Seventeen patients (age: 55 ± 10 yrs) underwent TMVr and repeat RHC at a mean follow-up of 5.7 ± 7.9 months. TMVr decreased PVR (3.5 ± 2.2 to 2.3 ± 1.2 wood units, p = 0.02) and systolic pulmonary artery pressure (55.4 ± 15 mmHg to 45.6 ± 9.8 mmHg, p = 0.02) from baseline to follow-up, respectively, while cardiac output was increased (3.7 ± 0.9 l/min to 4.6 ± 1.3 l/min, p = 0.02). In addition, transpulmonary gradient decreased significantly (12.0 ± 7.5 mmHg to 9.7 ± 5.3 mmHg, p = 0.04). The prevalence of New York Heart Association functional class ≥III at follow-up was reduced from 88% (15/17 patients) to 47% (8/17 patients, p = 0.01). All five patients with initially too high PVR (>3.5 WU) showed a significant decrease in PVR and three of them became potential candidates for heart transplantation after TMVr. CONCLUSION TMVr is associated with reduction in PVR which may increase eligibility for transplantation in some HFrEF patients with severe SMR.
Collapse
|
13
|
Rivinius R, Helmschrott M, Ruhparwar A, Schmack B, Darche FF, Thomas D, Bruckner T, Doesch AO, Katus HA, Ehlermann P. Elevated pre-transplant pulmonary vascular resistance is associated with early post-transplant atrial fibrillation and mortality. ESC Heart Fail 2021; 7:176-187. [PMID: 32197001 PMCID: PMC7083465 DOI: 10.1002/ehf2.12549] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/16/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Severely elevated pre-transplant pulmonary vascular resistance (PVR) has been linked to adverse effects after heart transplantation (HTX). The impact of a moderately increased PVR before HTX on post-transplant outcomes remains uncertain. The aim of this study was to investigate the effects of an elevated pre-transplant PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) on outcomes after HTX. METHODS AND RESULTS This observational retrospective single-centre study included 561 patients receiving HTX at Heidelberg Heart Center between 1989 and 2015. Patients were stratified by degree of pre-transplant PVR. Analyses covered demographics, post-transplant medication, mortality and causes of death after HTX, early post-transplant atrial fibrillation (AF), and length of the initial hospital stay after HTX. Ninety-four patients (16.8%) had a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units). These patients had a higher rate of early post-transplant AF [20.2 vs. 10.7%, difference: 9.5%, 95% confidence interval (CI): 0.9-18.1%, P = 0.01] and an increased 30 day post-transplant mortality (25.5 vs. 6.4%, hazard ratio: 4.4, 95% CI: 2.6-7.6, P < 0.01), along with a higher percentage of death due to transplant failure (21.2 vs. 4.1%, difference: 17.1%, 95% CI: 8.7-25.5%, P < 0.01). Multivariate analysis revealed a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) as a significant risk factor for increased 30 day mortality after HTX (hazard ratio: 4.4, 95% CI: 2.5-7.6, P < 0.01). Kaplan-Meier estimator showed a lower 2 year survival after HTX (P < 0.01) in patients with a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units). CONCLUSIONS Elevated pre-transplant PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) is associated with early post-transplant AF and increased mortality after HTX.
Collapse
Affiliation(s)
- Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabrice F Darche
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Andreas O Doesch
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Department of Pneumology and Oncology, Asklepios Hospital, Bad Salzungen, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| |
Collapse
|
14
|
Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
Collapse
Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
| |
Collapse
|