Peripheral vascular involvement in heart transplant patients

Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association

Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.

Complex interventions in the failing heart

PURPOSE OF REVIEW

Heart failure is a complex clinical syndrome with a substantial disease burden. We aim to review the interventional aspects of management of advanced heart failure, focusing on the role of management of coronary artery disease, valvular heart disease, and mechanical circulatory support.

RECENT FINDINGS

The patients with coronary artery disease and heart failure requiring revascularization are at higher risk than the rest of the general population. Coronary artery bypass grafting or percutaneous intervention can be used depending on varied patient characteristics and coronary anatomy. Transcatheter aortic valve implantation, Mitraclip and transcatheter ventricular restoration help in tackling the valvular and left ventricular remodeling concerns often seen in this patient population. Temporary hemodynamic circulatory support helps stabilizing patients in cardiogenic shock while long-term support can help bridge them to more definitive therapies.

SUMMARY

The management strategies in this disease state are ever evolving with robust evidence coming in support of interventional therapies whenever deemed appropriate. It is the multidisciplinary patient-centered approach, which yields maximum benefit out of these complex interventions.

Effect of peripheral vascular disease on mortality in cardiac transplant recipients (from the United Network of Organ Sharing Database)

Peripheral vascular disease (PVD) portends increased morbidity and mortality in patients with heart failure. In those with advanced heart failure, heart transplantation (HT) is the only causative therapy to increase survival. However, little is known about the impact of symptomatic PVD on survival of HT recipients in large multicenter cohorts. The aim of this study was to investigate an association between recipient symptomatic PVD and survival after HT. We analyzed 20,297 patients from the United Network of Organ Sharing data set. Survival analysis using a control cohort established by propensity matching was performed. There was an increased prevalence of traditional cardiovascular risk factors in 711 patients with symptomatic PVD compared with 19,586 patients without PVD. Patients with pretransplant symptomatic PVD had increased post-transplant mortality compared with those without PVD (1-, 5- and 10-year survival rate 91.5% vs 94.9%, 74.8% vs 82.6%, 48.6% vs 54.7%, respectively, log-rank p<0.001). On multivariate analysis based on the propensity matching, factors associated with a lower survival rate were presence of PVD (hazard ratio 1.20, 95% confidential interval 1.02 to 1.42, p=0.030), and female gender (hazard ratio 1.22, 95% confidence interval 1.02 to 1.47, p=0.034). In conclusion, patients with symptomatic PVD have a lower survival rate after HT. Symptomatic PVD should be considered an independent risk factor for poor prognosis in patients undergoing HT evaluation.

Characteristics of extracoronary vascular disease in heart transplant recipient

BACKGROUND

Heart transplant candidates carry many of risk factors for vascular disease, and in addition, recipients continue to accumulate them following heart transplantation (HTx). However, very limited information is available on this entity. This study was designed to address characteristics of extracoronary vascular disease in heart transplant recipients.

METHODS

This is a nonconcurrent cohort study of 402 patients who received HTx at the University of Washington between 1985 and 2004. Pretransplant arterial evaluation included carotid, lower extremity, and renal artery duplex studies. CT angiogram was obtained when indicated. Patients with severe arterial disease were excluded from the transplant list. Posttransplant vascular evaluation was done with the patient's history and physical examination.

RESULTS

Median follow-up was 5.5 years. Seventy vascular diseases were detected in 49 patients (12% of study population). Patients with pretransplant vascular disease, compared to those without, were older at the HTx, carried the diagnosis of ischemic cardiomyopathy more commonly, and had more comorbidities including history of smoking, alcohol drinking, chronic obstructive pulmonary disease, and prior heart operations. The prevalence of vascular disease was 6% prior to HTx and it cumulatively increased up to 17% at 17 years after HTx. Nineteen percent of these diseases were the result of arterial traumas mostly caused by medical interventions. Fourteen patients developed abdominal aortic aneurysm (AAA) with two deaths.

CONCLUSIONS

It is important for care providers to be aware of the high probability of vascular disease, to be familiar with vascular disease, and to provide appropriate prophylactic and therapeutic measures when evaluating this patient population.

The transplant recipient for nontransplant surgery

The transplant recipient has traded a life-threatening illness for a chronically immunosuppressed state. Subsequent anesthetic management for non-transplant surgical procedures may be challenging. The anesthesia provider must be aware of the degree of post-transplant organ dysfunction and alter anesthesia techniques accordingly. This article reviews the anesthetic concerns for patients who have undergone a variety of organ transplants.

Extramediastinal surgical problems in heart transplant recipients

BACKGROUND

As heart transplantation has gained wide acceptance, a growing number of recipients are at risk of experiencing extramediastinal surgical problems.

STUDY DESIGN

We retrospectively reviewed our experience in the diagnosis and management of surgical problems occurring in 94 consecutive patients having heart transplantation. During the period of the study, we progressively adopted a policy of low-level immunosuppression, aiming toward monotherapy with cyclosporine.

RESULTS

Seventy-four extramediastinal surgical problems developed in 44 of 94 patients (47%). The type of problems were gastrointestinal in 17 of 74 (23%), vascular in 13 of 74 (17.5%), urogenital in 8 of 74 (11%), and neurologic in 4 of 74 (5.5%). There were also 9 of 74 cases of trauma (12%), 9 of 74 skin tumors (12%), and 14 of 74 miscellaneous diseases (19%). Sixty-two surgical diseases occurring in 40 patients required 75 surgical interventions, 11 of them (15%) on an emergency basis. Operations were performed for 12 of 74 neoplasms (16%) and 12 of 74 infectious or potentially infectious diseases (16%). Surgical diseases occurred most commonly within the first 6 months after transplantation (20 of 74; 27%). Complications occurred in 8 of 75 surgical interventions (9%). A high proportion of surgical disease was potentially related to immunosuppressive therapy (37 of 74; 50%) or to transplantation itself (7 of 74; 9%).

CONCLUSIONS

Extramediastinal diseases after heart transplantation involve most surgical specialties. Most of them are potentially linked with either the immunosuppressive therapy or the transplantation procedure, supporting our low-level immunosuppression policy. Expectant management is not justified in this population, who withstands operations well both early and late after transplantation.

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation

OBJECTIVE

The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported.

SUMMARY BACKGROUND DATA

Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published.

METHODS

A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported.

RESULTS

Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities.

CONCLUSIONS

Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Prospective evaluation of peripheral vascular disease in heart transplant recipients

PURPOSE

Retrospective reviews suggest that the progression of peripheral vascular disease (PVD) may be accelerated in heart transplant recipients. This study was undertaken to determine the incidence and to identify those risk factors that may be associated with the development or progression of PVD in these patients.

METHODS

Between January 1990 and December 1993 a prospective vascular screening protocol including abdominal ultrasonography, Doppler-derived ankel-brachial pressure indexes (ABI), and carotid artery duplex imaging was added to the routine preoperative and annual postoperative evaluation of 239 heart transplant recipients.

RESULTS

Thirty-one significant vascular lesions were detected in 10% (24 of 239) of patients 52 +/- 9 years of age at a mean of 3.2 years after transplant. The distribution of lesions included carotid artery stenosis (11), femoropopliteal occlusive disease (10), aortoiliac occlusive disease (five), aortic aneurysm (four), and renal artery stenosis in one patient. Revascularization procedures were performed in 12 (50%) patients (carotid endarterectomy (four), aortobifemoral bypass grafting (three), abdominal aortic aneurysm repair (two), transluminal angioplasty (two), splenorenal bypass (one), and femorotibial bypass grafting (one)). One patient with diabetes mellitus (DM) was found to have noncompressible vessels during pretransplant evaluation. An additional 26 patients (11%), seven with DM, had noncompressible vessels in the lower extremities during the follow-up period. Logistic regression analysis revealed that the development of posttransplant PVD was associated with smoking (p < 0.05) and ischemic cardiomyopathy as an indication for transplantation (p < 0.05). The development of noncompressible vessels was associated with younger age (p < 0.05) and the presence of diabetes (p < 0.05).

CONCLUSION

Posttransplant peripheral vascular disease occurred in 10% of heart transplant recipients and is associated with pretransplant ischemic cardiomyopathy and smoking. A previously unrecognized subgroup of patients who have noncompressible vessels after operation is described. If the long-term survival of the heart transplant recipient is to be improved, routine follow-up to identify and treat those patients at greater risk appears justified.