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M’Pembele R, Roth S, Jenkins F, Hettlich V, Nucaro A, Stroda A, Tenge T, Polzin A, Ramadani B, Lurati Buse G, Aubin H, Lichtenberg A, Huhn R, Boeken U. Association between early postoperative hypoalbuminaemia and outcome after orthotopic heart transplantation. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae012. [PMID: 38230700 PMCID: PMC10827358 DOI: 10.1093/icvts/ivae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/20/2023] [Accepted: 01/13/2024] [Indexed: 01/18/2024]
Abstract
OBJECTIVES In patients undergoing heart transplantation (HTX), preoperative liver impairment and consecutive hypoalbuminaemia are associated with increased mortality. The role of early postoperative hypoalbuminaemia after HTX is unclear. This study investigated the association between early postoperative hypoalbuminaemia and 1-year mortality as well as 'days alive and out of hospital' (DAOH) after HTX. METHODS This retrospective cohort study included patients who underwent HTX at the University Hospital Duesseldorf, Germany, between 2010 and 2022. The main exposure was serum albumin concentration at intensive care unit (ICU) arrival. The primary endpoints were mortality and DAOH within 1 year after surgery. Receiver operating characteristic (ROC) curve analysis was performed and logistic and quantile regression models with adjustment for 13 a priori defined clinical risk factors were conducted. RESULTS Out of 241 patients screened, 229 were included in the analysis (mean age 55 ± 11 years, 73% male). ROC analysis showed moderate discrimination for 1-year mortality by postoperative serum albumin after HTX [AUC = 0.74; 95% confidence interval (CI): 0.66-0.83]. The cutoff for serum albumin at ICU arrival was 3.0 g/dl. According to multivariate logistic and quantile regression, there were independent associations between hypoalbuminaemia and mortality/DAOH [odds ratio of 4.76 (95% CI: 1.94-11.67) and regression coefficient of -46.97 (95% CI: -83.81 to -10.13)]. CONCLUSIONS Postoperative hypoalbuminaemia <3.0 g/dl is associated with 1-year mortality and reduced DAOH after HTX and therefore might be used for early postoperative risk re-assessment in clinical practice.
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Affiliation(s)
- René M’Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Freya Jenkins
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Vincent Hettlich
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Anthony Nucaro
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Theresa Tenge
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Bedri Ramadani
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Amsterdam, Netherlands
| | - Udo Boeken
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
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Fiorentino M, Loforte A, Murana G, Gliozzi G, Cavalli GG, Santamaria V, Mariani C, Botta L, Martin-Suarez S, Potena L, Pacini D. Effect of Preoperative Right Ventricular Dysfunction on Heart Transplantation Outcomes. Transplant Proc 2023; 55:199-207. [PMID: 36577636 DOI: 10.1016/j.transproceed.2022.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/15/2022] [Accepted: 09/20/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated if the occurrence of preoperative right ventricular dysfunction is capable of influencing heart transplant results in terms of in-hospital mortality, incidence of primary graft dysfunction, and follow-up mortality. METHODS We retrospectively analyzed 517 patients who underwent heart transplant between January 2000 and December 2020. We defined right ventricular dysfunction (RVD), as central venous pressure (CVP) > 15 mm Hg and CVP/pulmonary capillary wedge pressure ratio > 0.63. We identified 2 subgroups in our population: 33 patients with preoperative RVD and 484 patients without RVD. RESULTS In-hospital mortality was 7.9%. Severe early graft failure occurred in 6.6% of patients, with 26 patients (5.1%) needing intra-aortic balloon pump and 17 patients (3.3%) needing extracorporeal membrane oxygenation support. Clinical variables that significantly influenced in-hospital mortality were age, peripheral artery disease, and bilirubin > 1.5 mg/dL, while hemodynamic variables influencing in-hospital mortality were CVP (odds ratio [OR], 1.09 [confidence interval {CI}, 1.03-1.15], P = .004], pulmonary artery systolic pressure (OR, 1.02 [CI, 1.00-1.04], P = .05), CVP/pulmonary capillary wedge pressure ratio (OR, 2.78 [CI, 1.14-6.80], P = .025), pulmonary vascular resistance (OR, 1.15 [CI, 1.01-1.32], P = .042), transpulmonary gradient (TPG) (OR, 1.11 [CI, 1.03-1.18], P = .003) , diastolic transpulmonary gradient (OR, 1.10 [CI, 1.02-1.20], P = .015], together with right ventricular dysfunction (OR, 3.56 [CI, 1.44-8.80], P = .011). On the other hand, clinical variables influencing the incidence of early graft failure were body mass index (calculated as weight in kilograms divided by height in meters squared) > 30, peripheral artery disease, bilirubin > 1.5 mg/dL, Model for End-Stage Liver Disease score excluding international normalized ratio before transplant, and preoperative extracorporeal membrane oxygenation support, while hemodynamic variables were pulmonary arterial systolic pressure (OR, 1.03 [CI, 1.00-1.05], P = .016), TPG (OR, 1.08 [1.01-1.17], P = .03), and right ventricular dysfunction (OR, 3.00 [CI, 1.07-8.40] P = .046). On the multivariable analysis, RVD and TPG were independent predictors of in-hospital mortality, while only TPG was a predictor of early graft failure. Follow-up mortality was 38.7% and was influenced by recipient age, recipient body mass index, and preoperative diabetes. Moreover, 1-, 5-, and 10-year survival of patients with preoperative RVD was significantly worse than patients without RVD (log-rank = 0.001). CONCLUSIONS In our population, RVD influenced both in-hospital and long-term results after heart transplant. For these reasons, it appears crucially important to optimize preoperative right ventricular function to improve these patients' outcomes.
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Affiliation(s)
- Mariafrancesca Fiorentino
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy.
| | - Antonio Loforte
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Valeria Santamaria
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Carlo Mariani
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Luca Botta
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Sofia Martin-Suarez
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Luciano Potena
- Division of Cardiology, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, Bologna, Italy
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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4
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Leven EA, Kurdi AT, Govindarajulu U, Schiano T, Pinney S, Crismale JF. Child-Turcotte-Pugh versus MELD-XI identify distinct high-risk populations for heart transplantation following ventricular assist device placement. Clin Transplant 2022; 36:e14617. [PMID: 35191097 DOI: 10.1111/ctr.14617] [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: 10/05/2021] [Revised: 01/05/2022] [Accepted: 02/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with end-stage heart failure frequently have significant congestive hepatopathy requiring hepatology assessment prior to heart transplantation listing. An elevated Model for End-stage Liver Disease score with modification to exclude INR (MELD-XI) has been associated with increased mortality following heart transplantation (HT). This study's primary aim was to examine whether Child-Turcotte-Pugh (CTP) classification is associated with post-transplant mortality in patients bridged to transplant with left ventricular assist devices. METHODS AND RESULTS We conducted a retrospective analysis of 134 patients from our center. Age, CTP class, and MELD-XI at HT were included in the multivariate model for the primary outcome, which demonstrated a significant association between 1-year mortality and CTP class (CTP-A HR: .08, CI .01-.46, P < .01; CTP-B HR: .25, CI .05-1.2, P = .08; reference group CTP-C), and MELD-XI (HR: 1.15; CI: 1.03-1.28; P = .01), but no significant difference for age (HR: .97; CI: .93-1.01; P = .15). Only 13/33 patients with CTP improvement after assist device also had improvement in MELD-XI. CONCLUSIONS Patients with relatively low MELD-XI scores with discordantly high CTP classification may be a distinct subset for whom MELD-XI underestimates the risk of mortality after heart transplantation compared to CTP.
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Affiliation(s)
- Emily A Leven
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed T Kurdi
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Usha Govindarajulu
- Center for Biostatistics, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Pinney
- Department of Medicine, Division of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - James F Crismale
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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6
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Karnib M, Haraf R, Tashtish N, Zanath E, Elshazly T, Garcia RA, Billings S, Fetros M, Bradigan A, Zacharias M, Abu-Omar Y, Elgudin Y, Pelletier M, Al-Kindi S, Lytle F, ElAmm C. MELD score is predictive of 90-day mortality after veno-arterial extracorporeal membrane oxygenation support. Int J Artif Organs 2021; 45:404-411. [PMID: 34702105 DOI: 10.1177/03913988211054865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease (MELD) score was originally described as a marker of survival in chronic liver disease. More recently, MELD and its derivatives, MELD excluding INR (MELD-XI) and MELD with sodium (MELD-Na), have been applied more broadly as outcome predictors in heart transplant, left ventricular assist device placement, heart failure, and cardiogenic shock, with additional promising data to support the use of these scores for prediction of survival in those undergoing veno-arterial extracorporeal membrane oxygenation (VA ECMO). METHODS This study assessed the prognostic impact of MELD in patients with cardiogenic shock undergoing VA ECMO via a single-center retrospective review from January 2014 to March 2020. MELD, MELD-XI, and MELD-Na scores were calculated using laboratory values collected within 48 h of VA ECMO initiation. Multivariate Cox regression analyses determined the association between MELD scores and the primary outcome of 90-day mortality. Receiver operating characteristics (ROC) were used to estimate the discriminatory power for MELD in comparison with previously validated SAVE score. RESULTS Of the 194 patients, median MELD was 20.1 (13.7-26.2), and 90-day mortality was 62.1%. There was a significant association between MELD score and mortality up to 90 days (hazard ratio (HR) = 1.945, 95% confidence interval (95% CI) = 1.244-3.041, p = 0.004) after adjustment for age, indication for VA ECMO, and sex. The prognostic significance of MELD score for 90-day mortality revealed an AUC of 0.645 (95% CI = 0.565-0.725, p < 0.001). MELD-Na score and MELD-XI score were not associated with mortality. CONCLUSION MELD score accurately predicts long-term mortality and may be utilized as a valuable decision-making tool in patients undergoing VA ECMO.
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Affiliation(s)
- Mohamad Karnib
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rebecca Haraf
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nour Tashtish
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Erica Zanath
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Tarek Elshazly
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Raul Angel Garcia
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO, USA
| | - Scott Billings
- Enterprise Data Services Department, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael Fetros
- Enterprise Data Services Department, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Allison Bradigan
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael Zacharias
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yasir Abu-Omar
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yakov Elgudin
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Marc Pelletier
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sadeer Al-Kindi
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Francis Lytle
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Chantal ElAmm
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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7
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Naghashzadeh F, Noorali S, Hosseini-Baharanchi FS, Shafaghi S, Sharif-Kashani B, Ahmadi ZH, Keshmiri MS. Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients. EXP CLIN TRANSPLANT 2021; 19:963-969. [PMID: 34545779 DOI: 10.6002/ect.2020.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. MATERIALS AND METHODS Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. RESULTS Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). CONCLUSIONS Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.
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Affiliation(s)
- Farah Naghashzadeh
- From the Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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8
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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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Coutance G, Kransdorf E, Bonnet G, Loupy A, Kobashigawa J, Patel JK. Statistical performance of 16 posttransplant risk scores in a contemporary cohort of heart transplant recipients. Am J Transplant 2021; 21:645-656. [PMID: 32713121 DOI: 10.1111/ajt.16217] [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: 05/26/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 01/25/2023]
Abstract
Accurate risk stratification of early heart transplant failure is required to avoid futile transplants and rationalize donor selection. We aimed to evaluate the statistical performance of existing risk scores on a contemporary cohort of heart transplant recipients. After an exhaustive search, we identified 16 relevant risk scores. From the UNOS database, we selected all first noncombined adult heart transplants performed between 2014 and 2017 for validation. The primary endpoint was death or retransplant during the first year posttransplant. For all scores, we analyzed their association with outcomes, sensitivity, specificity, likelihood ratios, and discrimination (concordance index and overlap of individual scores). The cohort included 9396 patients. All scores were significantly associated with the primary outcome (P < .001 for all scores). Their likelihood ratios, both negative and positive, were poor. The discriminative performance of all scores was limited, with concordance index ranging from 0.544 to 0.646 (median 0.594) and an important overlap of individual scores between patients with or without the primary endpoint. Subgroup analyses revealed important variation in discrimination according to donor age, recipient age, and the type of assist device used at transplant. Our findings raise concerns about the use of currently available scores in the clinical field.
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Affiliation(s)
- Guillaume Coutance
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA.,Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Evan Kransdorf
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Guillaume Bonnet
- Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
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10
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Murana G, Fiorentino M, Gliozzi G, Di Marco L, Potena L, Martin Suarez S, Pacini D, Loforte A. Donor risk analysis and validation in heart transplants: a single-centre experience. Interact Cardiovasc Thorac Surg 2020; 31:860-867. [PMID: 33155036 DOI: 10.1093/icvts/ivaa207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES A heart transplant (Htx) remains the gold standard treatment for patients with advanced heart failure. Considering the limited availability of organs, donor risk scores might improve organ selection and allocation. The objective of the study was to compare United Network for Organ Sharing, RADIAL and Eurotransplant scoring models in calculating post-Htx outcomes in an Italian Htx population. METHODS Between January 2000 and December 2017, a total of 461 adult patients underwent Htxs. United Network for Organ Sharing, RADIAL and Eurotransplant scores were calculated. Clinical features and donor risk scores were tested to identify preoperative, intraoperative and postoperative risk variables and eventually validate the scores on our population. RESULTS Early graft failure was detected in 16.1% (74/461). Post-Htx extracorporeal life support was used in 11.1% (51/461). Of the donor-related factors, the use of noradrenaline (P = 0.015) negatively influenced early outcomes, whereas an ischaemic time >240 min (P = 0.037) influenced early graft failure occurrence. The Eurotransplant donor score did not impact outcomes; the RADIAL score significantly influenced both early and late mortality; and the United Network for Organ Sharing score influenced only late mortality. On the multivariable analysis, after adjustment of scores per cohort, noradrenaline infusion was the main independent predictor of in-hospital mortality for the donors, whereas age of the recipient [odds ratio (OR) 1.003, 1.003-1.081; P = 0.032] and use of preoperative extracorporeal membrane oxygenation (OR 3.320, 1.124-9.805; P = 0.030) were the main independent predictors for the recipients. CONCLUSIONS None of the validated donor scoring systems fully behave as reliable predictors of transplant outcomes. According to our 'local only' graft selection, specific donor and recipient risk variables should be monitored in order to predict early and late outcomes satisfactorily.
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Affiliation(s)
- Giacomo Murana
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Gregorio Gliozzi
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luciano Potena
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Sofia Martin Suarez
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Antonio Loforte
- Department of Cardiothoracic Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Loforte A, Fiorentino M, Murana G, Gliozzi G, Cavalli GG, Mariani C, Martin Suarez S, Pacini D. Mechanically Supported Early Graft Failure After Heart Transplantation. Transplant Proc 2020; 53:311-317. [PMID: 32768287 DOI: 10.1016/j.transproceed.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The occurrence of early graft failure (EGF) after heart transplantation (Htx) often requires a mechanical circulatory support (MCS) therapy. The aims of our study were to identify risk factors of mechanically supported severe EGF and evaluate their impact on both early and late outcomes. METHODS Between January 2000 and December 2019, 499 consecutive adult patients underwent Htx at our institution. Severe EGF was defined as the need for extracorporeal life support (ECLS) within 24 hours after surgery. All available recipient and donor variables were retrospectively analyzed. RESULTS Overall, EGF occurred in 58 (11.6%) patients. Post-Htx peripheral or central ECLS was necessary in 32 (6.4%) cases. Independent predictors of severe EGF were, in the recipient group, preoperative transpulmonary gradient (TPG) >12 mm Hg (odds ratio [OR] 4.1, P = .013), preoperative inotropic score >10 (OR 7.3, P = .0001), and pre-Htx ECLS support (OR 5.2, P = .015), while in the donors, a Eurotransplant donor score ≥17 (OR 8.5, P = .005). The absence of EGF was related with a better survival at 1 year and 5 years (94% and 85%, respectively) compared with EGF requiring ECLS population (36% and 28% at 1 year and 5 years, respectively; P < .001). A five-year conditional survival rate did not differ significantly (85% no EGF vs 83% EGF requiring ECLS). CONCLUSION Both donor and recipient factors may influence EGF occurrence. Post-Htx ECLS may impact negatively early; however, patients weaned from ECLS eventually benefit from such a rescue treatment with outcomes comparable with Htx patients who did not suffer EGF.
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Affiliation(s)
- Antonio Loforte
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy.
| | - Mariafrancesca Fiorentino
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Giacomo Murana
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Gregorio Gliozzi
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Carlo Mariani
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Sofia Martin Suarez
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
| | - Davide Pacini
- Cardio-Thorac-Vascular Department, Cardiac Surgery Unit, S. Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna University, Bologna, Italy
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