1
|
Kumar N, Fitzsimons MG, Iyer MH, Essandoh M, Kumar JE, Dalia AA, Osho A, Sawyer TR, Bardia A. Vasoplegic syndrome during heart transplantation: A systematic review and meta-analysis. J Heart Lung Transplant 2024; 43:931-943. [PMID: 38428755 DOI: 10.1016/j.healun.2024.02.1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Vasoplegic syndrome (VS) is a common occurrence during heart transplantation (HT). It currently lacks a uniform definition between transplant centers, and its pathophysiology and treatment remain enigmatic. This systematic review summarizes the available published clinical data regarding VS during HT. METHODS We searched databases for all published reports on VS during HT. Data collected included the incidence of VS in the HT population, patient and intraoperative characteristics, and postoperative outcomes. RESULTS Twenty-two publications were included in this review. The prevalence of VS during HT was 28.72% (95% confidence interval: 27.37%, 30.10%). Factors associated with VS included male sex, higher body mass index, hypothyroidism, pre-HT left ventricular assist device or venoarterial extracorporeal membrane oxygenation (VA-ECMO), pre-HT calcium channel blocker or amiodarone usage, longer cardiopulmonary bypass time, and higher blood product transfusion requirement. Patients who developed VS were more likely to require postoperative VA-ECMO support, renal replacement therapy, reoperation for bleeding, longer mechanical ventilation, and a greater 30-day and 1-year mortality. CONCLUSIONS The results of our systematic review are an initial step for providing clinicians with data that can help identify high-risk patients and avenues for potential risk mitigation. Establishing guidelines that officially define VS will aid in the precise diagnosis of these patients during HT and guide treatment. Future studies of treatment strategies for refractory VS are needed in this high-risk patient population.
Collapse
Affiliation(s)
- Nicolas Kumar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia E Kumar
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adam A Dalia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Asishana Osho
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tamara R Sawyer
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan
| | - Amit Bardia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Lamba HK, Kim M, Li M, Civitello AB, Nair AP, Simpson L, Herlihy JP, Frazier O, Rogers JG, Loor G, Liao KK, Shafii AE, Chatterjee S. Predictors and Impact of Prolonged Vasoplegia After Continuous-Flow Left Ventricular Assist Device Implantation. JACC. ADVANCES 2024; 3:100916. [PMID: 38939630 PMCID: PMC11198707 DOI: 10.1016/j.jacadv.2024.100916] [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: 12/27/2022] [Revised: 11/07/2023] [Accepted: 01/22/2024] [Indexed: 06/29/2024]
Abstract
Background Vasoplegia after cardiac surgery is associated with adverse outcomes. However, the clinical effects of vasoplegia and the significance of its duration after continuous-flow left ventricular assist device (CF-LVAD) implantation are less known. Objectives This study aimed to identify predictors of and outcomes from transient vs prolonged vasoplegia after CF-LVAD implantation. Methods The study was a retrospective review of consecutive patients who underwent CF-LVAD implantation between January 1, 2005, and December 31, 2017. Vasoplegia was defined as the presence of all of the following: mean arterial pressure ≤65 mm Hg, vasopressor (epinephrine, norepinephrine, vasopressin, or dopamine) use for >6 hours within the first 24 hours postoperatively, cardiac index ≥2.2 L/min/m2 and systemic vascular resistance <800 dyne/s/cm5, and vasodilatory shock not attributable to other causes. Prolonged vasoplegia was defined as that lasting 12 to 24 hours; transient vasoplegia was that lasting 6 to <12 hours. Patient characteristics, outcomes, and risk factors were analyzed. Results Of the 600 patients who underwent CF-LVAD implantation during the study period, 182 (30.3%) developed vasoplegia. Mean patient age was similar between the vasoplegia and no-vasoplegia groups. Prolonged vasoplegia (n = 78; 13.0%), compared with transient vasoplegia (n = 104; 17.3%), was associated with greater 30-day mortality (16.7% vs 5.8%; P = 0.02). Risk factors for prolonged vasoplegia included preoperative dialysis and elevated body mass index. Conclusions Compared with vasoplegia overall, prolonged vasoplegia was associated with worse survival after CF-LVAD implantation. Treatment to avoid or minimize progression to prolonged vasoplegia may be warranted.
Collapse
Affiliation(s)
- Harveen K. Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Mary Kim
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Meng Li
- Department of Statistics, Rice University, Houston, Texas, USA
| | - Andrew B. Civitello
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiology, The Texas Heart Institute, Houston, Texas, USA
| | - Ajith P. Nair
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiology, The Texas Heart Institute, Houston, Texas, USA
| | - Leo Simpson
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiology, The Texas Heart Institute, Houston, Texas, USA
| | - J. Patrick Herlihy
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - O.H. Frazier
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas, USA
| | - Joseph G. Rogers
- Department of Cardiology, The Texas Heart Institute, Houston, Texas, USA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas, USA
| | - Kenneth K. Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas, USA
| | - Alexis E. Shafii
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas, USA
| | - Subhasis Chatterjee
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas, USA
- Division of Trauma and Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
3
|
Qin TX, Yao YT. Vasoplegic syndrome in patients undergoing heart transplantation. Front Surg 2023; 10:1114438. [PMID: 36860952 PMCID: PMC9968842 DOI: 10.3389/fsurg.2023.1114438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023] Open
Abstract
Objectives To summarize the risk factors, onset time, and treatment of vasoplegic syndrome in patients undergoing heart transplantation. Methods The PubMed, OVID, CNKI, VIP, and WANFANG databases were searched using the terms "vasoplegic syndrome," "vasoplegia," "vasodilatory shock," and "heart transplant*," to identify eligible studies. Data on patient characteristics, vasoplegic syndrome manifestation, perioperative management, and clinical outcomes were extracted and analyzed. Results Nine studies enrolling 12 patients (aged from 7 to 69 years) were included. Nine (75%) patients had nonischemic cardiomyopathy, and three (25%) patients had ischemic cardiomyopathy. The onset time of vasoplegic syndrome varied from intraoperatively to 2 weeks postoperatively. Nine (75%) patients developed various complications. All patients were insensitive to vasoactive agents. Conclusions Vasoplegic syndrome can occur at any time during the perioperative period of heart tranplantation, especially after the discontinuation of bypass. Methylene blue, angiotensin II, ascorbic acid, and hydroxocobalamin have been used to treat refractory vasoplegic syndrome.
Collapse
Affiliation(s)
- Tong-xin Qin
- Department of Anesthesiology, Shanxian Central Hospital, Heze, China
| | - Yun-tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Correspondence: Qin T-x, Yao Y-t
| | | |
Collapse
|
4
|
Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [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: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
Collapse
Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
| |
Collapse
|
5
|
Balancing the tug of war: intraoperative and postoperative management of multiorgan transplantation. Curr Opin Organ Transplant 2022; 27:57-63. [PMID: 34939965 DOI: 10.1097/mot.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiorgan heart transplants (MOHT) have steadily increased and account for approximately 4% of all heart transplants performed. Although long-term outcomes of MOHT are similar to heart transplant alone, perioperative management remains an issue with nearly double the rate of prolonged hospitalization. Better understanding of hemodynamic environments encountered and appropriate therapeutic targets can help improve perioperative management. RECENT FINDINGS Accurate and precise hemodynamic monitoring allows for early identification of complications and prompt assessment of therapeutic interventions. This can be achieved with a multimodal approach using traditional monitoring tools, such a pulmonary artery catheter and arterial line in conjunction with transesophageal echocardiography. Specific targets for optimizing graft perfusion are determined by phase of surgery and organ combination. In some circumstances, the surgical sequence of transplant can help mitigate or avoid certain detrimental hemodynamic environments. SUMMARY With better understanding of the array of hemodynamic environments that can develop during MOHT, we can work to standardize hemodynamic targets and therapeutic interventions to optimize graft perfusion. Effectively navigating this perioperative course with multimodal monitoring including transesophageal echocardiography can mitigate impact of complications and reduce prolonged hospitalization associated with MOHT.
Collapse
|
6
|
ARNI Pre-Operative Use and Vasoplegic Syndrome in Patients Undergoing Heart Transplantation or Left Ventricular Assist Device Surgery. Med Sci (Basel) 2021; 10:medsci10010002. [PMID: 35076588 PMCID: PMC8788526 DOI: 10.3390/medsci10010002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 12/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Vasoplegic syndrome after orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation is a rare but highly lethal syndrome with complex etiologies. The objective of this study was to assess if the preoperative use of sacubitril-valsartan combination is associated with an increased vasoplegic syndrome (VS) frequency after OHT or LVAD implantation and its relationship with 30-day mortality. Methods: A retrospective review of perioperative data, between January 2016 and December 2017, from 73 consecutive OHT and LVAD surgery adult patients at our institution was performed. VS was defined as normal cardiac output with persistent low systemic resistance requiring a norepinephrine intravenous perfusion > 0.5 µg/kg/min and the absence of sepsis or hemorrhagic shock within 48 h after surgery. Patients were all followed-up for adverse events and all-cause mortality at 30 days. Results: In our cohort of 73 patients (median age 51.7 years, 65% male patients), 25 (34%) patients developed VS. Twenty-two (30.1%) patients were on ARNI at the time of surgery, 31 (42.5%) were on other RAS blockers, 12 (16.4%) were on norepinephrine and 8 (11%) had no pre-operative drug. The pre-operative use of any vasoactive agent, was not significantly associated with VS (OR = 1.36; IC95% [0.78; 2.35]; p = 0.38). The pre-operative use of an ARNI compared to all other groups was not significantly associated with VS (OR = 2.0; IC95% [0.71; 5.62]; p = 0.19). The pre-operative use of an ARNI compared to other RAS blockers was also not significantly associated with VS (OR = 1.25; IC95% [0.37; 4.26]; p = 0.72). At 30 days, 18 (24.7%) patients had died. The pre-operative treatment with ARNI, or other RAS inhibitors was associated with a significantly lower rate of death compared to the absence of treatment (HR = 0.11; IC95% [0.02; 0.55]; p = 0.009 for ARNI and HR = 0.20; IC95% [0.06; 0.69]; p = 0.011 for other RASi). Conclusions: Preoperative use of sacubitril-valsartan was not significantly associated with development of vasoplegic syndrome in patients undergoing OHT or LVAD surgery. Furthermore, our data suggests a significant 30-day survival benefit with efficient renin-angiotensin blockade before surgery.
Collapse
|
7
|
Sathianathan S, Bhat G, Dowling R. Vasoplegia from Continuous Flow Left Ventricular Assist Devices. Curr Cardiol Rep 2021; 23:101. [PMID: 34196837 DOI: 10.1007/s11886-021-01534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The contribution of continuous flow left ventricular assist devices (c-LVAD) to vasoplegic syndrome and postoperative outcomes after orthotopic heart transplant (OHT) is contested in the literature. A standardized definition of vasoplegic syndrome (VS) is needed to better recognize and manage vasoplegic shock. RECENT FINDINGS Vasoplegic syndrome occurs after orthotopic heart transplant more frequently than after other surgeries requiring cardiopulmonary bypass. c-LVADs lead to small vessel endothelial dysfunction and desensitized adrenal receptors; however, their contribution to the development of vasoplegia is debated in clinical studies. Pulsatility may mitigate vascular dysfunction resulting from long-term continuous flow, and should be further explored in the clinical setting when considering risk factors for vasoplegic syndrome. The incidence of vasoplegic syndrome after orthotopic heart transplant is rising with the increasing use of c-LVAD bridge to therapy. Robust clinical studies are needed to advance our understanding and approach to mitigating VS after OHT.
Collapse
Affiliation(s)
- Shyama Sathianathan
- School of Medicine, Penn State College of Medicine, 500 University Dr, Hershey, PA, 17033, USA.
| | - Geetha Bhat
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Robert Dowling
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
8
|
Guo P, Liu Y, Xu X, Ma G, Hou X, Fan Y, Zhang M. Coronary hypercontractility to acidosis owes to the greater activity of TMEM16A/ANO1 in the arterial smooth muscle cells. Biomed Pharmacother 2021; 139:111615. [PMID: 34243598 DOI: 10.1016/j.biopha.2021.111615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Severe acidosis deteriorates cardiac injury. Rat coronary arteries (RCAs) are unusually hypercontractive to extracellular (o) acidosis (EA). TMEM16A-encoded anoctamin 1 (ANO1), a Ca2+-activated chloride channel (CaCC), plays an important role in regulating coronary arterial tension. PURPOSE We tested the possibility that the activation of CaCCs in the arterial smooth muscle cell (ASMC) contributes to EA-induced RCA constriction. METHODS ANO1 expression was detected with immunofluorescence staining and Western blot. TMEM16A mRNA was assessed with quantitative Real-Time PCR. Cl- currents and membrane potentials were quantified with a patch clamp. The vascular tension was recorded with a myograph. Intracellular (i) level of Cl- and Ca2+ was measured with fluorescent molecular probes. RESULTS ANO1 was expressed in all tested arterial myocytes, but was much more abundant in RCA ASMCs as compared with ASMCs isolated from rat cerebral basilar, intrarenal and mesenteric arteries. EA reduced [Cl-]i levels, augmented CaCC currents exclusively in RCA ASMCs and depolarized RCA ASMCs to a greater extent. Cl- deprivation, which depleted [Cl-]i by incubating the arteries or their ASMCs in Cl--free bath solution, decreased EA-induced [Cl-]i reduction, diminished EA-induced CaCC augmentation and time-dependently depressed EA-induced RCA constriction. Inhibitor studies showed that these EA-induced effects including RCA constriction, CaCC current augmentation, [Cl-]i reduction and/or [Ca2+]i elevation were depressed by various Cl- channel blockers, [Ca2+]i release inhibitors and L-type voltage-gated Ca2+ channel inhibitor nifedipine. ANO1 antibody attenuated all observed changes induced by EA in RCA ASMCs. CONCLUSION The greater activity of RCA ASMC CaCCs complicated with an enhanced Ca2+ mobilization from both [Ca2+]i release and [Ca2+]o influx plays a pivotal role in the distinctive hypercontractility of RCAs to acidosis. Translation of these findings to human beings may lead to a new conception in our understanding and treating cardiac complications in severe acidosis.
Collapse
Affiliation(s)
- Pengmei Guo
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China
| | - Yu Liu
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China
| | - Xiaojia Xu
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China
| | - Guijin Ma
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China
| | - Xiaomin Hou
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China
| | - Yanying Fan
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China.
| | - Mingsheng Zhang
- Department of Pharmacology, Shanxi Medical University, Xinjiannanlu 56, Taiyuan 030001, Shanxi Province, China.
| |
Collapse
|
9
|
Cutler NS, Rasmussen BM, Bredeck JF, Lata AL, Khanna AK. Angiotensin II for Critically Ill Patients With Shock After Heart Transplant. J Cardiothorac Vasc Anesth 2020; 35:2756-2762. [PMID: 32868151 DOI: 10.1053/j.jvca.2020.07.087] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 12/18/2022]
Abstract
Patients undergoing heart transplant are at high risk for vasodilatory shock in the postoperative period, due to a combination of vascular dysfunction from end-stage heart failure and inflammatory response to cardiopulmonary bypass and, increasingly, long-term exposure to nonpulsatile blood flow in those who have received a left ventricular assist device as a bridge to transplant. Patients who have this vasoplegic syndrome, which may be refractory to traditional agents used in the treatment of shock, are vulnerable to organ dysfunction and death. Angiotensin II (ANG-2) is of increasing interest as an adjunct to traditional therapy, both for improvement in blood pressure and for sparing the use of high-dose catecholamine vasopressors. This case series describes the use of ANG-2 in 4 clinical scenarios for the treatment of shock due to heart transplant surgery, supporting its use in this role and justifying further prospective studies to clarify the appropriate place for ANG-2 in the hierarchy of adjunctive therapies.
Collapse
Affiliation(s)
- Nathan S Cutler
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Bridget M Rasmussen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Joseph F Bredeck
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Adrian L Lata
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ashish K Khanna
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
10
|
Domínguez JM, García-Romero E, Pàmies J, Mirabet S, Gonzalez-Costello J, Spitaleri G, Perez-Villa F, Farrero M. Incidence of vasoplegic syndrome after cardiac transplantation in patients treated with sacubitril/valsartan. Clin Transplant 2020; 34:e13994. [PMID: 32463124 DOI: 10.1111/ctr.13994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 05/07/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022]
Abstract
Vasoplegic syndrome (VS) is associated with poor outcomes after heart transplantation (HT). Our aim was to determine whether SAC/VALS is associated with VS after HT. We retrospectively analyzed all consecutive HT performed in three centers between January 2017 and August 2018. VS was defined as vasopressor need (norepinephrine or epinephrine >.5 mcg/kg/min or vasopressin) for more than 24 hours to maintain a mean arterial pressure >70 mm Hg. Ninety-six recipients underwent HT in the study period: 60 elective HT with no LVAD, 5 elective HT on long term LVAD, and 31 emergent HT: 3 on long-term LVAD and 28 on temporary mechanical circulatory support. Fourteen patients were on SAC/VALS treatment at the time of transplant, and 82 were not. The global incidence of VS was 15.6%, with no significant differences between the groups (7.14% in with SAC/VALS vs 17.07% in no-SAC/VALS). In conclusion, in our small cohort SAC/VALS was not associated with VS development.
Collapse
Affiliation(s)
- Juan M Domínguez
- Advanced Heart Failure and Heart transplantation Unit, Hospital Clinic i Provincial, Barcelona, Spain
| | - Elena García-Romero
- Advanced Heart Failure and Heart transplantation Unit, IDIBELL, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Julia Pàmies
- Advanced Heart Failure and Heart transplantation Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sonia Mirabet
- Advanced Heart Failure and Heart transplantation Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jose Gonzalez-Costello
- Advanced Heart Failure and Heart transplantation Unit, IDIBELL, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Giosafat Spitaleri
- Advanced Heart Failure and Heart transplantation Unit, Hospital Clinic i Provincial, Barcelona, Spain
| | - Felix Perez-Villa
- Advanced Heart Failure and Heart transplantation Unit, Hospital Clinic i Provincial, Barcelona, Spain
| | - Marta Farrero
- Advanced Heart Failure and Heart transplantation Unit, Hospital Clinic i Provincial, Barcelona, Spain
| |
Collapse
|
11
|
Ali JM, Patel S, Catarino P, Vuylsteke A, Pettit S, Bhagra S, Kydd A, Lewis C, Parameshwar J, Kaul P, Sudarshan C, Tsui S, Jenkins D, Abu-Omar Y, Berman M. Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes. J Thorac Dis 2020; 12:2426-2434. [PMID: 32642148 PMCID: PMC7330418 DOI: 10.21037/jtd.2020.03.53] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Vasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx. Methods Patients undergoing LVAD explant followed by HTx from 01/2013–12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 μg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database. Results During the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 vs. 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% vs. 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% vs. 100% P=0.99) and 1-year (67.7% vs. 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period. Conclusions Vasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.
Collapse
Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Serena Patel
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Pedro Catarino
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Alain Vuylsteke
- Department of Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Stephen Pettit
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Sai Bhagra
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Anna Kydd
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Clive Lewis
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Jayan Parameshwar
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Pradeep Kaul
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Catherine Sudarshan
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Steven Tsui
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - David Jenkins
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Yasir Abu-Omar
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Marius Berman
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| |
Collapse
|
12
|
van Vessem ME, Petrus AH, Palmen M, Braun J, Schalij MJ, Klautz RJ, Beeres SL. Vasoplegia After Restrictive Mitral Annuloplasty for Functional Mitral Regurgitation in Patients With Heart Failure. J Cardiothorac Vasc Anesth 2019; 33:3273-3280. [DOI: 10.1053/j.jvca.2019.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 06/05/2019] [Accepted: 06/09/2019] [Indexed: 12/28/2022]
|
13
|
Asleh R, Alnsasra H, Daly RC, Schettle SD, Briasoulis A, Taher R, Dunlay SM, Stulak JM, Behfar A, Pereira NL, Frantz RP, Edwards BS, Clavell AL, Kushwaha SS. Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation With Continuous-Flow Left Ventricular Assist Devices. J Am Heart Assoc 2019; 8:e013108. [PMID: 31701791 PMCID: PMC6915279 DOI: 10.1161/jaha.119.013108] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background The presence of a durable left ventricular assist device (LVAD) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation (HT). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD. Methods and Results We identified 94 patients who underwent HT after bridging with continuous‐flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT. Patients with and without vasoplegia had similar preoperative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; P=0.010), longer LVAD support (odds ratio: 1.06 per month; P=0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; P=0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; P=0.044) were independent predictors of vasoplegia. After mean follow‐up of 4.0 years after HT, vasoplegia was associated with increased risk of all‐cause mortality (hazard ratio: 5.20; 95% CI, 1.71–19.28; P=0.003). Conclusions Older age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.
Collapse
Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Richard C Daly
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | | | - Riad Taher
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - John M Stulak
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Atta Behfar
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - Robert P Frantz
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | | | | |
Collapse
|
14
|
Vasoplegia after pediatric cardiac transplantation in patients supported with a continuous flow ventricular assist device. J Thorac Cardiovasc Surg 2019; 157:2433-2440. [DOI: 10.1016/j.jtcvs.2019.01.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 01/22/2019] [Accepted: 01/27/2019] [Indexed: 12/22/2022]
|
15
|
de Waal EEC, van Zaane B, van der Schoot MM, Huisman A, Ramjankhan F, van Klei WA, Marczin N. Vasoplegia after implantation of a continuous flow left ventricular assist device: incidence, outcomes and predictors. BMC Anesthesiol 2018; 18:185. [PMID: 30526494 PMCID: PMC6286572 DOI: 10.1186/s12871-018-0645-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/22/2018] [Indexed: 12/14/2022] Open
Abstract
Background Vasoplegia after routine cardiac surgery is associated with severe postoperative complications and increased mortality. It is also prevalent in patients undergoing implantation of pulsatile flow left ventricular assist devices (LVAD). However, less is known regarding vasoplegia after implantation of newer generations of continuous flow LVADs (cfLVAD). We aim to report the incidence, impact on outcome and predictors of vasoplegia in these patients. Methods Adult patients scheduled for primary cfLVAD implantation were enrolled into a derivation cohort (n = 118, 2006–2013) and a temporal validation cohort (n = 73, 2014–2016). Vasoplegia was defined taking into consideration low mean arterial pressure and/or low systemic vascular resistance, preserved cardiac index and high vasopressor support. Vasoplegia was considered after bypass and the first 48 h of ICU stay lasting at least three consecutive hours. This concept of vasoplegia was compared to older definitions reported in the literature in terms of the incidence of postoperative vasoplegia and its association with adverse outcomes. Logistic regression was used to identify independent predictors. Their ability to discriminate patients with vasoplegia was quantified by the area under the receiver operating characteristic curve (AUC). Results The incidence of vasoplegia was 33.1% using the unified definition of vasoplegia. Vasoplegia was associated with increased ICU length-of-stay (10.5 [6.9–20.8] vs 6.1 [4.6–10.4] p = 0.002), increased ICU-mortality (OR 5.8, 95% CI 1.9–18.2) and one-year-mortality (OR 3.9, 95% CI 1.5–10.2), and a higher incidence of renal failure (OR 4.3, 95% CI 1.8–10.4). Multivariable analysis identified previous cardiothoracic surgery, preoperative dopamine administration, preoperative bilirubin levels and preoperative creatinine clearance as independent preoperative predictors of vasoplegia. The resultant prediction model exhibited a good discriminative ability (AUC 0.80, 95% CI 0.71–0.89, p < 0.01). Temporal validation resulted in an AUC of 0.74 (95% CI 0.61–0.87, p < 0.01). Conclusions In the era of the new generation of cfLVADs, vasoplegia remains a prevalent (33%) and critical condition with worse short-term outcomes and survival. We identified previous cardiothoracic surgery, preoperative treatment with dopamine, preoperative bilirubin levels and preoperative creatinine clearance as independent predictors. Electronic supplementary material The online version of this article (10.1186/s12871-018-0645-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Eric E C de Waal
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Bas van Zaane
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands
| | | | - Albert Huisman
- Clinical chemist, Department of Clinical Chemistry and Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Faiz Ramjankhan
- Cardiothoracic surgeon, Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands
| | - Nandor Marczin
- Anaesthesiologist, Section of Anaesthesia, Pain Medicine and Intensive Care, Imperial College, London, UK.,Department of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| |
Collapse
|
16
|
Raza FS, Lee AY, Jamil AK, Qin H, Felius J, Rafael AE, Gonzalez-Stawinski GV, Hall SA, Joseph SM, Lima B, Bindra AS. Relation of Vasoplegia in the Absence of Primary Graft Dysfunction to Mortality Following Cardiac Transplantation. Am J Cardiol 2018; 122:1902-1908. [PMID: 30442225 DOI: 10.1016/j.amjcard.2018.08.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/08/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022]
Abstract
Vasoplegia following cardiac transplantation is associated with increased morbidity and mortality. Previous studies have not accounted for primary graft dysfunction (PGD). The definition of vasoplegia is based on pressor requirement at 48 hours, many PGD parameters may have normalized after the initial 24 hours on inotropes. We surmised that the purported negative effects of vasoplegia following transplantation may in part be driven by PGD. We reviewed 240 consecutive adult cardiac transplants at our center between 2012 and 2016. The severity of vasoplegia was evaluated as a risk factor for 1-year survival, and the analysis was repeated for the subgroup of 177 patients who did not develop PGD. Overall, 63 (26%) of patients developed mild, moderate, or severe PGD. In those without PGD, vasoplegia was associated with length of stay but not with short- or long-term mortality. Moderate and/or severe vasoplegia occurred in 35 (15%) patients and was associated with higher short-term mortality, length of stay, and PGD. Multivariate logistic regression identified body mass index ≥35 kg/m2, left ventricular assist device before transplantation, and use of extracorporeal membrane oxygenation as joint risk factors for vasoplegia. In patients without PGD, only left ventricular assist device before transplantation was associated with vasoplegia. In conclusion, our results show that, in the sizeable subgroup of patients with no signs of PGD, vasoplegia had a much more modest impact on post-transplant morbidity and no significant effect on 1- and 3-year survival. This suggests that PGD may be a confounder when assessing vasoplegia as a risk factor for adverse outcomes.
Collapse
|
17
|
Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation. Ann Thorac Surg 2018; 105:770-777. [DOI: 10.1016/j.athoracsur.2017.09.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/27/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
|
18
|
Incidence and Impact of On-Cardiopulmonary Bypass Vasoplegia During Heart Transplantation. ASAIO J 2018; 64:43-51. [DOI: 10.1097/mat.0000000000000623] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
19
|
Chan JL, Kobashigawa JA, Aintablian TL, Li Y, Perry PA, Patel JK, Kittleson MM, Czer LS, Zarrini P, Velleca A, Rush J, Arabia FA, Trento A, Esmailian F. Vasoplegia after heart transplantation: outcomes at 1 year. Interact Cardiovasc Thorac Surg 2017; 25:212-217. [PMID: 28459983 DOI: 10.1093/icvts/ivx081] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/15/2017] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Vasoplegia syndrome is a potentially life-threatening condition that can occur following cardiopulmonary bypass. Heart transplantation is a recognized risk factor for developing this vasodilatory state. The objective of this study was to determine the effects of vasoplegia syndrome on 1-year heart transplant outcomes. METHODS A retrospective review of orthotopic heart transplants at a single institution between November 2010 and December 2014 was performed. Of the 347 consecutive adult patients, 107 patients (30.8%) met criteria for vasoplegia syndrome. Preoperative factors and intraoperative variables were collected and compared between vasoplegia and non-vasoplegia cohorts. The incidence of postoperative complications, transplant rejection and patient survival within 1 year were evaluated. RESULTS Demographics and preoperative medication profiles were similar in both groups, while mechanical circulatory support device use was associated with vasoplegia syndrome (30.8% vs 20.0%; P = 0.039). Perioperative characteristics such as longer cardiopulmonary bypass [165.0 (interquartile range [IQR] 74) min vs 140.0 (IQR 42.7) min; P < 0.001] and increased blood product usage (24.7 ± 17.2 units vs 17.7 ± 14.3 units; P < 0.001) were associated with vasoplegia. Non-vasoplegia patients were more likely to be extubated [42.9 (IQR 37.3) h vs 66.8 (IQR 50.2) h; P < 0.001] and discharged earlier [10.0 (IQR 6) days vs 14.0 (IQR 11.5) days; P < 0.001]. One-year patient survival (92.0% vs 88.6%; P = 0.338) and any-treated rejection rates (82.7% vs 84.3%; P = 0.569) were not significantly different between groups. CONCLUSIONS Although vasoplegia syndrome was associated with an increase in perioperative morbidity, including greater mechanical ventilation time and hospital length of stay, no significant differences in survival or allograft rejection at 1 year was demonstrated.
Collapse
Affiliation(s)
- Joshua L Chan
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Yanqing Li
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Paul A Perry
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Jenna Rush
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Francisco A Arabia
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alfredo Trento
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Fardad Esmailian
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
20
|
Cooper LB, Mentz RJ, Edwards LB, Wilk AR, Rogers JG, Patel CB, Milano CA, Hernandez AF, Stehlik J, Lund LH. Amiodarone use in patients listed for heart transplant is associated with increased 1-year post-transplant mortality. J Heart Lung Transplant 2017; 36:202-210. [PMID: 27520780 PMCID: PMC5241253 DOI: 10.1016/j.healun.2016.07.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/24/2016] [Accepted: 07/13/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pre-transplant amiodarone use has been postulated as a risk factor for morbidity and mortality after orthotopic heart transplantation (OHT). We assessed pre-OHT amiodarone use and tested the hypothesis that it is associated with impaired post-OHT outcomes. METHODS We performed a retrospective cohort analysis of adult OHT recipients from the registry of the International Society for Heart and Lung Transplantation (ISHLT). All patients had been transplanted between 2005 and 2013 and were stratified by pre-OHT amiodarone use. We derived propensity scores using logistic regression with amiodarone use as the dependent variable, and assessed the associations between amiodarone use and outcomes with Kaplan-Meier analysis after matching patients 1:1 based on propensity score, and with Cox regression with adjustment for propensity score. RESULTS Of the 14,944 OHT patients in the study cohort, 32% (N = 4,752) received pre-OHT amiodarone. Amiodarone use was higher in recent years (29% in 2005 to 2007, 32% in 2008 to 2010, 35% in 2011 to 2013). Amiodarone-treated patients were older and more frequently had a history of sudden cardiac death (27% vs 13%) and pre-OHT mechanical circulatory support. Key donor characteristics and allograft ischemia times were similar between groups. In propensity-matched analyses, amiodarone-treated patients had higher rates of cardiac reoperation (15% vs 13%) and permanent pacemaker (5% vs 3%) after OHT and before discharge. Amiodarone-treated patients also had higher 1-year mortality (hazard ratio 1.15, 95% confidence interval 1.02 to 1.30), but the risks of early graft failure, retransplantation and rehospitalization were similar between groups. CONCLUSIONS Amiodarone use before OHT was independently associated with increased 1-year mortality. The need for amiodarone therapy should be carefully and continuously assessed in patients awaiting OHT.
Collapse
Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Leah B Edwards
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Amber R Wilk
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Joseph G Rogers
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chetan B Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo A Milano
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiovascular & Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Josef Stehlik
- Department of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
21
|
Zundel MT, Boettcher BT, Feih JT, Gaglianello N, Pagel PS. Use of Oral Droxidopa to Improve Arterial Pressure and Reduce Vasoactive Drug Requirements During Persistent Vasoplegic Syndrome After Cardiac Transplantation. J Cardiothorac Vasc Anesth 2016; 30:1624-1626. [DOI: 10.1053/j.jvca.2015.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Indexed: 11/11/2022]
|
22
|
Niu L, Liu Y, Hou X, Cui L, Li J, Zhang X, Zhang M. Extracellular acidosis contracts coronary but neither renal nor mesenteric artery via modulation of H+,K+-ATPase, voltage-gated K+channels and L-type Ca2+channels. Exp Physiol 2014; 99:995-1006. [DOI: 10.1113/expphysiol.2014.078634] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Longgang Niu
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
- Medical Functional Experimental Center; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Yu Liu
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Xiaomin Hou
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Lijuan Cui
- Medical Functional Experimental Center; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Jiangtao Li
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Xuanping Zhang
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| | - Mingsheng Zhang
- Department of Pharmacology; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
- Medical Functional Experimental Center; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
- Cardiovascular Division of Physiology Department; Shanxi Medical University; Xinjiannanlu 56 Taiyuan 030001 Shanxi Province China
| |
Collapse
|
23
|
|
24
|
Pre-operative risk factors and clinical outcomes associated with vasoplegia in recipients of orthotopic heart transplantation in the contemporary era. J Heart Lung Transplant 2012; 31:282-7. [DOI: 10.1016/j.healun.2011.10.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 10/16/2011] [Accepted: 10/19/2011] [Indexed: 11/20/2022] Open
|
25
|
Sigurdsson G, Carrascosa P, Yamani MH, Greenberg NL, Perrone S, Lev G, Desai MY, Garcia MJ. Detection of transplant coronary artery disease using multidetector computed tomography with adaptative multisegment reconstruction. J Am Coll Cardiol 2006; 48:772-8. [PMID: 16904548 DOI: 10.1016/j.jacc.2006.04.082] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Revised: 04/18/2006] [Accepted: 04/25/2006] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to determine whether multidetector computed tomography (MDCT) may be able to detect occlusive coronary disease in transplanted hearts. BACKGROUND In heart transplant recipients, asymptomatic coronary disease requiring frequent surveillance commonly develops. Recent advancements in MDCT allow for noninvasive assessment of the coronary vessels. METHODS Electrocardiogram-gated contrast-enhanced MDCT scans (16 x 0.75-mm detectors, 420 ms rotation, 100 ml contrast) with multisegment reconstruction were performed on 54 transplant recipients within 6 +/- 11 days of quantitative coronary angiography (QCA). Heart rate at the time of the scan was 90 +/- 11 beats/min. Coronary arterial segments >1.5 mm in diameter were analyzed by independent investigators. RESULTS There was a good correlation between MDCT and QCA percent stenosis (r = 0.75, p < 0.01, SEE = 15%). Of the 791 segments identified by QCA, 754 (95%) were analyzable by MDCT. The sensitivity, specificity, and positive and negative predictive values of MDCT compared with QCA for the detection of segments with significant (>50%) stenosis were 86%, 99%, 81%, and 99%, respectively. The MDCT correctly identified 15 of the 16 (94%) transplant patients classified by QCA as having occlusive coronary artery disease and 29 of the 37 patients without significant stenosis (78%). In 1 patient who received intravenous beta-blockers, transient bradycardia requiring temporary pacing developed, but there were no other complications. CONCLUSIONS Detection of occlusive coronary disease in heart transplant recipients with elevated resting heart rate by MDCT is feasible using multicycle reconstruction. The need for surveillance invasive coronary angiography in transplant recipients might be mitigated by use of MDCT.
Collapse
|
26
|
Huang J, Trinkaus K, Huddleston CB, Mendeloff EN, Spray TL, Canter CE. Risk factors for primary graft failure after pediatric cardiac transplantation: importance of recipient and donor characteristics. J Heart Lung Transplant 2004; 23:716-22. [PMID: 15366432 DOI: 10.1016/j.healun.2003.08.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Primary graft failure, or circulatory insufficiency immediately after transplantation, frequently occurs after pediatric cardiac transplantation and is the most common cause of death after infant transplantation. Risk factors for pediatric primary graft failure are poorly defined. METHODS We retrospectively reviewed donor, procedural and recipient characteristics for primary graft failure in 165 pediatric cardiac transplant recipients (median age at transplant 1.1 years) by multivariatle logistic regression. Primary graft failure was defined as the need for mechanical circulatory support or use of multiple intravenous inotrope/pressors, including epinephrine, for circulatory support within the first 24 hours after transplantation. RESULTS Primary graft failure occurred in 54 patients (33%); 24 patients (15%) required mechanical support for their graft failure; and primary graft failure was the cause of death or graft loss in 10 patients. Recipient risk factors associated with an increased risk of primary graft failure included diagnosis of congenital heart disease and a need for mechanical support before transplantation. Ventilator support before transplantation and maximal pulmonary vascular resistance index were risk factors for the development of isolated right ventricular graft failure. Donor risk factors associated with an increased risk for primary graft failure included increasing donor recipient weight and body surface area ratios; increasing donor ischemic time; anoxia as a cause of death; and increasing cardiopulmonary resuscitation time. Donor blood type O+ and hyperdynamic donor systolic function were associated with a decreased risk of primary graft failure. CONCLUSIONS Multiple donor, recipient and procedural risk factors, including the type and severity of heart disease in the recipient before transplantation, are associated with primary graft failure after pediatric cardiac transplantation. Avoidance of matching high-risk donors to high-risk recipients may improve morbidity and mortality after transplantation.
Collapse
Affiliation(s)
- Jennifer Huang
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University, St. Louis, Missouri, USA
| | | | | | | | | | | |
Collapse
|
27
|
Paniagua MJ, Crespo-Leiro MG, Muñiz J, Vázquez E, Tabuyo T, Castro-Orjales M, Fojon S, López JM, Garrido IP, Juffé A, Castro-Beiras A. Hypotension, acidosis and vasodilation syndrome after heart transplant: incidence, risk factors, and prognosis. Transplant Proc 2003; 35:1957-8. [PMID: 12962862 DOI: 10.1016/s0041-1345(03)00730-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND HAV syndrome, the combination of hypotension, acidosis and vasodilation (HAV), is a serious postoperative complication after heart transplantation (HT). Its etiology and prognosis are poorly understood. AIM To determine the incidence and prognosis of post-HT HAV syndrome and examine possible risk factors. METHODS Retrospective examination of the records of 85 consecutive patients who underwent HT between December 1999 and June 2002 sought the HAV criteria: systolic BP <85 mm Hg plus HCO3 <19 mEq/l whole excluding cardiogenic, hypovolemic and septic shock. Donor variables included sex, age, weight, height, cause of death, time in ICU, and ischemic time; while recipient variables, sex, age, weight, height, etiology of cardiopathy, previous cardiopulmonary bypass surgery, preoperative amiodarone, beta-blockers, catecholamines, mechanical ventilation or intra aortic balloon pump (IABP), RVP, time on waiting list, pump time, reoperations, polytransfusion, preoperative creatinine, GOT, GPT and GGT, induction with OKT3 or anti-CD25, bypass-to-HAV time, duration of catecholamine treatment, and 1 month survival after HT. RESULTS The 11 HAV cases (13%) appeared between 1 and 72 h after HT (75% in the first hour). Catecholamines were used for 1 to 6 days; control was achieved within 48 h in 58% of cases. Two HAV patients (18%) died within the first month versus six non-HAV patients (8.1%) (P=.275). Only polytransfusion showed more than a borderline value to predict HAV syndrome. CONCLUSIONS HAV syndrome has an incidence of 13% and a mortality of 18% within 1 month post-HT. The only likely risk factor is polytransfusion.
Collapse
Affiliation(s)
- M J Paniagua
- Heart Transplant Programme, Juan Canalejo University Hospital Complex, A Coruña, Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|