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Xiong T, Yim WY, Chi J, Wang Y, Lan H, Zhang J, Sun Y, Shi J, Chen S, Dong N. The Utility of the Vasoactive-Inotropic Score and Its Nomogram in Guiding Postoperative Management in Heart Transplant Recipients. Transpl Int 2024; 37:11354. [PMID: 39119063 PMCID: PMC11306011 DOI: 10.3389/ti.2024.11354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/21/2024] [Indexed: 08/10/2024]
Abstract
Background In the early postoperative stage after heart transplantation, there is a lack of predictive tools to guide postoperative management. Whether the vasoactive-inotropic score (VIS) can aid this prediction is not well illustrated. Methods In total, 325 adult patients who underwent heart transplantation at our center between January 2015 and December 2018 were included. The maximum VIS (VISmax) within 24 h postoperatively was calculated. The Kaplan-Meier method was used for survival analysis. A logistic regression model was established to determine independent risk factors and to develop a nomogram for a composite severe adverse outcome combining early mortality and morbidity. Results VISmax was significantly associated with extensive early outcomes such as early death, renal injury, cardiac reoperation and mechanical circulatory support in a grade-dependent manner, and also predicted 90-day and 1-year survival (p < 0.05). A VIS-based nomogram for the severe adverse outcome was developed that included VISmax, preoperative advanced heart failure treatment, hemoglobin and serum creatinine. The nomogram was well calibrated (Hosmer-Lemeshow p = 0.424) with moderate to strong discrimination (C-index = 0.745) and good clinical utility. Conclusion VISmax is a valuable prognostic index in heart transplantation. In the early post-transplant stage, this VIS-based nomogram can easily aid intensive care clinicians in inferring recipient status and guiding postoperative management.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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2
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Jones MM, Tangel V, White RS, Rong L. The IMPACT Score: Does Sex Matter? J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00442-7. [PMID: 39069380 DOI: 10.1053/j.jvca.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/10/2024] [Accepted: 07/03/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score is a quantitative risk index that predicts 1-year mortality risk, derived from United Network for Organ Sharing data in which women are underrepresented. The validity of the IMPACT score in 1-year mortality risk after OHT in women is unknown. The objective of this study was to assess differences in score performance by sex. We hypothesized that the IMPACT score is a poor predictor of 1-year mortality risk after orthotopic heart transplantation (OHT) in women. DESIGN In this external validation study, demographic and clinical characteristics were compared by sex. The IMPACT score was calculated and regression models were constructed for the entire sample and stratified by sex. Model discrimination was assessed with the area under the receiver operating characteristic curve, and calibration was assessed graphically. PARTICIPANTS Patients 18 years and older who were first-time single OHT recipients from the International Society for Heart and Lung Transplantation registry from 2009 to 2018. MEASUREMENTS AND MAIN RESULTS For 1-year mortality, the area under the receiver operating characteristic curve (95% confidence interval) for the full sample was 0.59 (0.57-0.60): 0.58 (0.55-0.61) for women and 0.59 (0.58-0.61) for men. The 1-year mortality was 9.4% in the overall cohort, with no difference in mortality by sex (9.0% v 9.6% women v men, p = 0.22). CONCLUSIONS The IMPACT score exhibited poor discrimination and calibration in the International Society for Heart and Lung Transplantation 2009-2019 cohort, overall and by sex. There was no difference in 1-year mortality between women and men.
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Affiliation(s)
- Mandisa-Maia Jones
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, New York Presbyterian Weill Cornell Medical Center, New York, NY.
| | - Virginia Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Robert S White
- Department of Anesthesiology, Division of Obstetric Anesthesia, New York Presbyterian Weill Cornell Medical Center, New York, NY
| | - Lisa Rong
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, New York Presbyterian Weill Cornell Medical Center, New York, NY
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3
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Lescroart M, Kransdorf EP, Scuppa MF, Patel JK, Coutance G. Importance of Transplant Era on Post-Heart Transplant Predictive Models: A UNOS Cohort Analysis. Clin Transplant 2024; 38:e15403. [PMID: 39023089 DOI: 10.1111/ctr.15403] [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: 03/27/2024] [Revised: 05/14/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The application of posttransplant predictive models is limited by their poor statistical performance. Neglecting the dynamic evolution of demographics and medical practice over time may be a key issue. OBJECTIVES Our objective was to develop and validate era-specific predictive models to assess whether these models could improve risk stratification compared to non-era-specific models. METHODS We analyzed the United Network for Organ Sharing (UNOS) database including first noncombined heart transplantations (2001-2018, divided into four transplant eras: 2001-2005, 2006-2010, 2011-2015, 2016-2018). The endpoint was death or retransplantation during the 1st-year posttransplant. We analyzed the dynamic evolution of major predictive variables over time and developed era-specific models using logistic regression. We then performed a multiparametric evaluation of the statistical performance of era-specific models and compared them to non-era-specific models in 1000 bootstrap samples (derivation set, 2/3; test set, 1/3). RESULTS A total of 34 738 patients were included, 3670 patients (10.5%) met the composite endpoint. We found a significant impact of transplant era on baseline characteristics of donors and recipients, medical practice, and posttransplant predictive models, including significant interaction between transplant year and major predictive variables (total serum bilirubin, recipient age, recipient diabetes, previous cardiac surgery). Although the discrimination of all models remained low, era-specific models significantly outperformed the statistical performance of non-era-specific models in most samples, particularly concerning discrimination and calibration. CONCLUSIONS Era-specific models achieved better statistical performance than non-era-specific models. A regular update of predictive models may be considered if they were to be applied for clinical decision-making and allograft allocation.
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Affiliation(s)
- Mickaël Lescroart
- Department of Cardiac Surgery, Institute of Cardiology, La Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne Université-Medical School, Paris, France
| | - Evan P Kransdorf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Guillaume Coutance
- Department of Cardiac Surgery, Institute of Cardiology, La Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne Université-Medical School, Paris, France
- INSERM UMR 970, Paris Translational Research Centre for Organ Transplantation, Université de Paris, Paris, France
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4
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Miller G, Ankerst DP, Kattan MW, Hüser N, Stocker F, Vogelaar S, van Bruchem M, Assfalg V. Pancreas Transplantation Outcome Predictions-PTOP: A Risk Prediction Tool for Pancreas and Pancreas-Kidney Transplants Based on a European Cohort. Transplant Direct 2024; 10:e1632. [PMID: 38757051 PMCID: PMC11098189 DOI: 10.1097/txd.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 05/18/2024] Open
Abstract
Background For patients with complicated type 1 diabetes having, for example, hypoglycemia unawareness and end-stage renal disease because of diabetic nephropathy, combined pancreas and kidney transplantation (PKT) is the therapy of choice. However, the shortage of available grafts and complex impact of risk factors call for individualized, impartial predictions of PKT and pancreas transplantation (PT) outcomes to support physicians in graft acceptance decisions. Methods Based on a large European cohort with 3060 PKT and PT performed between 2006 and 2021, the 3 primary patient outcomes time to patient mortality, pancreas graft loss, and kidney graft loss were visualized using Kaplan-Meier survival curves. Multivariable Cox proportional hazards models were developed for 5- and 10-y prediction of outcomes based on 26 risk factors. Results Risk factors associated with increased mortality included previous kidney transplants, rescue allocations, longer waiting times, and simultaneous transplants of other organs. Increased pancreas graft loss was positively associated with higher recipient body mass index and donor age and negatively associated with simultaneous transplants of kidneys and other organs. Donor age was also associated with increased kidney graft losses. The multivariable Cox models reported median C-index values were 63% for patient mortality, 62% for pancreas loss, and 55% for kidney loss. Conclusions This study provides an online risk tool at https://riskcalc.org/ptop for individual 5- and 10-y post-PKT and PT patient outcomes based on parameters available at the time of graft offer to support critical organ acceptance decisions and encourage external validation in independent populations.
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Affiliation(s)
- Gregor Miller
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM – Munich Transplant Center, Klinikum rechts der Isar, Munich, Germany
- Technical University of Munich (TUM), TUM School of Computation, Information and Technology, Garching, Germany
- Core Facility Statistical Consulting, Helmholtz Munich, Neuherberg, Germany
| | - Donna P. Ankerst
- Technical University of Munich (TUM), TUM School of Computation, Information and Technology, Garching, Germany
| | - Michael W. Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Norbert Hüser
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM – Munich Transplant Center, Klinikum rechts der Isar, Munich, Germany
| | - Felix Stocker
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM – Munich Transplant Center, Klinikum rechts der Isar, Munich, Germany
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, The Netherlands
| | | | - Volker Assfalg
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM – Munich Transplant Center, Klinikum rechts der Isar, Munich, Germany
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5
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Gallo M, Slaughter MS, Trivedi JR. Donor heart preservation with controlled hypothermic technology: Insights into the data. J Heart Lung Transplant 2024; 43:1030-1031. [PMID: 38373558 DOI: 10.1016/j.healun.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/21/2024] Open
Affiliation(s)
- Michele Gallo
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jaimin R Trivedi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky.
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Halloran PF, Madill-Thomsen K, Mackova M, Aliabadi-Zuckermann AZ, Cadeiras M, Crespo-Leiro MG, Depasquale EC, Deng M, Gökler J, Hall SA, Kim DH, Kobashigawa J, Macdonald P, Potena L, Shah K, Stehlik J, Zuckermann A, Reeve J. Molecular states associated with dysfunction and graft loss in heart transplants. J Heart Lung Transplant 2024; 43:508-518. [PMID: 38042442 DOI: 10.1016/j.healun.2023.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND We explored the changes in gene expression correlating with dysfunction and graft failure in endomyocardial biopsies. METHODS Genome-wide microarrays (19,462 genes) were used to define mRNA changes correlating with dysfunction (left ventricular ejection fraction [LVEF] ≤ 55) and risk of graft loss within 3 years postbiopsy. LVEF data was available for 1,013 biopsies and survival data for 779 patients (74 losses). Molecular classifiers were built for predicting dysfunction (LVEF ≤ 55) and postbiopsy 3-year survival. RESULTS Dysfunction is correlated with dedifferentiation-decreased expression of normal heart transcripts, for example, solute carriers, along with increased expression of inflammation genes. Many genes with reduced expression in dysfunction were matrix genes such as fibulin 1 and decorin. Gene ontology (GO) categories suggested matrix remodeling and inflammation, not rejection. Genes associated with the risk of failure postbiopsy overlapped dysfunction genes but also included genes affecting microcirculation, for example, arginase 2, which reduces NO production, and endothelin 1. GO terms also reflected increased glycolysis and response to hypoxia, but decreased VEGF and angiogenesis pathways. T cell-mediated rejection was associated with reduced survival and antibody-mediated rejection with relatively good survival, but the main determinants of survival were features of parenchymal injury. Both dysfunction and graft loss were correlated with increased biopsy expression of BNP (gene NPPB). Survival probability classifiers divided hearts into risk quintiles, with actuarial 3-year postbiopsy survival >95% for the highest versus 50% for the lowest. CONCLUSIONS Dysfunction in transplanted hearts reflects dedifferentiation, decreased matrix genes, injury, and inflammation. The risk of short-term loss includes these changes but is also associated with microcirculation abnormalities, glycolysis, and response to hypoxia.
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Affiliation(s)
- Philip F Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Martina Mackova
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Mario Deng
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Johannes Gökler
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel H Kim
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Peter Macdonald
- The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Keyur Shah
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Josef Stehlik
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Jeff Reeve
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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7
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Trivedi J, Pahwa S, Rabkin D, Gallo M, Guglin M, Slaughter MS, Abramov D. Predictors of Survival After Heart Transplant in the New Allocation System: A UNOS Database Analysis. ASAIO J 2024; 70:124-130. [PMID: 37862683 DOI: 10.1097/mat.0000000000002070] [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: 10/22/2023] Open
Abstract
Clinical predictors of posttransplant graft loss since the United Network for Organ Sharing (UNOS) heart allocation system change have not been well characterized. Single organ adult heart transplants from the UNOS database were identified (n = 10,252) and divided into a test cohort (n = 6,869, 67%) and validation cohort (n = 3,383, 33%). A Cox regression analysis was performed on the test cohort to identify recipient and donor risk factors for posttransplant graft loss. Based on the risk factors, a score (max 16) was developed to classify patients in the validation cohort into risk groups of low (≤1), mid (2-3), high (≥4) risk. Recipient factors of advanced age, Black race, recipient blood group O, diabetes, etiology of heart failure, renal dysfunction, elevated bilirubin, redo-transplantation, elevated pulmonary artery pressure, transplant with a durable ventricular assist device, or transplant on extracorporeal membrane oxygenation (ECMO) or ventilator were associated with more posttransplant graft loss. Donor factors of ischemic time and donor age were also associated with outcomes. One year graft survival for the low-, mid-, high-risk groups was 94%, 91%, and 85%, respectively. In conclusion, easily obtainable clinical characteristics at time of heart transplant can predict posttransplant outcomes in the current era.
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Affiliation(s)
- Jaimin Trivedi
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Siddharth Pahwa
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - David Rabkin
- Department of Cardiovascular Surgery, Loma Linda University Hospital, Loma Linda, California
| | - Michele Gallo
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Maya Guglin
- Division of Cardiovascular Disease, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark S Slaughter
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Dmitry Abramov
- Department of Cardiovascular Medicine, Loma Linda University Hospital, Loma Linda, California
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8
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Bonnesen K, Mols RE, Løgstrup B, Gustafsson F, Eiskjær H, Schmidt M. The Ability of Comorbidity Indices to Predict Mortality After Heart Transplantation: A Validation of the Danish Comorbidity Index for Acute Myocardial Infarction, Charlson Comorbidity Index, and Elixhauser Comorbidity Index. Transplant Direct 2023; 9:e1438. [PMID: 36935871 PMCID: PMC10019203 DOI: 10.1097/txd.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/28/2022] [Indexed: 03/17/2023] Open
Abstract
Advanced heart failure patients often have comorbidities of prognostic importance. However, whether total pretransplantation comorbidity burden predicts mortality in patients treated with heart transplantation (HTx) is unknown. We used population-based hospital and prescription data to examine the ability of the Danish Comorbidity Index for Acute Myocardial Infarction (DANCAMI), DANCAMI restricted to noncardiovascular diseases, Charlson Comorbidity Index, and Elixhauser Comorbidity Index to predict 30-d, 1-y, 5-y, and 10-y all-cause and cardiovascular mortality after HTx. Methods We identified all adult Danish patients with incident HTx from the Scandiatransplant Database between March 1, 1995, and December 31, 2018 (n = 563). We calculated Harrell's C-Statistics to examine discriminatory performance. Results The C-Statistic for predicting 1-y all-cause mortality after HTx was 0.58 (95% confidence interval [CI], 0.50-0.65) for a baseline model including age and sex. Adding comorbidity score to the baseline model did not increase the C-Statistics for DANCAMI (0.58; 95% CI, 0.50-0.65), DANCAMI restricted to noncardiovascular diseases (0.57; 95% CI, 0.50-0.64), Charlson Comorbidity Index (0.59; 95% CI, 0.51-0.66), or Elixhauser Comorbidity Index (0.58; 95% CI, 0.51-0.65). The results for 30-d, 5-y, and 10-y all-cause and cardiovascular mortality were consistent. Conclusions After accounting for patient age and sex, none of the commonly used comorbidity indices added predictive value to short- or long-term all-cause or cardiovascular mortality after HTx.
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Affiliation(s)
- Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rikke E. Mols
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Brian Løgstrup
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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9
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Linse B, Ohlsson M, Stehlik J, Lund LH, Andersson B, Nilsson J. A machine learning model for prediction of 30-day primary graft failure after heart transplantation. Heliyon 2023; 9:e14282. [PMID: 36938431 PMCID: PMC10015245 DOI: 10.1016/j.heliyon.2023.e14282] [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: 11/24/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023] Open
Abstract
Background Primary graft failure (PGF) remains the most common cause of short-term mortality after heart transplantation. The main objective was to develop and validate a risk model for prediction of short-term mortality due to PGF after heart transplantation using the ISHLT Heart Transplant Registry. Methods We developed a non-linear artificial neural networks (ANN) model to evaluate the association between recipient-donor variables and post-transplant PGF. Patients in the ISHLT registry were randomly divided into derivation and an independent internal validation cohort. The primary endpoint was PGF defined as death within 30 days due to Graft failure or Cardiovascular causes or retransplant within 30 days for causes other than rejection. Results Among 64,964 adult recipients transplanted between 1994 and 2013, mean age was 51 years and 22% were female. The incidence of PGF up to 30 days was 3.7%. The ANN model selected 33 of 77 risk variables as relevant for PGF prediction. The C-index in the test cohort was 0.70 (95% CI: 0.68-0.71). The risk variables which most influenced the PGF were underlying HF diagnosis, ischemia time and sex, while renal function had a lower influence. Conclusion An ANN model to predict primary graft dysfunction was derived and independently validated. The good discrimination of the ANN model likely results from its flexibility to model potentially non-linear relationships and interactions. Whether this model with improved discrimination can assist in clinical decisions at the time of transplant should be tested.
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Affiliation(s)
- Björn Linse
- Computational Biology and Biological Physics, Lund University, Lund, Sweden
| | - Mattias Ohlsson
- Computational Biology and Biological Physics, Lund University, Lund, Sweden
- Center for Applied Intelligent Systems Research, Halmstad University, Sweden
| | - Joseph Stehlik
- Department of Cardiovascular Medicine, University of Utah School of Medicine, Utah, USA
- The ISHLT Transplant Registry, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institute, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences, Surgery, Lund University, Sweden
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Johan Nilsson
- Department of Translational Medicine, Cardiothoracic Surgery and Bioinformatics, Lund University, Sweden
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
- Corresponding author.
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10
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Impact of the 2018 French two-score allocation scheme on the profile of heart transplantation candidates and recipients: Insights from a high-volume centre. Arch Cardiovasc Dis 2023; 116:54-61. [PMID: 36624026 DOI: 10.1016/j.acvd.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND In 2018, a new cardiac allograft allocation scheme, based on an individual scoring system, considering the risk of death both on the waiting list and after heart transplantation, was implemented in France. AIM To assess the impact of this new scheme on the profile of transplantation candidates and recipients. METHODS In this single-centre retrospective study, we included consecutive patients listed and/or transplanted between 01 January 2012 and 30 September 2021 at La Pitié-Salpêtrière Hospital. Baseline characteristics of patients were retrieved from the national CRISTAL registry and were compared according to the type of allocation scheme (before or after 2018). RESULTS A total of 1098 newly listed transplantation candidates and 855 transplant recipients were included. One-year mortality rates after listing and after transplantation were 12.4% and 20%, respectively. At listing, the proportion of candidates on inotropes significantly declined following the scheme update (26.3 versus 20.9%; P=0.038), reflecting a change in medical practice. At transplantation, recipients had worse kidney function (estimated glomerular filtration rate<60mL/min/1.73 m2: old scheme, 29.7%; new scheme, 46.4%; P<0.001) and were more likely to be on extracorporeal membrane oxygenation support (33.5% versus 28.1%; P=0.080) under the new scheme, reflecting the prioritization of more severe patients. Outcomes after transplantation were not significantly influenced by the allocation system. CONCLUSIONS The implementation of the 2018 French allocation scheme had a limited impact on the profile of transplantation candidates, but selected more severe patients for transplantation without significant impact on outcomes after transplantation.
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11
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M’Pembele R, Roth S, Nucaro A, Stroda A, Tenge T, Lurati Buse G, Bönner F, Scheiber D, Ballázs C, Tudorache I, Aubin H, Lichtenberg A, Huhn R, Boeken U. Postoperative high-sensitivity troponin T predicts 1-year mortality and days alive and out of hospital after orthotopic heart transplantation. Eur J Med Res 2023; 28:16. [PMID: 36624515 PMCID: PMC9827673 DOI: 10.1186/s40001-022-00978-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Orthotopic heart transplantation (HTX) is the gold standard to treat end-stage heart failure. Numerous risk stratification tools have been developed in the past years. However, their clinical utility is limited by their poor discriminative ability. High sensitivity troponin T (hsTnT) is the most specific biomarker to detect myocardial cell injury. However, its prognostic relevance after HTX is not fully elucidated. Thus, this study evaluated the predictive value of postoperative hsTnT for 1-year survival and 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 2011 and 2021. The main exposure was hsTnT concentration at 48 h after HTX. The primary endpoints were mortality and DAOH within 1 year after surgery. Receiver operating characteristic (ROC) curve analysis, logistic regression model and linear regression with adjustment for risk index for mortality prediction after cardiac transplantation (IMPACT) were performed. RESULTS Out of 231 patients screened, 212 were included into analysis (mean age 55 ± 11 years, 73% male). One-year mortality was 19.7% (40 patients) and median DAOH was 298 days (229-322). ROC analysis revealed strongest discrimination for mortality by hsTnT at 48 h after HTX [AUC = 0.79 95% CI 0.71-0.87]. According to Youden Index, the cutoff for hsTnT at 48 h and mortality was 1640 ng/l. After adjustment for IMPACT score multivariate logistic and linear regression showed independent associations between hsTnT and mortality/DAOH with odds ratio of 8.10 [95%CI 2.99-21.89] and unstandardized regression coefficient of -1.54 [95%CI -2.02 to -1.06], respectively. CONCLUSION Postoperative hsTnT might be suitable as an early prognostic marker after HTX and is independently associated with 1-year mortality and poor DAOH.
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Affiliation(s)
- René M’Pembele
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Sebastian Roth
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Anthony Nucaro
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Alexandra Stroda
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Theresa Tenge
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Giovanna Lurati Buse
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Florian Bönner
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Daniel Scheiber
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Christina Ballázs
- grid.411327.20000 0001 2176 9917Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Igor Tudorache
- grid.411327.20000 0001 2176 9917Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Hug Aubin
- grid.411327.20000 0001 2176 9917Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Artur Lichtenberg
- grid.411327.20000 0001 2176 9917Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Ragnar Huhn
- grid.411327.20000 0001 2176 9917Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany ,Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Udo Boeken
- grid.411327.20000 0001 2176 9917Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
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12
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Copeland H, Knezevic I, Baran DA, Rao V, Pham M, Gustafsson F, Pinney S, Lima B, Masetti M, Ciarka A, Rajagopalan N, Torres A, Hsich E, Patel JK, Goldraich LA, Colvin M, Segovia J, Ross H, Ginwalla M, Sharif-Kashani B, Farr MA, Potena L, Kobashigawa J, Crespo-Leiro MG, Altman N, Wagner F, Cook J, Stosor V, Grossi PA, Khush K, Yagdi T, Restaino S, Tsui S, Absi D, Sokos G, Zuckermann A, Wayda B, Felius J, Hall SA. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant 2023; 42:7-29. [PMID: 36357275 PMCID: PMC10284152 DOI: 10.1016/j.healun.2022.08.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023] Open
Abstract
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.
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Affiliation(s)
- Hannah Copeland
- Department of Cardiovascular and Thoracic Surgery Lutheran Hospital, Fort Wayne, Indiana; Indiana University School of Medicine-Fort Wayne, Fort Wayne, Indiana.
| | - Ivan Knezevic
- Transplantation Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David A Baran
- Department of Medicine, Division of Cardiology, Sentara Heart Hospital, Norfolk, Virginia
| | - Vivek Rao
- Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Pham
- Sutter Health California Pacific Medical Center, San Francisco, California
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois
| | - Brian Lima
- Medical City Heart Hospital, Dallas, Texas
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, Katholieke Universiteit Leuven, Leuven, Belgium; Institute of Civilisation Diseases and Regenerative Medicine, University of Information Technology and Management, Rzeszow, Poland
| | | | - Adriana Torres
- Los Cobos Medical Center, Universidad El Bosque, Bogota, Colombia
| | | | | | | | | | - Javier Segovia
- Cardiology Department, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Heather Ross
- University of Toronto, Toronto, Ontario, Canada; Sutter Health California Pacific Medical Center, San Francisco, California
| | - Mahazarin Ginwalla
- Cardiovascular Division, Palo Alto Medical Foundation/Sutter Health, Burlingame, California
| | - Babak Sharif-Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MaryJane A Farr
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luciano Potena
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | | | | | | | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - Susan Restaino
- Division of Cardiology Columbia University, New York, New York; New York Presbyterian Hospital, New York, New York
| | - Steven Tsui
- Department of Cardiothoracic Surgery Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Daniel Absi
- Department of Cardiothoracic and Transplant Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina
| | - George Sokos
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Brian Wayda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joost Felius
- Baylor Scott & White Research Institute, Dallas, Texas; Texas A&M University Health Science Center, Dallas, Texas
| | - Shelley A Hall
- Texas A&M University Health Science Center, Dallas, Texas; Division of Transplant Cardiology, Mechanical Circulatory Support and Advanced Heart Failure, Baylor University Medical Center, Dallas, Texas
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13
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Enhanced survival prediction using explainable artificial intelligence in heart transplantation. Sci Rep 2022; 12:19525. [PMID: 36376402 PMCID: PMC9663731 DOI: 10.1038/s41598-022-23817-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
The most limiting factor in heart transplantation is the lack of donor organs. With enhanced prediction of outcome, it may be possible to increase the life-years from the organs that become available. Applications of machine learning to tabular data, typical of clinical decision support, pose the practical question of interpretation, which has technical and potential ethical implications. In particular, there is an issue of principle about the predictability of complex data and whether this is inherent in the data or strongly dependent on the choice of machine learning model, leading to the so-called accuracy-interpretability trade-off. We model 1-year mortality in heart transplantation data with a self-explaining neural network, which is benchmarked against a deep learning model on the same development data, in an external validation study with two data sets: (1) UNOS transplants in 2017-2018 (n = 4750) for which the self-explaining and deep learning models are comparable in their AUROC 0.628 [0.602,0.654] cf. 0.635 [0.609,0.662] and (2) Scandinavian transplants during 1997-2018 (n = 2293), showing good calibration with AUROCs of 0.626 [0.588,0.665] and 0.634 [0.570, 0.698], respectively, with and without missing data (n = 982). This shows that for tabular data, predictive models can be transparent and capture important nonlinearities, retaining full predictive performance.
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14
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Rieth AJ, Rivinius R, Lühring T, Grün D, Keller T, Grinninger C, Schüttler D, Bara CL, Helmschrott M, Frey N, Sandhaus T, Schulze C, Kriechbaum S, Vietheer J, Sindermann J, Welp H, Lichtenberg A, Choi YH, Richter M, Tello K, Richter MJ, Hamm CW, Boeken U. Hemodynamic markers of pulmonary vasculopathy for prediction of early right heart failure and mortality after heart transplantation. J Heart Lung Transplant 2022; 42:512-521. [PMID: 36333208 DOI: 10.1016/j.healun.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/13/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) is broadly accepted as an imminent risk factor for mortality after heart transplantation (HTx). However, no current HTx recipient risk score includes PVR or other hemodynamic parameters. This study examined the utility of various hemodynamic parameters for risk stratification in a contemporary HTx population. METHODS Patients from seven German HTx centers undergoing HTx between 2011 and 2015 were included retrospectively. Established risk factors and complete hemodynamic datasets before HTx were analyzed. Outcome measures were overall all-cause mortality, 12-month mortality, and right heart failure (RHF) after HTx. RESULTS The final analysis included 333 patients (28% female) with a median age of 54 (IQR 46-60) years. The median mean pulmonary artery pressure was 30 (IQR 23-38) mm Hg, transpulmonary gradient 8 (IQR 5-10) mm Hg, and PVR 2.1 (IQR 1.5-2.9) Wood units. Overall mortality was 35.7%, 12-month mortality was 23.7%, and the incidence of early RHF was 22.8%, which was significantly associated with overall mortality (log-rank HR 4.11, 95% CI 2.47-6.84; log-rank p < .0001). Pulmonary arterial elastance (Ea) was associated with overall mortality (HR 1.74, 95% CI 1.25-2.30; p < .001) independent of other non-hemodynamic risk factors. Ea values below a calculated cutoff represented a significantly reduced mortality risk (HR 0.38, 95% CI 0.19-0.76; p < .0001). PVR with the established cutoff of 3.0 WU was not significant. Ea was also significantly associated with 12-month mortality and RHF. CONCLUSIONS Ea showed a strong impact on post-transplant mortality and RHF and should become part of the routine hemodynamic evaluation in HTx candidates.
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Affiliation(s)
- Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany.
| | - Rasmus Rivinius
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tom Lühring
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Dimitri Grün
- Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Carola Grinninger
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Dominik Schüttler
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph L Bara
- Department of Cardiac, Thorax, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Norbert Frey
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tim Sandhaus
- Department of Cardiac Surgery, University Hospital Jena, Jena, Germany
| | | | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Julia Vietheer
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Jürgen Sindermann
- Department of Cardiology, Münster University Hospital, Münster, Germany; Department of Rehabilitation, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, Münster University Hospital, Münster, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Manfred Richter
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
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15
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Giangreco NP, Lebreton G, Restaino S, Farr M, Zorn E, Colombo PC, Patel J, Soni RK, Leprince P, Kobashigawa J, Tatonetti NP, Fine BM. Alterations in the kallikrein-kinin system predict death after heart transplant. Sci Rep 2022; 12:14167. [PMID: 35986069 PMCID: PMC9391369 DOI: 10.1038/s41598-022-18573-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 08/16/2022] [Indexed: 11/09/2022] Open
Abstract
Heart transplantation remains the definitive treatment for end stage heart failure. Because availability is limited, risk stratification of candidates is crucial for optimizing both organ allocations and transplant outcomes. Here we utilize proteomics prior to transplant to identify new biomarkers that predict post-transplant survival in a multi-institutional cohort. Microvesicles were isolated from serum samples and underwent proteomic analysis using mass spectrometry. Monte Carlo cross-validation (MCCV) was used to predict survival after transplant incorporating select recipient pre-transplant clinical characteristics and serum microvesicle proteomic data. We identified six protein markers with prediction performance above AUROC of 0.6, including Prothrombin (F2), anti-plasmin (SERPINF2), Factor IX, carboxypeptidase 2 (CPB2), HGF activator (HGFAC) and low molecular weight kininogen (LK). No clinical characteristics demonstrated an AUROC > 0.6. Putative biological functions and pathways were assessed using gene set enrichment analysis (GSEA). Differential expression analysis identified enriched pathways prior to transplant that were associated with post-transplant survival including activation of platelets and the coagulation pathway prior to transplant. Specifically, upregulation of coagulation cascade components of the kallikrein-kinin system (KKS) and downregulation of kininogen prior to transplant were associated with survival after transplant. Further prospective studies are warranted to determine if alterations in the KKS contributes to overall post-transplant survival.
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Affiliation(s)
- Nicholas P Giangreco
- Departments of Systems Biology, Biomedical Informatics, and Medicine, Columbia University, New York, NY, USA
| | - Guillaume Lebreton
- Chirurgie Thoracique et Cardiovasculaire, Pitíe-Salpetriere University Hospital, Paris, France
| | - Susan Restaino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emmanuel Zorn
- Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jignesh Patel
- Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rajesh Kumar Soni
- Proteomics and Macromolecular Crystallography Shared Resource, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Pascal Leprince
- Chirurgie Thoracique et Cardiovasculaire, Pitíe-Salpetriere University Hospital, Paris, France
| | - Jon Kobashigawa
- Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Nicholas P Tatonetti
- Departments of Systems Biology, Biomedical Informatics, and Medicine, Columbia University, New York, NY, USA
- Institute for Genomic Medicine, Columbia University, New York, NY, USA
| | - Barry M Fine
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA.
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16
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Assessing the Relationship Between Molecular Rejection and Parenchymal Injury in Heart Transplant Biopsies. Transplantation 2022; 106:2205-2216. [PMID: 35968995 DOI: 10.1097/tp.0000000000004231] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The INTERHEART study (ClinicalTrials.gov #NCT02670408) used genome-wide microarrays to detect rejection in endomyocardial biopsies; however, many heart transplants with no rejection have late dysfunction and impaired survival. We used the microarray measurements to develop a molecular classification of parenchymal injury. METHODS In 1320 endomyocardial biopsies from 645 patients previously studied for rejection-associated transcripts, we measured the expression of 10 injury-induced transcript sets: 5 induced by recent injury; 2 reflecting macrophage infiltration; 2 normal heart transcript sets; and immunoglobulin transcripts, which correlate with time. We used archetypal clustering to assign injury groups. RESULTS Injury transcript sets correlated with impaired function. Archetypal clustering based on the expression of injury transcript sets assigned each biopsy to 1 of 5 injury groups: 87 Severe-injury, 221 Late-injury, and 3 with lesser degrees of injury, 376 No-injury, 526 Mild-injury, and 110 Moderate-injury. Severe-injury had extensive loss of normal transcripts (dedifferentiation) and increase in macrophage and injury-induced transcripts. Late-injury was characterized by high immunoglobulin transcript expression. In Severe- and Late-injury, function was depressed, and short-term graft failure was increased, even in hearts with no rejection. T cell-mediated rejection almost always had parenchymal injury, and 85% had Severe- or Late-injury. In contrast, early antibody-mediated rejection (ABMR) had little injury, but late ABMR often had the Late-injury state. CONCLUSION Characterizing heart transplants for their injury state provides new understanding of dysfunction and outcomes and demonstrates the differential impact of T cell-mediated rejection versus ABMR on the parenchyma. Slow deterioration from ABMR emerges as a major contributor to late dysfunction.
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17
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Wayda B, Khush KK. Expecting the unexpected, and prioritizing the predictable. J Heart Lung Transplant 2022; 41:1128-1129. [PMID: 35599176 PMCID: PMC10863669 DOI: 10.1016/j.healun.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Brian Wayda
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California.
| | - Kiran K Khush
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California
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18
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Ortiz-Bautista C, Muñiz J, Almenar-Bonet L, Crespo-Leiro MG, Sobrino-Márquez JM, Farrero-Torres M, García-Cosio MD, Díaz-Molina B, Zegrí-Reiriz I, González-Vilchez F, Blázquez-Bermejo Z, López Granados A, Gómez-Bueno M, de la Fuente-Galán L, Blasco-Peiró T, Garrido-Bravo IP, García-Romero E, Rábago Juan-Aracil G, García-Guereta L, Delgado-Jiménez JF. Utility of the IMPACT score for predicting heart transplant mortality. Analysis on a contemporary cohort of the Spanish Heart Transplant Registry. Clin Transplant 2022; 36:e14774. [PMID: 35829691 DOI: 10.1111/ctr.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort. METHODS Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N = 2,810). RESULTS Median value of the IMPACT score was 5 points (IQR: 3, 8). Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥ 15) were 84.4%, 81.5%, 79.3%, 77.3% and 58.5% respectively (Log-Rank test: p<0.001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for one year was 7.56; p = 0.47) and poor discrimination ability (AUC-ROC 0.59) of the IMPACT score as a predictive model. CONCLUSIONS In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Universidade da Coruña, Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica (INIBIC), A Coruña, Spain
| | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María G Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña (UDC), A Coruña, Spain
| | - José M Sobrino-Márquez
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Marta Farrero-Torres
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Clínic, Barcelona, Spain
| | - María D García-Cosio
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Beatriz Díaz-Molina
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Isabel Zegrí-Reiriz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco González-Vilchez
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Zorba Blázquez-Bermejo
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Manuel Gómez-Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia cardiaca avanzada y Trasplante, Servicio de Cardiología, Hospital Universitario Puerta de Hierro de Majadahonda, Madrid, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Elena García-Romero
- Servicio de Cardiología, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases group, Cardiovascular, Respiratory and Systemic Diseases and cellular aging program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Juan F Delgado-Jiménez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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19
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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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20
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Patient selection for heart transplant: balancing risk. Curr Opin Organ Transplant 2022; 27:36-44. [PMID: 34939963 DOI: 10.1097/mot.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation. RECENT FINDINGS Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply. SUMMARY The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.
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21
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Liu Z, Perry LA, Penny-Dimri JC, Handscombe M, Overmars I, Plummer M, Segal R, Smith JA. Donor Cardiac Troponin for Prognosis of Adverse Outcomes in Cardiac Transplantation Recipients: a Systematic Review and Meta-analysis. Transplant Direct 2022; 8:e1261. [PMID: 34912948 PMCID: PMC8670586 DOI: 10.1097/txd.0000000000001261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cardiac troponin is a highly specific and widely available marker of myocardial injury, and elevations in cardiac transplant donors may influence donor selection. We aimed to investigate whether elevated donor troponin has a role as a prognostic biomarker in cardiac transplantation. METHODS In a systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library, without language restriction, from inception to December 2020. We included studies reporting the association of elevated donor troponin with recipient outcome after cardiac transplant. We generated summary odds ratios and hazard ratios for the association of elevated donor troponin with short- and long-term adverse outcomes. Methodological quality was monitored using the Quality In Prognosis Studies tool, and interstudy heterogeneity was assessed using a series of sensitivity and subgroup analyses. RESULTS We included 17 studies involving 15 443 patients undergoing cardiac transplantation. Elevated donor troponin was associated with increased odds of graft rejection at 1 y (odds ratio, 2.54; 95% confidence interval, 1.22-5.28). No significant prognostic relationship was found between donor troponin and primary graft failure, short- to long-term mortality, cardiac allograft vasculopathy, and pediatric graft loss. CONCLUSIONS Elevated donor troponin is not associated with an increased short- or long-term mortality postcardiac transplant despite increasing the risk of graft rejection at 1 y. Accordingly, an elevated donor troponin in isolation should not exclude donation.
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Affiliation(s)
- Zhengyang Liu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia
| | - Luke A. Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia
| | - Jahan C. Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Michael Handscombe
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia
| | - Isabella Overmars
- Infection and Immunity Theme, Murdoch Children’s Research Institute, Parkville, Australia
| | - Mark Plummer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Reny Segal
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia
- Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Julian A. Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
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22
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Schramm R, Zittermann A, Fuchs U, Fleischhauer J, Costard-Jäckle A, Ruiz-Cano M, Krenz LA, Fox H, Götte J, Günther SPW, Wlost S, Rojas SV, Hakim-Meibodi K, Morshuis M, Gummert JF. Donor-recipient risk assessment tools in heart transplant recipients: the Bad Oeynhausen experience. ESC Heart Fail 2021; 8:4843-4851. [PMID: 34704397 PMCID: PMC8712925 DOI: 10.1002/ehf2.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS Some risk assessment tools have been developed to categorize mortality risk in heart transplant recipients, but it is unclear whether these tools can be used interchangeable in different transplant regions. METHODS AND RESULTS We performed a retrospective single-centre study in 1049 adult German heart transplant recipients under jurisdiction of Eurotransplant. Univariable and multivariable Cox regression analysis was used to generate a risk scoring system. C-statistics were used to compare our score with a US score and a French score regarding their ability to discriminate between 1 year survivors and non-survivors within our study cohort. Of 38 parameters assessed, seven recipient-specific parameters [age, height, dilated cardiomyopathy (DCM), ischaemic cardiomyopathy (ICM), total bilirubin, extracorporeal membrane oxygenation (ECMO), and biventricular assist device/total artificial heart (BVAD/TAH) implant], one donor-specific parameter (cold ischaemic time), and one recipient-independent and donor-independent other parameter (late transplant era) were statistically significant in predicting 1 year mortality. The initial score was generated by using the regression coefficients from the multivariable analysis as follows: 1.70 * ln age - 4.0 * ln height - 0.9 * diagnosis (= 1 if diagnosis = DCM) - 0.67 * diagnosis (= 1 if diagnosis = ICM) + 0.33 * ln total bilirubin + 1.74 * ln cold ischaemic time + 0.98 * mechanical circulatory support (MCS) implant (= 1 if MCS implant = ECMO) + 0.47 * MCS implant (= 1 of MCS implant = BVAD/TAH) - 0.66 * transplant era (= 1 if transplant era = 2017-2018). The initial score was converted into the Bad Oeynhausen (BO) score as a positive integer variable by means of the following formula: BO score = (initial score + 8) * 3. In patients scoring 2 to <7 points (n = 112), 7 to <11 points (n = 580), 11 to <15 points (n = 339), and 15 to 20 points (n = 18), 1 year survival was 93.1%, 84.2%, 66.9%, and 27.8%, respectively. The c-index of our score was 0.73 [95% confidence interval (CI): 0.69-0.77]. Values were in our cohort for the US and French scores 0.66 (95% CI: 0.62-0.70) and 0.63 (95% CI: 0.59-0.67), respectively. CONCLUSIONS Data indicate that our score, but also risk assessment tools from other transplant regions, may be used as a reliable support for risk-adjusted organ allocation and potentially help to improve outcomes in heart transplantation. Further developments will have to include as yet unaccounted risk factors for even more reliable predictions.
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Affiliation(s)
- Rene Schramm
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Armin Zittermann
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Uwe Fuchs
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Jan Fleischhauer
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Angelika Costard-Jäckle
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Maria Ruiz-Cano
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Luminata-Adriana Krenz
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Henrik Fox
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Julia Götte
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Sabina P W Günther
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Stefan Wlost
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Sebastian V Rojas
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Kavous Hakim-Meibodi
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Michiel Morshuis
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
| | - Jan F Gummert
- Clinic for Thoracic- and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, D-32545, Germany
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23
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Potena L, Rossano J. Development of post-transplant risk scores: Dancing to off-key tunes. J Heart Lung Transplant 2021; 40:1668-1669. [PMID: 34656417 DOI: 10.1016/j.healun.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Luciano Potena
- Heart Failure and Heart Transplant Unit - IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Joseph Rossano
- The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Ayers B, Sandholm T, Gosev I, Prasad S, Kilic A. Using machine learning to improve survival prediction after heart transplantation. J Card Surg 2021; 36:4113-4120. [PMID: 34414609 DOI: 10.1111/jocs.15917] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/01/2021] [Accepted: 07/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). METHODS Retrospective study of adult patients undergoing primary, isolated OHT between 2000 and 2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was 1-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. The discriminatory capability was assessed using the area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). RESULTS A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n = 3738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI, 0.628-0.670) compared to 0.691 (95% CI, 0.671-0.711) with random forest, 0.691 (95% CI, 0.671-0.712) with deep neural network, and 0.653 (95% CI, 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI, 0.745-0.782) (p < .001). The ensemble ML model improved predictive performance by 72.9% ±3.8% (p < .001) as assessed by NRI compared to logistic regression. DCA showed the final ensemble method improved risk prediction across the entire spectrum of predicted risk as compared to all other models (p < .001). CONCLUSIONS Modern ML techniques can improve risk prediction in OHT compared to traditional approaches. This may have important implications in patient selection, programmatic evaluation, allocation policy, and patient counseling and prognostication.
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Affiliation(s)
- Brian Ayers
- Department of Surgery, The Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Igor Gosev
- Division of Cardiac Surgery, The University of Rochester Medical Center, Rochester, New York, USA
| | - Sunil Prasad
- Division of Cardiac Surgery, The University of Rochester Medical Center, Rochester, New York, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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25
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de Jong Y, Ramspek CL, Zoccali C, Jager KJ, Dekker FW, van Diepen M. Appraising prediction research: a guide and meta-review on bias and applicability assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). Nephrology (Carlton) 2021; 26:939-947. [PMID: 34138495 PMCID: PMC9291738 DOI: 10.1111/nep.13913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 12/23/2022]
Abstract
Over the past few years, a large number of prediction models have been published, often of poor methodological quality. Seemingly objective and straightforward, prediction models provide a risk estimate for the outcome of interest, usually based on readily available clinical information. Yet, using models of substandard methodological rigour, especially without external validation, may result in incorrect risk estimates and consequently misclassification. To assess and combat bias in prediction research the prediction model risk of bias assessment tool (PROBAST) was published in 2019. This risk of bias (ROB) tool includes four domains and 20 signalling questions highlighting methodological flaws, and provides guidance in assessing the applicability of the model. In this paper, the PROBAST will be discussed, along with an in‐depth review of two commonly encountered pitfalls in prediction modelling that may induce bias: overfitting and composite endpoints. We illustrate the prevalence of potential bias in prediction models with a meta‐review of 50 systematic reviews that used the PROBAST to appraise their included studies, thus including 1510 different studies on 2104 prediction models. All domains showed an unclear or high ROB; these results were markedly stable over time, highlighting the urgent need for attention on bias in prediction research. This article aims to do just that by providing (1) the clinician with tools to evaluate the (methodological) quality of a clinical prediction model, (2) the researcher working on a review with methods to appraise the included models, and (3) the researcher developing a model with suggestions to improve model quality. Most published prediction models have limited clinical uptake, are not externally validated and come with methodological issues. The PROBAST (Prediction model Risk Of Bias ASssessment Tool) guides the researcher writing a review, or the clinician interested in a model for risk calculation in a clinical setting. This review examines the aspects of bias in prediction research, and provides information on the prevalence of bias in published models.
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Affiliation(s)
- Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carmine Zoccali
- Renal Research Institute, New York, USA.,Associazione Ipertensione Nefrologia Trapianto Renale (IPNET) Reggio Cal, Italy
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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26
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Wang L, Thompson E, Bates L, Pither TL, Hosgood SA, Nicholson ML, Watson CJ, Wilson C, Fisher AJ, Ali S, Dark JH. Flavin Mononucleotide as a Biomarker of Organ Quality-A Pilot Study. Transplant Direct 2020; 6:e600. [PMID: 32904032 PMCID: PMC7447496 DOI: 10.1097/txd.0000000000001046] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Flavin mononucleotide (FMN), released from damaged mitochondrial complex I during hypothermic liver perfusion, has been shown to be predictive of 90-day graft loss. Normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP) are used for organ reconditioning and quality assessment before transplantation. This pilot study aimed to investigate the changes of FMN levels during normothermic reperfusion of kidneys, livers, and lungs and examine whether FMN could serve as a biomarker to predict posttransplant allograft quality. METHODS FMN concentrations, in perfusates collected during NMP of kidneys, abdominal NRP, and ex vivo lung perfusion, were measured using fluorescence spectrometry and correlated to the available perfusion parameters and clinical outcomes. RESULTS Among 7 transplanted kidneys out of the 11 kidneys that underwent NMP, FMN levels at 60 minutes of NMP were significantly higher in the allografts that developed delayed graft function and primary nonfunction (P = 0.02). Fifteen livers from 23 circulatory death donors that underwent NRP were deemed suitable for transplantation. Their FMN levels at 30 minutes of NRP were significantly lower than those not procured for transplantation (P = 0.004). In contrast, little FMN was released during the 8 lung perfusions. CONCLUSIONS This proof of concept study suggested that FMN in the perfusates of kidney NMP has the potential to predict posttransplant renal function, whereas FMN at 30 minutes of NRP predicts whether a liver would be accepted for transplantation. More work is required to validate the role of FMN as a putative biomarker to facilitate safe and reliable decision-making before embarking on transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily Thompson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas L. Pither
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | | | | | - Colin Wilson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew J. Fisher
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H. Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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