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Abstract
Heart transplantation (HT) remains the best treatment of patients with severe heart failure who are deemed to be transplant candidates. The authors discuss postoperative management of the HT recipient by system, emphasizing areas where care might differ from other cardiac surgery patients. Working together, critical care physicians, heart transplant surgeons and cardiologists, advanced practice providers, pharmacists, transplant coordinators, nursing staff, physical therapists, occupational therapists, rehabilitation specialists, nutritionists, health psychologists, social workers, and the patient and their loved ones partner to increase the likelihood of a successful outcome.
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Affiliation(s)
- Gozde Demiralp
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Robert T Arrigo
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA
| | - Christopher Cassara
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA
| | - Maryl R Johnson
- Heart Failure and Transplant Cardiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, E5/582 CSC, Mail Code 5710, Madison, WI 53792, USA.
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Oehler D, Oehler H, Sigetti D, Immohr MB, Böttger C, Bruno RR, Haschemi J, Aubin H, Horn P, Westenfeld R, Bönner F, Akhyari P, Kelm M, Lichtenberg A, Boeken U. Early Postoperative Neurologic Events Are Associated With Worse Outcome and Fatal Midterm Survival After Adult Heart Transplantation. J Am Heart Assoc 2023; 12:e029957. [PMID: 37548172 PMCID: PMC10492937 DOI: 10.1161/jaha.123.029957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023]
Abstract
Background Neurologic events during primary stay in heart transplant (HTx) recipients may be associated with reduced outcome and survival, which we aim to explore with the current study. Methods and Results We screened and included all patients undergoing HTx in our center between September 2010 and December 2022 (n=268) and checked for the occurrence of neurologic events within their index stay. Neurologic events were defined as ischemic stroke, hemorrhage, hypoxic ischemic injury, or acute symptomatic neurologic dysfunction without central nervous system injury. The cohort was then divided into recipients with (n=33) and without (n=235) neurologic events after HTx. Using a multivariable Cox regression model, the association of neurologic events after HTx and survival was assessed. Recipients with neurologic events displayed a longer intensive care unit stay (30 versus 16 days; P=0.009), longer mechanical ventilation (192 versus 48 hours; P<0.001), and higher need for blood transfusion, and need for hemodialysis after HTx was substantially higher (81% versus 55%; P=0.01). Resternotomy (36% versus 26%; P=0.05) and mechanical life support (extracorporeal life support) after HTx (46% versus 24%; P=0.02) were also significantly higher in patients with neurologic events. Covariable-adjusted multivariable Cox regression analysis revealed a significant independent association of neurologic events and increased 30-day (hazard ratio [HR], 2.5 [95% CI, 1.0-6.0]; P=0.049), 1-year (HR, 2.2 [95% CI, 1.1-4.3]; P=0.019), and overall (HR, 2.5 [95% CI, 1.5-4.2]; P<0.001) mortality after HTx and reduced Kaplan-Meier survival up to 5 years after HTx (P<0.001). Conclusions Neurologic events after HTx were strongly and independently associated with worse postoperative outcome and reduced survival up to 5 years after HTx.
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Affiliation(s)
- Daniel Oehler
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hannah Oehler
- Department of NeurologyHeidelberg UniversityHeidelbergGermany
| | - Dennis Sigetti
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | | | - Charlotte Böttger
- Department of Diagnostic and Interventional RadiologyHeinrich‐Heine UniversityDuesseldorfGermany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Jafer Haschemi
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hug Aubin
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Patrick Horn
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Florian Bönner
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Payam Akhyari
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Artur Lichtenberg
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Udo Boeken
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
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Thangappan K, Haney LC, Riggs K, Chen S, Mehegan M, VanderPluym C, Woods R, LaPar D, Lorts A, Zafar F, Morales DLS. Children who stroke on VAD support: when is it safe to transplant and what are their outcomes? Artif Organs 2022; 46:1389-1398. [PMID: 35132634 DOI: 10.1111/aor.14194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/04/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Ventricular assist devices (VADs) increase waitlist survival, yet the risk of stroke remains notable. The purpose of this study was to analyze how strokes on VAD support impact post-transplant (post-Tx) outcomes in children. METHODS 520 pediatric (<18 yo) heart transplant candidates listed from January 2011 to April 2018 with a VAD implant date were matched between the United Network of Organ Sharing and Pediatric Health Information System databases. Patients were divided into pre-Tx Stroke and No Stroke cohorts. RESULTS 81% of the 520 patients were transplanted. 28% (n=146) had a pre-Tx Stroke. 59% (n=89) of the Stroke patients were transplanted at a median of 57 (IQR 17-102) days from stroke. Significantly more No Stroke cohort (90%) were transplanted (p<0.001). There was no difference in post-Tx survival between the Stroke and No Stroke cohorts (p=0.440). Time between stroke and transplant for patients who died within one year of transplant was 32.0 days (median) compared to 60.5 days for those alive > 1year (p=0.18). Regarding patients in whom time from stroke to transplant was more than 60 days, one-year survival of Stroke vs. No Stroke patients was 96% vs. 95% (p=0.811), respectively. CONCLUSION Patients with stroke during VAD support, once transplanted, enjoy similar survival compared to No Stroke patients. We hypothesize that allowing Stroke patients more time to recover could improve post-Tx outcomes. Unfortunately, the ideal duration of time between stroke and safe transplantation could not be determined and will require more detailed and larger studies in the future.
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Affiliation(s)
- Karthik Thangappan
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Li Cai Haney
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kyle Riggs
- Division of Cardiothoracic Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Mary Mehegan
- Division of Cardiothoracic Surgery, St. Louis Children's Hospital, Saint Louis, MO, USA
| | | | - Ronald Woods
- Division of Congenital Heart Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Damien LaPar
- Department of Pediatric Cardiac Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Şahintürk H, Yurtsever BM, Ersoy Ö, Kibaroğlu S, Zeyneloğlu P. Neurologic Complications in Heart Transplant Recipients Readmitted to the Intensive Care Unit. Cureus 2021; 13:e19425. [PMID: 34926017 PMCID: PMC8654072 DOI: 10.7759/cureus.19425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Neurologic complications after transplantation surgery are major causes of morbidity, and the incidence of neurologic complications among heart transplant recipients varies from 7% to 81%. In our study, we aimed to determine the incidence, etiologies, and risk factors of neurologic complications among patients readmitted to the intensive care unit (ICU) after heart transplantation. Method In this retrospective cohort study, the medical records of all patients who underwent cardiac transplantation from February 2003 to July 2019 were reviewed, and those admitted to the ICU due to neurologic complications during the early and late postoperative period were evaluated. The patients were divided into two groups based on the development of neurologic complications to compare demographic and other characteristics. Results A total of 130 heart transplant recipients were analyzed. We excluded 33 patients from the study because they either had neurologic complications or died postoperatively without discharge from the intensive care unit. The mean age of the cohort was 35.4 ± 18.5 years, and 74 (76.3%) were male. Out of those 97 heart transplant recipients, 22 (22.7%) developed neurologic complications. Five patients (22.7% ) were admitted to the ICU in the first month, six patients (27.3%) were admitted to the ICU between one and six months, and 11 patients (50%) were admitted to the ICU six months after transplantation due to neurologic complications. The most common diagnosis was posterior reversible encephalopathy syndrome (PRES) (n = 6, 27.3%). The other diagnoses were calcineurin inhibitor toxicity (n = 5, 22.7%), intracranial hemorrhage (n = 3, 13.6%), seizures (n = 2, 9.2%), stroke (n = 2, 9.2%), femoral neuropathy (n = 1, 4.5%), myopathy (n = 1, 4.5%), phrenic nerve damage (n = 1, 4.5%), and cerebral abscess (n = 1, 4.5%). The rate of neurologic complications was higher in males when compared with females (p = 0.03). Both groups were similar in terms of the etiologies of cardiac failure, coexisting disease, and anticoagulant and immunosuppressive usage. The requirement for mechanical ventilation, renal replacement therapy, and the incidence of acute kidney injury were similar in both groups (p > 0.05). The incidence of sepsis was significantly higher in patients with neurologic complications (n = 8, 36.4%, versus n = 5, 6.7%; p < 0.001). The mean length of hospital stay was significantly higher in patients with neurologic complications (21.4 ± 15.8 versus 11.1 ± 13.3 days, p = 0.01). The risk of developing neurologic complications is 3.036 times higher in males, and this is statistically significant (odds ratio (OR), 3.036; 95% confidence interval (CI), 1.078-8.444; p = 0.036). Conclusion Our results suggest that neurologic complications develop in 22.7% of heart transplant recipients admitted to the ICU, and half of them are seen after six months postoperatively. PRES was the most frequent (27.3%) neurologic complication. The risk of neurologic complications is three times higher for males. The mean length of hospital stay and incidence of sepsis were significantly higher in heart transplant recipients who developed neurologic complications.
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Affiliation(s)
- Helin Şahintürk
- Anesthesiology and Critical Care, Başkent University Faculty of Medicine, Ankara, TUR
| | | | - Özgür Ersoy
- Cardiovascular Surgery, Dışkapı Yıldırım Beyazıd Eğitim ve Araştırma Hastanesi, Ankara, TUR
| | - Seda Kibaroğlu
- Neurology, Başkent University Faculty of Medicine, Ankara, TUR
| | - Pınar Zeyneloğlu
- Anesthesiology and Critical Care, Başkent University Faculty of Medicine, Ankara, TUR
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Alvarez P, Kitai T, Okamoto T, Niikawa H, McCurry KR, Papamichail A, Doulamis I, Briasoulis A. Trends, risk factors, and outcomes of post-operative stroke after heart transplantation: an analysis of the UNOS database. ESC Heart Fail 2021; 8:4211-4217. [PMID: 34431235 PMCID: PMC8497374 DOI: 10.1002/ehf2.13562] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HTx) are limited. METHODS AND RESULTS We conducted a retrospective analysis of the United Network for Organ Sharing (UNOS) database from 2009 to 2020 to identify adults who developed stroke after orthotropic HTx. Heart transplant recipients were divided according to the presence or absence of post-operative stroke. The primary endpoint was all-cause mortality. A total of 25 015 HT recipients were analysed, including 719 (2.9%) patients who suffered a post-operative stroke. The stroke rates increased from 2.1% in 2009 to 3.7% in 2019, and the risk of stroke was higher after the implantation of the new allocation system [odds ratio 1.29, 95% confidence intervals (CI) 1.06-1.56, P = 0.01]. HTx recipients with post-operative stroke were older (P = 0.008), with higher rates of prior cerebrovascular accident (CVA) (P = 0.004), prior cardiac surgery (P < 0.001), longer waitlist time (P = 0.04), higher rates of extracorporeal membrane oxygenation (ECMO) support (P < 0.001), left ventricular assist devices (LVADs) (P < 0.001), mechanical ventilation (P = 0.003), and longer ischaemic time (P < 0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischaemic time, and mechanical ventilation at the time of HTx were independent predictors of post-operative stroke. Stroke was associated with increased risk of 30 day and all-cause mortality (hazard ratio 1.49, 95% CI 1.12-1.99, P = 0.007). CONCLUSIONS Post-operative stroke after HTx is infrequent but associated with higher mortality. Redo sternotomy, LVAD, and ECMO support at HTx are among the risk factors identified.
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Affiliation(s)
- Paulino Alvarez
- Division of Cardiology, Heart and Vascular InstituteCleveland ClinicClevelandOHUSA
| | - Takeshi Kitai
- Department of Cardiovascular MedicineKobe City Medical Center General HospitalKobeJapan
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular SurgeryCleveland ClinicClevelandOHUSA
| | - Hiromichi Niikawa
- Department of Thoracic and Cardiovascular SurgeryTohoku UniversitySendaiJapan
| | - Kenneth R. McCurry
- Department of Thoracic and Cardiovascular SurgeryCleveland ClinicClevelandOHUSA
| | | | - Ilias Doulamis
- Department of Cardiac Surgery, Boston's Children HospitalHarvard Medical SchoolBostonMAUSA
| | - Alexandros Briasoulis
- National Kapodistrian University of Athens Medical SchoolAthensGreece
- Division of Cardiovascular Medicine, Section of Heart Failure and TransplantationUniversity of Iowa200 Hawkins DrIowa CityIA52242USA
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Sakusic A, Rabinstein AA. Neurological Complications in Patients with Heart Transplantation. Semin Neurol 2021; 41:447-452. [PMID: 33851398 DOI: 10.1055/s-0041-1726285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Neurological complications after heart transplantation are common and include cerebrovascular events (ischemic strokes, hemorrhagic strokes, and transient ischemic attacks), seizures, encephalopathy, central nervous system (CNS) infections, malignancies, and peripheral nervous system complications. Although most neurological complications are transient, strokes and CNS infections can result in high mortality and morbidity. Early recognition and timely management of these serious complications are crucial to improve survival and recovery. Diagnosing CNS infections can be challenging because their clinical presentation can be subtle in the setting of immunosuppression. Immunosuppressive medications themselves can cause a broad spectrum of neurological complications including seizures and posterior reversible encephalopathy syndrome. This article provides a review of the diagnosis and management of neurological complications after cardiac transplantation.
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Affiliation(s)
- Amra Sakusic
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida.,Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, Minnesota
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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Ko SB. Perioperative stroke: pathophysiology and management. Korean J Anesthesiol 2018; 71:3-11. [PMID: 29441169 PMCID: PMC5809704 DOI: 10.4097/kjae.2018.71.1.3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/19/2017] [Indexed: 01/01/2023] Open
Abstract
Although perioperative stroke is uncommon during low-risk non-vascular surgery, if it occurs, it can negatively impact recovery from the surgery and functional outcome. Based on the Society for Neuroscience in Anesthesiology and Critical Care Consensus Statement, perioperative stroke includes intraoperative stroke, as well as postoperative stroke developing within 30 days after surgery. Factors related to perioperative stroke include age, sex, a history of stroke or transient ischemic attack, cardiac surgery (aortic surgery, mitral valve surgery, or coronary artery bypass graft surgery), and neurosurgery (external carotid-internal carotid bypass surgery, carotid endarterectomy, or aneurysm clipping). Concomitant carotid and cardiac surgery may further increase the risk of perioperative stroke. Preventive strategies should be individualized based on patient factors, including cerebrovascular reserve capacity and the time interval since the previous stroke.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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10
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McCartney SL, Patel C, Del Rio JM. Long-term outcomes and management of the heart transplant recipient. Best Pract Res Clin Anaesthesiol 2017; 31:237-248. [PMID: 29110796 DOI: 10.1016/j.bpa.2017.06.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 01/02/2023]
Abstract
Cardiac transplantation remains the gold standard in the treatment of advanced heart failure. With advances in immunosuppression, long-term outcomes continue to improve despite older and higher risk recipients. The median survival of the adult after heart transplantation is currently 10.7 years. While early graft failure and multiorgan system dysfunction are the most important causes of early mortality, malignancy, rejection, infection, and cardiac allograft vasculopathy contribute to late mortality. Chronic renal dysfunction is common after heart transplantation and occurs in up to 68% of patients by year 10, with 6.2% of patients requiring dialysis and 3.7% undergoing renal transplant. Functional outcomes after heart transplantation remain an area for improvement, with only 26% of patients working at 1-year post-transplantation, and are likely related to the high incidence of depression after cardiac transplantation. Areas of future research include understanding and managing primary graft dysfunction and reducing immunosuppression-related complications.
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Affiliation(s)
- Sharon L McCartney
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
| | - Chetan Patel
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA.
| | - J Mauricio Del Rio
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
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Lee YJ, Yum MS, Kim EH, Kim MJ, Kim KM, Im HJ, Kim YH, Park YS, Ko TS. Clinical Characteristics of Transplant-associated Encephalopathy in Children. J Korean Med Sci 2017; 32:457-464. [PMID: 28145649 PMCID: PMC5290105 DOI: 10.3346/jkms.2017.32.3.457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/30/2016] [Indexed: 12/27/2022] Open
Abstract
We aimed to analyze characteristics of encephalopathy after both hematopoietic stem cell and solid organ pediatric transplantation. We retrospectively reviewed medical records of 662 pediatric transplant recipients (201 with liver transplantation [LT], 55 with heart transplantation [HT], and 67 with kidney transplantation [KT], 339 with allogeneic hematopoietic stem cell transplantation [HSCT]) who received their graft organs at Asan Medical Center between January 2000 and July 2014. Of the 662 patients, 50 (7.6%) experienced encephalopathy after transplantation. The incidence of encephalopathy was significantly different according to the type of organ transplant: LT, 16/201 (8.0%), HT, 13/55 (23.6%), KT, 5/67 (7.5%), and HSCT, 16/339 (4.7%) (P < 0.001). Drug-induced encephalopathy (n = 14) was the most common encephalopathy for all transplant types, but particularly after HSCT. Hypertensive encephalopathy was the most common after KT and HT, whereas metabolic encephalopathy was the most common after LT. The median time to encephalopathy onset also differed according to the transplant type: 5 days after KT (range 0-491 days), 10 days after HT (1-296 days), 49.5 days after HSCT (9-1,405 days), and 39 days after LT (1-1,092 days) (P = 0.018). The mortality rate among patients with encephalopathy was 42.0% (n = 21/50). Only 5 patients died of neurologic complications. Transplant-associated encephalopathy presented different characteristics according to the type of transplant. Specialized diagnostic approach for neurologic complications specific to the type of transplant may improve survival and quality of life in children after transplantation.
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Affiliation(s)
- Yun Jeong Lee
- Department of Pediatrics, Kyungpook National University Hospital, Daegu, Korea
| | - Mi Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Kim
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Min Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Joon Im
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hwue Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea.
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Doumouras BS, Alba AC, Foroutan F, Burchill LJ, Dipchand AI, Ross HJ. Outcomes in adult congenital heart disease patients undergoing heart transplantation: A systematic review and meta-analysis. J Heart Lung Transplant 2016; 35:1337-1347. [DOI: 10.1016/j.healun.2016.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/08/2016] [Accepted: 06/01/2016] [Indexed: 11/16/2022] Open
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Acampa M, Lazzerini PE, Guideri F, Tassi R, Martini G. Ischemic Stroke after Heart Transplantation. J Stroke 2016; 18:157-68. [PMID: 26915504 PMCID: PMC4901943 DOI: 10.5853/jos.2015.01599] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/13/2015] [Accepted: 01/04/2016] [Indexed: 12/16/2022] Open
Abstract
Cerebrovascular complications after orthotopic heart transplantation (OHT) are more common in comparison with neurological sequelae subsequent to routine cardiac surgery. Ischemic stroke and transient ischemic attack (TIA) are more common (with an incidence of up to 13%) than intracranial hemorrhage (2.5%). Clinically, ischemic stroke is manifested by the appearance of focal neurologic deficits, although sometimes a stroke may be silent or manifests itself by the appearance of encephalopathy, reflecting a diffuse brain disorder. Ischemic stroke subtypes distribution in perioperative and postoperative period after OHT is very different from classical distribution, with different pathogenic mechanisms. Infact, ischemic stroke may be caused by less common and unusual mechanisms, linked to surgical procedures and to postoperative inflammation, peculiar to this group of patients. However, many strokes (40%) occur without a well-defined etiology (cryptogenic strokes). A silent atrial fibrillation (AF) may play a role in pathogenesis of these strokes and P wave dispersion may represent a predictor of AF. In OHT patients, P wave dispersion correlates with homocysteine plasma levels and hyperhomocysteinemia could play a role in the pathogenesis of these strokes with multiple mechanisms increasing the risk of AF. In conclusion, stroke after heart transplantation represents a complication with considerable impact not only on mortality but also on subsequent poor functional outcome.
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Affiliation(s)
- Maurizio Acampa
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, viale Bracci, Siena, Italy
| | - Francesca Guideri
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
| | - Giuseppe Martini
- Stroke Unit, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, viale Bracci, Siena, Italy
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Smirl JD, Haykowsky MJ, Nelson MD, Tzeng YC, Marsden KR, Jones H, Ainslie PN. Relationship Between Cerebral Blood Flow and Blood Pressure in Long-Term Heart Transplant Recipients. Hypertension 2014; 64:1314-20. [DOI: 10.1161/hypertensionaha.114.04236] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heart transplant recipients are at an increased risk for cerebral hemorrhage and ischemic stroke; yet, the exact mechanism for this derangement remains unclear. We hypothesized that alterations in cerebrovascular regulation is principally involved. To test this hypothesis, we studied cerebral pressure-flow dynamics in 8 clinically stable male heart transplant recipients (62±8 years of age and 9±7 years post transplant, mean±SD), 9 male age-matched controls (63±8 years), and 10 male donor controls (27±5 years). To increase blood pressure variability and improve assessment of the pressure-flow dynamics, subjects performed squat–stand maneuvers at 0.05 and 0.10 Hz. Beat-to-beat blood pressure, middle cerebral artery velocity, and end-tidal carbon dioxide were continuously measured during 5 minutes of seated rest and throughout the squat–stand maneuvers. Cardiac baroreceptor sensitivity gain and cerebral pressure-flow responses were assessed with linear transfer function analysis. Heart transplant recipients had reductions in R-R interval power and baroreceptor sensitivity low frequency gain (
P
<0.01) compared with both control groups; however, these changes were unrelated to transfer function metrics. Thus, in contrast to our hypothesis, the increased risk of cerebrovascular complication after heart transplantation does not seem to be related to alterations in cerebral pressure-flow dynamics. Future research is, therefore, warranted.
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Affiliation(s)
- Jonathan D. Smirl
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Mark J. Haykowsky
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Michael D. Nelson
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Yu-Chieh Tzeng
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Katelyn R. Marsden
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Helen Jones
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
| | - Philip N. Ainslie
- From the Department of Health and Social Development, Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, British Columbia, Canada (J.D.S., K.R.M., P.N.A.); Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta and Mazankowki Alberta Heart Institute, Edmonton, Canada (M.J.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (M.D.N.); Department of Surgery and Anaesthesia, Cardiovascular
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16
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Abstract
Cardiac transplantation remains the best treatment option for patients with end-stage, NYHA class IV heart failure who have failed conventional therapy. However, transplant rates have remained static largely due to limited organ donor supplies. Therefore, appropriate allocation of this precious resource is critical to maximize benefit, both at a patient level and at a societal level. Neurologic diseases, such as cerebrovascular disease and peripheral neuropathy, are prevalent in this patient population, as the major risk factors for heart disease place patients at risk for neurologic disease as well. Examples include hypertension, smoking, hypercholesterolemia, obesity, and diabetes. Pretransplant neurologic evaluation is very important to identify conditions that may limit survival after cardiac transplantation. In general, systemic diseases exacerbated by immunosuppression, conditions limiting ability to rehabilitate, and dementias are considered contraindications. Post-transplant neurologic complications are divided into central versus peripheral, and early versus late. The most common early complication is ischemic stroke. Other serious complications include hemorrhagic stroke, encephalopathy, and critical illness neuropathy. Over the long term, post-transplant immunosuppressive regimens are considered "a double edged sword." Although immunosuppressive medications are critical to preventing rejection and allograft dysfunction, they do have significant risk of morbidity and mortality associated with them, including neurologic side-effects. These include: (1) drug toxicities, such as lowering of seizure thresholds; (2) encephalopathy, such as posterior reversible encephalopathy syndrome (PRES); (3) infections; (4) malignancies, such as post-transplant lymphoproliferative disorder (PTLD). Many of the same considerations discussed in adult heart transplant recipients apply to pediatric heart transplant recipients as well. In children, seizures are the most common neurologic complication, although other neurologic complication rates are comparable.
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Affiliation(s)
- Alain Heroux
- Heart Failure and Heart Transplant Program, Loyola University Medical Center, Maywood, IL, USA.
| | - Salpy V Pamboukian
- Section of Advanced Heart Failure, Cardiac Transplant, Mechanical Circulatory Support and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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Imamura T, Kinugawa K, Shiga T, Endo M, Kato N, Inaba T, Maki H, Hatano M, Yao A, Nishimura T, Hirata Y, Kyo S, Ono M, Nagai R. An elevated ratio of early to late diastolic filling velocity recovers after heart transplantation in a time-dependent manner. J Cardiol 2012; 60:295-300. [DOI: 10.1016/j.jjcc.2012.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/14/2012] [Accepted: 05/16/2012] [Indexed: 11/29/2022]
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Häusler KG, Laufs U, Endres M. [Neurological aspects of chronic heart failure]. DER NERVENARZT 2012; 82:733-42. [PMID: 20694790 DOI: 10.1007/s00115-010-3093-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic heart failure (CHF) is one of the leading causes of hospitalization, morbidity and mortality. Moreover, there is a high rate of neurological as well as neuropsychological comorbidities, namely ischemic stroke, structural brain alterations, cognitive impairment, sleep apnea and possible side-effects of HF medication such as delirium or (intracerebral) hemorrhage. The higher stroke risk in patients with HF increases further with age, concomitant arterial hypertension or atrial fibrillation (AF). In women the stroke risk increases with reduced ejection fraction (EF). In general stroke in HF patients is associated with a poor outcome and higher mortality, which is increased more than 2-fold. Furthermore, approximately 25-80% of all patients with CHF experience cognitive impairments such as decreased attention and concentration, memory loss, diminished psychomotor reaction time and decreased executive functions. Cognitive impairment in patients with HF has been linked to losses in gray matter, (silent) ischemic strokes, decreased cerebral perfusion and higher mortality. Moreover, sleep apnea occurs in more than half of all patients with CHF and reduced EF. However, prospective studies are needed to test whether early detection and optimal treatment of HF reduces the burden of neurological and neuropsychological sequelae.
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Affiliation(s)
- K G Häusler
- Klinik und Poliklinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin.
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19
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Font MÀ, Krupinski J, Arboix A. Antithrombotic medication for cardioembolic stroke prevention. Stroke Res Treat 2011; 2011:607852. [PMID: 21822469 PMCID: PMC3148601 DOI: 10.4061/2011/607852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 03/02/2011] [Accepted: 03/27/2011] [Indexed: 01/28/2023] Open
Abstract
Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed.
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Affiliation(s)
- M. Àngels Font
- Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Department of Neurology, Hospital Sant Joan de Déu de Manresa (Fundació Althaia), Catalonia, 08243 Manresa, Spain
| | - Jerzy Krupinski
- Department of Neurology, Cerebrovascular Diseases Unit, Hospital Universitari Mútua de Terrassa, Catalonia, 08227 Terrassa, Spain
| | - Adrià Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari Sagrat Cor, University of Barcelona, C/Viladomat 288, Catalonia, 08029 Barcelona, Spain
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Alejaldre A, Delgado-Mederos R, Santos MÁ, Martí-Fàbregas J. Cerebrovascular complications after heart transplantation. Curr Cardiol Rev 2010; 6:214-7. [PMID: 21804780 PMCID: PMC2994113 DOI: 10.2174/157340310791658811] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 11/30/2022] Open
Abstract
Neurological complications in orthotopic heart transplantation represent a major cause of morbidity and mortality despite successful transplantation. The most frequent perioperative neurological complications are delirium or encephalopathy. In this period cerebrovascular complication ranges between 5-11%. After the perioperative period, the 5-year stroke risk after cardiac transplantation is 4.1%. In a retrospective study conducted with 314 patients who underwent cardiac transplantation, it was found that 20% of cerebrovascular complications occurred within the first two weeks after transplantation, while 80% occurred in the late postoperative phase. Of these, ischemic stroke is the most common subtype. In the perioperative periode, hemodynamic instability, cardiac arrest, extracorporeal circulation over 2 hours, prior history of stroke, and carotid stenosis greater than 50% have been reported to be risk factors for the occurrence of cerebrovascular complications. Perioperative cerebrovascular complications are associated with higher mortality and poor functional outcome at one year follow-up.After the perioperative period, the only factor that has been significantly associated with an increased risk of cerebrovascular complications is a history of prior stroke, either ischemic or hemorrhagic. Other associated factors include unknown atrial fibrillation, septic emboli from endocarditis, cardiac catheterization and perioperative hemodynamic shock. According to the TOAST etiologic classification, the most prevalent etiologic subtype of ischemic stroke is undetermined cause.
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Affiliation(s)
| | | | | | - Joan Martí-Fàbregas
- Stroke Unit, Neurology Department, Hospital de la Santa Creu i Sant Pau, Spain
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21
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Díez-Tejedor E, Fuentes B. Stroke related to systemic illness and complicated surgery. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:935-954. [PMID: 18804687 DOI: 10.1016/s0072-9752(08)93046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Exuperio Díez-Tejedor
- Stroke Unit, Department of Neurology, La Paz University Hospital, Madrid autonomous university, Madrid, Spain.
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22
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Meschia JF, Barrett KM, Chukwudelunzu F, Brown WM, Case LD, Kissela BM, Brown RD, Brott TG, Olson TS, Rich SS, Silliman S, Worrall BB. Interobserver agreement in the trial of org 10172 in acute stroke treatment classification of stroke based on retrospective medical record review. J Stroke Cerebrovasc Dis 2008; 15:266-72. [PMID: 17904086 PMCID: PMC2031226 DOI: 10.1016/j.jstrokecerebrovasdis.2006.07.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 07/06/2006] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The reliability of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system of stroke in siblings of stroke-affected probands has not been tested. Similarly, the reliability of using clinical medical records to classify ischemic stroke has not been assessed. The purpose of this study was to establish the interrater reliability of sibling stroke subtyping by applying the TOAST criteria to retrospectively obtained medical records. METHODS Thirty medical records were randomly sampled from among the records of all siblings previously classified as stroke affected by the Siblings with Ischemic Stroke Study (SWISS) Stroke Verification Committee. Blinded medical records for these individuals were sent to 6 physician reviewers who independently classified TOAST stroke subtype on the basis of record review. RESULTS Using the kappa statistic to assess interrater reliability, the overall reliability (SE) for assigning a TOAST subtype of stroke was 0.54 (0.03). Pair-wise comparisons between the original SWISS Stroke Verification Committee diagnoses and the diagnoses made by other reviewers exhibited moderate reliability (kappa range 0.41-0.56). The kappa statistics for common stroke subtypes were large vessel, 0.80 (0.06); cardioembolic, 0.80 (0.06); small vessel, 0.53 (0.06); and unknown cause, 0.40 (0.06). CONCLUSION We conclude that TOAST subtyping had moderate interrater reliability. Large-artery and cardioembolic subtype diagnoses seemed most reliable.
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Affiliation(s)
- James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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