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Rajagopalan G, Balakrishnan KR, Suresh Rao KG, Ravi Kumar R, Kumar RK. Low Mean Perfusion Pressure Indexed to Body Surface Area is a Powerful Predictor of Poor Outcomes After Heart Transplantation in Patients With High Pre-Transplant Venous Pressure: A Clinical Study With Physiological Insights From Mathematical Modelling of Biventricular Heart Failure. Heart Lung Circ 2024; 33:292-303. [PMID: 38360502 DOI: 10.1016/j.hlc.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND & AIM The deleterious consequences of chronically elevated venous pressure in patients with profound right ventricular or biventricular dysfunction are well known, including renal and hepatic dysfunction, and volume overload. The only option for these patients, if they fail optimal medical treatment, is a heart transplant, as they are not candidates for left ventricular assist device therapy. Mean perfusion pressure (MPP) is important in the outcomes of critically ill patients with high venous pressure. The question arises whether MPP is important for the outcomes of heart transplants in patients with elevated pre-transplant venous pressure. Medical management of heart failure patients with reduced ejection fraction involves lowering the systemic afterload with vasodilators while awaiting a transplant. We hypothesised that when venous pressure is elevated prior to transplant, a substantial reduction in systemic arterial elastance (Ea) through vasodilation may significantly decrease MPP, resulting in compromised end-organ function and consequent unfavourable outcomes after heart transplantation. This study aims to investigate whether a low MPP serves as a risk factor for adverse outcomes in heart transplant recipients with high venous pressure. METHOD A retrospective analysis was conducted on 250 heart transplant recipients undergoing isolated heart transplantation at a single institution from October 2012 to March 2020. Right atrial pressure (RAP) of more than 15 mmHg was considered high. Additionally, Ea calculated as the ratio of end-systolic pressure to stroke volume, and MPP calculated as the difference between mean arterial pressure and RAP were considered in our analysis. The outcomes of transplantation were measured in terms of 90-day mortality and survival up to 7 years. RESULTS High RAP was a significant risk factor for short-term and medium-term survival if Ea was low (<2.7 mmHg/mL, the median value). This group had 39.39% in-hospital mortality compared to 14.49% for RAP<15 mmHg (p∼0.005). When Ea was high, this difference in survival was not evident: 8% for RAP<15 mmHg vs 4.8% for RAP>15 mmHg (p∼0.550). This effect was mediated through a lower MPP, and the mortality due to lower MPP increased strikingly with higher body surface area (BSA). A negative correlation was observed between MPP indexed to BSA (MPPI) and the Model for End-Stage Liver Disease score (r∼-0.3580, p<0.0001) as well as creatinine (r∼-0.3551, p<0.0001). MPPI less than 40 mmHg/m2 was associated with poorer short-term (23.2% for MPPI<40 mmHg/m2 vs 7.1% for MPPI>40 mmHg/m2, p∼0.001) and medium-term survival. The impact of high RAP and low Ea on survival was evident even on medium-term follow-up; only 30% survival at 7 years follow-up for high RAP and low Ea vs 75% for RAP<15 mmHg (p∼0.0033). CONCLUSION The acceptable blood pressure during vasodilator therapy in patients with high RAP needs to be higher, especially in those with higher BSA. MPPI less than 40 mmHg/m2 is a risk factor for survival, in the short and medium-term, after heart transplantation.
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Affiliation(s)
- G Rajagopalan
- Department of Engineering Design, Indian Institute of Technology Madras, Chennai, India. https://twitter.com/iitmadras
| | - Komarakshi R Balakrishnan
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - K G Suresh Rao
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - R Ravi Kumar
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - Ramarathnam Krishna Kumar
- Department of Medical Sciences and Technology, Indian Institute of Technology Madras, Chennai, India.
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Naghashzadeh F, Noorali S, Hosseini-Baharanchi FS, Shafaghi S, Sharif-Kashani B, Ahmadi ZH, Keshmiri MS. Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients. EXP CLIN TRANSPLANT 2021; 19:963-969. [PMID: 34545779 DOI: 10.6002/ect.2020.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. MATERIALS AND METHODS Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. RESULTS Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). CONCLUSIONS Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.
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Affiliation(s)
- Farah Naghashzadeh
- From the Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Schiller O, Goldshmid O, Mowassi S, Shostak E, Manor O, Amir G, Frenkel G, Dagan O. The Utility of Albumin Level as a Marker of Postoperative Course in Infants Undergoing Repair of Congenital Heart Disease. Pediatr Cardiol 2020; 41:939-946. [PMID: 32172337 DOI: 10.1007/s00246-020-02339-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/05/2020] [Indexed: 12/17/2022]
Abstract
We sought to examine the role of preoperative and 2nd postoperative day albumin levels as predictors for postoperative course in infants undergoing repair of congenital heart disease. This retrospective, single-center, observational study comprised consecutive infants younger than 1 year who had undergone repair of tetralogy of Fallot, ventricular septal defect, complete atrioventricular canal or transposition of the great arteries over a 25 months period. We correlated preoperative and postoperative day (POD) #2 albumin level to vaso-inotropic score (VIS) and intensive care unit (ICU) length of stay (LOS) as markers for degree and duration of postoperative cardiac support. A composite outcome was defined as maximal vaso-inotropic score of > 10 and ICU LOS > 96 h. Preoperative albumin level negatively correlated with VIS and ICU LOS. Compared to preoperative albumin level of > 4 g/dL, the relative risk of meeting composite criteria was 1.5 for preoperative albumin of 3.1-4 g/dL and 2.6 for preoperative albumin ≤ 3 g/dL. Compared to POD#2 albumin level > 3 g/dL, the relative risk of meeting composite criteria was 1.8 for albumin of 2.6-3 g/dL, and 2.5 for albumin ≤ 2.5 g/dL. In summary, we found that preoperative and POD#2 albumin levels predicted prolonged and complicated postoperative course. These finding may help clinicians to inform the patient's parents, early in the ICU hospitalization, as to the predicted risks and difficulties of their infant's postoperative course.
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Affiliation(s)
- Ofer Schiller
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
| | - Oran Goldshmid
- Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, 49420235, Petach Tikva, Israel
| | - Sahar Mowassi
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Orit Manor
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Gabriel Amir
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, 49420235, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Georgy Frenkel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, 49420235, Petach Tikva, Israel
| | - Ovadia Dagan
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
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Lebray P, Varnous S, Pascale A, Leger P, Luyt CE, Ratziu V, Munteanu M, Ould Amar S, Thabut D, Chastre J, Pavie A, Poynard T, Leprince P. Predictive value of liver damage for severe early complications and survival after heart transplantation: A retrospective analysis. Clin Res Hepatol Gastroenterol 2018; 42:416-426. [PMID: 29655525 DOI: 10.1016/j.clinre.2018.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hepatic dysfunction is often associated with advanced heart failure. Its impact on complications following heart transplantation is not well known. We studied the influence of preoperative hepatic dysfunction on the results of heart transplantation with a specific priority access for critical patients. METHODS Consecutive heart transplantation patients were retrospectively analyzed at listing to detect predictive factors for early complications and survival following heart transplantation. RESULTS Among heart transplant candidates (n=384), median age was 52 years, dilated and ischemic cardiopathies were present in 44% and 32%, respectively. Clinical ascites was present in 15.6% and median MELD score was 13. A temporary circulatory support and a national priority access were necessary in 14.8% and 35% respectively. Whereas 12% of the global cohort died on the waiting list, 321 patients were transplanted, 34.2% suffered from severe early complications, 26.3% needed extracorporeal membrane oxygenation in postoperative period, 27.7% died before 3 months with a 5-year survival rate of 56%. At listing, clinical ascites, and creatinine were independently associated with specific early complications i.e. primary graft dysfunction and septic shock respectively. Bilirubin level was also an independent marker of other early complications. Finally, need for postoperative circulatory support and postoperative 90-day mortality were strongly and exclusively associated with clinical ascites and creatinine at listing. In a subgroup analysis, we predicted more accurately the postoperative survival at 3 months by combining MELD score and ascites. CONCLUSION At listing, hepatic and renal dysfunctions are independent risk factors that could predict severe early complications and mortality following heart transplantation in the most severe patients.
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Affiliation(s)
- Pascal Lebray
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | | | - Alina Pascale
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Philippe Leger
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Cardiothoracic Surgical Unit, Paris, France; Anaesthesia and Intensive Care Unit Department, Pitié-Salpêtrière Hospital, Paris, France; Biopredictive Research, Paris, France
| | - Charles Edouard Luyt
- Anaesthesia and Intensive Care Unit Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Vlad Ratziu
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | | | | | - Dominique Thabut
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Jean Chastre
- Anaesthesia and Intensive Care Unit Department, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Thierry Poynard
- Hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
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Oner T, Ozdemir R, Genc DB, Kucuk M, Karadeniz C, Demirpence S, Yilmazer MM, Mese T, Tavli V, Genel F. Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression. J Pediatr (Rio J) 2016; 92:581-587. [PMID: 27553592 DOI: 10.1016/j.jped.2016.01.013] [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: 09/23/2015] [Revised: 01/04/2016] [Accepted: 01/15/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC). METHODS Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement. RESULTS During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6±0.48g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1. CONCLUSION The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.
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Affiliation(s)
- Taliha Oner
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | - Rahmi Ozdemir
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey.
| | - Dildar Bahar Genc
- Sisli Etfal Training and Research Hospital, Pediatric Oncology, Istanbul, Turkey
| | - Mehmet Kucuk
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | - Cem Karadeniz
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | - Savas Demirpence
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | | | - Timur Mese
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | - Vedide Tavli
- Izmir Dr. Behcet Uz Children's Hospital, Pediatric Cardiology, Izmir, Turkey
| | - Ferah Genel
- Izmir Dr. Behçet Uz Children's Hospital, Pediatric Immunology, Izmir, Turkey
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Oner T, Ozdemir R, Genc DB, Kucuk M, Karadeniz C, Demirpence S, Yilmazer MM, Mese T, Tavli V, Genel F. Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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7
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Shah DK, Deo SV, Althouse AD, Teuteberg JJ, Park SJ, Kormos RL, Burkhart HM, Morell VO. Perioperative mortality is the Achilles heel for cardiac transplantation in adults with congenital heart disease: Evidence from analysis of the UNOS registry. J Card Surg 2016; 31:755-764. [DOI: 10.1111/jocs.12857] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Dipesh K. Shah
- Cardiothoracic Surgery; Heart and Vascular Institute, UPMC; Pittsburgh Pennsylvania
| | - Salil V. Deo
- Cardiothoracic Surgery; University Hospitals; Cleveland Ohio
| | - Andrew D. Althouse
- Biostatistician, Heart and Vascular Institute; UPMC; Pittsburgh Pennsylvania
| | - Jeffery J. Teuteberg
- Cardiovascular Diseases; Heart and Vascular Institute, UPMC; Pittsburgh Pennsylvania
| | - Soon J. Park
- Cardiothoracic Surgery; University Hospitals; Cleveland Ohio
| | - Robert L. Kormos
- Cardiothoracic Surgery; Heart and Vascular Institute, UPMC; Pittsburgh Pennsylvania
| | - Harold M. Burkhart
- Pediatric Cardiothoracic Surgery; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma
| | - Victor O. Morell
- Pediatric Cardiothoracic Surgery; Children's Hospital of Pittsburgh; Pittsburgh Pennsylvania
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Kim B, Tan A, Limketkai BN, Pinney SP, Schiano TD. Comparison of outcome in patients with versus without ascites referred for either cardiac transplantation or ventricular assist device placement. Am J Cardiol 2015; 116:1596-600. [PMID: 26385517 DOI: 10.1016/j.amjcard.2015.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 11/18/2022]
Abstract
Cardiac ascites is frequently diagnosed, but there is a paucity of data regarding the predictors for its formation. In a group of patients with heart failure referred for orthotopic heart transplantation and ventricular assist device (VAD) placement, we attempted to identify patient characteristics and predictors associated with the development of ascites. Long-term outcomes of patients with and without ascites were examined. Patients were divided into 2 groups based on the presence or absence of significant ascites on imaging. Demographic information, laboratory values, and results of transthoracic echocardiograms and right-sided cardiac catheterizations were compared between the groups. Of the 196 patients, 29 patients (15%) had significant ascites. The group with significant ascites had higher mean creatinine (2.3 vs 1.6 mg/dl, p = 0.03). On transthoracic echocardiograms, the group with significant ascites had more severe right ventricular dilation (p = 0.03) and tricuspid valve regurgitation (p <0.01). On right-sided cardiac catheterizations, the group with significant ascites had higher mean right atrial (RA) pressure (17 vs 13 mm Hg, p = 0.01). There was no difference in pulmonary capillary wedge pressure between the groups (22 vs 23 mm Hg, p = 0.57). No threshold value of RA pressure was identified for the development of significant ascites. The presence of significant ascites was associated with decreased overall survival (p <0.01). In conclusion, impaired renal function and elevated right-sided cardiac pressures were more commonly seen in the group with significant ascites. No minimum RA pressure elevation was required for significant ascites formation. The presence of significant ascites was correlated with higher mortality.
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Affiliation(s)
- Brian Kim
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
| | - Amy Tan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sean P Pinney
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas D Schiano
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Louie CY, Pham MX, Daugherty TJ, Kambham N, Higgins JPT. The liver in heart failure: a biopsy and explant series of the histopathologic and laboratory findings with a particular focus on pre-cardiac transplant evaluation. Mod Pathol 2015; 28:932-43. [PMID: 25793895 DOI: 10.1038/modpathol.2015.40] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/30/2014] [Accepted: 12/31/2014] [Indexed: 11/09/2022]
Abstract
The pathologic liver changes in chronic heart failure have been characterized mostly based on autopsy series and include sinusoidal dilation and congestion progressing to pericellular fibrosis, bridging fibrosis, and ultimately to cardiac cirrhosis or sclerosis. Liver biopsies are commonly obtained as part of the work up before heart transplantation in patients with longstanding right heart failure, particularly if ascites, abnormal liver function tests or abnormal abdominal imaging are noted as part of the pre-transplant evaluation. In these cases, the liver biopsy findings may be used to further risk stratify patients for isolated heart or combined heart and liver transplantation. Thus, it is important to be able to correlate the histologic changes with post-transplant outcomes. We report the pathologic and clinical findings in liver explants from six patients who underwent combined heart-liver transplantation. We also report preoperative liver biopsy findings from 21 patients who underwent heart transplantation without simultaneous liver transplantation. We staged the changes related to chronic passive congestion as follows: stage 0-no fibrosis; stage I-pericellular fibrosis; stage II-bridging fibrosis; and stage III-regenerative nodules. Nineteen biopsies showed fibrosis with bridging fibrosis in 13 and regenerative nodules in 6. Fifteen patients were alive at 1 year post transplant. Only three patients had a post-operative course that was characterized by signs and symptoms of chronic liver disease. Pre-transplant liver biopsies from these patients all showed at least stage II fibrosis. These patients survived for 3, 6, and 10 months after cardiac transplant. The presence of bridging fibrosis was not significantly associated with post-operative survival (P=0.336) or post-operative liver failure (P=0.257). We conclude that patients with bridging fibrosis may still be considered viable candidates for isolated heart transplantation. Because the pattern of fibrosis due to passive congestion is highly variable throughout the liver, a diagnosis of cirrhosis, which implies fibrosis and regenerative nodules throughout the liver, should be made with great caution on biopsy.
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Affiliation(s)
- Christine Y Louie
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael X Pham
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Stanford, CA, USA
| | - Tami J Daugherty
- Department of Medicine (Hepatology), Stanford University School of Medicine, Stanford, CA, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - John P T Higgins
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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Castleberry C, White-Williams C, Naftel D, Tresler MA, Pruitt E, Miyamoto SD, Murphy D, Spicer R, Bannister L, Schowengerdt K, Gilmore L, Kaufman B, Zangwill S. Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients. Pediatr Transplant 2014; 18:280-7. [PMID: 24646199 DOI: 10.1111/petr.12239] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2014] [Indexed: 11/28/2022]
Abstract
Children with end-stage cardiac failure are at risk of HA and PG. The effects of these factors on post-transplant outcome are not well defined. Using the PHTS database, albumin and growth data from pediatric heart transplant patients from 12/1999 to 12/2009 were analyzed for effect on mortality. Covariables were examined to determine whether HA and PG were risk factors for mortality at listing and transplant. HA patients had higher waitlist mortality (15.81% vs. 10.59%, p = 0.015) with an OR of 1.59 (95% CI 1.09-2.30). Survival was worse for patients with HA at listing and transplant (p ≤ 0.01 and p = 0.026). Infants and patients with congenital heart disease did worse if they were HA at time of transplant (p = 0.020 and p = 0.028). Growth was poor while waiting with PG as risk factor for mortality in multivariate analysis (p = 0.008). HA and PG are risk factors for mortality. Survival was worse in infants and patients with congenital heart disease. PG was a risk factor for mortality in multivariate analysis. These results suggest that an opportunity may exist to improve outcomes for these patients by employing strategies to mitigate these risk factors.
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11
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Chamogeorgakis T, Mason DP, Murthy SC, Thuita L, Raymond DP, Pettersson GB, Blackstone EH. Impact of nutritional state on lung transplant outcomes. J Heart Lung Transplant 2013; 32:693-700. [PMID: 23664761 DOI: 10.1016/j.healun.2013.04.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 03/06/2013] [Accepted: 04/01/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND When high-risk lung transplant candidates are evaluated, nutritional state is often neglected. We evaluated the prevalence of markers reflecting pre-transplant malnutrition and their association with post-operative complications and death. METHODS From January 2005 to July 2010, 453 patients underwent primary lung transplantation at our institution. Pre-operative nutrition-related variables, including body mass index and weight/height ratio, reflecting cachexia, and albumin, total protein, immunoglobulins, and absolute lymphocyte count were considered in identifying risk factors for time-related major post-operative complications (renal failure requiring dialysis, respiratory failure requiring tracheostomy), pulmonary or bloodstream infections, and death. RESULTS Forty-eight patients had BMI <18.5 kg/m(2), 41 had a weight/height ratio ≤ 0.3, 102 had albumin <3.5 g/dl, 110 had total protein <6 g/dl, and 112 had an absolute lymphocyte count <1,000/μl, indicative of a malnourished state. At 6 months, 30% had experienced pulmonary infection, with lower total serum protein concentration an important risk (p = 0.02). One-year actuarial mortality was 15%; risk factors included lower serum albumin (p = 0.004), particularly when <3 g/dl. In contrast, variables reflecting nutritional state were not statistically significantly correlated with dialysis, respiratory failure requiring tracheostomy, or bloodstream infections. CONCLUSION Although malnutrition is uncommon in lung transplant patients, those at extremes of low serum albumin and total protein have worse survival and increased risk of post-operative infection. Strategies to improve nutrition of these high-risk candidates awaiting lung transplantation should be developed.
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Affiliation(s)
- Themistokles Chamogeorgakis
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Kransdorf EP, Kittleson MM. Dissecting the "CHF admission": an evidence-based review of the evaluation and management of acute decompensated heart failure for the hospitalist. J Hosp Med 2012; 7:439-45. [PMID: 22371370 DOI: 10.1002/jhm.1919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 12/16/2011] [Accepted: 01/08/2012] [Indexed: 11/09/2022]
Abstract
Acute decompensated heart failure (ADHF) is one of the most common conditions managed by hospitalists. Here we review the most recent evidence applicable to hospitalists for the diagnosis, risk stratification, and management of patients presenting with ADHF. By following a structured approach based on the patient's symptoms, history, physical examination, and laboratory testing, the clinician can make the diagnosis of heart failure efficiently. Because patients exhibit a wide spectrum of risk for adverse outcomes, both in the hospital and after discharge, assessing for clinical factors associated with these outcomes is essential. Congestion should be managed primarily with diuretics, and vasodilators may be helpful in certain patients. Given high rates of readmission, hospitalists should ensure that patients received evidence-based therapy, heart failure education is performed, and follow-up is in place before discharge.
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Affiliation(s)
- Evan P Kransdorf
- Department of Heart Failure and Heart Transplantation, Cedars-Sinai Heart Institute, Los Angeles, California, USA
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Everitt MD, Donaldson AE, Stehlik J, Kaza AK, Budge D, Alharethi R, Bullock EA, Kfoury AG, Yetman AT. Would access to device therapies improve transplant outcomes for adults with congenital heart disease? Analysis of the United Network for Organ Sharing (UNOS). J Heart Lung Transplant 2011; 30:395-401. [DOI: 10.1016/j.healun.2010.09.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 08/13/2010] [Accepted: 09/14/2010] [Indexed: 11/12/2022] Open
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