Underutilization of Donor Hearts: An Observational Study

BACKGROUND

Utilization of donor hearts remains insufficient. In this observational study, we explored the rate and reasons of rejection of cardiac donors in 1 organ procurement organization.

METHODS

Donors were enrolled in the study for 1 year, from October 5, 2014, through October 4, 2015. Data on demographics, medical history, and diagnostic tests were collected. We compared continuous variables between groups using a Mann-Whitney U test, and categorical variables using the χ²test. Multivariate logistic regression analysis was performed to identify factors predicting transplantation.

RESULTS

Of 134 adult hearts, only 39.5% were transplanted. Moreover, almost half (46.9%) of non-transplanted hearts were normal by all data available. In 12 (31.5%) of all hearts, coronary artery disease was discovered by pathology, making them unusable for transplantation. Overall, 26 normal hearts (19.4%) were not accepted for transplantation. The most common abnormality of hearts not suitable for transplantation was a decreased left ventricular ejection fraction (LVEF). In about one-fifth of donors with low LVEF on the first echocardiogram, LVEF improved on a second echocardiogram. In a majority of cases with low LVEF, echocardiogram was never repeated.

CONCLUSIONS

Almost 20% of normal donor hearts were not transplanted. Coronary artery disease was the most common abnormality in seemingly normal hearts. Coronary angiography should be performed more liberally in potential donors. Decreased LVEF was the most common reason for not using a heart. Since impaired LVEF may be reversible, repeated echocardiogram is encouraged in order to maximize the rate of transplantation.

Post-discharge rise in BNP and rehospitalization for heart failure

BACKGROUND

The B‑type natriuretic peptide (BNP) level on discharge of patients hospitalized with decompensated heart failure (HF) is widely considered as the "baseline" value, and treatment should be targeted to maintain this level. The prognostic value of an increase in BNP level from discharge to the 1‑month follow-up in predicting rehospitalization has not been previously explored.

METHODS

The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial data were utilized to determine whether an increase in BNP level from discharge to the 1‑month follow-up is associated with a higher risk of rehospitalization. The study endpoints were all-cause rehospitalization up to 6 months following randomization.

RESULTS

Among 44 patients (mean age, 56 years, 71% men) who had their BNP levels checked on discharge and at the 1‑month follow-up, the average BNP level on discharge of the whole cohort was 467 pg/ml, which increased to 919 pg/ml at 1 month (p = 0.001). The median and interquartile range of the magnitude of rise in BNP level from discharge to 1‑month follow-up was higher in rehospitalized compared with non-rehospitalized patients (329 [11, 956] vs. 44 [-90, 316] pg/ml, p = 0.039, in both groups, respectively). Receiver operator characteristic curves showed that the magnitude of the rise in BNP from discharge to the 1‑month follow-up had an area under the curve of 0.686 (p = 0.0255) in predicting all-cause rehospitalization. Rehospitalized and non-rehospitalized patients had similar degree of clinical congestion and comparable BNP level on hospital discharge.

CONCLUSION

The magnitude of the rise in BNP level from discharge to the 1‑month follow-up is a useful prognostic factor that predicts rehospitalization in patients with HF.

Admission-to-discharge temperature reduction in decompensated heart failure is associated with rehospitalization

INTRODUCTION

Decreasing body temperature on first follow-up visit-relative to discharge-predicts early rehospitalization in heart failure (HF). We studied whether admission-to-discharge temperature reduction was associated with increased HF rehospitalization in the ESCAPE trial.

METHODS

We compared patients with or without ≥1 °C decrease in temperature from admission-to-discharge. The study endpoint was rehospitalization due to HF for up to 6 months after discharge.

RESULTS

Among 354 patients (average age 57 years, 73% men) with recorded admission and discharge temperature, 22 (6.2%) had an admission-to-discharge temperature reduction ≥1 ºC. Patients with admission-to-discharge temperature reduction ≥1 ºC had higher frequency of rehospitalization for HF (68.2% vs. 44.3%, estimated odds ratio [OR] 2.697, 95% confidence interval [CI] 1.072-6.787, P = 0.029) despite a significantly higher admission temperature. On multivariate analysis, admission-to-discharge temperature reduction ≥1 ºC predicted rehospitalization for HF (OR 2.02, 95% CI 1.028-3.966, P = 0.041) after adjustment for age, BMI, baseline Na, creatinine, ejection fraction and discharge NYHA class. A standard logistic model treating temperature change as a continuous variable, and a model using a restricted cubic spline, did not demonstrate a statistically significant relationship between temperature reduction and HF rehospitalization. Subsequently, an altered logistic model was fit expressing the log odds of HF rehospitalization as a piecewise linear function of temperature decrease; this model did demonstrate statistical significance (P = 0.013) with an estimated odds ratio of 1.140 per 0.1 ºC beyond 0.5 ºC.

CONCLUSION

Admission-to-discharge temperature reduction ≥1 ºC is an unfavorable prognostic sign associated with future rehospitalization due to HF.

The value of coronary angiography in the work-up of atrial myxomas

Atrial myxomas are the most common primary cardiac tumors. They are highly vascular with evidence of neovascularization and a characteristic"tumor blush" in approximately half of the cases. Although the visualization of feeding vessels has several clinical and therapeutic implications, there is still no consensus on the indication of preoperative coronary angiography to assess tumor vascularity except in patients with angina or those older than 40 years to rule out coronary artery disease. Herein, I present a case of an incidentally discovered right atrial mass receiving vascular supply from the right coronary artery. The mass was successfully excised and the diagnosis of cardiac myxoma was confirmed via histopathology. A review of the value of coronary angiography in detecting myxoma neovascularization is provided, which suggests that it can offer additional valuable information that can alter the surgical approach and therefore may be considered prior to myxoma resection.