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Javorski MJ, Bauza K, Xiang F, Soltesz E, Chen L, Bakaeen FG, Svensson L, Thuita L, Blackstone EH, Tong MZ. Identifying and mitigating risk of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00191-0. [PMID: 38452888 DOI: 10.1016/j.jtcvs.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVES To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function. METHODS From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors. RESULTS Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min-1 m-2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group. CONCLUSIONS Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock.
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Affiliation(s)
- Michael J Javorski
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karolis Bauza
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lin Chen
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars Svensson
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio.
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Elgharably H, Ibrahim A, Rosinski B, Thuita L, Blackstone EH, Collier PH, Pettersson GB. Right heart failure and patient selection for isolated tricuspid valve surgery. J Thorac Cardiovasc Surg 2023; 166:740-751.e8. [PMID: 35123790 DOI: 10.1016/j.jtcvs.2021.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function. PATIENTS AND METHODS From January 2007 to January 2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone previous heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed. RESULTS On average, the right ventricle was dilated (diastolic area 32 cm2), but its function was preserved (free-wall strain -17% ± 5.8%) and right heart failure manifestations were moderate, with 40 (65%) having congested neck veins, 35 (56%) dependent edema, and 15 (24%) ascites. Average model for end-stage liver disease with sodium score was 11 ± 4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function, but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including greater model for end-stage liver disease with sodium scores (12 ± 44 vs 9.1 ± 3.9; P = .008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery. CONCLUSIONS The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Ibrahim
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick H Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Rappaport JM, Siddiqui HU, Thuita L, Budev M, McCurry KR, Blackstone EH, Ahmad U. Effect of donor smoking and substance use on post-lung transplant outcomes. J Thorac Cardiovasc Surg 2023; 166:383-393.e13. [PMID: 36967372 DOI: 10.1016/j.jtcvs.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 01/11/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE The study objective was to determine effects of donor smoking and substance use on primary graft dysfunction, allograft function, and survival after lung transplant. METHODS From January 2007 to February 2020, 1366 lung transplants from 1291 donors were performed in 1352 recipients at Cleveland Clinic. Donor smoking and substance use history were extracted from the Uniform Donor Risk Assessment Interview and medical records. End points were post-transplant primary graft dysfunction, longitudinal forced expiratory volume in 1 second (% of predicted), and survival. RESULTS Among lung transplant recipients, 670 (49%) received an organ from a donor smoker, 163 (25%) received an organ from a donor with a 20 pack-year or more history (median pack-years 8), and 702 received an organ from a donor with substance use (51%). There was no association of donor smoking, pack-years, or substance use with primary graft dysfunction (P > .2). Post-transplant forced expiratory volume in 1 second was 74% at 1 year in donor nonsmoker recipients and 70% in donor smoker recipients (P = .0002), confined to double-lung transplant, where forced expiratory volume in 1 second was 77% in donor nonsmoker recipients and 73% in donor smoker recipients. Donor substance use was not associated with allograft function. Donor smoking was associated with 54% non-risk-adjusted 5-year survival versus 59% (P = .09) and greater pack-years with slightly worse risk-adjusted long-term survival (P = .01). Donor substance use was not associated with any outcome (P ≥ 8). CONCLUSIONS Among well-selected organs, lungs from smokers were associated with non-clinically important worse allograft outcomes without an inflection point for donor smoking pack-years. Substance use was not associated with worse allograft function. Given the paucity of organs, donor smoking or substance use alone should not preclude assessment for lung donation or transplant.
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Affiliation(s)
- Jesse M Rappaport
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hafiz Umair Siddiqui
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marie Budev
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; Lung Transplantation Center, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Lung Transplantation Center, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Lung Transplantation Center, Cleveland Clinic, Cleveland, Ohio
| | - Usman Ahmad
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Lung Transplantation Center, Cleveland Clinic, Cleveland, Ohio.
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Meza JM, Blackstone EH, Argo MB, Thuita L, Lowry A, Rajeswaran J, Jegatheeswaran A, Caldarone CA, Kirklin JK, DeCampli WM, Pourmoghadam K, Gruber PJ, McCrindle BW. A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation. JTCVS Open 2023; 14:426-440. [PMID: 37425467 PMCID: PMC10329031 DOI: 10.1016/j.xjon.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 07/11/2023]
Abstract
Objective Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
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Affiliation(s)
- James M. Meza
- Division of Cardiothoracic and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Madison B. Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Ashley Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - James K. Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - William M. DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Kamal Pourmoghadam
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Peter J. Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Brian W. McCrindle
- Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Tantawi A, Itoda Y, Ayyat K, Okamoto T, Thuita L, Sakanoue I, Elgharably H, Yun J, McCurry K. Impact of Donor Age on Survival of Lung Transplant Recipients According to Their Primary Diagnosis. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Kelava M, Mehta A, Sale S, Gillinov M, Johnston D, Thuita L, Kumar N, Blackstone EH. Effectiveness and safety of E-aminocaproic acid in overall and less invasive cardiac surgeries. J Cardiothorac Vasc Anesth 2022; 36:3780-3790. [DOI: 10.1053/j.jvca.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/18/2022] [Accepted: 06/05/2022] [Indexed: 11/11/2022]
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Rappaport JM, Raja S, Gabbard S, Thuita L, Sanaka MR, Blackstone EH, Ahmad U. Endoscopic Pyloromyotomy Is Feasible and Effective in Improving Post–Lung Transplant Gastroparesis. J Thorac Cardiovasc Surg 2021; 164:711-719.e4. [DOI: 10.1016/j.jtcvs.2021.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
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Elgharably H, Ayyat K, Okamoto T, Thuita L, Yun J, Ahmad U, McCurry K. High Grade Primary Graft Dysfunction after Lung Transplantation is Associated with Acute Rejection but Not Chronic Allograft Dysfunction. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Addoumieh A, Abdallah MS, Ballout JA, Thuita L, Klein A, Jaber WA, Arsanjani R, Carey W, Majdalany D. Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation. Am Heart J Plus 2021; 4:100026. [PMID: 38559677 PMCID: PMC10976285 DOI: 10.1016/j.ahjo.2021.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/04/2021] [Accepted: 06/05/2021] [Indexed: 04/04/2024]
Abstract
Introduction Patients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes. Methods Patients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO. Results Of the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay. Conclusion Inducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.
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Affiliation(s)
| | | | - Jad A. Ballout
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Lucy Thuita
- Quantitative Health Science Department, Cleveland Clinic Foundation, USA
| | - Allan Klein
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Wael A. Jaber
- Heart and Vascular Institute, Cleveland Clinic Foundation, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - William Carey
- Digestive Disease Institute, Cleveland Clinic Foundation, USA
| | - David Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
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Tang A, Siddiqui HU, Thuita L, Rappaport J, Bribriesco AC, McCurry KR, Yun J, Unai S, Budev M, Murthy SC, Blackstone EH, Ahmad U. Natural History of Pleural Complications After Lung Transplantation. Ann Thorac Surg 2021; 111:407-415. [DOI: 10.1016/j.athoracsur.2020.06.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/08/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
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Tang A, Thuita L, Siddiqui HU, Rappaport J, Blackstone EH, McCurry KR, Ahmad U. Urgently listed lung transplant patients have outcomes similar to those of electively listed patients. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30997-1. [PMID: 32622567 DOI: 10.1016/j.jtcvs.2020.02.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To (1) determine outcomes after urgent listing compared with elective listing for lung transplant and (2) compare in-hospital morbidity and mortality, survival, and allograft function in these 2 groups. METHODS From January 2006 to September 2017, 201 patients were urgently and 1423 electively listed. Among urgently listed patients, 130 subsequently underwent primary lung transplant as did 995 electively listed patients. Competing-risks analysis for death and transplant after listing and weighted balancing score matching (76 pairs) were used to compare in-hospital morbidity and survival. Mixed-effect longitudinal modeling was used to compare allograft function to 8 years post-transplant. RESULTS At 1 month, mortality was 26% in urgently listed patients, and 58% were transplanted. Risk factors for death included older age, higher bilirubin, and transfer from an outside hospital. At transplantation, urgently listed transplant patients were younger (53 ± 13 vs 55 ± 12 years), had more ventilator and extracorporeal membrane oxygenation support (32/25% vs 20/2.0%), more restrictive lung disease (95/73% vs 509/51%), and a higher lung allocation score (82 ± 13 vs 47 ± 17). In-hospital morbidity and mortality, time-related survival, and longitudinal allograft function were similar between matched groups. CONCLUSIONS Urgent listing more often than not leads to transplantation. Although urgently listed patients are sicker overall, after transplant their perioperative morbidity and mortality, overall survival, and allograft function are similar to those of electively listed patients. Appropriate patient selection and aggressive supportive care allow urgently listed lung transplant patients to achieve these similar post-transplant outcomes.
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Affiliation(s)
- Andrew Tang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hafiz Umair Siddiqui
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jesse Rappaport
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Institute, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Usman Ahmad
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Institute, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
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Blackstone EH, Rajeswaran J, Cruz VB, Hsich EM, Koprivanac M, Smedira NG, Hoercher KJ, Thuita L, Starling RC. Continuously Updated Estimation of Heart Transplant Waitlist Mortality. J Am Coll Cardiol 2019; 72:650-659. [PMID: 30071995 DOI: 10.1016/j.jacc.2018.05.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
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Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vincent B Cruz
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Eileen M Hsich
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Katherine J Hoercher
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C Starling
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Lehr CJ, Blackstone EH, McCurry KR, Thuita L, Tsuang WM, Valapour M. Extremes of Age Decrease Survival in Adults After Lung Transplant. Chest 2019; 157:907-915. [PMID: 31419403 DOI: 10.1016/j.chest.2019.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/11/2019] [Accepted: 06/29/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Age has been implicated as a factor in the plateau of long-term survival after lung transplant. METHODS We used data from the Scientific Registry of Transplant Recipients to identify all recipients of lung transplant aged ≥18 years of age between January 1, 2006, and February 19, 2015. A total of 14,253 patients were included in the analysis. Survival was estimated using a nonproportional hazard model and random-survival forest methodology was used to examine risk factors for death. Final selection of model variables was performed using bootstrap aggregation. Age was analyzed as both a continuous and categorical variable (age <30, 30-55, and >55 years). Risk factors for death were obtained for the entire cohort and additional age-specific risk factors were identified for each age category. RESULTS The median age at transplant was 59 years. There were 1,098 (7.7%) recipients <30 years, 4,201 (29.5%) 30 to 55 years, and 8,954 (62.8%) >55 years of age. Age was the most significant risk factor for death at all time-points following transplant and its impact becomes more prominent as time from transplant increases. Risk factors for death for all patients included extremes of age, higher creatinine, single lung transplant, hospitalization before transplant, and increased bilirubin. Risk factors for death differed by age with social determinants of health disproportionately affecting survival for those in the youngest age category. CONCLUSIONS The youngest and oldest adult recipients experienced the lowest posttransplant survival through divergent pathways that may present opportunities for intervention to improve survival after lung transplant.
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Affiliation(s)
- Carli J Lehr
- Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Kenneth R McCurry
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lucy Thuita
- The Respiratory Institute, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Hurst TE, Xanthopoulos A, Ehrlinger J, Rajeswaran J, Pande A, Thuita L, Smedira NG, Moazami N, Blackstone EH, Starling RC. Dynamic prediction of left ventricular assist device pump thrombosis based on lactate dehydrogenase trends. ESC Heart Fail 2019; 6:1005-1014. [PMID: 31318170 PMCID: PMC6816063 DOI: 10.1002/ehf2.12473] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 12/04/2022] Open
Abstract
Aims The risk of HeartMate II (HMII) left ventricular assist device (LVAD) thrombosis has been reported, and serum lactate dehydrogenase (LDH), a biomarker of haemolysis, increases secondary to LVAD thrombosis. This study evaluated longitudinal measurements of LDH post‐LVAD implantation, hypothesizing that LDH trends could timely predict future LVAD thrombosis. Methods and results From October 2004 to October 2014, 350 HMIIs were implanted in 323 patients at Cleveland Clinic. Of these, patients on 339 HMIIs had at least one post‐implant LDH value (7996 total measurements). A two‐step joint model combining longitudinal biomarker data and pump thrombosis events was generated to assess the effect of changing LDH on thrombosis risk. Device‐specific LDH trends were first smoothed using multivariate boosted trees, and then used as a time‐varying covariate function in a multiphase hazard model to analyse time to thrombosis. Pre‐implant variables associated with time‐varying LDH values post‐implant using boostmtree were also investigated. Standardized variable importance for each variable was estimated as the difference between model‐based prediction error of LDH when the variable was randomly permuted and prediction error without permuting the values. The larger this difference, the more important a variable is for predicting the trajectory of post‐implant LDH. Thirty‐five HMIIs (10%) had either confirmed (18) or suspected (17) thrombosis, with 15 (43%) occurring within 3 months of implant. LDH was associated with thrombosis occurring both early and late after implant (P < 0.0001 for both hazard phases). The model demonstrated increased probability of HMII thrombosis as LDH trended upward, with steep changes in LDH trajectory paralleling trajectories in probability of pump thrombosis. The most important baseline variables predictive of the longitudinal pattern of LDH were higher bilirubin, higher pre‐implant LDH, and older age. The effect of some pre‐implant variables such as sodium on the post‐implant LDH longitudinal pattern differed across time. Conclusions Longitudinal trends in surveillance LDH for patients on HMII support are useful for dynamic prediction of pump thrombosis, both early after implant and late. Incorporating upward and downward trends in LDH that dynamically update a model of LVAD thrombosis risk provides a useful tool for clinical management and decisions.
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Affiliation(s)
- Thomas E Hurst
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Andrew Xanthopoulos
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - John Ehrlinger
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Amol Pande
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
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Hsich EM, Thuita L, McNamara DM, Rogers JG, Valapour M, Goldberg LR, Yancy CW, Blackstone EH, Ishwaran H. Variables of importance in the Scientific Registry of Transplant Recipients database predictive of heart transplant waitlist mortality. Am J Transplant 2019; 19:2067-2076. [PMID: 30659754 PMCID: PMC6591021 DOI: 10.1111/ajt.15265] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/20/2018] [Accepted: 01/08/2019] [Indexed: 01/25/2023]
Abstract
The prelisting variables essential for creating an accurate heart transplant allocation score based on survival are unknown. To identify these we studied mortality of adults on the active heart transplant waiting list in the Scientific Registry of Transplant Recipients database from January 1, 2004 to August 31, 2015. There were 33 069 candidates awaiting heart transplantation: 7681 UNOS Status 1A, 13 027 Status 1B, and 12 361 Status 2. During a median waitlist follow-up of 4.3 months, 5514 candidates died. Variables of importance for waitlist mortality were identified by machine learning using Random Survival Forests. Strong correlates predicting survival were estimated glomerular filtration rate (eGFR), serum albumin, extracorporeal membrane oxygenation, ventricular assist device, mechanical ventilation, peak oxygen capacity, hemodynamics, inotrope support, and type of heart disease with less predictive variables including antiarrhythmic agents, history of stroke, vascular disease, prior malignancy, and prior tobacco use. Complex interactions were identified such as an additive risk in mortality based on renal function and serum albumin, and sex-differences in mortality when eGFR >40 mL/min/1.73 m. Most predictive variables for waitlist mortality are in the current tiered allocation system except for eGFR and serum albumin which have an additive risk and complex interactions.
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Affiliation(s)
- Eileen M. Hsich
- The Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Maryam Valapour
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Lee R. Goldberg
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Medical Center, Chicago, IL, USA
| | - Eugene H. Blackstone
- The Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hemant Ishwaran
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Miami, FL, USA
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Itoda Y, Sato M, Thuita L, NIikawa H, Ayyat K, Okamoto T, Farver C, Zhang A, Budev M, Balckstone E, McCurry K. Impact for Survival and Chronic Lung Allograft Dysfunction of ISHLT Consensus of Antibody Mediated Rejection after Lung Transplantation. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.1031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Steffen RJ, Blackstone EH, Smedira NG, Soltesz EG, Hoercher KJ, Thuita L, Starling RC, Mountis M, Moazami N. Optimal Timing of Heart Transplant After HeartMate II Left Ventricular Assist Device Implantation. Ann Thorac Surg 2017; 104:1569-1576. [DOI: 10.1016/j.athoracsur.2017.03.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/01/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
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18
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Hsich EM, Blackstone EH, Thuita L, McNamara DM, Rogers JG, Ishwaran H, Schold JD. Sex Differences in Mortality Based on United Network for Organ Sharing Status While Awaiting Heart Transplantation. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003635. [PMID: 28611123 DOI: 10.1161/circheartfailure.116.003635] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 05/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are sex differences in mortality while awaiting heart transplantation, and the reason remains unclear. METHODS AND RESULTS We included all adults in the Scientific Registry of Transplant Recipients placed on the heart transplant active waitlist from 2004 to 2015. The primary end point was all-cause mortality. Multivariable Cox proportional hazards models were performed to evaluate survival by United Network for Organ Sharing (UNOS) status at the time of listing. Random survival forest was used to identify sex interactions for the competing risk of death and transplantation. There were 33 069 patients (25% women) awaiting heart transplantation. This cohort included 7681 UNOS status 1A (26% women), 13 027 UNOS status 1B (25% women), and 12 361 UNOS status 2 (26% women). During a median follow-up of 4.3 months, 1351 women and 4052 men died. After adjusting for >20 risk factors, female sex was associated with a significant risk of death among UNOS status 1A (adjusted hazard ratio, 1.14; 95% confidence interval, 1.01-1.29) and UNOS status 1B (adjusted hazard ratio, 1.17; 95% confidence interval, 1.05-1.30). In contrast, female sex was significantly protective for time to death among UNOS status 2 (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95). Sex differences in probability of transplantation were present for every UNOS status, and >20 sex interactions were identified for mortality and transplantation. CONCLUSIONS When stratified by initial UNOS status, women had a higher mortality than men as UNOS status 1 and a lower mortality as UNOS status 2. With >20 sex interactions for mortality and transplantation, further evaluation is warranted to form a more equitable allocation system.
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Affiliation(s)
- Eileen M Hsich
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.).
| | - Eugene H Blackstone
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Lucy Thuita
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Dennis M McNamara
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Joseph G Rogers
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Hemant Ishwaran
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Jesse D Schold
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
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Hsich E, Thuita L, McNamara D, Rogers J, Schold J, Blackstone E, Ishwaran H. Informative and Uninformative Variables in the Scientific Registry of Transplant Recipients. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.1104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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20
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Omara M, Okamoto T, Arafat A, Thuita L, Blackstone EH, McCurry KR. Lung transplantation in patients who have undergone prior cardiothoracic procedures. J Heart Lung Transplant 2016; 35:1462-1470. [DOI: 10.1016/j.healun.2016.05.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/10/2016] [Accepted: 05/30/2016] [Indexed: 11/28/2022] Open
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21
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Steffen R, Blackstone E, Smedira N, Soltesz E, Hoercher K, Thuita L, Starling R, Mountis M, Moazami N. Optimal Timing of Heart Transplantation After HeartMate II Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2016.01.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Smedira NG, Blackstone EH, Ehrlinger J, Thuita L, Pierce CD, Moazami N, Starling RC. Current risks of HeartMate II pump thrombosis: Non-parametric analysis of Interagency Registry for Mechanically Assisted Circulatory Support data. J Heart Lung Transplant 2015; 34:1527-34. [DOI: 10.1016/j.healun.2015.10.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 10/22/2022] Open
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23
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Shafii AE, Mason DP, Brown CR, Thuita L, Murthy SC, Budev MM, Pettersson GB, Blackstone EH. Too high for transplantation? Single-center analysis of the lung allocation score. Ann Thorac Surg 2014; 98:1730-6. [PMID: 25218678 DOI: 10.1016/j.athoracsur.2014.05.083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recent studies using United Network for Organ Sharing data suggest that lung transplantation in patients with high lung allocation scores (LAS) may lead to organ and resource wastage. Therefore, to determine whether a LAS cutoff value should be considered, we evaluated the relation of LAS to waitlist and posttransplant mortality in our center to determine if it could identify patients for whom listing for transplantation may be futile. METHODS From May 1, 2005 to July 1, 2010, 537 adults were listed and 426 underwent primary lung transplantation at our institution. Endpoints were mortality before and after lung transplantation. The relationships of LAS at listing to waitlist mortality and of pretransplant LAS to posttransplant mortality were both analyzed by multiphase hazard function methodology. RESULTS Higher LAS was strongly associated with waitlist mortality (p<0.0001), with the highest quartile (LAS ranging from 47 to 95) experiencing 75% mortality within a year of listing. Although early (p=0.05), but not late (p=0.4), posttransplant survival was associated with higher LAS at transplantation, once other clinical characteristics predictive of early mortality were accounted for, neither waitlist nor pretransplant LAS was independently related to posttransplant mortality (p=0.12). CONCLUSIONS Higher LAS strongly predicts higher mortality on the lung transplantation waitlist, underscoring the value of LAS in prioritizing patients with the highest scores for transplantation. Early posttransplant mortality is modestly higher with higher pretransplant LAS, but the data of our center do not suggest a value above which transplantation should be denied as futile. This suggests that donor organs and resources are not being wasted.
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Affiliation(s)
- Alexis E Shafii
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio
| | - David P Mason
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio.
| | - Chase R Brown
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio
| | - Marie M Budev
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Masabni K, Rafael A, Soltesz EG, Thuita L, Carey WD, Blackstone EH, Johnston DR. Role of Hepatic Dysfunction in Outcomes after Cardiac Surgery. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Koval CE, Thuita L, Moazami N, Blackstone E. Evolution and impact of drive-line infection in a large cohort of continuous-flow ventricular assist device recipients. J Heart Lung Transplant 2014; 33:1164-72. [PMID: 25034793 DOI: 10.1016/j.healun.2014.05.011] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Drive-line infections (DLIs) frequently complicate ventricular assist device (VAD) support. We sought to describe the detailed effects of DLIs over time in patients with continuous-flow VADs, including the onset, risk factors, organisms involved, association with invasive infections, and outcomes. METHODS We reviewed data for patients with HeartMate II VADs (HMII) who were implanted at the Cleveland Clinic from October 2004 to September 2011 and followed through December 2011. DLIs were defined according to published criteria. RESULTS DLIs developed in 45 of 194 HMII VADs over a median period of 232 days (range 22 to 883 days). Hazard for DLI was 2.0%/month, but transiently peaked at 11%/month at 7.5 months after implant. Pseudomonas aeruginosa accounted for 31%, 42% and 55% of initial, final and deep DLIs, respectively. Of the 40 superficial DLIs, 13 (32.5%) became deep. DLI-associated bacteremia and hospitalization occurred in 14 of 45 (31%) and 30 of 45 (67%), respectively. All patients received antibiotics (median 171 days), but only 3 of 44 (6.8%) developed an antibiotic complication. DLIs increased the risk for death while on VAD support (HR 2.20, 95% CI 1.20 to 4.05; p = 0.01). Six and 12 months after DLI, mortality was 9.8% and 31%, but the competing event of transplantation occurred successfully in 20% and 28%, respectively. CONCLUSIONS Most DLIs begin superficially with peak hazard at 7.5 months after implant. Depth of infection and infecting organism may evolve over months on support, with Pseudomonas becoming more prominent. Although effectively managed for prolonged periods, DLIs are associated with reduced survival on VAD support. Earlier transplantation is the most successful approach to treatment.
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Affiliation(s)
- Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Eugene Blackstone
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
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Starling RC, Moazami N, Silvestry SC, Ewald G, Rogers JG, Milano CA, Rame JE, Acker MA, Blackstone EH, Ehrlinger J, Thuita L, Mountis MM, Soltesz EG, Lytle BW, Smedira NG. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370:33-40. [PMID: 24283197 DOI: 10.1056/nejmoa1313385] [Citation(s) in RCA: 596] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We observed an apparent increase in the rate of device thrombosis among patients who received the HeartMate II left ventricular assist device, as compared with preapproval clinical-trial results and initial experience. We investigated the occurrence of pump thrombosis and elevated lactate dehydrogenase (LDH) levels, LDH levels presaging thrombosis (and associated hemolysis), and outcomes of different management strategies in a multi-institutional study. METHODS We obtained data from 837 patients at three institutions, where 895 devices were implanted from 2004 through mid-2013; the mean (±SD) age of the patients was 55±14 years. The primary end point was confirmed pump thrombosis. Secondary end points were confirmed and suspected thrombosis, longitudinal LDH levels, and outcomes after pump thrombosis. RESULTS A total of 72 pump thromboses were confirmed in 66 patients; an additional 36 thromboses in unique devices were suspected. Starting in approximately March 2011, the occurrence of confirmed pump thrombosis at 3 months after implantation increased from 2.2% (95% confidence interval [CI], 1.5 to 3.4) to 8.4% (95% CI, 5.0 to 13.9) by January 1, 2013. Before March 1, 2011, the median time from implantation to thrombosis was 18.6 months (95% CI, 0.5 to 52.7), and from March 2011 onward, it was 2.7 months (95% CI, 0.0 to 18.6). The occurrence of elevated LDH levels within 3 months after implantation mirrored that of thrombosis. Thrombosis was presaged by LDH levels that more than doubled, from 540 IU per liter to 1490 IU per liter, within the weeks before diagnosis. Thrombosis was managed by heart transplantation in 11 patients (1 patient died 31 days after transplantation) and by pump replacement in 21, with mortality equivalent to that among patients without thrombosis; among 40 thromboses in 40 patients who did not undergo transplantation or pump replacement, actuarial mortality was 48.2% (95% CI, 31.6 to 65.2) in the ensuing 6 months after pump thrombosis. CONCLUSIONS The rate of pump thrombosis related to the use of the HeartMate II has been increasing at our centers and is associated with substantial morbidity and mortality.
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Affiliation(s)
- Randall C Starling
- From the Departments of Cardiovascular Medicine (R.C.S., M.M.M.), Thoracic and Cardiovascular Surgery (N.M., E.H.B., E.G.S., B.W.L., N.G.S.), and Quantitative Health Sciences (E.H.B., J.E., L.T.) and Kaufman Center for Heart Failure (R.C.S., N.M., E.H.B., M.M.M., E.G.S., N.G.S.), Cleveland Clinic, Cleveland; the Division of Cardiovascular Surgery (S.C.S.) and the Cardiovascular Division (G.E.), Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis; the Cardiology Division (J.G.R.) and the Cardiovascular Surgery Division (C.A.M.), Duke University School of Medicine, Durham, NC; and the Divisions of Cardiology (J.E.R.) and Cardiovascular Surgery (M.A.A.), University of Pennsylvania, Philadelphia
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Bunte MC, Blackstone EH, Thuita L, Fowler J, Joseph L, Ozaki A, Starling RC, Smedira NG, Mountis MM. Major bleeding during HeartMate II support. J Am Coll Cardiol 2013; 62:2188-96. [PMID: 23994419 DOI: 10.1016/j.jacc.2013.05.089] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/07/2013] [Accepted: 05/28/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The aim of this study was to characterize a single-center experience of major bleeding complications during HeartMate II (HMII) (Thoratec Corp., Pleasanton, California) left ventricular assist device support, with focus on the subtypes and temporal patterns of post-operative bleeding. BACKGROUND Bleeding complications are the most common post-operative adverse events after HMII implantation. The timing of bleeding events, relationship to coagulation status, and effect on post-operative survival are incompletely understood. METHODS From October 2004 to June 2010, 139 HMII recipients at the Cleveland Clinic received 145 devices as a bridge to transplant or destination therapy for advanced heart failure. Major bleeding was defined using Interagency Registry for Mechanically Assisted Circulatory Support criteria, with an additional category created to maximize sensitivity for events. Pre-operative variables, coagulation status, and bleeding recurrence were assessed for correlation to primary events using modulated renewal within a multivariable analysis. RESULTS The cumulative occurrence of major bleeding was 58% during 171 patient-years of follow-up. There were 1.14 major bleeds per patient-year, with 44% occurring as repeat bleeding events. A first bleed did not predict subsequent bleeding. The greatest risk of bleeding was noted within 2 weeks post-implantation. The international normalized ratio profile correlated poorly with the risk of bleeding. Bleeding early after surgery was associated with reduced survival while on HMII support. CONCLUSIONS The risk of bleeding peaks early after HMII implantation. Bleeding of thoracic and gastrointestinal sources dominates these events, although many patients undergo transfusions for anemia without an apparent source of hemolysis or bleeding.
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Affiliation(s)
- Matthew C Bunte
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Pettersson GB, Karam K, Thuita L, Johnston DR, McCurry KR, Kapadia SR, Budev MM, Avery RK, Mason DP, Murthy SC, Blackstone EH. Comparative study of bronchial artery revascularization in lung transplantation. J Thorac Cardiovasc Surg 2013; 146:894-900.e3. [PMID: 23820173 DOI: 10.1016/j.jtcvs.2013.04.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 03/22/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Restoring dual blood supply to transplanted lungs by bronchial artery revascularization (BAR) remains controversial. We compared outcomes after lung transplantation performed with and without BAR. METHODS From December 2007 to July 2010, 283 patients underwent transplantation; 187 were 18 years or older, without previous or concomitant cardiac surgery. Of these patients, 27 underwent BAR in a pilot study to test success, safety, effectiveness, and teachability. A propensity score was generated to match BAR patients and 54 routine non-BAR patients. Follow-up was 1.3 ± 0.68 years. RESULTS BAR was angiographically successful in 26 (96%) of 27 patients. BAR and non-BAR patients had similar skin-to-skin time (P = .07) and postoperative hospital stays (P = .2), but more reoperations for bleeding (P = .002). Tracheostomy was performed in 9 (33%) of 27 BAR and 10 (19%) of 54 non-BAR patients (P = .2, log-rank). One BAR (3.7%) and 4 non-BAR (7.4%) patients required extracorporeal membrane oxygenation (P = .7). Airway ischemia was observed in 1 BAR (3.7%) versus 12 non-BAR (22%) patients (P = .03); anastomotic intervention was required in no BAR versus 8 non-BAR (15%) patients (P = .04). Hospital mortality was 1 of 27 versus 2 of 54 (P = .9). BAR patients had lower early biopsy tissue rejection grades (P = .008) and fewer pulmonary (P < .04) and bloodstream (P < .02) infections. Forced 1-second expiratory volume was similar (P > .2); 3 BAR versus 9 non-BAR patients developed bronchiolitis obliterans syndrome (BOS) (P = .14, log-rank). During follow-up, 4 BAR and 8 non-BAR patients died (P = .6, log-rank). CONCLUSIONS BAR is safe, with comparable early outcomes. Benefits of BAR include reduced airway ischemia and complications, lower biopsy tissue grades, fewer infections, and delay of BOS. A multicenter study is needed to establish these benefits.
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Affiliation(s)
- Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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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: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Koval C, Thuita L, Moazami N, Mountis M, Blackstone E. Driveline Infections in a Large Cohort of Continuous Flow Left Ventricular Assist Device (LVAD) Recipients: The Impact of Pseudomonas on Deep Driveline Involvement. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Almond CS, Morales DL, Blackstone EH, Turrentine MW, Imamura M, Massicotte MP, Jordan LC, Devaney EJ, Ravishankar C, Kanter KR, Holman W, Kroslowitz R, Tjossem C, Thuita L, Cohen GA, Buchholz H, St Louis JD, Nguyen K, Niebler RA, Walters HL, Reemtsen B, Wearden PD, Reinhartz O, Guleserian KJ, Mitchell MB, Bleiweis MS, Canter CE, Humpl T. Berlin Heart EXCOR pediatric ventricular assist device for bridge to heart transplantation in US children. Circulation 2013; 127:1702-11. [PMID: 23538380 DOI: 10.1161/circulationaha.112.000685] [Citation(s) in RCA: 329] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data suggest that the Berlin Heart EXCOR Pediatric ventricular assist device is superior to extracorporeal membrane oxygenation for bridge to heart transplantation. Published data are limited to 1 in 4 children who received the device as part of the US clinical trial. We analyzed outcomes for all US children who received the EXCOR to characterize device outcomes in an unselected cohort and to identify risk factors for mortality to facilitate patient selection. METHODS AND RESULTS This multicenter, prospective cohort study involved all children implanted with the Berlin Heart EXCOR Pediatric ventricular assist device at 47 centers from May 2007 through December 2010. Multiphase nonproportional hazards modeling was used to identify risk factors for early (<2 months) and late mortality. Of 204 children supported with the EXCOR, the median duration of support was 40 days (range, 1-435 days). Survival at 12 months was 75%, including 64% who reached transplantation, 6% who recovered, and 5% who were alive on the device. Multivariable analysis identified lower weight, biventricular assist device support, and elevated bilirubin as risk factors for early mortality and bilirubin extremes and renal dysfunction as risk factors for late mortality. Neurological dysfunction occurred in 29% and was the leading cause of death. CONCLUSIONS Use of the Berlin Heart EXCOR has risen dramatically over the past decade. The EXCOR has emerged as a new treatment standard in the United States for pediatric bridge to transplantation. Three-quarters of children survived to transplantation or recovery; an important fraction experienced neurological dysfunction. Smaller patient size, renal dysfunction, hepatic dysfunction, and biventricular assist device use were associated with mortality, whereas extracorporeal membrane oxygenation before implantation and congenital heart disease were not.
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Affiliation(s)
- Christopher S Almond
- The Heart Center, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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Smedira NG, Hoercher KJ, Lima B, Mountis MM, Starling RC, Thuita L, Schmuhl DM, Blackstone EH. Unplanned Hospital Readmissions After HeartMate II Implantation. JACC: Heart Failure 2013; 1:31-9. [DOI: 10.1016/j.jchf.2012.11.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
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Mihaljevic T, Jarrett CM, Gonzalez-Stawinski G, Smedira NG, Nowicki ER, Thuita L, Mountis M, Blackstone EH. Mechanical circulatory support after heart transplantation. Eur J Cardiothorac Surg 2012; 41:200-6; discussion 206. [PMID: 21640601 DOI: 10.1016/j.ejcts.2011.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Mechanical circulatory support (MCS) may be used for severe graft failure after heart transplantation, but the degree to which it is lifesaving is uncertain. METHODS Between June 1990 and December 2009, 53 patients after 1417 heart transplants (3.7%) required post-transplant MCS for acute rejection (n=17), biventricular failure (n=16), right ventricular failure (n=16), left ventricular failure (n=1), or respiratory failure (n=3). Although support was occasionally instituted remotely post-transplant (5>1 year), in 39 (73%) instances it was required within 1 week. Initial mode of support was extracorporeal membrane oxygenation in 43 patients (81%), biventricular assist device in 4 (7.5%), and right ventricular assist device in 6 (11%). RESULTS Risk of requiring respiratory support was highest in those with restrictive cardiomyopathy as indication for transplant, women, and those with elevated pulmonary pressure or renal failure. Complications of support, which increased progressively with its duration, included stroke in two patients (3.8%), infection in two (3.8%), and reoperation for bleeding (seven instances) in four (7.0%). Nineteen patients (36%) recovered and were removed from support, five (9.4%) underwent retransplantation (four after biventricular failure and one after acute rejection), and 29 died while on support (55%). Overall survival after initiating support was 94%, 83%, 66%, and 43% at 1, 3, 7, and 30 days, respectively. Patients requiring support for biventricular failure had better survival than those having acute rejection or other indications (P=0.03). Survival after retransplantation or removal from support following recovery was 88% at 1 year and 61% at 10 years. CONCLUSION Severe refractory heart failure after transplantation is a rare catastrophic event for which MCS offers the possibility of recovery or bridge to retransplantation, particularly for patients with biventricular failure in the absence of rejection. Early retransplantation should be considered in patients who show no evidence of graft recovery on MCS.
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Affiliation(s)
- Tomislav Mihaljevic
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
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Bunte M, Mountis M, Fowler J, Ozaki A, Joseph L, Thuita L, Gonzalez-Stawinski G, Blackstone E. TIMING AND RISK FACTORS OF GASTROINTESTINAL BLEEDING AND ANEMIA OF UNDETERMINED SOURCE AFTER HEARTMATE II VENTRICULAR ASSIST DEVICE. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60880-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bunte M, Thuita L, Blackstone E, Gonzalez-Stawinski G, Mountis M. 277 Analysis of Bleeding and Thromboembolic Events during Mechanical Circulatory Support with an Axial Flow Left Ventricular Assist Device. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Reyes KG, Mason DP, Thuita L, Nowicki ER, Murthy SC, Pettersson GB, Blackstone EH. Guidelines for Donor Lung Selection: Time for Revision? Ann Thorac Surg 2010; 89:1756-64; discussion 1764-5. [PMID: 20494023 DOI: 10.1016/j.athoracsur.2010.02.056] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 02/10/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
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Gallicchio L, Chang HH, Christo DK, Thuita L, Huang HY, Strickland P, Ruczinski I, Clipp S, Helzlsouer KJ. Single nucleotide polymorphisms in obesity-related genes and all-cause and cause-specific mortality: a prospective cohort study. BMC Med Genet 2009; 10:103. [PMID: 19818126 PMCID: PMC2763854 DOI: 10.1186/1471-2350-10-103] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 10/09/2009] [Indexed: 01/06/2023]
Abstract
Background The aim of this study was to examine the associations between 16 specific single nucleotide polymorphisms (SNPs) in 8 obesity-related genes and overall and cause-specific mortality. We also examined the associations between the SNPs and body mass index (BMI) and change in BMI over time. Methods Data were analyzed from 9,919 individuals who participated in two large community-based cohort studies conducted in Washington County, Maryland in 1974 (CLUE I) and 1989 (CLUE II). DNA from blood collected in 1989 was genotyped for 16 SNPs in 8 obesity-related genes: monoamine oxidase A (MAOA), lipoprotein lipase (LPL), paraoxonase 1 and 2 (PON1 and PON2), leptin receptor (LEPR), tumor necrosis factor-α (TNFα), and peroxisome proliferative activated receptor-γ and -δ (PPARG and PPARD). Data on height and weight in 1989 (CLUE II baseline) and at age 21 were collected from participants at the time of blood collection. All participants were followed from 1989 to the date of death or the end of follow-up in 2005. Cox proportional hazards regression was used to obtain the relative risk (RR) estimates and 95% confidence intervals (CI) for each SNP and mortality outcomes. Results The results showed no patterns of association for the selected SNPs and the all-cause and cause-specific mortality outcomes, although statistically significant associations (p < 0.05) were observed between PPARG rs4684847 and all-cause mortality (CC: reference; CT: RR 0.99, 95% CI 0.89, 1.11; TT: RR 0.60, 95% CI 0.39, 0.93) and cancer-related mortality (CC: reference; CT: RR 1.01, 95% CI 0.82, 1.25; TT: RR 0.22, 95% CI 0.06, 0.90) and TNFα rs1799964 and cancer-related mortality (TT: reference; CT: RR 1.23, 95% CI 1.03, 1.47; CC: RR 0.83, 95% CI 0.54, 1.28). Additional analyses showed significant associations between SNPs in LEPR with BMI (rs1137101) and change in BMI over time (rs1045895 and rs1137101). Conclusion Findings from this cohort study suggest that the selected SNPs are not associated with overall or cause-specific death, although several LEPR SNPs may be related to BMI and BMI change over time.
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Affiliation(s)
- Lisa Gallicchio
- The Prevention and Research Center, The Weinberg Center for Women's Health & Medicine, Mercy Medical Center, Baltimore, Maryland 21202, USA.
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Tiong H, Goldfarb D, Kattan M, Alster J, Thuita L, Yu C, Wee A, Poggio E. Nomograms for Predicting Graft Function and Survival in Living Donor Kidney Transplantation Based on the UNOS Registry. J Urol 2009; 181:1248-55. [DOI: 10.1016/j.juro.2008.10.164] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Indexed: 01/06/2023]
Affiliation(s)
- H.Y. Tiong
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - D.A. Goldfarb
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - M.W. Kattan
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - J.M. Alster
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - L. Thuita
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - C. Yu
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - A. Wee
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - E.D. Poggio
- Section of Renal Transplantation, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
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Murthy S, Nowicki E, Mason D, Budev M, Nunez A, Thuita L, Chapman J, Pettersson G, Blackstone E. 428: Preoperative Gastroesophageal Reflux Impacts Early Outcomes after Lung Transplantation. J Heart Lung Transplant 2009. [DOI: 10.1016/j.healun.2008.11.435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Zahr F, Ootaki Y, Starling RC, Smedira NG, Yamani M, Thuita L, Fukamachi K. Preoperative Risk Factors for Mortality After Biventricular Assist Device Implantation. J Card Fail 2008; 14:844-9. [DOI: 10.1016/j.cardfail.2008.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 08/17/2008] [Accepted: 08/26/2008] [Indexed: 10/21/2022]
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Gallicchio L, Chang H, Christo DK, Thuita L, Huang HY, Strickland P, Ruczinski I, Hoffman SC, Helzlsouer KJ. Single nucleotide polymorphisms in inflammation-related genes and mortality in a community-based cohort in Washington County, Maryland. Am J Epidemiol 2008; 167:807-13. [PMID: 18263601 DOI: 10.1093/aje/kwm378] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study was to examine the associations between single nucleotide polymorphisms (SNPs) in genes controlling inflammatory processes and mortality. Data were analyzed from 9,933 individuals who participated in two large community-based cohort studies conducted in Washington County, Maryland, in 1974 and 1989, designated "CLUE I" and "CLUE II," respectively. DNA from blood collected in 1989 was genotyped for 47 SNPs in 23 inflammation-related genes, including interferon-gamma (IFNgamma), lymphotoxin-alpha (LTalpha), tumor necrosis factor-alpha (TNFalpha), C-reactive protein (CRP), peroxisome proliferator-activated receptor (PPAR), and the human endothelial nitric oxide synthase (eNOS). All participants were followed from 1989 to the date of death or to June 20, 2005. The results showed no observable patterns of association for the SNPs and the all-cause and cause-specific mortality outcomes, although statistically significant associations were observed between at least one mortality outcome and SNPs in eNOS (reference SNP (rs) 1799983), PPARG (rs4684847), CRP (rs2794521), IFNgamma (rs2069705), TNFalpha (rs1799964), and LTalpha (rs2229094). Additionally, three of the four examined CRP SNPs were strongly associated with CRP serum concentration among those with CRP measurements. The authors' findings from this community-based prospective cohort study suggest that the selected SNPs are not associated with overall or cause-specific death, although CRP genotypes may be associated with systemic inflammation.
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Affiliation(s)
- Lisa Gallicchio
- Prevention and Research Center, Weinberg Center for Women's Health and Medicine, Mercy Medical Center, Baltimore, MD 21202, USA.
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Mason DP, Solovera-Rozas M, Feng J, Rajeswaran J, Thuita L, Murthy SC, Budev MM, Mehta AC, Haug M, McNeill AM, Pettersson GB, Blackstone EH. Dialysis After Lung Transplantation: Prevalence, Risk Factors and Outcome. J Heart Lung Transplant 2007; 26:1155-62. [DOI: 10.1016/j.healun.2007.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 07/18/2007] [Accepted: 08/17/2007] [Indexed: 11/24/2022] Open
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Rohrmann S, Platz EA, Kavanaugh CJ, Thuita L, Hoffman SC, Helzlsouer KJ. Meat and dairy consumption and subsequent risk of prostate cancer in a US cohort study. Cancer Causes Control 2007; 18:41-50. [PMID: 17315319 DOI: 10.1007/s10552-006-0082-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the association of meat and dairy food consumption with subsequent risk of prostate cancer. METHODS In 1989, 3,892 men 35+ years old, who participated in CLUE II study of Washington County, MD, completed an abbreviated Block food frequency questionnaire. Intake of meat and dairy related foods was calculated using consumption frequency and portion size. Incident prostate cancer cases (n = 199) were ascertained through October 2004. Cox proportional hazards regression was used to calculate hazard ratios (HR) of total and advanced (SEER states three and four; n = 54) prostate cancer and 95% confidence intervals (CI) adjusted for age, BMI at age 21, and intake of energy, saturated fat, and tomato products. RESULTS Intakes of total mean (HR = 0.90, 95% CI 0.60-1.33, comparing highest to lowest tertile) and red meat (HR = 0.87, 95% CI 0.59-1.32) were not statistically significantly associated with prostate cancer. However, processed meat consumption was associated with a non-statistically significant higher risk of total (5+ vs. < or =1 servings/week: HR = 2.24; 95% CI 0.90-5.59) prostate cancer. There was no association across tertiles of dairy or calcium with total prostate cancer, although compared tp < or =1 servings/week consumption of 5+ servings/week of dairy foods was associated with an increased risk of prostate cancer (HR = 1.65, 98% CI 1.02-2.66). CONCLUSION Overall, consumption of processed meat, but not total meat or red meat, was associated with a possible increased risk of total prostate cancer in this prospective study. Higher intake of dairy foods but not calcium was positively associated with prostate cancer. Further investigation into the mechanisms by which processed meat and dairy consumption might increase the risk of prostate cancer is suggested.
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Affiliation(s)
- Sabine Rohrmann
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Rm. E 6138, Baltimore, MD 21205, USA
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Goldfarb DA, Kattan MW, Alster JM, Thuita L, Poggio ED. 1898: Nomograms to Predict Graft Function and Survival in Living Donor Kidney Transplantation. J Urol 2007. [DOI: 10.1016/s0022-5347(18)32071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Huang HY, Thuita L, Strickland P, Hoffman SC, Comstock GW, Helzlsouer KJ. Frequencies of single nucleotide polymorphisms in genes regulating inflammatory responses in a community-based population. BMC Genet 2007; 8:7. [PMID: 17355643 PMCID: PMC1838428 DOI: 10.1186/1471-2156-8-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Accepted: 03/14/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Allele frequencies reported from public databases or articles are mostly based on small sample sizes. Differences in genotype frequencies by age, race and sex have implications for studies designed to examine genetic susceptibility to disease. In a community-based cohort of 9,960 individuals, we compared the allele frequencies of 49 single nucleotide polymorphisms (SNPs) of genes involved in inflammatory pathways to the frequencies reported on public databases, and examined the genotypes frequencies by age and sex. The genes in which SNPs were analyzed include CCR2, CCR5, COX1, COX2, CRP, CSF1, CSF2, IFNG, IL1A, IL1B, IL2, IL4, IL6, IL8, IL10, IL13, IL18, LTA, MPO, NOS2A, NOS3, PPARD, PPARG, PPARGC1 and TNF. RESULTS Mean(SD) age was 53.2(15.5); 98% were Caucasians and 62% were women. Only 1 out of 33 SNPs differed from the SNP500Cancer database in allele frequency by >10% in Caucasians (n = 9,831), whereas 12 SNPs differed by >10% (up to 50%) in African Americans (n = 105). Two out of 15 SNPs differed from the dbSNP database in allele frequencies by >10% in Caucasians, and 5 out of 15 SNPs differed by >10% in African Americans. Age was similar across most genotype groups. Genotype frequencies did not differ by sex except for TNF(rs1799724), IL2(rs2069762), IL10(rs1800890), PPARG(rs1801282), and CRP(rs1800947) with differences of less than 4%. CONCLUSION When estimating the size of samples needed for a study, particularly if a reference sample is used, one should take into consideration the size and ethnicity of the reference sample. Larger sample size is needed for public databases that report allele frequencies in non-Caucasian populations.
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Affiliation(s)
- Han-Yao Huang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucy Thuita
- Department of Biostatistics & Epidemiology/Wb4, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Paul Strickland
- Department of Environmental Health Sciences, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sandra C Hoffman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - George W Comstock
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathy J Helzlsouer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Prevention and Research Center, Women's Center for Health & Medicine, Mercy Medical Center, Baltimore, Maryland, USA
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Jorgensen TJ, Visvanathan K, Ruczinski I, Thuita L, Hoffman S, Helzlsouer KJ. Breast cancer risk is not associated with polymorphic forms of xeroderma pigmentosum genes in a cohort of women from Washington County, Maryland. Breast Cancer Res Treat 2006; 101:65-71. [PMID: 16823510 DOI: 10.1007/s10549-006-9263-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 04/24/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND The genes mutated in the cancer-prone syndrome, xeroderma pigmentosum (XP genes), have been well studied both biochemically and mechanistically. These genes are important components of the DNA nucleotide excision repair (NER) pathway, which protects against environmentally-induced cancers. XP genes are also downstream of the hereditary breast cancer syndrome gene, BRCA1, suggesting that XP genes may be important to hereditary forms of breast cancer as well. Although mutated XP genes are rare, polymorphic forms with potential functional deficiencies are common, and could pose a significant cancer risk in the general population. HYPOTHESIS This study tested the hypothesis that common polymorphic variants of XP genes were associated with the risk of breast cancer among a population of women in Washington County, Maryland. METHODS Five single nucleotide polymorphisms (SNPs) among four XP genes (XPC, XPD, XPF and XPG) were genotyped from DNA samples collected at baseline, and then analyzed by conditional logistic regression for association with the incidence of breast cancer. 321 cases were individually matched to 321 controls, by age and menopausal status. RESULTS No significant associations were found between breast cancer risk and any of the XP genotypes. Odds ratios for all genotypes ranged from 0.61 to 1.14, and none were statistically significant. Adjustment and stratification for family history of breast cancer did not alter the findings. CONCLUSION These results suggest that polymorphisms of XP genes are not likely to be significant risk factors for women within the general population. This study did not address, however, risks for subpopulations of women with high exposures to DNA damaging agents.
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Affiliation(s)
- T J Jorgensen
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University, 3970 Reservoir Road, NW, TRB Room E212, Washington, DC 20057, USA.
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Brewster AM, Jorgensen TJ, Ruczinski I, Huang HY, Hoffman S, Thuita L, Newschaffer C, Lunn RM, Bell D, Helzlsouer KJ. Polymorphisms of the DNA repair genes XPD (Lys751Gln) and XRCC1 (Arg399Gln and Arg194Trp): relationship to breast cancer risk and familial predisposition to breast cancer. Breast Cancer Res Treat 2005; 95:73-80. [PMID: 16319991 DOI: 10.1007/s10549-005-9045-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Accepted: 08/03/2005] [Indexed: 11/29/2022]
Abstract
Family history is a risk factor for breast cancer and could be due to shared environmental factors or polymorphisms of cancer susceptibility genes. Deficient function of DNA repair enzymes may partially explain familial risk as polymorphisms of DNA repair genes have been associated, although inconsistently, with breast cancer. This population based case-control study examined the association between polymorphisms in XPD (Lys751Gln) and XRCC1 (Arg399Gln and Arg194Trp) genes, and breast cancer. Breast cancer cases (n=321) and controls (n=321) were matched on age and menopausal status. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). The analysis was conducted omitting observations with missing data, and by using imputation methods to handle missing data. No significant association was observed between the XPD 751Gln/Lys (OR 1.37, 95% CI 0.96-1.96) and Gln/Gln genotypes (OR 1.08, 95% CI 0.62-1.86) (referent Lys/Lys), XRCC1 399Arg/Gln (OR 1.48, 95% CI 0.92-2.38) and Gln/Gln genotypes (1.11, 95% CI 0.67-1.83) (referent Arg/Arg) or the XRCC1 Arg/Trp and Trp/Trp genotypes (OR 1.12, 95% CI 0.69-1.83) (referent Arg/Arg) and breast cancer. In multivariate analysis, the adjusted odds ratios for the XPD and XRCC1 399 polymorphisms increased and became statistically significant, however, were attenuated when imputation methods were used to handle missing data. There was no interaction with family history. These results indicate that these polymorphisms in XPD and XRCC1 genes are only weakly associated with breast cancer. Without imputation methods for handling missing data, a statistically significant association was observed between the genotypes and breast cancer, illustrating the potential for bias in studies that inadequately handle missing data.
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Affiliation(s)
- A M Brewster
- Department of Clinical Cancer Prevention, University of Texas M.D. Anderson Cancer Center, Houston, TX 77230-1439, USA.
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48
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Suguitan AL, Gowda DC, Fouda G, Thuita L, Zhou A, Djokam R, Metenou S, Leke RGF, Taylor DW. Lack of an association between antibodies to Plasmodium falciparum glycosylphosphatidylinositols and malaria-associated placental changes in Cameroonian women with preterm and full-term deliveries. Infect Immun 2004; 72:5267-73. [PMID: 15322022 PMCID: PMC517432 DOI: 10.1128/iai.72.9.5267-5273.2004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sequestration of Plasmodium falciparum parasites within the placenta often leads to an accumulation of macrophages within the intervillous space and increased production of tumor necrosis factor alpha (TNF-alpha), a cytokine associated with placental pathology and poor pregnancy outcomes. P. falciparum glycosylphosphatidylinositol (GPI) anchors have been shown to be the major parasite component that induces TNF-alpha production by monocytes and macrophages. Antibodies against P. falciparum GPI (anti-PfGPI), however, can inhibit the induction of TNF-alpha and inflammation. Thus, the study was undertaken to determine whether anti-PfGPI antibodies down-regulate inflammatory-type changes in the placentas of women with malaria. Anti-PfGPI immunoglobulin M (IgM) and IgG levels were measured in 380 pregnant women with or without placental malaria, including those who delivered prematurely and at term. Results showed that anti-PfGPI antibody levels increased with gravidity and age and that malaria infection boosted anti-PfGPI antibodies in pregnant women. However, no association was found between anti-PfGPI antibodies and placental TNF-alpha levels or the presence of acute or chronic placental malaria. Furthermore, anti-PfGPI antibody levels were similar in women with preterm and full-term deliveries and were not associated with an increase in infant birth weight. Thus, these results fail to support a strong role for anti-PfGPI antibodies in the prevention of chronic placental malaria infections and malaria-associated poor birth outcomes.
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Affiliation(s)
- Amorsolo L Suguitan
- Department of Biology, Georgetown University, 37th and O Sts., N.W., Washington, D.C. 20057, USA
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49
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Suguitan AL, Cadigan TJ, Nguyen TA, Zhou A, Leke RJI, Metenou S, Thuita L, Megnekou R, Fogako J, Leke RGF, Taylor DW. Malaria-associated cytokine changes in the placenta of women with pre-term deliveries in Yaounde, Cameroon. Am J Trop Med Hyg 2003; 69:574-81. [PMID: 14740871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
The prevalence of pre-term deliveries (PTDs) is increased in women who become infected with Plasmodium falciparum during pregnancy. Because prematurity is a risk factor for newborns, it is important to identify conditions that contribute to malaria-associated PTDs. Plasmodium falciparum-infected erythrocytes sequester in the placenta and attract activated mononuclear cells that secrete pro-inflammatory cytokines. Increased inflammatory cytokine levels in other microbial infections are associated with PTDs. To determine if such is the case in women with placental malaria, concentrations of interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4), and IL-10 were measured in placental plasma of 391 malaria-infected and -uninfected Cameroonian women with premature and full-term deliveries. Risk factors for malaria-associated PTDs included peripheral and placental parasitemias greater than 1%, maternal anemia, elevated IL-10 levels, and low TNF-alpha:IL-10 ratios due to over-expression of IL-10. Alterations in cytokine levels may contribute to PTDs through the induction of anemia and/or altering cellular immune responses required for eliminating placental parasites.
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Affiliation(s)
- Amorsolo L Suguitan
- Department of Biology, Georgetown University, Washington, District of Columbia 20057, USA
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50
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Suguitan AL, Leke RGF, Fouda G, Zhou A, Thuita L, Metenou S, Fogako J, Megnekou R, Taylor DW. Changes in the levels of chemokines and cytokines in the placentas of women with Plasmodium falciparum malaria. J Infect Dis 2003; 188:1074-82. [PMID: 14513430 DOI: 10.1086/378500] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2002] [Accepted: 04/23/2003] [Indexed: 11/03/2022] Open
Abstract
Plasmodium falciparum-infected erythrocytes often are sequestered in the placenta and stimulate the accumulation of maternal mononuclear cells. In this study, the role that chemokines and cytokines play in mediating the inflammatory response was investigated. Placental parasites elicited a statistically significant increase in the levels of interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-10, in plasma collected from the intervillous space. Explants of fetal tissue from malaria-positive placentas also secreted significantly enhanced amounts of IFN-gamma. Culture supernatant of maternal intervillous leukocytes obtained from infected placentas contained significantly higher levels of TNF-alpha, IL-10, monocyte chemotactic protein-1, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta, and IFN-gamma inducible protein-10 than did cultures of white blood cells obtained from uninfected placentas. Taken together, these results show that both fetal and maternal cells secrete inflammatory and immunoregulatory cytokines in response to P. falciparum and suggest that beta-chemokines produced by maternal cells contribute to the accumulation of macrophages in the intervillous space.
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