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Tapaskar N, Wayda B, Malinoski D, Luikart H, Groat T, Nguyen J, Belcher J, Nieto J, Neidlinger N, Salehi A, Geraghty PJ, Nicely B, Jendrisak M, Pearson T, Wood RP, Zhang S, Weng Y, Zaroff J, Khush KK. Donor Electrocardiogram Associations With Cardiac Dysfunction, Heart Transplant Use, and Survival: The Donor Heart Study. JACC Heart Fail 2024; 12:722-736. [PMID: 38244008 DOI: 10.1016/j.jchf.2023.12.007] [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] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/07/2023] [Accepted: 12/13/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Potential organ donors often exhibit abnormalities on electrocardiograms (ECGs) after brain death, but the physiological and prognostic significance of such abnormalities is unknown. OBJECTIVES This study sought to characterize the prevalence of ECG abnormalities in a nationwide cohort of potential cardiac donors and their associations with cardiac dysfunction, use for heart transplantation (HT), and recipient outcomes. METHODS The Donor Heart Study enrolled 4,333 potential cardiac organ donors at 8 organ procurement organizations across the United States from 2015 to 2020. A blinded expert reviewer interpreted all ECGs, which were obtained once hemodynamic stability was achieved after brain death and were repeated 24 ± 6 hours later. ECG findings were summarized, and their associations with other cardiac diagnostic findings, use for HT, and graft survival were assessed using univariable and multivariable regression. RESULTS Initial ECGs were interpretable for 4,136 potential donors. Overall, 64% of ECGs were deemed clinically abnormal, most commonly as a result of a nonspecific St-T-wave abnormality (39%), T-wave inversion (19%), and/or QTc interval >500 ms (17%). Conduction abnormalities, ectopy, pathologic Q waves, and ST-segment elevations were less common (each present in ≤5% of donors) and resolved on repeat ECGs in most cases. Only pathological Q waves were significant predictors of donor heart nonuse (adjusted OR: 0.39; 95% CI: 0.29-0.53), and none were associated with graft survival at 1 year post-HT. CONCLUSIONS ECG abnormalities are common in potential heart donors but often resolve on serial testing. Pathologic Q waves are associated with a lower likelihood of use for HT, but they do not portend worse graft survival.
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Affiliation(s)
- Natalie Tapaskar
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | - Brian Wayda
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Darren Malinoski
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Tahnee Groat
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - John Nguyen
- Division of Transplant Surgery, Department of Surgery, University of California-San Francisco, San Francisco, California, USA
| | - John Belcher
- New England Donor Services, Waltham, Massachusetts, USA
| | - Javier Nieto
- LifeGift Organ Procurement Organization, Houston, Texas, USA
| | - Nikole Neidlinger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | | | - Martin Jendrisak
- Gift of Hope Organ and Tissue Donor Network, Itasca, Illinois, USA
| | | | - R Patrick Wood
- LifeGift Organ Procurement Organization, Houston, Texas, USA
| | - Shiqi Zhang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jonathan Zaroff
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Ruch B, Kumm K, Kirk WV, Geraghty PJ, Harbell JW, Aqel BA, Reddy KS, Katariya NN, Mathur AK. P2.3: Rapid Maastricht type 3 donors and normothermic perfusion: Relieving time constraints in non-renal organ recovery. Transplantation 2023; 107:82. [PMID: 37845975 DOI: 10.1097/01.tp.0000993480.41080.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- Brianna Ruch
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Kayla Kumm
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | | | - P J Geraghty
- Donor Network of Arizona, Tempe, AZ, United States
| | - Jack W Harbell
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Bashar A Aqel
- Transplant Hepatology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Kunam S Reddy
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Nitin N Katariya
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Amit K Mathur
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
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Khush KK, Malinoski D, Luikart H, Wayda B, Groat T, Nguyen J, Belcher J, Nieto J, Neidlinger N, Salehi A, Geraghty PJ, Nicely B, Jendrisak M, Pearson T, Wood RP, Zhang S, Weng Y, Zaroff J. Left Ventricular Dysfunction Associated With Brain Death: Results From the Donor Heart Study. Circulation 2023; 148:822-833. [PMID: 37465972 PMCID: PMC10529108 DOI: 10.1161/circulationaha.122.063400] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/26/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Left ventricular dysfunction in potential donors meeting brain death criteria often results in nonuse of donor hearts for transplantation, yet little is known about its incidence or pathophysiology. Resolving these unknowns was a primary aim of the DHS (Donor Heart Study), a multisite prospective cohort study. METHODS The DHS enrolled potential donors by neurologic determination of death (n=4333) at 8 organ procurement organizations across the United States between February 2015 and May 2020. Data included medications administered, serial diagnostic tests, and transthoracic echocardiograms (TTEs) performed: (1) within 48 hours after brain death was formally diagnosed; and (2) 24±6 hours later if left ventricular (LV) dysfunction was initially present. LV dysfunction was defined as an LV ejection fraction <50% and was considered reversible if LV ejection fraction was >50% on the second TTE. TTEs were also examined for presence of LV regional wall motion abnormalities and their reversibility. We assessed associations between LV dysfunction, donor heart acceptance for transplantation, and recipient 1-year survival. RESULTS An initial TTE was interpreted for 3794 of the 4333 potential donors by neurologic determination of death. A total of 493 (13%) of these TTEs showed LV dysfunction. Among those donors with an initial TTE, LV dysfunction was associated with younger age, underweight, and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) and troponin levels. A second TTE was performed within 24±6 hours for a subset of donors (n=224) with initial LV dysfunction; within this subset, 130 (58%) demonstrated reversibility. Sixty percent of donor hearts with normal LV function were accepted for transplant compared with 56% of hearts with reversible LV dysfunction and 24% of hearts with nonreversible LV dysfunction. Donor LV dysfunction, whether reversible or not, was not associated with recipient 1-year survival. CONCLUSIONS LV dysfunction associated with brain death occurs in many potential heart donors and is sometimes reversible. These findings can inform decisions made during donor evaluation and help guide donor heart acceptance for transplantation.
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Affiliation(s)
- Kiran K. Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Darren Malinoski
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, Portland, OR
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Brian Wayda
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Tahnee Groat
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, Portland, OR
| | - John Nguyen
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | - Javier Nieto
- LifeGift Organ Procurement Organization, Houston, TX
| | - Nikole Neidlinger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | | | | | | | | | - Shiqi Zhang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jonathan Zaroff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Malinoski D, Saunders C, Swain S, Groat T, Wood PR, Reese J, Nelson R, Prinz J, Kishish K, Van De Walker C, Geraghty PJ, Broglio K, Niemann CU. Hypothermia or Machine Perfusion in Kidney Donors. N Engl J Med 2023; 388:418-426. [PMID: 36724328 DOI: 10.1056/nejmoa2118265] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [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: 02/03/2023]
Abstract
BACKGROUND Therapeutic hypothermia in brain-dead organ donors has been shown to reduce delayed graft function in kidney recipients after transplantation. Data are needed on the effect of hypothermia as compared with machine perfusion on outcomes after kidney transplantation. METHODS At six organ-procurement facilities in the United States, we randomly assigned brain-dead kidney donors to undergo therapeutic hypothermia (hypothermia group), ex situ kidney hypothermic machine perfusion (machine-perfusion group), or both (combination-therapy group). The primary outcome was delayed graft function in the kidney transplant recipients (defined as the initiation of dialysis during the first 7 days after transplantation). We also evaluated whether hypothermia alone was noninferior to machine perfusion alone and whether the combination of both methods was superior to each of the individual therapies. Secondary outcomes included graft survival at 1 year after transplantation. RESULTS From 725 enrolled donors, 1349 kidneys were transplanted: 359 kidneys in the hypothermia group, 511 in the machine-perfusion group, and 479 in the combined-therapy group. Delayed graft function occurred in 109 patients (30%) in the hypothermia group, in 99 patients (19%) in the machine-perfusion group, and in 103 patients (22%) in the combination-therapy group. Adjusted risk ratios for delayed graft function were 1.72 (95% confidence interval [CI], 1.35 to 2.17) for hypothermia as compared with machine perfusion, 1.57 (95% CI, 1.26 to 1.96) for hypothermia as compared with combination therapy, and 1.09 (95% CI, 0.85 to 1.40) for combination therapy as compared with machine perfusion. At 1 year, the frequency of graft survival was similar in the three groups. A total of 10 adverse events were reported, including cardiovascular instability in 9 donors and organ loss in 1 donor owing to perfusion malfunction. CONCLUSIONS Among brain-dead organ donors, therapeutic hypothermia was inferior to machine perfusion of the kidney in reducing delayed graft function after transplantation. The combination of hypothermia and machine perfusion did not provide additional protection. (Funded by Arnold Ventures; ClinicalTrials.gov number, NCT02525510.).
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Affiliation(s)
- Darren Malinoski
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Christina Saunders
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Sharon Swain
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Tahnee Groat
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Patrick R Wood
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Jeffrey Reese
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Rachel Nelson
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Jennifer Prinz
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Kate Kishish
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Craig Van De Walker
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - P J Geraghty
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Kristine Broglio
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
| | - Claus U Niemann
- From the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M., T.G., R.N.), and the Pacific Northwest Transplant Bank (C.V.D.W.) - both in Portland; Berry Consultants, Austin (C.S., K.B.), LifeGift, Houston (P.R.W.), and South West Transplant Alliance, Dallas (J.R.) - all in Texas; Donor Alliance, Denver (J.P.); LifeSource, Minneapolis (K.K.); Donor Network Arizona, Tempe (P.J.G.); and Donor Network West, San Ramon (S.S.), and the Department of Anesthesia and Perioperative Care and the Department of Surgery, Division of Transplantation (C.U.N.), University of California, San Francisco - both in California
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Khush KK, Luikart H, Neidlinger N, Salehi A, Nguyen J, Geraghty PJ, Belcher J, Nicely B, Jendrisak M, Pearson T, Wood RP, Groat T, Wayda B, Zaroff JG, Malinoski D. Challenges encountered in conducting donor-based research: Lessons learned from the Donor Heart Study. Am J Transplant 2022; 22:1760-1765. [PMID: 35373509 PMCID: PMC9262765 DOI: 10.1111/ajt.17051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/30/2022] [Indexed: 01/25/2023]
Abstract
Solid organ transplantation continues to be constrained by a lack of suitable donor organs. Advances in donor management and evaluation are needed to address this shortage, but the performance of research studies in deceased donors is fraught with challenges. Here we discuss several of the major obstacles we faced in the conduct of the Donor Heart Study-a prospective, multi-site, observational study of donor management, evaluation, and acceptance for heart transplantation. These included recruitment and engagement of participating organ procurement organizations, ambiguities related to study oversight, obtaining authorization for donor research, logistical challenges encountered during donor management, sustaining study momentum, and challenges related to study data management. By highlighting these obstacles encountered, as well as the solutions implemented, we hope to stimulate further discussion and actions that will facilitate the design and execution of future donor research studies.
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Affiliation(s)
- Kiran K. Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nikole Neidlinger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - John Nguyen
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco
| | | | | | | | | | | | | | - Tahnee Groat
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, Portland, OR
| | - Brian Wayda
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jonathan G. Zaroff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Darren Malinoski
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, Portland, OR
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Geraghty PJ, Sicard GA. Abdominal aortic aneurysm repair in high-risk and elderly patients. J Cardiovasc Surg (Torino) 2003; 44:543-7. [PMID: 14627227] [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] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Elective open repair of abdominal aortic aneurysm (AAA) is a proven surgical therapy with acceptable rates of perioperative mortality. Open AAA repair in elderly and high-risk patients, however, carries a significantly greater risk of surgical mortality and perioperative complications. Given the steady increase of life expectancy in developed nations, assessment of surgical outcomes and clarification of the role of emerging therapies in the aging population are of significant interest to the vascular surgeon. Selection of treatment options for these patients must be based on an individual approach, and assessment of outcomes must include more subtle parameters, such as quality of life, in addition to operative survival. Recent studies assessing the applicability of endoluminal graft repair in the elderly demonstrate that this avenue of treatment may offer substantial benefit to selected patients. We review the historical data regarding operative aneurysm repair in the high-risk and elderly population, and examine the impact of endoluminal therapy of AAAs in these challenging patients.
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Affiliation(s)
- P J Geraghty
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110-1094, USA.
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Sicard GA, Rubin BG, Sanchez LA, Keller CA, Flye MW, Picus D, Hovsepian D, Choi ET, Geraghty PJ, Thompson RW. Endoluminal graft repair for abdominal aortic aneurysms in high-risk patients and octogenarians: is it better than open repair? Ann Surg 2001; 234:427-35; discussion 435-7. [PMID: 11573036 PMCID: PMC1422066 DOI: 10.1097/00000658-200110000-00002] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the short-term and midterm results of open and endoluminal repair of abdominal aortic aneurysms (AAA) in a large single-center series and specifically in octogenarians. METHODS Between January 1997 and October 2000, 470 consecutive patients underwent elective repair of AAA. Conventional open repair (COR) was performed in 210 patients and endoluminal graft (ELG) repair in 260 patients. Ninety of the patients were 80 years of age or older; of these, 38 underwent COR and 52 ELG repair. RESULTS Patient characteristics and risk factors were similar for both the entire series and the subgroup of patients 80 years or older. The overall complication rate was reduced by 70% or more in the ELG versus the COR groups. The postoperative death rate was similar for the COR and ELG groups in the entire series and lower (but not significantly) in the ELG 80 years or older subgroup versus the COR group. The 36-month rates of freedom from endoleaks, surgical conversion, and secondary intervention were 81%, 98.2%, and 88%, respectively. CONCLUSION The short-term and midterm results of AAA repair by COR or ELG are similar. The death rate associated with this new technique is low and comparable, whereas the complication rate associated with COR in all patients and those 80 years or older in particular is greater and more serious than ELG repair. Long-term results will establish the role of ELG repair of AAA, especially in elderly and high-risk patients.
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Affiliation(s)
- G A Sicard
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110-1093, USA.
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Brogan IJ, Geraghty PJ, Hutchinson IV. Interaction of immunophilin-binding immunosuppressives with the glucocorticoid receptor signaling pathway: implications for transplantation. Transplant Proc 2001; 33:2417-9. [PMID: 11377579 DOI: 10.1016/s0041-1345(01)02058-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- I J Brogan
- Transplant Immunology Research Group, School of Biological Sciences, University of Manchester, Manchester, UK.
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Azzawi M, Hasleton PS, Geraghty PJ, Yonan N, Krysiak P, El-Gammal A, Deiraniya AK, Hutchinson IV. RANTES chemokine expression is related to acute cardiac cellular rejection and infiltration by CD45RO T-lymphocytes and macrophages. J Heart Lung Transplant 1998; 17:881-7. [PMID: 9773860] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Despite the advances made in immunosuppression therapy, episodes of acute cellular rejection may affect graft function and survival. We investigated the role of RANTES in cellular recruitment and in cardiac allograft rejection. METHODS Endomyocardial biopsies (n = 65) from 30 patients were taken at various times after transplantation. In 4 subjects who died of acute cellular rejection, the profile of RANTES expression was monitored in all biopsy specimens and in postmortem tissue. Myocardial tissue from 10 other transplants was also analyzed. Sections were stained with an anti-human RANTES antibody with the streptavidin-biotin technique. RANTES-positive cells were related to macrophage, CD45RO "memory" T-cell, and eosinophil infiltration. RESULTS RANTES-positive cells were identified within the cellular infiltrate in 95% of biopsies with moderate/severe rejection and 28% with mild rejection. RANTES-positive, CD45RO-positive, and macrophage cell numbers were higher in subjects who died of acute cellular rejection than of other causes. A highly significant difference in RANTES-positive cell number was observed between moderate/severe, mild, and nonrejection groups (p = .0001) and correlated significantly with macrophage number in both right and left ventricles (r = .693, p < .01; r = .599, p < .05, respectively) and with the number of "memory" T cells (r = .829, p < .001; r = .779, p < .01, respectively). CONCLUSIONS These findings suggest that local release of RANTES is important in the recruitment of both macrophages and CD45RO T cells in cardiac allograft rejection. RANTES may be an important chemokine to target for therapeutic intervention in heart rejection.
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Affiliation(s)
- M Azzawi
- School of Biological Sciences, Manchester University, England, UK
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Abstract
In order to improve upon preclinical tumor vaccine strategies that employ dendritic cells (DC), we now have compared short-term cultures of spleen- and GM-CSF/IL-4-stimulated bone marrow (BM) to determine if differences exist in phenotype and function of murine DC derived from primary and secondary hematolymphoid organs. Although cultures of BM contained a lower percentage of DC compared to spleen, their capacity to stimulate a primary allogeneic mixed leukocyte reaction (MLR) and to uptake fluorescent dextran was substantially greater. In addition, the overall yields of DC per animal was at least twofold greater from BM compared to spleen. Cultures of BM harvested at day 3, 6, or 9 stimulated comparable levels of primary allo-MLR on a per-cell basis. However, there was a consistent loss (at least twofold) of all cells occurring beyond day 6 as compared with cell yields from earlier time points. Importantly, we also improved on methods to rapidly obtain highly enriched DC (> 90%) from BM, which has obviated the reported prior need for complex antibody and complement treatments to remove contaminating mature T and B lymphocytes, Ia-bearing cells, and granulocytes before DC generation. In contrast, although similar purity of DC with similar phenotype and function could be obtained from the spleen, substantial loss in yield occurred, suggesting a further difference in DC between the two tissue sources. The overall yield of DC derived from spleen and BM cultures could be substantially increased by in vivo pretreatment of the donor animals with recombinant Flt3-L. Collectively, these studies demonstrate that notable differences exist in DC preparations derived from spleen vs. BM and that BM provides the preferred source of DC that can be rapidly enriched to high purity for use in further vaccine development.
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Affiliation(s)
- R C Fields
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109-0666, USA
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11
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Abstract
This review focuses on the surgical treatment of primary cutaneous melanoma. Interpretation of biopsy results and a rational approach to preoperative screening methods for metastases are examined. The marked changes in operative approach to melanoma over the past century are reviewed, with emphasis on the impact of prospective, randomized trials upon the width of surgical margins for melanoma. General principles of current surgical technique are discussed, with attention given to modifications of technique dictated by unique anatomic tumor sites.
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Affiliation(s)
- P J Geraghty
- Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109, USA
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12
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Abstract
Advances in gene delivery systems have made possible the development of strategies to eradicate cancers via genetic manipulation. Although the strategy of 'gene therapy' remains in its infancy, experimental tumour models have produced encouraging results and have demonstrated that tumour growth or development can be altered by genetic manipulations. Investigators are hopeful that current and future human trials will confirm the role of these modalities in cancer treatment. This review focuses on several aspects of gene therapy that provide clinicians with a framework to understand the rationale and basic principles underlying current gene therapy protocols being conducted for cancer treatment. The relative merits of different gene delivery systems and the mechanisms underlying clinical gene therapy strategies are reviewed. In addition, we discuss the relevance of these new techniques to the oncologic surgeon.
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Affiliation(s)
- P J Geraghty
- Division of Surgical Oncology, University of Michigan, Ann Arbor, Michigan, USA
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Baila AE, Cervini OE, Bianchi HA, Geraghty PJ. [Cyst of the bile duct]. Prensa Med Argent 1969; 56:452-8. [PMID: 5345153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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