1
|
Breathett K, Knapp SM, Lewsey SC, Mohammed SF, Mazimba S, Dunlay SM, Hicks A, Ilonze OJ, Morris AA, Tedford RJ, Colvin MM, Daly RC. Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List. JAMA 2024; 331:1379-1386. [PMID: 38526480 PMCID: PMC10964157 DOI: 10.1001/jama.2024.0065] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 03/26/2024]
Abstract
Importance Barriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women. Objective To evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer. Design, Setting, and Participants This cohort study used the United Network for Organ Sharing datasets to identify organ acceptance with each offer for US non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) adults listed for heart transplant from October 18, 2018, through March 31, 2023. Exposures Black or White race and gender (men, women) of a heart transplant candidate. Main Outcomes and Measures The main outcome was heart offer acceptance by the transplant center team. The number of offers to acceptance was assessed using discrete time-to-event analyses, nonparametrically (stratified by race and gender) and parametrically. The hazard probability of offer acceptance for each offer was modeled using generalized linear mixed models adjusted for candidate-, donor-, and offer-level variables. Results Among 159 177 heart offers with 13 760 donors, there were 14 890 candidates listed for heart transplant; 30.9% were Black, 69.1% were White, 73.6% were men, and 26.4% were women. The cumulative incidence of offer acceptance was highest for White women followed by Black women, White men, and Black men (P < .001). Odds of acceptance were less for Black candidates than for White candidates for the first offer (odds ratio [OR], 0.76; 95% CI, 0.69-0.84) through the 16th offer. Odds of acceptance were higher for women than for men for the first offer (OR, 1.53; 95% CI, 1.39-1.68) through the sixth offer and were lower for the 10th through 31st offers. Conclusions and Relevance The cumulative incidence of heart offer acceptance by a transplant center team was consistently lower for Black candidates than for White candidates of the same gender and higher for women than for men. These disparities persisted after adjusting for candidate-, donor-, and offer-level variables, possibly suggesting racial and gender bias in the decision-making process. Further investigation of site-level decision-making may reveal strategies for equitable donor heart acceptance.
Collapse
Affiliation(s)
- Khadijah Breathett
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Shannon M. Knapp
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Sabra C. Lewsey
- Division of Cardiovascular Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Selma F. Mohammed
- Division of Cardiovascular Medicine, Creighton University, Omaha, Nebraska
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville
- AdventHealth, Orlando, Florida
| | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Albert Hicks
- Division of Cardiovascular Medicine, University of Maryland, Baltimore
| | - Onyedika J. Ilonze
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Alanna A. Morris
- Division of Cardiovascular Medicine, Emory University, Atlanta, Georgia
| | - Ryan J. Tedford
- Division of Cardiovascular Medicine, Medical University of South Carolina, Charleston
| | - Monica M. Colvin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
| | - Richard C. Daly
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
2
|
Ergi DG, Rowse PG, Daly RC, Crestanello JA, Schaff HV, Dearani JA, Todd A, Arghami A. Single Center Prospective Study of Cross-Clamp versus Balloon Occlusion in Robotic Mitral Surgery. Ann Thorac Surg 2024:S0003-4975(24)00291-1. [PMID: 38657703 DOI: 10.1016/j.athoracsur.2024.04.004] [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: 12/26/2023] [Revised: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Both transthoracic aortic cross-clamp and endoaortic balloon occlusion have been shown to have comparable safety profiles for aortic occlusion. Since most surgeons use only one technique, we sought to compare the outcomes when a homogeneous group of surgeons changed their occlusion technique from aortic cross-clamp to balloon occlusion. METHODS We changed our technique from aortic cross-clamp to balloon occlusion in November 2022. This allowed us to conduct a prospective treatment comparison study in the same group of surgeons. Propensity score matching (PSM) was used to match cases(balloon occlusion) 1:3 to controls (aortic cross-clamp) based on age, gender, body mass index, concomitant maze, and tricuspid valve repair. RESULTS Total of 411 patients underwent robotic mitral surgery from 2020 through 2023. Using PSM, 56 balloon occlusion patients were matched to 168 aortic cross-clamp patients. Median age was 65 years (interquartile range[IQR],55.6-70.0) and the majority were males(n=119,53%). All valves were successfully repaired. Balloon occlusion had a shorter median cardiopulmonary bypass (CPB) time compared to aortic cross-clamp (84.0 vs. 94.5 min,p=0.006). Median cross-clamp time (64.0 vs. 64.0 min,p=0.483) and total surgery time (5.9 vs. 6.1 hours,p=0.495) did not differ between groups. There was no in hospital death. There were five surgeons who performed various combinations of console and bedside roles. CPB, cross-clamp, and surgery durations were not significantly affected by the different surgeon combinations. CONCLUSIONS Compared to aortic cross-clamp, balloon occlusion has similar perioperative and early postoperative outcomes. Additionally, it likely introduces a 10-minute reduction in total CPB time.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin Todd
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
3
|
Ahmad A, El-Am EA, Mazur P, Akiki E, Sorour AA, Kurmann RD, Klarich KW, Arghami A, Rowse PG, Daly RC, Dearani JA. A Case Series of Minimally Invasive Robotic-Assisted Resection of Cardiac Papillary Fibroelastoma: The Mayo Clinic Experience. Mayo Clin Proc Innov Qual Outcomes 2024; 8:143-150. [PMID: 38434934 PMCID: PMC10905955 DOI: 10.1016/j.mayocpiqo.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Papillary fibroelastomas (PFEs) are small, slowly growing benign cardiac tumors with clinically significant risk of embolization. Surgical excision is the definitive treatment of symptomatic PFE and is conventionally performed through a median sternotomy. In this study, we report a series of 12 patients, who underwent robotic-assisted PFE removal at the Mayo Clinic. PFE involved the mitral valve, left atrium, and tricuspid valve. No major complications occurred after the procedure, and most patients were discharged 4 days after the surgery. On follow-up, 1 patient demonstrated pericarditis.
Collapse
Affiliation(s)
- Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Elias Akiki
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ahmed A Sorour
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Reto D Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Kyle W Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
4
|
Mazur P, Kurmann R, Klarich KW, Dearani JA, Arghami A, Daly RC, Greason K, Schaff HV, Ahmad A, El-Am E, Sorour A, Bois MC, Viehman J, King KS, Maleszewski JJ, Crestanello JA. Operative management of cardiac papillary fibroelastomas. J Thorac Cardiovasc Surg 2024; 167:1088-1097.e2. [PMID: 35989118 DOI: 10.1016/j.jtcvs.2022.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/03/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Papillary fibroelastomas are associated with an increased risk of embolic strokes. Excision of papillary fibroelastomas may be the primary indication for surgery (primary) or performed during other cardiac operations (secondary). The present study summarizes our experience with primary and secondary fibroelastoma surgery. METHODS We analyzed the medical records of patients who underwent surgical excision of papillary fibroelastoma between January 1998 and February 2020. Patient characteristics, indications for operation, tumor size and location, and operative and long-term outcomes were evaluated. RESULTS Among the 294 patients (median age: 66 years, 62% female), papillary fibroelastoma was the primary indication for surgery in 136 patients (46%), and 51% of patients had a history of stroke or transient ischemic attack. When papillary fibroelastoma was a secondary indication for surgery (158 patients, 54%), the lesion was identified preoperatively in 39%. Papillary fibroelastomas were located most commonly on the aortic valve and least commonly in the right side of the heart. For valvular papillary fibroelastoma resected from a normal valve, valve shave was sufficient in 96% (196/205). Operative mortality was low in both groups (primary, 0% vs secondary, 2.5%, P = .13), and early neurologic events occurred in 1.3%. Recurrence rate was 15.8% at 10 years. The estimated survival for patients with primary papillary fibroelastoma at 10 years was 78.4%, whereas for secondary papillary fibroelastoma removal it was 53.6% (log rank, P = .003). CONCLUSIONS Resection of papillary fibroelastomas can be performed safely, with preservation of the native valve, and with low rates of neurologic events. Operative and long-term outcomes after fibroelastoma resection are excellent.
Collapse
Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Reto Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Kyle W Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Edward El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Ahmed Sorour
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | - Melanie C Bois
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | - Jason Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Joseph J Maleszewski
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
5
|
Alwatari Y, Randall L, Rowse PG, Daly RC, Arghami A. Navigating missing link: innovative cannulation for robotic mitral valve repair in the absence of inferior vena cava. J Surg Case Rep 2024; 2024:rjae172. [PMID: 38524676 PMCID: PMC10960939 DOI: 10.1093/jscr/rjae172] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
Cardiac surgeries often require the use of cardiopulmonary bypass to allow visualization and manipulation of tissues. Vascular anomalies may impose challenges with access configuration. A patient was evaluated for robot-assisted mitral valve repair and found to have an atretic inferior vena cava secondary due to chronic occlusion. The patient was cannulated arterially through the left common femoral artery, and two cannulation sites were applied for venous drainage: the right intrajugular vein and a second percutaneous access site directly into the right atrium through the chest wall. The procedure was completed without immediate complications, and the patient's perioperative course was unremarkable.
Collapse
Affiliation(s)
- Yahya Alwatari
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN 55905, United States
| | - Lindsey Randall
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN 55905, United States
| | - Phillip G Rowse
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN 55905, United States
| | - Richard C Daly
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN 55905, United States
| | - Arman Arghami
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN 55905, United States
| |
Collapse
|
6
|
Ergi DG, Schaff HV, Pochettino A, Hurst PD, Greason KL, Daly RC, Crestanello JA, Dearani JA, Todd A, Saran N. Outcomes of aortic surgery in patients with Takayasu arteritis. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00099-0. [PMID: 38325517 DOI: 10.1016/j.jtcvs.2024.01.041] [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: 11/23/2023] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To investigate the presentation, aortic involvement, and surgical outcomes in patients with Takayasu arteritis undergoing aortic surgery. METHODS We queried our surgical database for patients with Takayasu arteritis who underwent aortic surgery from 1994 to 2022. RESULTS There were a total of 31 patients with Takayasu arteritis who underwent aortic surgery. Patients' median age at the time of diagnosis was 35.0 years (interquartile range, 25.0-42.0). The majority were female (n = 27, 87.0%). Most patients (n = 28, 90.3%) were diagnosed before surgery, and 3 patients (9.6%) were diagnosed perioperatively. The median time interval from diagnosis to surgery was 2.8 years (interquartile range, 0.5-13.9). The most common presentation was ascending aorta aneurysm (n = 22, 70.9%), and severe aortic regurgitation was the most common valve insufficiency (n = 17, 54.8%). The most common operation was ascending aorta replacement (n = 20, 64.5%), and aortic valve replacement was the most common valve intervention (n = 17, 54.8%). Active vasculitis was identified in 2 (11.7%) aortic valve specimens. Early mortality was 6.5% (n = 2). A total of 6 deaths occurred over a median follow-up of 13.1 years (interquartile range, 6.1-25.2). Survival at 10 years was 86.7% (95% CI, 75.4-99.7). A total of 5 patients (16.1%) required a subsequent operation in a median of 1.9 years (interquartile range, 0.2-7.4). Freedom from reoperation was 96.9% (95% CI, 90.1-100) at 1 year, 89.4% (95% CI, 78.7-100.0) at 5 years, and 77.5% (95% CI, 61.2-98.1) at 10 and 15 years. CONCLUSIONS Ascending aorta aneurysm and aortic valve regurgitation are the most frequent presentations in patients with Takayasu arteritis requiring aortic surgery. Surgery in these individuals is safe, with acceptable short- and long-term results.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Philip D Hurst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Austin Todd
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
7
|
Patlolla SH, Saran N, Schaff HV, Crestanello J, Pochettino A, Stulak JM, Greason KL, King KS, Lee AT, Daly RC, Dearani JA. Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes. J Thorac Cardiovasc Surg 2024; 167:668-679.e2. [PMID: 36028365 DOI: 10.1016/j.jtcvs.2022.07.003] [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: 10/17/2021] [Revised: 06/10/2022] [Accepted: 07/01/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. METHODS We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. RESULTS The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. CONCLUSIONS Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.
Collapse
Affiliation(s)
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | | | - Juan Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Alexander T Lee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
8
|
Akiki E, Arghami A, Abbasi MA, El-Am EA, Ahmad A, Foley TA, Daly RC, Maleszewski JJ, Kurmann R, Klarich KW. Case Report: A myxoma with a far reach. Front Cardiovasc Med 2024; 11:1340406. [PMID: 38327492 PMCID: PMC10847281 DOI: 10.3389/fcvm.2024.1340406] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024] Open
Abstract
A 73-year-old woman presented to the emergency department with a syncopal episode and a history of dizzy spells. A transthoracic echocardiogram demonstrated a large left atrial mass extending into the right upper pulmonary veins. Subsequently, cardiac magnetic resonance imaging and coronary computed tomography angiography with three-dimensional reconstruction and printing of the heart and mass were performed, which demonstrated a high index of suspicion for an atypical left atrial myxoma. The mass was excised robotically, and the pathology report confirmed a diagnosis of myxoma.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kyle W. Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
9
|
Choi K, Spadaccio C, Ribeiro RV, Langlais BT, Villavicencio MA, Pennington K, Spencer PJ, Daly RC, Mallea J, Keshavjee S, Cypel M, Saddoughi SA. Early national trends of lung allograft use during donation after circulatory death heart procurement in the United States. JTCVS Open 2023; 16:1020-1028. [PMID: 38204714 PMCID: PMC10775073 DOI: 10.1016/j.xjon.2023.08.014] [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: 05/11/2023] [Revised: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 01/12/2024]
Abstract
Objective Innovative technology such as normothermic regional perfusion and the Organ Care System has expanded donation after circulatory death heart transplantation. We wanted to investigate the impact of donation after circulatory death heart procurement in concurrent lung donation and implantation at a national level. Methods We reviewed the United Network for Organ Sharing database for heart donation between December 2019 and March 2022. Donation after circulatory death donors were separated from donation after brain death donors and further categorized based on concomitant organ procurement of lung and heart, or heart only. Results A total of 8802 heart procurements consisted of 332 donation after circulatory death donors and 8470 donation after brain death donors. Concomitant lung procurement was lower among donation after circulatory death donors (19.3%) than in donation after brain death donors (38.0%, P < .001). The transplant rate of lungs in the setting of concomitant procurement is 13.6% in donation after circulatory death, whereas it is 38% in donation after brain death (P < .001). Of the 121 lungs from 64 donation after circulatory death donors, 22 lungs were retrieved but discarded (32.2%). Normothermic regional perfusion was performed in 37.3% of donation after circulatory death donors, and there was no difference in lung use between normothermic regional perfusion versus direct procurement and perfusion (20.2% and 18.8%). There was also no difference in 1-year survival between normothermic regional perfusion and direct procurement and perfusion. Conclusions Although national use of donation after circulatory death hearts has increased, donation after circulatory death lungs has remained at a steady state. The implantation of lungs after concurrent procurement with the heart remains low, whereas transplantation of donation after circulatory death hearts is greater than 90%. The use of normothermic regional perfusion lungs has been controversial, and we report comparable 1-year outcomes to standard donation after circulatory death lungs. Further studies are warranted to investigate the underlying mechanisms of normothermic regional perfusion on lung function.
Collapse
Affiliation(s)
- Kukbin Choi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Blake T. Langlais
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Ariz
| | | | - Kelly Pennington
- Division of Pulmonary & Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | | | - Richard C. Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jorge Mallea
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Shaf Keshavjee
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Sahar A. Saddoughi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
10
|
Asleh R, Alnsasra H, Villavicencio MA, Daly RC, Kushwaha SS. Cardiac Transplantation: Physiology and Natural History of the Transplanted Heart. Compr Physiol 2023; 13:4719-4765. [PMID: 37358515 DOI: 10.1002/cphy.c220001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Heart transplantation (HT) is one of the prodigious achievements in modern medicine and remains the cornerstone in the treatment of patients with advanced heart failure. Advances in surgical techniques, immunosuppression, organ preservation, infection control, and allograft surveillance have improved short- and long-term outcomes thereby contributing to greater clinical success of HT. However, prolonged allograft and patient survival following HT are still largely restricted by the development of late complications, including allograft rejection, infection, cardiac allograft vasculopathy (CAV), and malignancy. The introduction of mTOR inhibitors early after HT has demonstrated multiple protective effects against CAV progression, renal dysfunction, and tumorigenesis. Therefore, several HT programs increasingly use mTOR inhibitors with partial or complete withdrawal of calcineurin inhibitor (CNI) in stable HT patients to reduce complications risk and improve long-term outcomes. Furthermore, despite a substantial improvement in exercise capacity and health-related quality of life after HT as compared to advanced heart failure patients, most HT recipients remain with a 30% to 50% lower peak oxygen consumption (Vo 2 ) than that of age-matched healthy subjects. Several factors, including alterations in central hemodynamics, HT-related complications and alterations in the musculoskeletal system, and peripheral physiological abnormalities, presumably contribute to the reduced exercise capacity following HT. Cardiac denervation and subsequent loss of sympathetic and parasympathetic regulation are responsible for various physiological alterations in the cardiovascular system, which contributes to restricted exercise tolerance. Restoration of cardiac innervation may improve exercise capacity and quality of life, but the reinnervation process is only partial even several years after HT. Multiple studies have shown that aerobic and strengthening exercise interventions improve exercise capacity by increasing maximal heart rate, chronotropic response, and peak Vo 2 after HT. Novel exercise modalities, such as high-intensity interval training (HIT), have been proven as safe and effective for further improvement in exercise capacity, including among de novo HT recipients. Further developments have recently emerged, including donor heart preservation techniques, noninvasive CAV and rejection surveillance methods, and improvements in immunosuppressive therapies, all aiming at increasing donor availability and improving late survival after HT. © 2023 American Physiological Society. Compr Physiol 13:4719-4765, 2023.
Collapse
Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
- Faculty of Medicine, Heart Institute, Hadassah University Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Richard C Daly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
11
|
Castro-Varela A, Schaff HV, Oh JK, Ghoniem K, Crestanello JA, Daly RC, Dearani JA, King KS, Greason KL. Diagnosis and Surgical Management of Pericardial Constriction after Cardiac Surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00457-9. [PMID: 37295645 DOI: 10.1016/j.jtcvs.2023.05.032] [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: 04/08/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Prior cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment. METHODS We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation. RESULTS Median patient age was 64 (56-72) years, and the median interval between prior operation and pericardiectomy was 2.7 years (range: 0-54 years). Previous operations included CABG 114 (43%), valve surgery 85 (32%), combined CABG and valve surgery 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate to severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P= 0.013), diabetes (P=0.019), and non-elective pericardiectomy within two years of cardiac surgery (P<0.001) were associated with decreased long-term survival. CONCLUSIONS Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.
Collapse
Affiliation(s)
| | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Khaled Ghoniem
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
12
|
Cangut B, Schaff HV, Suri RM, Greason KL, Stulak JM, Lahr BD, Michelena HI, Daly RC, Dearani JA, Crestanello JA. Excess Reintervention With Mitroflow Prosthesis for Aortic Valve Replacement: Ten-Year Outcomes of a Randomized Trial. Ann Thorac Surg 2023; 115:949-956. [PMID: 36183748 DOI: 10.1016/j.athoracsur.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 05/11/2021] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current bioprostheses are considered to have improved durability and better hemodynamic performance compared with previous designs, but there are limited comparative data on late outcomes. METHODS From 2009 through 2011, 300 adults with severe aortic valve stenosis undergoing aortic valve replacement (AVR) were randomly assigned to receive Edwards Magna, St Jude Epic, or Sorin Mitroflow bioprostheses (n = 100, n = 101, n = 99, respectively). Overall survival was analyzed using Kaplan-Meier and Cox proportional hazards methods, whereas competing risk analysis was used for all time-to-event outcomes. Serial echocardiographic data were fitted with longitudinal models stratified by implant valve size. RESULTS During median follow-up of 9.8 years (interquartile range, 8.7-10.2), 10-year survival was 50% for the Magna group, 42% for the Epic group, and 41% for the Mitroflow group (P = .415). Cumulative risk of stroke was 9% at 10 years, and rates were comparable for the three groups. Indexed aortic valve area and mean gradients were similar among the three groups receiving 19 mm and 21 mm valves, but in larger (23 mm or more) prostheses, gradients were lower (P < .001) and indexed aortic valve areas were higher in the Magna group (P < .001). The 10-year risk of endocarditis differed by group (P = .033), with higher incidence in the Mitroflow vs the Magna group (7% vs 0%, P = .019). Late risk of reinterventions in the Mitroflow group was 22%, compared with 0% in the Magna group (P < .001) and 5% in the Epic group (P = .008). CONCLUSIONS The Magna valve had the lowest gradients and largest indexed aortic valve area with larger implant sizes. The Mitroflow bioprosthesis is associated with an increased rate of reintervention and possible increased risk of infection compared with Magna and Epic valves.
Collapse
Affiliation(s)
- Busra Cangut
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Rakesh M Suri
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
13
|
Mazur PK, Arghami A, Macielak SA, Nei SD, Viehman JK, King KS, Daly RC, Crestanello JA, Schaff HV, Dearani JA. Apixaban for Anticoagulation After Robotic Mitral Valve Repair. Ann Thorac Surg 2023; 115:966-973. [PMID: 35973484 DOI: 10.1016/j.athoracsur.2022.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 01/11/2022] [Revised: 06/04/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is no consensus regarding postoperative anticoagulation after mitral valve repair (MVRep). We compared the outcomes of post-MVRep anticoagulation with apixaban compared to warfarin. METHODS We reviewed data of 666 patients who underwent isolated robotic MVRep between January 2008 and October 2019. We excluded patients who had conversion to sternotomy and those discharged without anticoagulation or on clopidogrel (n = 40). Baseline and intraoperative characteristics and antiplatelet/anticoagulation records were collected. In-hospital and post-discharge complications and overall survival were compared. RESULTS Among the 626 studied patients the median age was 58 years (interquartile range, 51-66), 71% were male, and 1% (n = 9) had atrial fibrillation. Eighty percent (n = 499) were discharged on warfarin and 20% on apixaban (n = 127). Almost all patients (126 of 127, 99%) in the apixaban group were also on aspirin at discharge, whereas in the warfarin group only 79% (n = 395) were also on aspirin at discharge. Baseline characteristics were similar, except that the apixaban group had more female patients (46 of 127, 36% vs 136 of 499, 27%, P = .047). There were no differences in in-hospital complications, including stroke. Readmission rate was higher in the apixaban group (15 of 127, 12% vs 30 of 499, 6%, P = .02), driven mostly by postoperative atrial fibrillation (6 of 127 [5%] vs 5 of 499 [1%], respectively; P = .01). There was no difference in other complications (including bleeding and thromboembolic events), or overall mortality within 3 years. Exclusion of patients who did not receive aspirin at discharge did not affect the results. CONCLUSIONS Anticoagulation with apixaban after minimally invasive robotic MVRep is safe and has similar rates of bleeding and thromboembolism compared to patients treated with warfarin.
Collapse
Affiliation(s)
- Piotr K Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Castro-Varela A, Gallego-Navarro C, Bhaimia E, Gupta A, Spencer PJ, Daly RC, Clavell AL, Knop GL, Maleszewski JJ, Villavicencio MA, Cummins NW. Heart Transplantation from COVID-19-Positive Donors: A Word of Caution. Transplant Proc 2023; 55:533-539. [PMID: 36948960 PMCID: PMC9981670 DOI: 10.1016/j.transproceed.2023.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, efforts to maintain solid-organ transplantation have continued, including the use of SARS-CoV-2-positive heart donors. METHODS We present our institution's initial experience with SARS-CoV-2-positive heart donors. All donors met our institution's Transplant Center criteria, including a negative bronchoalveolar lavage polymerase chain reaction result. All but 1 patient received postexposure prophylaxis with anti-spike monoclonal antibody therapy, remdesivir, or both. RESULTS A total of 6 patients received a heart transplant from a SARS-CoV-2-positive donor. One heart transplant was complicated by catastrophic secondary graft dysfunction requiring venoarterial extracorporeal membrane oxygenation and retransplant. The remaining 5 patients did well postoperatively and were discharged from the hospital. None of the patients had evidence of COVID-19 infection after surgery. CONCLUSION Heart transplants from SARS-CoV-2 polymerase chain reaction-positive donors are feasible and safe with adequate screening and postexposure prophylaxis.
Collapse
Affiliation(s)
| | | | - Eric Bhaimia
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aanchal Gupta
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alfredo L Clavell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gustavo L Knop
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Maleszewski
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Nathan W Cummins
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
15
|
Kawajiri H, Saran N, Dearani JA, Schaff HV, Daly RC, Viehman JK, King KS, Pochettino A. Whole Body Retrograde Perfusion Combined With Central Aortic Perfusion Strategy in the Repair of Distal Arch Pathology Through a Lateral Thoracotomy. Mayo Clin Proc 2023; 98:432-442. [PMID: 36868750 DOI: 10.1016/j.mayocp.2022.08.004] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/29/2022] [Accepted: 08/10/2022] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To compare the results of the hypothermic circulatory arrest (HCA) + retrograde whole-body perfusion (RBP) technique with those of deep hypothermic circulatory arrest (DHCA-only) approach. METHODS Limited data are available on cerebral protection techniques when distal arch repairs are performed through a lateral thoracotomy. In 2012, the RBP technique was introduced as adjunct to HCA during open distal arch repair via thoracotomy. We reviewed the results of the HCA + RBP technique compared with those of the DHCA-only approach. From February 2000 to November 2019, 189 patients (median age, 59 [IQR, 46 to 71] years; 30.7% female) underwent open distal arch repair via lateral thoracotomy to treat aortic aneurysms. The DHCA technique was used in 117 patients (62%, median age 53 [IQR, 41 to 60] years), whereas HCA + RBP was used in 72 patients (38%, median age 65 [IQR, 51 to 74] years). In HCA + RBP patients, cardiopulmonary bypass was interrupted when systemic cooling achieved isoelectric electroencephalogram; once the distal arch had been opened, RBP was then initiated via the venous cannula (flow of 700 to 1000 mL/min, central venous pressure <15 to 20 mm Hg). RESULTS The stroke rate was significantly lower in the HCA + RBP group (3%, n=2) compared with the DHCA-only (12%, n=14) (P=.031), despite longer circulatory arrest times in HCA + RBP compared with the DHCA-only (31 [IQR, 25 to 40] minutes vs 22 [IQR, 17 to 30] minutes, respectively; P<.001). Operative mortality for patients undergoing HCA + RBP was 6.7% (n=4), whereas for those undergoing DHCA-only it was 10.4% (n=12) (P=.410). The 1-, 3-, and 5-year age-adjusted survival rates for the DHCA group are 86%, 81%, and 75%, respectively. The 1-, 3-, and 5-year age-adjusted survival rates for the HCA + RBP group are 88%, 88%, and 76%, respectively. CONCLUSION The addition of RBP to HCA in the treatment of distal open arch repair via a lateral thoracotomy is safe and provides excellent neurological protection.
Collapse
Affiliation(s)
- Hidetake Kawajiri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
16
|
Griffeth EM, Burchill LJ, Dearani JA, Oberoi M, Abdelrehim AA, O'Leary PW, Edwards BS, Kushwaha SS, Daly RC, Cetta F, Johnson JN, Ameduri RK, Stephens EH. Optimizing Referral Timing of Patients With Fontan Circulatory Failure for Heart Transplant. Transplant Proc 2023; 55:417-425. [PMID: 36868954 PMCID: PMC10133013 DOI: 10.1016/j.transproceed.2023.02.014] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/11/2022] [Accepted: 02/03/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND There are no criteria guiding the timing of heart transplant referral for Fontan patients, nor are there any characteristics of those deferred or declined listing reported. This study examines comprehensive transplant evaluations for Fontan patients of all ages, listing decisions, and outcomes to inform referral practices. METHODS Retrospective review of 63 Fontan patients formally assessed by the advanced heart failure service and presented at Mayo Clinic transplant selection committee meetings (TSM) January 2006 to April 2021. The study is compliant with the Helsinki Congress and Declaration of Istanbul and included no prisoners. Statistical analysis was performed with Wilcoxon Rank Sum and Fisher's Exact tests. RESULTS Median age at TSM was 26 years (17.5, 36.5). Most were approved (38/63 [60%]); 9 of 63 (14%) were deferred and 16 of 63 (25%) were declined. Approved patients more commonly were <18 years old at TSM (15/38 [40%] vs 1/25 [4%], P = .002) compared with those deferred/declined. Complications of Fontan circulatory failure were less common in approved vs deferred/declined patients: ascites (15/38 [40%] vs 17/25 [68%], P = .039), cirrhosis (16/38 [42%] vs 19/25 [76%], P = .01), and renal insufficiency (6/38 [16%] vs 11/25 [44%], P = .02). Ejection fraction and atrioventricular valve regurgitation did not differ between groups. Pulmonary artery wedge pressure was overall high normal (12 mm Hg [9,16]) but higher in deferred/declined vs approved patients, 14.5 (11, 19) vs 10 (8, 13.5) mm Hg, P = .015. Overall survival was significantly lower in deferred/declined patients (P = .0018). CONCLUSION Fontan patient referral for heart transplant at younger age and before the onset of end-organ complications is associated with increased approval for transplant listing.
Collapse
Affiliation(s)
- Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Luke J Burchill
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Meher Oberoi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Brooks S Edwards
- Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Frank Cetta
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | | | | | | |
Collapse
|
17
|
Ahmad A, El-Am E, Kurmann R, Klarich KW, Arghami A, Rowse P, Daly RC, Dearani JA. A CASE SERIES OF MINIMALLY INVASIVE ROBOT-ASSISTED RESECTION OF CARDIAC PAPILLARY FIBROELASTOMA. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02649-9] [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: 03/06/2023]
|
18
|
Bradbrook K, Goff RR, Lindblad K, Daly RC, Hall S. A national assessment of one-year heart outcomes after the 2018 adult heart allocation change. J Heart Lung Transplant 2023; 42:196-205. [PMID: 36184382 DOI: 10.1016/j.healun.2022.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/21/2022] [Revised: 07/26/2022] [Accepted: 08/20/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE On 10/18/2018 the Organ Procurement and Transplantation Network (OPTN) implemented modifications to adult heart allocation to better stratify the most medically urgent candidates by WL mortality. This paper reviews two years of post-policy monitoring with focus on post-transplant outcomes, especially for recipients with MCSDs. METHODS Cohorts of WL additions and recipients pre (10/18/16-10/17/18) and post (10/18/18-10/17/20) policy implementation were compared using the OPTN database. Competing risks analyses of waitlist mortality and Kaplan-Meier one-year post-transplant survival were performed by medical urgency statuses and policy era. Similar analyses were performed for subsets of candidates and recipients on devices. RESULTS Pre-implementation status 1A candidates had the highest cumulative incidence of removal from the waitlist due to death or too sick to transplant and the highest cumulative incidence of transplant, followed by statuses 1B and 2. Median time to transplant decreased from 226 to 85 days for those transplanted. There was no difference in one-year patient survival (pre=91.3% [90.2, 92.4]; post=91.8% [90.8, 92.9]; p=0.44) overall, or for recipients transplanted with an LVAD (pre=91.7% [90.1, 93.2]; post=91.4% [89.7, 93.2]; p=0.85) or IABP (pre=91.7% [88.1, 95.4]; post=92.1% [90.1, 94.0]; p=0.92). CONCLUSION The policy improved stratification of the most medically urgent candidates according to risk of death on the WL with decreased median wait times, higher transplant rates and no observed adverse effect on 1-year patient survival. No adverse effects for candidates listed or transplanted on IABP, ECMO, or LVAD were observed.
Collapse
|
19
|
Vijayvargiya P, Esquer Garrigos Z, Kennedy CC, Daly RC, Wylam ME, Patel R, Beam E. Routine Donor and Recipient Screening for Mycoplasma hominis and Ureaplasma Species in Lung Transplant Recipients. Open Forum Infect Dis 2022; 9:ofac607. [PMID: 36467297 PMCID: PMC9709706 DOI: 10.1093/ofid/ofac607] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/03/2022] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum may cause post-transplant infections in lung transplant recipients. We evaluated routine pretransplant screening for these Mollicutes. METHODS We retrospectively reviewed records of lung transplant recipients at our tri-site institution from 01/01/2015 to 11/15/2019. M. hominis and/or Ureaplasma polymerase chain reaction (PCR) was performed on pretransplant recipient urine specimens and donor bronchial swabs at the time of transplantation. Development of Mollicute infection and hyperammonemia syndrome (HS) was recorded. RESULTS A total of 268 patients underwent lung transplantation during the study period, of whom 105 were screened with at least 1 Mollicute PCR. Twelve (11%) screened positive; 10 donors, 1 recipient, and 1 both. Among positive donors, 3 were positive for M. hominis, 5 for U. urealyticum, and 4 for U. parvum. Preemptive therapy included doxycycline, levofloxacin, and/or azithromycin administered for 1-12 weeks. Despite therapy, 1 case of M. hominis mediastinitis and 1 case of HS associated with Ureaplasma infection occurred, both donor-derived. Of those screened before transplant, cases with positive screening were more likely (P < 0.05) to develop Mollicute infection despite treatment (2/12, 17%) than those who screened negative (1/93, 1%). CONCLUSIONS Pretransplant recipient urine screening had a low yield and was not correlated with post-transplant Mollicute infection, likely because most M. hominis and U. parvum/urealyticum infections in lung transplant recipients are donor-derived. Routine donor bronchus swab PCR for M. hominis, U. urealyticum, and U. parvum followed by preemptive therapy did not obviously impact the overall incidence of Mollicute infection or HS in this cohort.
Collapse
Affiliation(s)
- Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Cassie C Kennedy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Richard C Daly
- Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Mark E Wylam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Elena Beam
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
20
|
Jahanian S, Arghami A, Wittwer ED, King KS, Daly RC, Dearani JA, Rowse PG, Crestanello JA, Schaff HV. Does Minimally Invasive Mitral Valve Repair Mean Less Postoperative Pain? Ann Thorac Surg 2022; 115:1172-1178. [PMID: 36395877 DOI: 10.1016/j.athoracsur.2022.11.009] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rapid recovery after minimally invasive mitral valve (MV) repair has been demonstrated in many studies, but the issue of postoperative pain has not been fully elucidated. We evaluated pain scores and medication use in patients undergoing MV repair by minimally invasive surgery (MIS) and open sternotomy (OS). METHODS Between 2008 and 2019, 1332 patients underwent isolated MV repair by OS, and 913 underwent minimally invasive MV repair. After 1:1 propensity score matching, the study included 709 patients in each group. Opioid use was quantified as oral morphine equivalents in milligrams for each hospital day. The highest pain scores were collected from a visual analogue scale at 6-hour intervals. Predictive modeling was employed to compare pain medications and pain scores between the groups. RESULTS The postoperative median length of stay was 3 (3-4) and 5 (4-5) days for the MIS and OS groups, respectively (P < .001). The predicted geometric mean oral morphine equivalents demonstrated lower opioid use for the MIS group compared with the OS group for the first 4 days. However, the predicted mean pain score was higher in the first 24 hours for the MIS group compared with the OS group (4.7 [4.5-4.8] vs 4.4 [4.3-4.5], respectively, on a visual analogue scale of 0 to 10). CONCLUSIONS MV repair by MIS methods was associated with decreased opioid use but not with decreased postoperative pain scores. Possible explanations include the difference in incision site pain and subjective differences in postoperative pain expectations.
Collapse
Affiliation(s)
- Sepideh Jahanian
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Erica D Wittwer
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
21
|
Zheng CR, Mazur P, Arghami A, Jahanian S, Viehman JK, King KS, Dearani JA, Daly RC, Rowse PG, Bagameri G, Crestanello JA. Robotic vs. minimally invasive mitral valve repair: A 5-year comparison of surgical outcomes. J Card Surg 2022; 37:3267-3275. [PMID: 35989503 DOI: 10.1111/jocs.16849] [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] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/15/2022] [Accepted: 07/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr. METHODS We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores. RESULTS Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range [IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively). CONCLUSIONS Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable.
Collapse
Affiliation(s)
- Clark R Zheng
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sepideh Jahanian
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
22
|
Hasan IS, Qrareya M, Crestanello JA, Daly RC, Dearani JA, Lahr BD, Lee AT, Stulak JM, Greason KL, Schaff HV. Impact of tricuspid valve regurgitation on intermediate outcomes of degenerative mitral valve surgery. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01025-X. [PMID: 36280428 DOI: 10.1016/j.jtcvs.2022.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 06/30/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND In patients undergoing mitral valve surgery, optimal management of less-than-severe concomitant tricuspid valve regurgitation (TR) is unclear, as there are few long-term data. This study examines progression of TR, patient survival, and reoperations in patients undergoing mitral valve surgery. METHODS There were 1588 patients who underwent degenerative mitral valve surgery and had pre- and postoperative echocardiograms for assessment of TR severity and tricuspid annulus diameter. Analysis used repeated-measures ordinal regression to model the longitudinal trends in TR grade and proportional hazards regression for long-term survival and reoperation outcomes. RESULTS Concomitant tricuspid valve (TV) surgery was performed in 235 (14.8%) patients. In response to surgery, TR grades improved more in patients with concomitant TV intervention regardless of the severity of preoperative TR, and these early trends were sustained over long-term follow-up. Risk of progression to severe TR was not influenced by tricuspid annulus diameter (P = .226). After we adjusted for underlying health characteristics, survival following mitral valve surgery was similar in patients with and without TV intervention. Late TV reoperation was observed in 22 patients (5-year cumulative risk 1.5%), but among these, only 6 patients had severe TR as the primary indication for reoperation; preoperative TR grade and initial concomitant TV surgery were not associated with incidence of reoperation. CONCLUSIONS Concomitant TV surgery for moderate TR reduces progression of TR but did not influence survival or incidence of reoperation. Among patients with less-than-severe preoperative TR, tricuspid annular diameter was not associated with progression to severe TR.
Collapse
Affiliation(s)
- Irsa S Hasan
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Mohammad Qrareya
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Brian D Lahr
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Alex T Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
23
|
Ahmad D, O'Malley TJ, Jordan AM, Maynes EJ, Saxena A, Prochno KW, Rajab TK, Massey HT, Daly RC, Tchantchaleishvili V. Bronchial artery revascularization in lung transplantation: a systematic review and meta-analysis. J Thorac Dis 2022; 14:3285-3294. [PMID: 36245610 PMCID: PMC9562503 DOI: 10.21037/jtd-22-213] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/16/2022] [Indexed: 01/18/2023]
Abstract
Background Bronchial artery revascularization (BAR) during lung transplantation has been hypothesized to improve early tracheal healing and delay the onset of bronchiolitis obliterans syndrome (BOS). We aimed to assess the outcomes of BAR after lung transplantation. Methods Electronic search in Ovid Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Controlled Trials Register (CCTR) databases was performed to identify all relevant studies published about lung transplantation with BAR. Studies discussing lung transplantation utilizing BAR were included while those without outcome data such as BOS and survival were excluded. Cohort-level data were extracted and pooled for analysis. A binary outcome meta-analysis of proportions with logit transformation was conducted. Newcastle-Ottawa scale was used for risk of bias assessment. Results Seven studies were selected for the analysis comprising 143 patients. Mean patient age was 47 (95% CI: 40-55) years. Sixty-one percent (48-72%) were male. Seventy-three percent (65-79%) of patients underwent double lung transplant while 27% (21-25%) underwent single lung transplant. In patients with postoperative angiography, successful BAR was demonstrated in 93% (82-97%) of all assessed conduits. The 30-day/in-hospital mortality was 6% (3-11%). Seventy-nine percent (63-89%) of patients were free from rejection at three months. Eighty-three percent (29-98%) of patients were free from signs of airway ischemia at three and six months. Pooled survival at one year and five years was 87% (78-92%) and 71% (46-87%), respectively, with a mean follow-up time of 21 (3-38) months. Pooled freedom from bronchiolitis obliterans was 86% (77-91%) at two years. Conclusions While this systematic review and meta-analysis is limited by the available surgeons, institutions, and papers discussing a highly specialized technique, it does show that BAR is a viable technique to minimize BOS and early anastomotic intervention following lung transplantation.
Collapse
Affiliation(s)
- Danial Ahmad
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J. O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew M. Jordan
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J. Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kyle W. Prochno
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Taufiek K. Rajab
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Howard T. Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Richard C. Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
24
|
Schumer EM, Saddoughi SA, Spencer PJ, Pochettino A, Daly RC, Villavicencio MA. Lung Transplantation Long-term Survival is Worse in Patients Who Have Undergone Previous Cardiac Surgery. Eur J Cardiothorac Surg 2022; 62:6677658. [PMID: 36029251 DOI: 10.1093/ejcts/ezac437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/30/2022] [Revised: 08/13/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level. METHODS The United Network for Organ Sharing database was analyzed from 2005-2019 to include adult patients who underwent lung transplant who had previous cardiac surgery, and previous thoracic surgery. T-test and chi-squared analysis was used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan-Meier method in an unadjusted and propensity matched analysis. RESULTS Out of 24,784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1,321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery 42(6.1%) versus no previous cardiac surgery 740(3.1%), p < 0.001, and in previous thoracic surgery 65(4.9%) versus no previous thoracic surgery 717(3.1%), p < 0.001. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 hours. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, p < 0.001) due to an increase in cardiovascular deaths (p = 0.008) and malignancy (p = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, p = 0.337). CONCLUSIONS Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long term survival.
Collapse
Affiliation(s)
- Erin M Schumer
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Sahar A Saddoughi
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | | |
Collapse
|
25
|
Patlolla SH, Saran N, Dearani JA, Stulak JM, Schaff HV, Greason KL, Daly RC, King KS, Pochettino AB. Outcomes and risk factors of late failure of valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2022; 164:493-501.e1. [PMID: 33077178 DOI: 10.1016/j.jtcvs.2020.09.070] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 01/10/2020] [Revised: 08/18/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Retention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. METHODS From January 1994 through June 2017, 342 patients (mean age 47.8 ± 15.5 years, 253 [74%] male) underwent VSARR. The most common etiologies were connective tissue disease (n = 143, 42%) followed by degenerative aortic aneurysm (n = 131, 38%). Aortic regurgitation (moderate or greater) was present in 35% (n = 119). RESULTS Reimplantation technique was used in 90% patients (n = 308). Valsalva graft was used in 38% patients (n = 131) and additional cusp repair was done in 15% (n = 50). Operative mortality was 1% (n = 5). The median follow-up time was 8.79 years (interquartile range, 4.08-13.51). The cumulative incidence of reoperation (while accounting for the competing risk of death) was 8.4%, 12.8%, and 17.1% at 5, 10, and 15 years, respectively. There were no differences in survival and incidence of reoperation between root reimplantation and remodeling. Larger preoperative annulus diameter was associated with greater risk of reoperation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19, P = .01). The estimated probability of developing severe aortic regurgitation after VSARR was 8% at 10 years postoperatively. Operative mortality, residual aortic regurgitation at dismissal, and survival improved in recent times with more experience. CONCLUSIONS VSARR is a viable and safe option with good long-term outcomes and low rates of late aortic valve replacement. Dilated annulus preoperatively was associated with early repair failure.
Collapse
Affiliation(s)
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
26
|
Choi K, Locker C, Fatima B, Schaff HV, Stulak JM, Lahr BD, Villavicencio MA, Dearani JA, Daly RC, Crestanello JA, Greason KL, Khullar V. Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients. Mayo Clin Proc 2022; 97:1257-1268. [PMID: 35738944 DOI: 10.1016/j.mayocp.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 11/30/2021] [Revised: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG). METHODS We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality. RESULTS Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality. CONCLUSION Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.
Collapse
Affiliation(s)
- Kukbin Choi
- Department of Cardiovascular Surgery, Rochester, MN
| | - Chaim Locker
- Department of Cardiovascular Surgery, Rochester, MN
| | | | | | | | - Brian D Lahr
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | |
Collapse
|
27
|
Kawajiri H, Schaff HV, Dearani JA, Daly RC, Greason KL, Arghami A, Rowse PG, Viehman JK, Lahr BD, Gallego-Navarro C, Crestanello JA. Clinical Outcomes of Mitral Valve Repair for Degenerative Mitral Regurgitation in Elderly Patients. Eur J Cardiothorac Surg 2022; 62:6582572. [PMID: 35532171 DOI: 10.1093/ejcts/ezac299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/08/2021] [Revised: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES This study analyzes the safety and outcomes of mitral valve repair for degenerative mitral valve regurgitation in patients 75 years of age or older. METHODS We retrospectively reviewed the clinical results of 343 patients aged ≥75 years who underwent mitral valve repair for degenerative mitral valve regurgitation as a primary indication between January 1998 and June 2017. RESULTS The median (IQR) age of the patients was 79.4 (76.9, 82.9) years, and 132 (38.5%) patients were women. Concomitant procedures were performed in 123 patients: tricuspid surgery in 68 (19.8%) and a maze procedure or pulmonary vein isolation in 55 (16.0%). Operative mortality was 1.2%. Operative complications included atrial fibrillation in 37.9%, prolonged ventilation in 7.0%, pacemaker implantation in 3.8, renal failure requiring dialysis in 1.5, and troke in 3 (0.9%). Median follow-up was 7.4 years (IQR, 3.5-14.1 years). The cumulative incidence rates of mitral valve reoperation were 2.2%, 3.2%, and 3.2% at 1, 5, and 10 years, respectively. Overall survival at 1, 5, and 10 years were 95%, 83%, and 51%, respectively. Older age, smoking, and over and under weight were associated with increased risk of mortality, while higher left ventricular ejection fraction and hypertension were associated with reduced risk. CONCLUSIONS Mitral valve repair in elderly patients can be accomplished with low operative mortality and complications. Mitral valve repair in the elderly remains the preferred treatment for degenerative mitral regurgitation.
Collapse
Affiliation(s)
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Philip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jason K Viehman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | | |
Collapse
|
28
|
Mazur P, Arghami A, Zheng C, Alkhouli M, Schaff HV, Dearani J, Daly RC, Greason K, Crestanello JA. Mitral valve surgery after failed transcatheter edge-to-edge repair. JTCVS Tech 2022; 14:79-88. [PMID: 35967213 PMCID: PMC9366625 DOI: 10.1016/j.xjtc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 10/27/2022] Open
|
29
|
Asleh R, Vucicevic D, Petterson TM, Kremers WK, Pereira NL, Daly RC, Edwards BS, Steidley DE, Scott RL, Kushwaha SS. Sirolimus-Based Immunosuppression Is Associated with Decreased Incidence of Post-Transplant Lymphoproliferative Disorder after Heart Transplantation: A Double-Center Study. J Clin Med 2022; 11:jcm11020322. [PMID: 35054016 PMCID: PMC8779206 DOI: 10.3390/jcm11020322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/14/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 02/01/2023] Open
Abstract
Mammalian target of rapamycin (mTOR) inhibitors have been shown to reduce proliferation of lymphoid cells; thus, their use for immunosuppression after heart transplantation (HT) may reduce post-transplant lymphoproliferative disorder (PTLD) risk. This study sought to investigate whether the sirolimus (SRL)-based immunosuppression regimen is associated with a decreased risk of PTLD compared with the calcineurin inhibitor (CNI)-based regimen in HT recipients. We retrospectively analyzed 590 patients who received HTs at two large institutions between 1 June 1988 and 31 December 2014. Cox proportional-hazard modeling was used to examine the association between type of primary immunosuppression and PTLD after adjustment for potential confounders, including Epstein-Barr virus (EBV) status, type of induction therapy, and rejection. Conversion from CNI to SRL as primary immunosuppression occurred in 249 patients (42.2%). During a median follow-up of 6.3 years, 30 patients developed PTLD (5.1%). In a univariate analysis, EBV mismatch was strongly associated with increased risk of PTLD (HR 10.0, 95% CI: 3.8-26.6; p < 0.001), and conversion to SRL was found to be protective against development of PTLD (HR 0.19, 95% CI: 0.04-0.80; p = 0.02). In a multivariable model and after adjusting for EBV mismatch, conversion to SRL remained protective against risk of PTLD compared with continued CNI use (HR 0.12, 95% CI: 0.03-0.55; p = 0.006). In conclusion, SRL-based immunosuppression is associated with lower incidence of PTLD after HT. These findings provide evidence of a benefit from conversion to SRL as maintenance therapy for mitigating the risk of PTLD, particularly among patients at high PTLD risk.
Collapse
Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
- Correspondence: or
| | - Darko Vucicevic
- Department of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Tanya M. Petterson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA;
| | - Walter K. Kremers
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA;
| | - Naveen L. Pereira
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
| | - Richard C. Daly
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
| | - Brooks S. Edwards
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
| | - D. Eric Steidley
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (D.E.S.); (R.L.S.)
| | - Robert L. Scott
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (D.E.S.); (R.L.S.)
| | - Sudhir S. Kushwaha
- Department of Cardiovascular Diseases and Health Sciences Research and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55905, USA; (W.K.K.); (N.L.P.); (R.C.D.); (B.S.E.); (S.S.K.)
| |
Collapse
|
30
|
Conway J, Ravekes W, McConnell P, Cantor RS, Koehl D, Sun B, Daly RC, Hsu DT. Early Improvement in Clinical Status Following Ventricular Assist Device Implantation in Children: A Marker for Survival. ASAIO J 2022; 68:87-95. [PMID: 33852494 DOI: 10.1097/mat.0000000000001420] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
While clinical status at the time of ventricular assist device (VAD) implant can negatively affect outcomes, it is unclear if early improvement after implant can have a positive effect. Therefore, the objectives of this study were to describe the clinical status of pediatric patients supported with a VAD and determine the impact of clinical status on the 1-month follow-up form on survival and ability to discharge. This was a retrospective analysis of data collected prospectively by the Pediatric Interagency Registry for Mechanical Circulatory Support Registry (Pedimacs) Registry. The Pedimacs database was queried for patients implanted between September 19, 2012, and September 30, 2019, who were alive on VAD support at 1-month postimplant on either a paracorporeal pulsatile or intracorporeal continuous device. Four factors on the 1-month follow-up were the focus of this study: mechanical ventilation, supplemental nutritional support, inotropic support, and ambulatory status. These factors were regarded as present if detected between 1-week and 1-month postimplant and were analyzed to determine their impact on survival following 1 month of VAD support and on successful discharge from hospital in patients with implantable continuous-flow devices. The eligible study cohort consisted of 414 patients with a mean age of 9.6 ± 6.2 years, weight of 40.8 ± 32.3 kg with the majority being male (56.7%) and having cardiomyopathy (68%). An isolated left ventricular assist device (LVAD) was the most common implant (85.5%). At implant, 40% were ventilated, 57% required nutritional support, 93% were on inotropes, and 58% were nonambulating. On the 1-month postimplant form, there were significant improvements in all four categories (14% ventilator support, 46% nutritional support, 53% on inotropes, and 25% nonambulating). However, there was no significant early change in the percentage of patients requiring supplemental nutrition in the paracorporeal pulsatile devices (88% vs. 82%; p = 0.2). Presence of these clinical parameters in early follow-up postimplant had a significant negative impact on survival and on the ability of patients with continuous-flow devices to be discharged. Presence of four specific clinical parameters early after VAD placement is associated with worse overall survival and an inability to discharge patients on VAD support. Ongoing work is needed for optimization of patients before implant and aggressive rehabilitation after implant to help improve long-term outcomes.
Collapse
Affiliation(s)
- Jennifer Conway
- From the Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes (KIRSO), The University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes (KIRSO), The University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Sun
- Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Daphne T Hsu
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
31
|
Arghami A, Jahanian S, Daly RC, Hemmati P, Lahr BD, Rowse PG, Crestanello JA, Dearani JA. Robotic Mitral Valve Repair: A Decade of Experience with Echocardiographic Follow-up. Ann Thorac Surg 2021; 114:1587-1595. [PMID: 34800487 DOI: 10.1016/j.athoracsur.2021.08.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Received: 03/20/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical approaches for mitral valve (MV) disease have evolved with the aim of developing minimally invasive techniques. While the safety of robotic procedures has been documented, there are limited data on long-term echocardiographic follow-up. This review demonstrates outcomes of 11 years of robotic MV repair at a single, tertiary institution. METHODS From 2008 to 2019, 843 patients underwent robotic MV repair at our institution. Repeated measures generalized least squares (GLS) modelling was used to assess the echocardiographic changes over time. RESULTS The median age was 58 years (IQR 50.8, 65.5) (591 males, 70.1%). Mechanism of MR was posterior leaflet prolapse in 479 (56.8%), bileaflet prolapse in 325 (38.6%), and anterior leaflet prolapse in 36 (4.3%). There were 3 early deaths (0.4%) and 24 early reoperations (2.8%). Echocardiographic follow up demonstrated left ventricular end systolic and diastolic dimensions, left atrial volume index and pulmonary pressure all continuously improvement up to 2 years postoperatively. Ejection fraction immediately declined postoperatively but then gradually improved to near normal over 2 years. Survival and freedom from reoperation at 10 years were 93% and 92.6%, respectively. When surveyed after dismissal, 93.4% reported their activity level at or above their peers and 93.3% reported no activity limitation from cardiac symptoms. CONCLUSIONS Robotic MV repair is safe and effective with excellent long-term results, including echocardiographic parameters that demonstrated early improvement in cardiac chamber size and maintenance of postoperative cardiac function. Exceedingly low mortality rates and freedom from reoperation are comparable to those of the standard open repair.
Collapse
Affiliation(s)
- Arman Arghami
- Cardiovascular Surgery Department, Mayo Clinic, Rochester MN.
| | | | - Richard C Daly
- Cardiovascular Surgery Department, Mayo Clinic, Rochester MN
| | - Pouya Hemmati
- Cardiovascular Surgery Department, Mayo Clinic, Rochester MN
| | - Brian D Lahr
- Biostatistics Department, Mayo Clinic, Rochester, MN
| | - Phillip G Rowse
- Cardiovascular Surgery Department, Mayo Clinic, Rochester MN
| | | | | |
Collapse
|
32
|
Alnsasra H, Asleh R, Kumar N, Lopez C, Toya T, Kremers WK, Edwards B, Daly RC, Kushwaha SS. Incidence, Risk Factors, and Outcomes of Stroke Following Cardiac Transplantation. Stroke 2021; 52:e720-e724. [PMID: 34470491 DOI: 10.1161/strokeaha.121.034874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose Less is known about the risk factors and outcomes associated with stroke in the current era of increasing heart transplantation (HT) being performed in older patients. The impact of immunosuppression on risk of stroke has not yet been previously studied. We aimed to determine the incidence, risk factors and outcomes of stroke after HT. Methods We retrospectively analyzed the incidence of ischemic and hemorrhagic strokes and associated outcomes in all consecutive HT recipients transplanted between 1994 and 2016 at a single institution. Results Of 529 patients who underwent HT, 57 (10.7%) developed stroke, 8.1% had an ischemic events and (2.6%) had a hemorrhagic stroke. Age at HT (adjusted hazard ratio [HR] 1.33; P=0.03) and diabetes (HR, 2.60; P=0.02) were associated with increased risk of ischemic events. Patients with stroke (any type) were more likely to have worse kidney function (HR, 1.81; P=0.02) whereas patients with ischemic events were more likely to undergo combined organ transplantation (HR, 2.01; P=0.05). Cytomegalovirus infection was found to be associated with increased risk of any stroke (HR, 2.09; P=0.02).Conversion from calcineurin inhibitor to sirolimus-based immunosuppression was not found to be associated with a significant change in stroke risk (HR, 1.39; P=0. 45) compared with calcineurin inhibitor maintenance therapy. Stroke of any type and ischemic events were independently associated with increased risk of death (HR, 1.90; P=0.001 and HR, 2.14; P<0.001, respectively). Conclusions Stroke after HT is associated with increased mortality. Older age at HT, diabetes, renal dysfunction, and CMV infection were associated with greater risk of stroke.
Collapse
Affiliation(s)
- Hilmi Alnsasra
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN.,Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel (H.A.)
| | - Rabea Asleh
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN.,Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel (R.A.)
| | - Neeraj Kumar
- Department of Neurology (N.K.), Mayo Clinic, Rochester, MN
| | - Camden Lopez
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| | - Takumi Toya
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| | - Walter K Kremers
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| | - Brooks Edwards
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| | - Richard C Daly
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| | - Sudhir S Kushwaha
- Department of cardiovascular diseases (H.A., R.A., C.L., T.T., W.K.K., B.E., R.C.D., S.S.K.), Mayo Clinic, Rochester, MN
| |
Collapse
|
33
|
Bubik RJ, Dierkhising RA, Mara KC, Daly RC, Kushwaha SS, Clavell AL, Bernard SA. Malignancy among adult heart transplant recipients following patient-tailored dosing of anti-thymocyte globulin: a retrospective, nested case-control study of individualized dosing. Transpl Int 2021; 34:2175-2183. [PMID: 34411345 DOI: 10.1111/tri.14012] [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] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
Post-transplant malignancy is diagnosed in approximately 18% of heart transplant patients and is a leading cause of death post-transplant. One modifiable risk factor is the type and amount of immunosuppression received. Contemporary rabbit anti-thymocyte globulin (rATG) dosing strategy using T-cell-guided dosing, and its effect on malignancy in heart transplant patients is unclear. This was a single-center, retrospective chart review of heart transplant recipients receiving rATG for induction. Patients diagnosed with malignancy post-transplant were matched 1:2 to controls using a nested case-control design. The primary endpoint was to determine the relative risk of rATG exposure with the actual incidence of malignancy post-transplant. The secondary endpoint was the impact of maintenance immunosuppression on malignancy risk. Of the 126 patients included in the study, 25 developed malignancy and were matched to 50 control patients. The median cumulative rATG dose in milligrams (mg) between groups was 365 mg in malignancy cases and 480 mg in controls (OR 0.90, 95% CI 0.75-1.08, P = 0.28). In both the univariate and multivariable analysis, there was no statistically significant difference in malignancy risk found with any maintenance immunosuppressant. The results of this study showed that patient-tailored rATG dosing strategies may not be associated with malignancy development as previously thought.
Collapse
Affiliation(s)
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.,Divison of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | |
Collapse
|
34
|
Huang Y, Dearani JA, Saran N, Stulak JM, Greason KL, Crestanello JA, Daly RC, Pochettino A, Lahr BD, Lin G, Schaff HV. Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads. Mayo Clin Proc 2021; 96:2133-2144. [PMID: 34226024 DOI: 10.1016/j.mayocp.2020.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 07/01/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients. PATIENTS AND METHODS We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences. RESULTS From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups. CONCLUSION Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Brian D Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
35
|
Schettini AV, Llado L, Heimbach JK, Costello JG, Tranäng M, Van Caenegem O, Daly RC, Van den Bergh P, Casanovas C, Fabregat J, Poterucha JJ, Foguenne M, Ericzon BG, Lerut J. Symptomatic Val122del mutated hereditary transthyretin amyloidosis: Need for early diagnosis and prioritization for heart and liver transplantation. Hepatobiliary Pancreat Dis Int 2021; 20:323-329. [PMID: 34116942 DOI: 10.1016/j.hbpd.2021.05.002] [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: 10/22/2020] [Accepted: 05/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hereditary transthyretin (ATTRv) amyloidosis is an autosomal dominant disease linked to transthyretin gene mutations which cause instability of the transthyretin tetramer. After dissociation and misfolding they reassemble as insoluble fibrils (i.e. amyloid). Apart from the common Val30Met mutation there is a very heterogeneous group of non-Val30Met mutations. In some cases, the clinical picture is dominated by a rapidly evolving restrictive and hypertrophic cardiomyopathy. METHODS A case series of four liver recipients with the highly clinically relevant, rare and particularly aggressive Val122del mutation is presented. Medical and surgical therapeutic options, waiting list policy for ATTRv-amyloidosis, including the need for heart transplantation, and status of heart-liver transplantation are discussed. RESULTS Three patients needed a staged (1 patient) or simultaneous (2 patients) heart-liver transplant due to rapidly progressing cardiac failure and/or neurologic disability. Domino liver transplantation was impossible in two due to fibrotic hepatic transformation caused by cardiomyopathy. After a follow-up ranging from 3.5 to 9.5 years, cardiac (allograft) function was maintained in all patients, but neuropathy progressed in three patients, one of whom died after 80 months. CONCLUSIONS This is the first report in (liver) transplant literature about the rare Val122del ATTRv mutation. Due to its aggressiveness, symptomatic patients should be prioritized on the liver and, in cases with cardiomyopathy, heart waiting lists in order to avoid the irreversible neurological and cardiac damage that leads to a rapid lethal outcome.
Collapse
Affiliation(s)
- Adriano-Valerio Schettini
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium
| | - Laura Llado
- Liver Transplant Unit, Department of Surgery, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Julie K Heimbach
- Division of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Jose Gonzalez Costello
- Advanced Heart Failure and Transplant Unit, Cardiology Department, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Marie Tranäng
- Familial Amyloidotic Polyneuropathy World Transplant Registry (FAPWTR), Division of Transplantation Surgery, Karolinska Universitetssjukhuset Huddinge, F82, Karolinska Institutet, Stockholm 141 86, Sweden
| | - Olivier Van Caenegem
- Cardiothoracic Intensive Care Unit, Department of Cardiovascular Diseases, University Hospitals Saint-Luc - UCL, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - Richard C Daly
- Cardiovascular Surgery Department, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Peter Van den Bergh
- Neuromuscular Reference Centre, University Hospital Saint-Luc - UCL, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - Carlos Casanovas
- Neuromuscular Unit, Neurology Department, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - Joan Fabregat
- Liver Transplant Unit, Department of Surgery, Hospital Universitari de Bellvitge, Calle de la Feixa Llarga, Barcelona 08907, Spain
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester MN 08907, USA
| | - Maxime Foguenne
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium
| | - Bo Göran Ericzon
- Division of Transplantation Surgery, CLINTEC, Karolinska Universitetssjukhuset Huddinge, F82, Karolinska Institutet, Stockholm 14186, Sweden
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Catholic University of Louvain (UCL), Avenue Hippocrate 55, Brussels 1200, Belgium.
| |
Collapse
|
36
|
Ashikhmina E, Schaff HV, Daly RC, Stulak JM, Greason KL, Michelena HI, Fatima B, Lahr BD, Dearani JA. Risk factors and progression of systolic anterior motion after mitral valve repair. J Thorac Cardiovasc Surg 2021; 162:567-577. [DOI: 10.1016/j.jtcvs.2019.12.106] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/24/2019] [Accepted: 12/19/2019] [Indexed: 11/24/2022]
|
37
|
Schmidt TJ, Rosenbaum AN, Kolluri N, Stulak JM, Daly RC, Schirger JA, Elwazir MY, Kapa S, Cooper LT, Blauwet LA. Natural History of Patients Diagnosed with Cardiac Sarcoidosis at Left Ventricular Assist Device Implantation or Cardiac Transplantation. ASAIO J 2021; 67:583-587. [PMID: 33902104 DOI: 10.1097/mat.0000000000001262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/28/2022] Open
Abstract
To our knowledge, natural history has not been reported for cardiac sarcoidosis (CS) diagnosed by pathologic evaluation of the apical core at left ventricular assist device (LVAD) implantation or cardiac transplantation. We retrospectively identified 232 consecutive patients meeting CS criteria. Of these patients, 54 were diagnosed by pathologic confirmation of CS, 10 after evaluation of the apical core (LVAD implant) or explanted heart (transplant). We compared clinical characteristics at initial evaluation and outcomes for these 10 patients with those of 10 patients with known CS before LVAD implant/transplant. In the study group, five patients (50%) had confirmed extracardiac sarcoidosis before LVAD implant/transplant; five had not been diagnosed with sarcoidosis. Mean (standard deviation) left ventricular ejection fraction at initial evaluation was 23% (16%), and left ventricular end-diastolic dimension was 61 (10) mm. Four patients died during follow-up; however, no survival difference was found for the 10 patients diagnosed incidentally and the group with a previous diagnosis or institutional LVAD/transplant cohorts. Patients diagnosed with CS on pathological examination of the apical core/explanted heart may have severe dilated cardiomyopathy as the initial presentation. Outcomes for patients with CS after advanced heart failure therapies may be comparable with those of non-CS patients.
Collapse
Affiliation(s)
| | | | | | - John M Stulak
- Department of Cardiovascular Surgery
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - John A Schirger
- Department of Cardiovascular Medicine
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | | | | | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | | |
Collapse
|
38
|
Asleh R, Briasoulis A, Smith B, Lopez C, Alnsasra H, Pereira NL, Edwards BS, Clavell AL, Stulak JM, Locker C, Kremers WK, Daly RC, Lerman A, Kushwaha SS. Association of Aspirin Treatment With Cardiac Allograft Vasculopathy Progression and Adverse Outcomes After Heart Transplantation. J Card Fail 2021; 27:542-551. [PMID: 33962742 DOI: 10.1016/j.cardfail.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/06/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Enhanced platelet reactivity may play a role in cardiac allograft vasculopathy (CAV) progression. The use of antiplatelet agents after heart transplantation (HT) has been inconsistent and although aspirin (ASA) is often a part of the medication regimen after HT, limited evidence is available on its benefit. METHODS AND RESULTS CAV progression was assessed by measuring the difference in plaque volume and plaque index between the last follow-up and the baseline coronary intravascular ultrasound examination. Overall, 529 HT recipients were retrospectively analyzed (337 had ≥2 intravascular ultrasound studies). The progression in plaque volume (P = .007) and plaque index (P = .002) was significantly attenuated among patients treated with early ASA (within the first year after HT). Over a 6.7-year follow-up, all-cause mortality was lower with early ASA compared with late or no ASA use (P < .001). No cardiac deaths were observed in the early ASA group, and the risk of CAV-related graft dysfunction was significantly lower in this group (P = .03). However, the composite of all CAV-related events (cardiac death, CAV-related graft dysfunction, or coronary angioplasty) was not significantly different between the groups (P = .16). CONCLUSIONS Early ASA use after HT may delay CAV progression and decrease mortality and CAV-related graft dysfunction, but does not seem to affect overall CAV-associated events.
Collapse
Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Heart Institute, Faculty of Medicine, Hadassah-Hebrew University Medical Center, Hebrew University, Jerusalem 90000, Israel.
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Byron Smith
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Camden Lopez
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Brooks S Edwards
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Alfredo L Clavell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Chaim Locker
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Walter K Kremers
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
39
|
Pahwa S, Stephens EH, Daly RC, Arghami A, Dearani JA. Mitral Valve Repair: How I Teach It. Ann Thorac Surg 2021; 112:363-367. [PMID: 33905734 DOI: 10.1016/j.athoracsur.2021.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Siddharth Pahwa
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
40
|
Patlolla SH, Schaff HV, Bagameri G, Dearani JA, Greason KL, Daly RC, Crestanello JA, Stulak JM, King KS, Pochettino A, Saran N. Natural history and outcomes of non-replaced aortic sinuses in patients with bicuspid aortic valves. Ann Thorac Surg 2021; 113:527-534. [PMID: 33811890 DOI: 10.1016/j.athoracsur.2021.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 11/06/2020] [Revised: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enlargement of the sinus of Valsalva (SOV) is common in patients with bicuspid aortic valves (BAV), and management at the time of aortic valve replacement (AVR) and concomitant ascending aorta replacement/repair is controversial. METHODS Between January 2000 and July 2017, 400 patients with BAV underwent AVR and concomitant ascending aorta repair (79%, graft replacement; 21%, aortoplasty). To assess the impact of the initial SOV dimension on future dilatation and outcomes, patients were stratified into two groups: SOV<40mm (n=209) and SOV≥40mm (n=191). RESULTS Patients with SOV≥40 mm were older, and more often male. At a median follow-up of 8.1 years (IQR 7.4-9.1), 6 patients underwent reoperations on the ascending or sinus portion of the aorta due to aneurysmal dilatation; enlargement of the sinus was the primary indication for operation in one patient. Adjusted analysis showed that baseline SOV and SOV dimension over time were not associated with late outcomes. A gradual increase in SOV diameter over time was identified (P=0.004). Patients with smaller baseline SOV diameters showed an initial early decrease in diameter followed by gradual increase, while those with larger baseline diameters had a stable early phase followed by gradual dilatation. CONCLUSIONS Ascending aorta replacement may lead to an initial remodeling/stabilizing effect on the spared bicuspid aortic root, which is more pronounced in patients with lower SOV diameters. In addition, our data demonstrate that the retained aortic sinuses enlarge slowly, and within the limited follow-up of our study, SOV diameter was not a risk factor for survival or reoperation.
Collapse
Affiliation(s)
| | | | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester
| | | | | | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester
| |
Collapse
|
41
|
Daly RC, Rosenbaum AN, Dearani JA, Clavell AL, Pereira NL, Boilson BA, Frantz RP, Behfar A, Dunlay SM, Rodeheffer RJ, Schirger JA, Taner T, Gandhi MJ, Heimbach JK, Rosen CB, Edwards BS, Kushwaha SS. Heart-After-Liver Transplantation Attenuates Rejection of Cardiac Allografts in Sensitized Patients. J Am Coll Cardiol 2021; 77:1331-1340. [PMID: 33706876 DOI: 10.1016/j.jacc.2021.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients undergoing heart transplantation, significant allosensitization limits access to organs, resulting in longer wait times and high waitlist mortality. Current desensitization strategies are limited in enabling successful transplantation. OBJECTIVES The purpose of this study was to describe the cumulative experience of combined heart-liver transplantation using a novel heart-after-liver transplant (HALT) protocol resulting in profound immunologic protection. METHODS Reported are the results of a clinical protocol that was instituted to transplant highly sensitized patients requiring combined heart and liver transplantation at a single institution. Patients were dual-organ listed with perceived elevated risk of rejection or markedly prolonged waitlist time due to high levels of allo-antibodies. Detailed immunological data and long-term patient and graft outcomes were obtained. RESULTS A total of 7 patients (age 43 ± 7 years, 86% women) with high allosensitization (median calculated panel reactive antibody = 77%) underwent HALT. All had significant, unacceptable donor specific antibodies (DSA) (>4,000 mean fluorescence antibody). Prospective pre-operative flow cytometric T-cell crossmatch was positive in all, and B-cell crossmatch was positive in 5 of 7. After HALT, retrospective crossmatch (B- and T-cell) became negative in all. DSA fell dramatically; at last follow-up, all pre-formed or de novo DSA levels were insignificant at <2,000 mean fluorescence antibody. No patients experienced >1R rejection over a median follow-up of 48 months (interquartile range: 25 to 68 months). There was 1 death due to metastatic cancer and no significant graft dysfunction. CONCLUSIONS A heart-after-liver transplantation protocol enables successful transplantation via near-elimination of DSA and is effective in preventing adverse immunological outcomes in highly sensitized patients listed for combined heart-liver transplantation.
Collapse
Affiliation(s)
- Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alfredo L Clavell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Boilson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA; VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard J Rodeheffer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Schirger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Timucin Taner
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manish J Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Charles B Rosen
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brooks S Edwards
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
42
|
Asleh R, Alnsasra H, Lerman A, Briasoulis A, Pereira NL, Edwards BS, Toya T, Stulak JM, Clavell AL, Daly RC, Kushwaha SS. Effects of mTOR inhibitor-related proteinuria on progression of cardiac allograft vasculopathy and outcomes among heart transplant recipients. Am J Transplant 2021; 21:626-635. [PMID: 32558174 DOI: 10.1111/ajt.16155] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 06/13/2020] [Indexed: 01/25/2023]
Abstract
We have previously described the use of sirolimus (SRL) as primary immunosuppression following heart transplantation (HT). The advantages of this approach include attenuation of cardiac allograft vasculopathy (CAV), improvement in glomerular filtration rate (GFR), and reduced malignancy. However, in some patients SRL may cause significant proteinuria. We sought to investigate the prognostic value of proteinuria after conversion to SRL. CAV progression and adverse clinical events were studied. CAV progression was assessed by measuring the Δ change in plaque volume (PV) and plaque index (PI) per year using coronary intravascular ultrasound. Proteinuria was defined as Δ urine protein ≥300 mg/24 h at 1 year after conversion to SRL. Overall, 137 patients were analyzed (26% with proteinuria). Patients with proteinuria had significantly lower GFR (P = .005) but similar GFR during follow-up. Delta PV (P < .001) and Δ PI (P = .001) were significantly higher among patients with proteinuria after adjustment for baseline characteristics. Multivariate Cox regression analysis showed higher all-cause mortality (hazard ratio 3.8; P = .01) with proteinuria but similar risk of CAV-related events (P = .61). Our results indicate that proteinuria is a marker of baseline renal dysfunction, and that HT recipients who develop proteinuria after conversion to SRL have less attenuation of CAV progression and higher mortality risk.
Collapse
Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Department of Cardiology, Hadassah University Medical Center, Jerusalem, Israel
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Brooks S Edwards
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Takumi Toya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Stulak
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alfredo L Clavell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard C Daly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
43
|
Mathew J, Dearani JA, Daly RC, Schaff HV. Management of Subaortic Left Ventricular Outflow Tract Obstruction After Aortic Valve Replacement. Ann Thorac Surg 2020; 112:1468-1473. [PMID: 33333082 DOI: 10.1016/j.athoracsur.2020.11.024] [Citation(s) in RCA: 3] [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] [Received: 03/25/2020] [Revised: 09/21/2020] [Accepted: 11/30/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Residual or new left ventricular outflow tract (LVOT) obstruction after an aortic valve replacement poses special challenges with respect to operative techniques. Our study assesses this gap. METHODS From January 1993 to May 2019, 18 patients underwent a septal myectomy at Mayo Clinic for subaortic obstruction after aortic valve replacement. We evaluated their demographics, clinical presentation, and echocardiograms, and the type of prior valve replacement, need for repeat replacement, and their short- and long-term outcomes. The data were analyzed using descriptive statistics. RESULTS All patients underwent septal myectomy for LVOT obstruction at a median interval of 7 years (interquartile range, 3-15 years) from their prior aortic valve procedure. Preoperatively, the median left ventricular outflow tract gradient was 57 mm Hg (interquartile range, 44-77 mm Hg); 10 patients (55.5%) had systolic anterior motion (SAM) of the mitral leaflets. Repeat replacement of the aortic valve at the time of myectomy was needed in 14 patients, and septal myectomy alone was performed in 4 patients. One hospital death occurred 34 days after myectomy and aortic valve replacement, and 2 patients needed permanent pacemaker placement for complete heart block. CONCLUSIONS Septal myectomy after aortic valve replacement may be performed with repeat replacement of the valve, if there is coexisting prosthetic dysfunction, through a normally functioning bioprosthesis or through an apical approach when visualization through the aortic prosthesis is poor. The complexity of reoperation supports a liberal approach to myectomy at the time of aortic valve replacement when there is significant subaortic septal hypertrophy.
Collapse
Affiliation(s)
- Jessey Mathew
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
44
|
Hemmati P, Arghami A, Dearani JA, Schaff HV, Daly RC, Nichols FC. The Man Behind the Clagett Procedure: Dr Oscar Theron "Jim" Clagett. Ann Thorac Surg 2020; 111:1087-1089. [PMID: 33248126 DOI: 10.1016/j.athoracsur.2020.08.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 07/10/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 10/22/2022]
Abstract
Dr O.T. "Jim" Clagett was a pioneer in surgery of the great vessels and thorax. The procedure that bears his name for treatment of postpneumonectomy empyema was only one of his many innovations in aortic, lung, and esophageal surgery. He performed over 35,000 operations and trained over 115 residents during his tenure at Mayo Clinic. His distinguished career highlights include: helping develop the field of cardiothoracic surgery during its infancy, starting the Thoracic Surgery Residency Program at Mayo Clinic, serving in numerous institutional and national leadership roles, and countless awards.
Collapse
Affiliation(s)
- Pouya Hemmati
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
45
|
Rosenbaum AN, Bohman JK, Rehfeldt KH, Stulak JM, Daly RC, Klompas AM, Behfar A, Yalamuri SM. Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report. A A Pract 2020; 14:e01181. [PMID: 32224696 DOI: 10.1213/xaa.0000000000001181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.
Collapse
Affiliation(s)
| | - John K Bohman
- Department of Anesthesiology and Perioperative Medicine
| | | | | | | | | | - Atta Behfar
- From the Department of Cardiovascular Diseases.,William J. von Liebig Center for Transplantation and Clinical Regeneration.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
46
|
Khan FW, Fatima B, Lahr BD, Greason KL, Schaff HV, Dearani JA, Daly RC, Stulak JM, Crestanello JA. Hyponatremia: An Overlooked Risk Factor Associated With Adverse Outcomes After Cardiac Surgery. Ann Thorac Surg 2020; 112:91-98. [PMID: 33080237 DOI: 10.1016/j.athoracsur.2020.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 10/06/2019] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hyponatremia is an unrecognized risk factor for adverse outcomes after cardiac surgery. We sought to study the prevalence of preoperative hyponatremia and its impact on short-term and long-term outcomes after cardiac surgery. METHODS Patients who had coronary artery bypass graft, valve, or coronary artery bypass graft and valve procedures from 2000 to 2016 and available preoperative serum sodium values within 30 days of the index procedure were included in the study. The effect of preoperative sodium on short-term and long-term outcomes was analyzed as a continuous and binary (hyponatremia [Na+ <135 mEq/L] versus no hyponatremia) predictor variable in multivariable regression models. RESULTS Preoperative hyponatremia was present in 9.9% of 16,238 patients with available sodium levels. Comorbidities were more common in patients with hyponatremia. Hyponatremia was independently associated with operative mortality (odds ratio [OR] = 1.80; 95% confidence interval [CI], 1.38-2.34; P < .001), long-term mortality (hazard ratio = 1.31; 95% CI, 1.21-1.40; P < .001), longer postoperative length of stay (hazard ratio = 1.35; 95% CI, 1.28-1.43; P < .001), renal failure (OR = 1.52; 95% CI, 1.20-1.93; P < .001), prolonged ventilation use (OR = 1.52; 95% CI, 1.30-1.78; P < .001), and stroke or transient ischemic attack (OR = 1.48; 95% CI, 1.09-2.02; P = .013). Severity of hyponatremia, as measured by sodium level, was similarly associated with increased risk for death and postoperative complications. CONCLUSIONS Preoperative hyponatremia is relatively common and is associated with adverse short-term and long-term outcomes after cardiac surgery. Preoperative hyponatremia can be used independently from standard risk factors to identify high-risk patients for cardiac surgery.
Collapse
Affiliation(s)
- Fazal Wahab Khan
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - Benish Fatima
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota
| | | |
Collapse
|
47
|
Nguyen A, Schaff HV, Arghami A, Bagameri G, Cicek MS, Crestanello JA, Daly RC, Greason KL, Pochettino A, Rowse PG, Stulak JM, Lahr BD, Dearani JA. Impact of Hematologic Malignancies on Outcome of Cardiac Surgery. Ann Thorac Surg 2020; 111:1278-1283. [PMID: 32822668 DOI: 10.1016/j.athoracsur.2020.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 10/08/2019] [Revised: 04/28/2020] [Accepted: 06/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous studies suggest that patients with prior or current hematologic malignancy are at increased risk of intraoperative and postoperative complications when undergoing cardiac surgery. The aim of this review was to compare clinical outcomes of patients with a history of hematologic malignancy to those of similar patients with no known blood dyscrasia. METHODS From January 1993 to June 2017, 37,839 patients underwent elective cardiac surgery at Mayo Clinic. We matched 612 patients (1.6%) with a history of hematologic malignancy to 612 controls, and compared operative details, early postoperative complications, and late survival. RESULTS The median age of matched patients with hematologic malignancy was 71 years (interquartile range [IQR], 62 to 77) and 71 years (IQR, 62 to 77) for patients without cancer. Patients with prior diagnosis of malignancy had lower hemoglobin levels, 12.8 (IQR, 11.5 to 13.8) vs 13.5 (IQR, 12.2 to 14.6; P < .001), but similar platelet counts, 195 (IQR, 147 to 263) vs 203 (IQR, 170 to 245; P = .533). Patients with malignancy were at greater risk of receiving postoperative blood transfusions (47.4% vs 35.6%, P < .001). However, reoperations for postoperative bleeding (4.7% vs 3.3%, P = .253) and stroke (1.3% vs 1.3%, P > .999) were similar. Thirty-day mortality was 3.3% among patients with hematologic malignancy and 1.5% among matched controls (P = .061). Overall survival among patients with cancer was reduced (P < .0001). CONCLUSIONS Although late survival is reduced in patients with hematologic malignancies, early outcomes are generally similar to those of matched controls. Therefore, surgery should not be withheld from patients with a diagnosis of hematologic malignancy who would benefit from cardiac procedures.
Collapse
Affiliation(s)
- Anita Nguyen
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - M Sertac Cicek
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
48
|
Hasan IS, Schaff HV, Daly RC, King KS, Stulak JM, Greason KL, Dearani JA. Does Referral Bias Impact Outcomes of Surgery for Degenerative Mitral Valve Disease? Ann Thorac Surg 2020; 110:1990-1996. [PMID: 32473837 DOI: 10.1016/j.athoracsur.2020.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 06/27/2019] [Revised: 03/02/2020] [Accepted: 04/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Geographic origin is cited as a possible factor influencing outcomes of operation for repair or replacement of degenerative mitral valve (MV) disease. Our study aimed to identify the potential impact of referral bias on clinical outcomes of MV surgery. METHODS We analyzed clinical and echocardiographic information of 2353 patients undergoing primary or secondary MV surgery for degenerative MV disease. Patients were grouped as local (in-state), regional (5 surrounding states), or national referrals. RESULTS The number of patients (local, 827; regional, 809; national, 717) and median follow-up time (9.1 years) were similar between geographic groups. More comorbidities were found in the local patient group. Overall operative risk was 0.7% and was greater in local and regional patients compared with national patients (0.7% and 1.1% vs 0.1%, P = .05). Valve repair was performed in 97% of isolated MV surgeries, and repair rate was similar in the 3 geographic groups. The 3 groups had similar incidences of major morbidity, but local and regional groups had higher 30-day readmissions. In univariate analysis, survival was improved in national and regional patients compared with local patients; however in multivariable analysis this difference was no longer significant. CONCLUSIONS There were important variations in baseline demographic and clinical characteristics between referral groups; local and regional patients presented with more comorbid conditions compared with national referrals. Aside from a small difference in perioperative mortality, early outcomes were generally similar. Late survival, however, was superior in national patients, and this referral bias is explained by fewer associated medical illnesses.
Collapse
Affiliation(s)
- Irsa S Hasan
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
49
|
Greiten LE, Laan D, Joyce LD, Greason KL, Daly RC, Schaff HV, King KS, Joyce DL. Management of Coronary Artery Aneurysms at the Time of Surgical Revascularization. J Surg Res 2020; 253:288-293. [PMID: 32402854 DOI: 10.1016/j.jss.2020.03.056] [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] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 03/21/2020] [Accepted: 03/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Coronary artery aneurysms (CAAs) represent a rare pathology occurring in 1.5%-5% of routine coronary angiograms. Limited data exist on the management of CAA at the time of cardiac surgery. MATERIALS AND METHODS A single-institution retrospective review was performed on 53 patients who underwent cardiac surgery in the setting of atherosclerotic CAA between 1993 and 2015. Patients were stratified based on treatment strategy: exclusion and distal bypass (n = 26) versus revascularization alone (n = 27). Comparisons were made with respect to mortality, need for further/concomitant interventions, and long-term cardiac function including myocardial infarctions and congestive heart failure. RESULTS A total of 53 patients underwent cardiac surgery in the setting of CAA disease. Management strategies included ligation and bypass in 26 patients and distal bypass only in 27 patients (with four of the patients in this group undergoing coronary stenting across the aneurysm). There were no significant differences in patient demographics between the two groups. No significant difference was found in either 30-d (P = 0.74) or long-term mortality when exclusion of the CAA was performed compared with revascularization alone (P = 0.20). More exclusion procedures were performed earlier in the experience (median surgical date 2000), whereas revascularization alone predominated later in the experience (median surgical date 2007; P ≤ 0.001). CONCLUSIONS The practice of CAA exclusion, while still performed in selected cases, has largely been supplanted in patients undergoing revascularization. Exclusion does not appear to offer any advantage over isolated revascularization, supporting the current trends in managing this rare condition.
Collapse
Affiliation(s)
- Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Alaska
| | - Daniel Laan
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota
| | - Lyle D Joyce
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - David L Joyce
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
50
|
Maynes EJ, O'Malley TJ, Austin MA, Deb AK, Choi JH, Weber MP, Khaghani A, Massey HT, Daly RC, Tchantchaleishvili V. Domino heart transplant following heart-lung transplantation: a systematic review and meta-analysis. Ann Cardiothorac Surg 2020; 9:20-28. [PMID: 32175236 DOI: 10.21037/acs.2019.12.02] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The domino-donor operation occurs when a "conditioned" heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure. Methods An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis. Results HLT indications included cystic fibrosis in 58% (95% CI: 27-84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12-24%), bronchiectasis in 5% (95% CI: 3-10%), emphysema in 5% (95% CI: 0-45%), and Eisenmenger's syndrome in 4% (95% CI: 2-8%). HT indications included ischemic heart disease in 40% (95% CI: 33-47%), non-ischemic disease in 39% (95% CI: 25-56%), and re-transplantation in 10% (95% CI: 1-59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95% CI: 18-41%) at an average follow-up of 15.68 months (95% CI: 0.82-30.54), and 35% (95% CI: 17-58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68-67.84). Freedom from rejection in HT was 94% (95% CI: 75-99%) at 1 month, 77% (95% CI: 30-96%) at 6 months, and 41% (95% CI: 33-50%) at 1 year. Conclusions The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.
Collapse
Affiliation(s)
- Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Melissa A Austin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Avijit K Deb
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | |
Collapse
|