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Eikelboom R, Manji RA. Commentary: Reducing unnecessary transfusions in cardiac surgery: A TEG talk. J Thorac Cardiovasc Surg 2024; 167:254-255. [PMID: 35354527 DOI: 10.1016/j.jtcvs.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Rachel Eikelboom
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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2
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Senage T, Paul A, Le Tourneau T, Fellah-Hebia I, Vadori M, Bashir S, Galiñanes M, Bottio T, Gerosa G, Evangelista A, Badano LP, Nassi A, Costa C, Cesare G, Manji RA, Cueff de Monchy C, Piriou N, Capoulade R, Serfaty JM, Guimbretière G, Dantan E, Ruiz-Majoral A, Coste du Fou G, Leviatan Ben-Arye S, Govani L, Yehuda S, Bachar Abramovitch S, Amon R, Reuven EM, Atiya-Nasagi Y, Yu H, Iop L, Casós K, Kuguel SG, Blasco-Lucas A, Permanyer E, Sbraga F, Llatjós R, Moreno-Gonzalez G, Sánchez-Martínez M, Breimer ME, Holgersson J, Teneberg S, Pascual-Gilabert M, Nonell-Canals A, Takeuchi Y, Chen X, Mañez R, Roussel JC, Soulillou JP, Cozzi E, Padler-Karavani V. The role of antibody responses against glycans in bioprosthetic heart valve calcification and deterioration. Nat Med 2022; 28:283-294. [PMID: 35177855 PMCID: PMC8863575 DOI: 10.1038/s41591-022-01682-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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] [Received: 03/30/2021] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
Bioprosthetic heart valves (BHVs) are commonly used to replace severely diseased heart valves but their susceptibility to structural valve degeneration (SVD) limits their use in young patients. We hypothesized that antibodies against immunogenic glycans present on BHVs, particularly antibodies against the xenoantigens galactose-α1,3-galactose (αGal) and N-glycolylneuraminic acid (Neu5Gc), could mediate their deterioration through calcification. We established a large longitudinal prospective international cohort of patients (n = 1668, 34 ± 43 months of follow-up (0.1–182); 4,998 blood samples) to investigate the hemodynamics and immune responses associated with BHVs up to 15 years after aortic valve replacement. Early signs of SVD appeared in <5% of BHV recipients within 2 years. The levels of both anti-αGal and anti-Neu5Gc IgGs significantly increased one month after BHV implantation. The levels of these IgGs declined thereafter but anti-αGal IgG levels declined significantly faster in control patients compared to BHV recipients. Neu5Gc, anti-Neu5Gc IgG and complement deposition were found in calcified BHVs at much higher levels than in calcified native aortic valves. Moreover, in mice, anti-Neu5Gc antibodies were unable to promote calcium deposition on subcutaneously implanted BHV tissue engineered to lack αGal and Neu5Gc antigens. These results indicate that BHVs manufactured using donor tissues deficient in αGal and Neu5Gc could be less prone to immune-mediated deterioration and have improved durability. In a large cohort of patients who underwent aortic valve replacement, antibody responses to glycans present in bioprosthetic heart valves, notably galactose-α1,3-galactose and N-glycolylneuraminic acid, were implicated in valve calcification and deterioration.
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Affiliation(s)
- Thomas Senage
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France.,Institut National de la Santé et de la Recherche Médicale UMR 1246-SPHERE, Nantes University, Tours University, Nantes, France
| | - Anu Paul
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thierry Le Tourneau
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Imen Fellah-Hebia
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Marta Vadori
- Consortium for Research in Organ Transplantation, Ospedale Giustinianeo, Padova, Italy
| | - Salam Bashir
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Manuel Galiñanes
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tomaso Bottio
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Surgery, University of Padova, Padova, Italy
| | - Gino Gerosa
- Department of Cardiac, Vascular and Thoracic Sciences and Public Health University of Padova, L.I.F.E.L.A.B. Program Veneto Region, Padova, Italy
| | - Arturo Evangelista
- Department of Cardiology, Vall d'Hebron Research Institut, Hospital Vall d'Hebron, Barcelona, Spain
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, San Luca Hospital, Milan, Italy
| | - Alberto Nassi
- Transplantation Immunology Unit, Padova University Hospital, Padova, Italy
| | - Cristina Costa
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Caroline Cueff de Monchy
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Romain Capoulade
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Jean-Michel Serfaty
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Guillaume Guimbretière
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Etienne Dantan
- Institut National de la Santé et de la Recherche Médicale UMR 1246-SPHERE, Nantes University, Tours University, Nantes, France
| | - Alejandro Ruiz-Majoral
- Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Guénola Coste du Fou
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Shani Leviatan Ben-Arye
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Liana Govani
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Yehuda
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shirley Bachar Abramovitch
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ron Amon
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Eliran Moshe Reuven
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yafit Atiya-Nasagi
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.,Israel Institute for Biological Research, Ness Ziona, Israel
| | - Hai Yu
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Laura Iop
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Surgery, University of Padova, Padova, Italy.,Department of Cardiac, Vascular and Thoracic Sciences and Public Health University of Padova, L.I.F.E.L.A.B. Program Veneto Region, Padova, Italy.,Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Kelly Casós
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Cardiovascular Disease at the Vall d'Hebron Institut Research, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastián G Kuguel
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arnau Blasco-Lucas
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Cardiac Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eduard Permanyer
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Cardiac Surgery, Quironsalud Teknon Heart Institute, Barcelona, Spain
| | - Fabrizio Sbraga
- Cardiac Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Roger Llatjós
- Pathology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gabriel Moreno-Gonzalez
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Intensive Care Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Michael E Breimer
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Jan Holgersson
- Institute of Biomedicine, Department of Laboratory Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Susann Teneberg
- Institute of Biomedicine, Department of Medical Biochemistry and Cell Biology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | | | | | - Yasuhiro Takeuchi
- Division of Infection and Immunity, University College London, London, UK
| | - Xi Chen
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Rafael Mañez
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. .,Intensive Care Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Jean-Christian Roussel
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France.
| | - Jean-Paul Soulillou
- Institut de Transplantation-Urologie-Néphrologie, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1064, Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Emanuele Cozzi
- Transplantation Immunology Unit, Padova University Hospital, Padova, Italy.
| | - Vered Padler-Karavani
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.
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Manji RA, Manji JS, Arora RC. Are maladaptive brain changes the reason for burnout and medical error? J Thorac Cardiovasc Surg 2021; 162:1136-1140. [DOI: 10.1016/j.jtcvs.2020.06.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 12/26/2022]
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Moran HRM, Arora RC, Manji RA. Commentary: The A-B-C's of H-I-T. Semin Thorac Cardiovasc Surg 2021; 34:581-582. [PMID: 34098116 DOI: 10.1053/j.semtcvs.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Hellmuth R Muller Moran
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
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Dubiel C, Hiebert BM, Stammers AN, Sanjanwala RM, Tangri N, Singal RK, Manji RA, Rudolph JL, Arora RC. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg 2020; 163:725-734. [DOI: 10.1016/j.jtcvs.2020.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 01/07/2023]
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Manji RA, Arora RC. Commentary: Should patients awaiting cardiac surgery who need anticoagulation be on direct oral anticoagulants or vitamin K antagonists? J Thorac Cardiovasc Surg 2020; 161:1876-1877. [PMID: 32057457 DOI: 10.1016/j.jtcvs.2019.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Abstract
Millions of patients with valvular heart disease have benefitted from heart valve replacement since the procedure was first introduced in the 1960s; however, there are still many patients who get early structural valve deterioration (SVD) of their bioprosthetic heart valves (BHV). BHV are porcine, bovine, or equine tissues that have been glutaraldehyde fixed to preserve the tissue and presumably make the tissue immunologically inert. These glutaraldehyde-fixed BHV with anti-calcification treatments last long periods of time in older adults but develop early SVD in younger patients. The consensus at present is that the early SVD in younger patients is due to more "wear and tear" of the valves and higher calcium turnover in younger patients. However, as younger patients likely have a more robust immune system than older adults, there is a new hypothesis that BHV xenografts may undergo xenograft rejection, and this may contribute to the early SVD seen in younger patients.At present, the technology to noninvasively study in vivo whether an implanted BHV in a human patient is undergoing rejection is not available. Thus, a small animal discordant xenotransplant model in young rodents (to match the young patient getting a pig/bovine/equine BHV) was developed to study whether the hypothesis that glutaraldehyde-fixed BHV undergo xenograft rejection had any merit. In this chapter, we describe our model and its merits and the results of our investigations. Our work provides clear evidence of xenograft rejection in glutaraldehyde-fixed tissue, and our small animal model offers an opportunity to study this process in detail.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.
- Cardiac Sciences Program, I.H. Asper Clinical Research Institute, Winnipeg Regional Health Authority and St. Boniface Hospital, Winnipeg, MB, Canada.
| | - Jacqueline S Manji
- Cardiac Sciences Program, I.H. Asper Clinical Research Institute, Winnipeg Regional Health Authority and St. Boniface Hospital, Winnipeg, MB, Canada
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Manji RA, Grocott HP, Arora RC. Medical Error and "Psycho-Physiology". Semin Thorac Cardiovasc Surg 2019; 31:397-398. [PMID: 31100339 DOI: 10.1053/j.semtcvs.2019.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rizwan A Manji
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; Department of Anesthesia, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Hilary P Grocott
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; Department of Anesthesia, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
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Arcinas LA, Manji RA, Hrymak C, Dao V, Sheppard JAI, Warkentin TE. Autoimmune heparin-induced thrombocytopenia and venous limb gangrene after aortic dissection repair: in vitro and in vivo effects of intravenous immunoglobulin. Transfusion 2019; 59:1924-1933. [PMID: 30903805 DOI: 10.1111/trf.15263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder characterized by heparin-dependent antibodies that activate platelets (PLTs) via PLT FcγIIa receptors. "Autoimmune" HIT (aHIT) indicates a HIT subset where thrombocytopenia progresses or persists despite stopping heparin; aHIT sera activate PLTs strongly even in the absence of heparin (heparin-independent PLT-activating properties). Affected patients are at risk of severe complications, including dual macro- and microvascular thrombosis leading to venous limb gangrene. High-dose intravenous immunoglobulin (IVIG) offers an approach to interrupt heparin-independent PLT-activating effects of aHIT antibodies. CASE REPORT A 78-year-old male who underwent cardiopulmonary bypass for aortic dissection developed aHIT, disseminated intravascular coagulation, and deep vein thrombosis; progression to venous limb gangrene occurred during partial thromboplastin time (PTT)-adjusted bivalirudin infusion (underdosing from "PTT confounding"). Thrombocytopenia recovered with high-dose IVIG, although the PLT count increase began only after the third dose of a 5-day IVIG regimen (0.4 g/kg/day × 5 days). We reviewed case reports and case series of IVIG for treating HIT, focusing on various IVIG dosing regimens used. RESULTS Patient serum-induced PLT activation was inhibited in vitro by IVIG in a dose-dependent fashion; inhibition of PLT activation by IVIG was much more marked in the absence of heparin versus the presence of heparin (0.2 U/mL). Our literature review indicated 1 g/kg × 2 IVIG dosing as most common for treating HIT, usually associated with rapid PLT count recovery. CONCLUSION Our clinical and laboratory observations support dose-dependent efficacy of IVIG for decreasing PLT activation and thus correcting thrombocytopenia in aHIT. Our case experience and literature review suggests dosing of 1 g/kg IVIG × 2 for patients with severe aHIT.
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Affiliation(s)
- Liane A Arcinas
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carmen Hrymak
- Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vi Dao
- Section of Hematology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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10
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Barrie K, Cornick A, Debreuil S, Lee E, Hiebert BM, Manji RA, Bienvenu OJ, McDonald B, Singal RK, Arora RC. Patients With a Prolonged Intensive Care Unit Length of Stay Have Decreased Health-Related Quality of Life After Cardiac Surgery. Semin Thorac Cardiovasc Surg 2018; 31:21-31. [PMID: 30012367 DOI: 10.1053/j.semtcvs.2018.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/06/2018] [Indexed: 11/11/2022]
Abstract
Cardiac surgery patients with a prolonged ICU length of stay (prICULOS) have lower rates of functional survival following their procedure, however detailed information on their health related quality of life (HRQoL) is lacking. We sought to investigate the potential need for intervention in these high-risk patients through comprehensive HRQoL assessments in the months to year following their surgery. A prospective, observational pilot study was undertaken and cardiac surgery patients with a prICULOS (ICU length of stay of ≥5 days) were recruited. A control group was obtained through recruitment of cardiac surgery patients with an ICU length of stay of <5 days. In-person clinical or telephone survey HRQoL assessments were completed at 3-6 months and 1-year time points after their procedure. The standardized mean difference (SMD) was calculated for all study variable comparisons to quantify the standardized effect size observed between non-prICULOS and prICULOS patients. 789 cardiac procedures were performed during the study period and 89 patients experienced a prICULOS (10.7%). Of these 89 patients, 35 prICULOS patients were recruited along with 35 controls. 29 out of 35 prICULOS patients completed the study (83%). At the 3-6 month follow up the prICULOS patients had higher levels of weight loss, fear of falling, and driving deficits. At 1-year, prICULOS patients had persistent difficulties with activities of daily living and required more family and external support. This study demonstrates the need for closer follow up and intervention for cardiac surgery patients with a prICULOS who were found to have poorer mid and long-term HRQoL.
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Affiliation(s)
- K Barrie
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba.; Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba
| | - A Cornick
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba
| | - S Debreuil
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba.; Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba
| | - E Lee
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba
| | - B M Hiebert
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba
| | - R A Manji
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba.; Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba; Section of Critical Care, Department of Medicine, Max Rady College of Medicine University of Manitoba
| | - O J Bienvenu
- John Hopkins School of Medicine, Baltimore, Maryland
| | - B McDonald
- Cardiac Surgical Intensive Care Unit, Division of Cardiac Anesthesia & Critical Care Medicine, University of Ottawa Heart Institute, Ottawa, Ontario
| | - R K Singal
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba.; Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba; Section of Critical Care, Department of Medicine, Max Rady College of Medicine University of Manitoba
| | - R C Arora
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Manitoba.; Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba; Section of Critical Care, Department of Medicine, Max Rady College of Medicine University of Manitoba..
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11
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Yan W, Shah P, Hiebert B, Pozeg Z, Ghorpade N, Singal RK, Manji RA, Arora RC. Long-term non-institutionalized survival and rehospitalization after surgical aortic and mitral valve replacements in a large provincial cardiac surgery centre. Interact Cardiovasc Thorac Surg 2018; 27:131-138. [PMID: 29462406 DOI: 10.1093/icvts/ivy018] [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: 07/18/2017] [Accepted: 01/14/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Long-term quality of life following open surgical valve replacement is an increasingly important outcome to patients and their caregivers. This study examines non-institutionalized survival and rehospitalization within our surgical aortic valve replacement (AVR) and mitral valve replacement (MVR) populations. METHODS A retrospective single-centre study of all consecutive open surgical valve replacements between 1995 and 2014 was undertaken. Clinical data were linked to provincial administrative data for 3219 patients who underwent AVR, MVR or double (aortic and mitral) valve replacement with or without concomitant coronary artery bypass grafting (CABG). Non-institutionalized survival and cumulative incidence of rehospitalization was examined up to 15 years. RESULTS Follow-up was complete for 96.9% of the 2146 patients who underwent AVR ± CABG (66.7% of the overall cohort), 878 who underwent MVR ± CABG (27.3%) and 195 who underwent double (aortic and mitral) valve replacement ± CABG (6.0%) with a median follow-up time of 5.6 years. Overall non-institutionalized survival was 35.4% at 15 years, and the cumulative incidence of rehospitalization was 34.4%, 63.2% and 87.0% at 1, 5 and 15 years, respectively, without significant differences between valve procedure cohorts. Both non-institutionalized survival and cumulative incidence of rehospitalization improved in more recent eras, despite increasing age and comorbidities. CONCLUSIONS Non-institutionalized survival and rehospitalization data for up to 15 years suggest good functional outcomes long after surgical AVR and/or MVR. Continued improvements are seen in these metrics over the past 2 decades. This provides a unique insight into the quality of life after surgical valve replacement in the ageing demographics with valvular heart disease.
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Affiliation(s)
- Weiang Yan
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Pallav Shah
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Zlatko Pozeg
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Nitin Ghorpade
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Rohit K Singal
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
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Kuo K, Shah P, Hiebert B, Love K, Menkis AH, Manji RA, Arora RC. Predictors of survival, functional survival, and hospital readmission in octogenarians after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2017; 154:1544-1553.e1. [PMID: 28673707 DOI: 10.1016/j.jtcvs.2017.05.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Kendra Kuo
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Pallav Shah
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Karin Love
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alan H Menkis
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Arora RC, Manji RA, Singal RK, Hiebert B, Menkis AH. Outcomes of octogenarians discharged from the hospital after prolonged intensive care unit length of stay after cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1668-1678.e2. [PMID: 28688711 DOI: 10.1016/j.jtcvs.2017.04.083] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 06/01/2016] [Revised: 04/13/2017] [Accepted: 04/26/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Octogenarians offered complex cardiac surgery frequently experience a prolonged intensive care unit length of stay; however, minimal data exist on the outcomes of these patients. We sought to determine the rates and predictors of 1-year noninstitutionalized survival ("functional survival") and rehospitalization for octogenarian patients with prolonged intensive care unit length of stay after cardiac surgery and who were discharged from hospital. METHODS The outcomes of discharged patients aged 80 years or more who underwent cardiac surgery with prolonged intensive care unit length of stay (≥5 consecutive days) from January 1, 2000, to December 31, 2011, were examined retrospectively from linked clinical and administrative provincial databases. Regression analysis was used to determine predictors of 1-year functional survival and rehospitalization after discharge from the hospital. RESULTS A total of 80 of 683 (11.7%) discharged octogenarian patients had prolonged intensive care unit length of stay. Functional survival at 1 year was 92% and 81% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively (P < .01). Lack of outpatient physician visits within 30 days of discharge (hazard ratio, 5.18; P < .01) was a significant predictor of poor 1-year functional survival. The 1-year rehospitalization rates were 38% and 48% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively, with 41% of all rehospitalizations occurring within 30 days of initial discharge. A rural residence (hazard ratio, 1.82; P < .01) and nosocomial pneumonia during patients' operative admissions (hazard ratio, 2.74; P < .01) were associated with rehospitalization within 30 days of discharge. CONCLUSIONS Octogenarians with prolonged intensive care unit length of stay have acceptable functional survival at 1 year but have high rates of early rehospitalization. Access to health services may influence functional survival and early rehospitalizations. These data suggest that close follow-up of these vulnerable patients after hospital discharge is warranted.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rohit K Singal
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan H Menkis
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
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Manji RA, Arora RC, Singal RK, Hiebert BM, Menkis AH. Early Rehospitalization After Prolonged Intensive Care Unit Stay Post Cardiac Surgery: Outcomes and Modifiable Risk Factors. J Am Heart Assoc 2017; 6:JAHA.116.004072. [PMID: 28174166 PMCID: PMC5523740 DOI: 10.1161/jaha.116.004072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Prolonged intensive care unit length of stay (prICULOS) following cardiac surgery (CS) in older adults is increasingly common but rehospitalization characteristics and outcomes are understudied. We sought to describe the rehospitalization characteristics and subsequent non‐institutionalized survival of prICULOS (ICULOS ≥5 days) patients and identify modifiable risk factors to decrease 30‐day rehospitalization. Methods and Results Consecutive patients from January 1, 2000 to December 31, 2011 were analyzed utilizing linked clinical and administrative databases. Logistic regression was used to identify risk factors associated with 30‐day rehospitalization. Out of 9210 consecutive patients discharged from the hospital alive, 596 (6.5%) experienced prICULOS. Cumulative incidence of rehospitalization for the prICULOS cohort at 30 and 365 days was 17.5% and 45.6% versus 11.4% and 28.1% for non‐prICULOS (P<0.01). Over 40% of rehospitalizations for the entire cohort occurred within 30 days of discharge costing over $12 million. The most common reasons for rehospitalization were heart failure (in prICULOS) and infection (in non‐prICULOS). Rehospitalization within 30 days was associated with a 2.29‐fold risk of poor 1‐year noninstitutionalized survival for the entire cohort. Potentially modifiable factors affecting 30‐day rehospitalization included lack of physician visits within 30 days of discharge (odds ratio 2.11; P=0.01), and preoperative anxiety diagnosis (odds ratio 2.20; P=0.01). Conclusions PrICULOS patients have high rates of rehospitalization that is associated with an increased rate of poor noninstitutionalized survival. Addressing modifiable risk factors including early postdischarge access to physician services, as well as access to mental health services may improve patient outcomes.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, MB, Canada
| | - Rakesh C Arora
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, MB, Canada
| | - Rohit K Singal
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, MB, Canada
| | - Brett M Hiebert
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, MB, Canada
| | - Alan H Menkis
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, MB, Canada
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Singal RK, Singal D, Bednarczyk J, Lamarche Y, Singh G, Rao V, Kanji HD, Arora RC, Manji RA, Fan E, Nagpal AD. Current and Future Status of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest. Can J Cardiol 2016; 33:51-60. [PMID: 28024556 DOI: 10.1016/j.cjca.2016.10.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 01/06/2023] Open
Abstract
Numerous series, propensity-matched trials, and meta-analyses suggest that appropriate use of extracorporeal cardiopulmonary resuscitation (E-CPR) for in-hospital cardiac arrest (IHCA) can be lifesaving. Even with an antecedent cardiopulmonary resuscitation (CPR) duration in excess of 45 minutes, 30-day survival with favourable neurologic outcome using E-CPR is approximately 35%-45%. Survival may be related to age, duration of CPR, or etiology. Associated complications include sepsis, renal failure, limb and neurologic complications, hemorrhage, and thrombosis. However, methodological biases-including small sample size, selection bias, publication bias, and inability to control for confounders-in these series prevent definitive conclusions. As such, the 2015 American Heart Association Advanced Cardiac Life Support guidelines update recommended E-CPR as a Level of Evidence IIb recommendation in appropriate cases. The absence of high-quality evidence presents an opportunity for clinician/scientists to generate practice-defining data through collaborative investigation and prospective trials. A multidisciplinary dialogue is required to standardize the field and promote multicentre investigation of E-CPR with data sharing and the development of a foundation for high-quality trials. The objectives of this review are to (1) provide an overview of the strengths and limitations of currently available studies investigating the use of E-CPR in patients with IHCA and highlight knowledge gaps; (2) create a framework for the standardization of terminology, clinical practice, data collection, and investigation of E-CPR for patients with IHCA that will help ensure congruence in future work in this area; and (3) propose suggestions to guide future research by the cardiovascular community to advance this important field.
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Affiliation(s)
- Rohit K Singal
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deepa Singal
- Department of Community Health Sciences, Max Rady College of Medicine, Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph Bednarczyk
- Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute and Department of Critical Care, Hôpital du Sacré Coeur de Montréal, Université de Montréal, Québec, Canada
| | - Gurmeet Singh
- Departments of Critical Care Medicine and Surgery, Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hussein D Kanji
- Division of Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - A Dave Nagpal
- London Health Sciences Centre/Western University, London Ontario, Canada
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Lee W, Long C, Ramsoondar J, Ayares D, Cooper DKC, Manji RA, Hara H. Human antibody recognition of xenogeneic antigens (NeuGc and Gal) on porcine heart valves: could genetically modified pig heart valves reduce structural valve deterioration? Xenotransplantation 2016; 23:370-80. [DOI: 10.1111/xen.12254] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/07/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Whayoung Lee
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh PA USA
| | - Cassandra Long
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh PA USA
| | | | | | - David K. C. Cooper
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh PA USA
| | - Rizwan A. Manji
- Department of Surgery; University of Manitoba; Winnipeg MB Canada
- Cardiac Sciences Program; Winnipeg Regional Health Authority and St Boniface Hospital; Winnipeg MB Canada
| | - Hidetaka Hara
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh PA USA
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Linkins LA, Warkentin TE, Pai M, Shivakumar S, Manji RA, Wells PS, Wu C, Nazi I, Crowther MA. Rivaroxaban for treatment of suspected or confirmed heparin-induced thrombocytopenia study. J Thromb Haemost 2016; 14:1206-10. [PMID: 27061271 DOI: 10.1111/jth.13330] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Indexed: 11/29/2022]
Abstract
UNLABELLED Essentials Heparin-induced thrombocytopenia (HIT) is a thrombogenic condition that is difficult to treat. We evaluated rivaroxaban as a treatment option in patients with suspected or confirmed HIT. One patient had recurrent thrombosis and 9/10 patients with thrombocytopenia had platelet recovery. Rivaroxaban may be an effective and safe treatment option for HIT. SUMMARY Background Rivaroxaban is a direct oral anti-Xa inhibitor that has the potential to greatly simplify treatment of heparin-induced thrombocytopenia (HIT). Objectives To evaluate the efficacy and safety of rivaroxaban in this patient population, we conducted a multicenter, single-arm, prospective cohort study of patients with suspected or confirmed HIT. Patients/Methods Twenty-two consecutive adults with suspected or confirmed HIT received rivaroxaban 15 mg bid until a local HIT assay result was available. Participants with a positive local assay result continued rivaroxaban 15 mg bid until platelet recovery (or until day 21 if they had acute thrombosis at study entry), then stepped down to rivaroxaban 20 mg daily until day 30. Results and Conclusions The primary outcome measure, incidence of new symptomatic, objectively-confirmed venous and arterial thromboembolism at 30 days, occurred in one HIT-positive participant (4.5%; 95% confidence interval [CI], 0-23.5%) and one HIT-positive participant required limb amputation despite platelet recovery. Platelet recovery was achieved in nine out of 10 HIT-positive patients with thrombocytopenia. Rivaroxaban appears to be effective for treating patients with confirmed HIT, although the small number of patients enrolled limits precision.
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Affiliation(s)
- L A Linkins
- Department of Medicine, McMaster University, TAARI, Hamilton, ON, Canada
| | - T E Warkentin
- Department of Medicine, McMaster University, TAARI, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Medicine, McMaster University, TAARI, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - S Shivakumar
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - R A Manji
- Department of Surgery and Cardiac Sciences Program, University of Manitoba, Winnipeg, MB, Canada
| | - P S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - C Wu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - I Nazi
- Department of Medicine, McMaster University, TAARI, Hamilton, ON, Canada
| | - M A Crowther
- Department of Medicine, McMaster University, TAARI, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Manji RA, Grocott HP, Manji JS, Menkis AH, Jacobsohn E. Recurrent Seizures Following Cardiac Surgery: Risk Factors and Outcomes in a Historical Cohort Study. J Cardiothorac Vasc Anesth 2015; 29:1206-11. [DOI: 10.1053/j.jvca.2015.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Indexed: 11/11/2022]
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Manji RA, Hara H, Cooper DKC. Characterization of the cellular infiltrate in bioprosthetic heart valves explanted from patients with structural valve deterioration. Xenotransplantation 2015; 22:406-7. [DOI: 10.1111/xen.12187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rizwan A. Manji
- Department of Surgery; University of Manitoba; Winnipeg MB Canada
- Cardiac Sciences Program; Winnipeg Regional Health Authority and St Boniface Hospital; Winnipeg MB Canada
| | - Hidetaka Hara
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - David K. C. Cooper
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
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Abstract
The transplantation (implantation) of xenograft heart valves into humans has been carried out for >50 years. There has been considerable research into making this form of xenotransplantation successful, though it is not perfect yet. We review the understanding of the immune response to xenograft heart valves. Important steps in the history include understanding (i) the importance of glutaraldehyde in decreasing the immune response and (ii) the relationship between calcification (which is the main problem leading to xenograft failure) and the immune response. We subsequently discuss the importance of identifying xenoantigens that are important in leading to xenograft valve failure, and the potential of genetically-engineered pigs to allow the development of the 'ideal' heart valve for clinical valve replacement.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, Winnipeg Regional Health Authority and St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Whayoung Lee
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David K C Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Affiliation(s)
- Whayoung Lee
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Hidetaka Hara
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - David K. C. Cooper
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Rizwan A. Manji
- Department of Surgery; University of Manitoba; Winnipeg MB Canada
- Cardiac Sciences Program; Winnipeg Regional Health Authority and St Boniface Hospital; Winnipeg MB Canada
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Manji RA, Witt J, Tappia PS, Jung Y, Menkis AH, Ramjiawan B. Cost-effectiveness analysis of rheumatic heart disease prevention strategies. Expert Rev Pharmacoecon Outcomes Res 2014; 13:715-24. [PMID: 24219047 DOI: 10.1586/14737167.2013.852470] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rheumatic heart disease (RHD), secondary to group A streptococcal infection is endemic in the developing as well as parts of the developed world with significant costs to the patient, and to the healthcare system. We briefly review the prevalence and cost of RHD in developed and developing nations. We subsequently develop a Markov model to evaluate the cost-effectiveness of three strategies (vs standard no prevention) for preventing RHD in a developing world country: primary prophylaxis (throat swab to detect and subsequently treat group A streptococci as needed); primary prophylaxis (antibiotic prophylaxis for all) with benzathine penicillin G once monthly to all patients (ages 5-21 years) regardless of evidence of infection; and secondary prophylaxis with monthly only to those with echocardiographic evidence of early RHD. Our model suggests that echocardiographic screening and secondary prophylaxis is the best strategy although the strategies change depending on parameters used.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Linkins LA, Warkentin TE, Pai M, Shivakumar S, Manji RA, Wells PS, Crowther MA. Design of the rivaroxaban for heparin-induced thrombocytopenia study. J Thromb Thrombolysis 2014; 38:485-92. [DOI: 10.1007/s11239-014-1064-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
Glutaraldehyde-fixed bioprosthetic heart valves (GBHVs), derived from pigs or cows, undergo structural valve deterioration (SVD) over time, with calcification and eventual failure. It is generally accepted that SVD is due to chemical processes between glutaraldehyde and free calcium ions in the blood. Valve companies have made significant progress in decreasing SVD from calcification through various valve chemical treatments. However, there are still groups of patients (e.g., children and young adults) that have accelerated SVD of GBHV. Unfortunately, these patients are not ideal patients for valve replacement with mechanical heart valve prostheses as they are at high long-term risk from complications of the mandatory anticoagulation that is required. Thus, there is no "ideal" heart valve replacement for children and young adults. GBHVs represent a form of xenotransplantation, and there is increasing evidence that SVD seen in these valves is at least in part associated with xenograft rejection. We review the evidence that suggests that xenograft rejection of GBHVs is occurring, and that calcification of the valve may be related to this rejection. Furthermore, we review recent research into the transplantation of live porcine organs in non-human primates that may be applicable to GBHVs and consider the potential use of genetically modified pigs as sources of bioprosthetic heart valves.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada; Cardiac Sciences Program, Winnipeg Regional Health Authority and St. Boniface Hospital, Winnipeg, MB, Canada
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Manji RA, Jacobsohn E, Grocott HP, Menkis AH. Longer in-hospital wait times do not result in worse outcomes for patients requiring urgent coronary artery bypass graft surgery. Hosp Pract (1995) 2013; 41:15-22. [PMID: 23948617 DOI: 10.3810/hp.2013.08.1064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In certain health care systems, patients wait for non-emergency services. Although waiting may not be considered acceptable, the delay may allow for patient optimization, such as giving time for "toxic" agents to be cleared, that could improve outcomes. We sought to determine the relationship between wait times and outcomes in in-hospital patients undergoing urgent coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS A prospectively collected database of consecutive, medically urgent, but clinically stable patients undergoing CABG surgery from 1995 to 2007, was analyzed. A total of 3067 patients with need for urgent CABG surgery with various in-hospital wait times (n = 440, 0-2 days; n = 799, 3-5 days; n = 1317, 6-10 days; n = 511, 11-15 days) were included. There were no differences in mortality, intensive care unit (ICU) or post-surgery hospital length of stay (LOS) among the patient groups. Multivariate logistic regression analysis revealed that wait time was not associated with mortality (P = 0.625). Due to changes in the nonsurgical management of coronary artery disease, a separate analysis of patients, from 2002 to 2007, was also performed to explore contemporary results. In the latter subset, 1495 patients (n = 175, 341, 720, 259, in the same 4 respective wait-time groups) were included; the 0-2 days patient group underwent more blood transfusions (50% vs 38%; P = 0.01), prolonged ventilation (6% vs 2%; P = 0.05), post-operative dialysis (2% vs 0%; P = 0.08), and longer ICU LOS (26 vs 23 hours; P = 0.02) compared with the 3-5 days patient group. The Society of Thoracic Surgeons mortality risk scores of the 0-2 days and 3-5 days groups were the same (1.5%). Multivariate regression analysis revealed that increased wait time was associated with fewer patients requiring blood transfusion (P < 0.05) for CABG surgery. CONCLUSION Waiting for in-hospital urgent CABG surgery does not lead to worse patient outcomes and may, in fact, reduce the procedural and medical risks of postoperative blood transfusions, prolonged ventilation, dialysis, and shorten ICU LOS.
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Affiliation(s)
- Rizwan A Manji
- Department of Surgery; Department of Anaesthesia, Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada.
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Manji RA, Menkis AH, Ekser B, Cooper DK. The future of bioprosthetic heart valves. Indian J Med Res 2012; 135:150-1. [PMID: 22446853 PMCID: PMC3336842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rizwan A. Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada,Cardiac Sciences Program, Winnipeg Regional Health Authority & St. Boniface Hospital, Winnipeg, Manitoba, Canada,For correspondence: I.H. Asper Clinical Research Institute, St. Boniface Hospital, CR3014 - 369 Tache Avenue, Winnipeg, Manitoba, Canada R2H 2A6
| | - Alan H. Menkis
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada,Cardiac Sciences Program, Winnipeg Regional Health Authority & St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Burcin Ekser
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Department of Surgery, Transplantation & Advanced Technologies, Vascular Surgery & Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - David K.C. Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Manji RA, Menkis AH, Cooper DKC. Cardiac xenotransplantation technology provides materials for improved bioprosthetic heart valves. J Thorac Cardiovasc Surg 2011; 142:238-9; author reply 239. [PMID: 21683844 DOI: 10.1016/j.jtcvs.2011.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/11/2011] [Indexed: 11/19/2022]
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Abstract
The importance of adrenal function to survival in critically ill patients has been established; however, identifying the best method to diagnose adrenal insufficiency has been problematic. Multiple methods of determining adrenal function have been developed, each with its advantages and disadvantages. Serum-free cortisol levels are probably the most accurate, although obtaining this result is technically demanding. Cohen and colleagues investigated the feasibility of measuring tissue cortisol levels in burn patients and whether tissue cortisol levels could be used as a surrogate for plasma-free cortisol levels.
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Abstract
This article reviews the development of early ideas regarding the origins and pathogenesis of shock. The early history of shock is related primarily to traumatic shock. More recent history centers on differentiation of clinical syndromes and individual characteristics. Definitions, classification systems, pathogenic theories, and treatments have evolved. Progress has been aided by constant development of improved assessment technologies. Today, shock is not a single syndrome and the definition of shock no longer is descriptive in nature. The most accepted current definition involves an oxygen supply/demand imbalance that can have various causes-hypovolemia, cardiac dysfunction, vascular failure, or obstructive processes.
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Affiliation(s)
- Rizwan A Manji
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
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Schaffer SA, Manji RA, Kirkpatrick I, Fang T, Arora RC, Zieroth S, Jassal DS. Negative pressure pulmonary edema in the coronary care unit. Can J Cardiol 2008; 24:e58-9. [PMID: 18787726 DOI: 10.1016/s0828-282x(08)70672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A 63-year-old woman with no known cardiac history presented with pulmonary edema accompanied by electrocardiographic evidence of ischemia. Echocardiography demonstrated normal cardiac dimensions, normal wall motion and mild diastolic dysfunction. Despite repeat attempts at extubation following aggressive diuresis, the patient required ongoing ventilatory support. Although cardiac catheterization revealed normal coronary arteries, computed tomography revealed a 4 cm 9 cm multinodular goiter extending into the mediastinum and compressing the trachea. A diagnosis of negative pressure pulmonary edema should be considered in the differential diagnosis of any patient presenting with acute heart failure.
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Affiliation(s)
- Stephen A Schaffer
- Department of Cardiac Sciences, University of Manitoba, Winnipeg, Canada
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Manji RA, Zhu LF, Nijjar NK, Rayner DC, Korbutt GS, Churchill TA, Rajotte RV, Koshal A, Ross DB. Glutaraldehyde-Fixed Bioprosthetic Heart Valve Conduits Calcify and Fail From Xenograft Rejection. Circulation 2006; 114:318-27. [PMID: 16831988 DOI: 10.1161/circulationaha.105.549311] [Citation(s) in RCA: 176] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Glutaraldehyde fixation (G-F) decreases but likely does not eliminate the antigenicity of bioprosthetic heart valves. Rejection (with secondary dystrophic calcification) may be why G-F xenograft valves fail, especially in young patients, who are more immunocompetent than the elderly. Therefore, we sought to determine whether rejection of G-F xenograft occurs and to correlate this with graft calcification. METHODS AND RESULTS Ascending aortas/valves (from rats [syngeneic] or guinea pigs [xenogeneic]) were transplanted (fresh or after 48 hour of G-F) into the infrarenal aortas of young rat recipients for 20 days. A xenogeneic group was also treated with steroids until graft harvest. The valves and media/adventitia were scored blindly for inflammation (0 to 4). Percent graft infiltration by T cells/macrophages was determined (immunohistochemistry), and rat IgG ELISAs were performed. There was >3 times more valve inflammation, >10 times more valve T-cell/macrophage infiltrate, and >3 times antibody rise in the G-F xenogeneic groups compared with the fresh syngeneic or the G-F syngeneic groups (P<0.05). There was >2 times more adventitial inflammation and T-cell/macrophage infiltrate in the xenogeneic groups (P<0.05). Steroid treatment decreased inflammation and antibody rise in the xenogeneic groups (P<0.05). Correlation analysis revealed media/adventitia inflammation (P=0.02) and percent macrophage (P=0.01) infiltration to be predictors of calcification. CONCLUSIONS G-F xenografts have cellular/humoral rejection and calcify secondarily.
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Affiliation(s)
- Rizwan A Manji
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada..
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Manji RA, Rajotte RV, Arvind K. Human O red blood cells and pig-to-human xenotransplantation. Xenotransplantation 2004; 11:107. [PMID: 14962300 DOI: 10.1046/j.1399-3089.2003.00101.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Manji RA, Rajotte RV, Arvind K. Human O red blood cells and pig-to-human xenotransplantation. Xenotransplantation 2003. [DOI: 10.1111/j.1741-6787.2004.04019.x-i1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Pig organs express alphaGal antigen and thus are hyperacutely rejected if perfused by human blood. Human B/A antigens are similar to pig alphaGal antigen, suggesting that the corresponding antibodies may cross-react. Our purpose was to determine if there is a human ABO blood-group difference in porcine-human xenotransplantation. Plasma from six A, five B, seven AB, and six O individuals pooled by blood group were tested in an ex-vivo porcine working heart model. Blood-group A plasma-perfused hearts survived 20 +/- 14 min (n = 5), B 241 +/- 9 min (n = 3), AB 151 +/- 37 min (n = 5), and O 9 +/- 1 min (n = 8). A and O were different (p < 0.001) from B and AB. Function was significantly better in group B. Edema accumulation and creatine kinase change was highest in A and O. All groups had comparable levels of anti-alphaGal antibody, as well as comparable perfusion and operative conditions. Multivariate linear regression analysis showed the anti-B antibody levels to be predictive of survival (p < 0.001). At higher plasma concentrations, hearts perfused with B plasma survived longer (p = 0.01) than AB (218 +/- 45 min, n = 4 vs. 6 +/- 0 min, n = 3). These results suggest a human ABO blood-group difference in porcine-to-human xenotransplantation, which may be mediated by the anti-A and anti-B antibodies.
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Affiliation(s)
- Rizwan A Manji
- The Division of Cardiac Surgery, Department of Surgery, and The Surgical Medical Research Institute, University of Alberta, Edmonton, Alberta, Canada.
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