1
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Vaikunth SS, Ortega-Legaspi JM, Conrad DR, Chen S, Daugherty T, Haeffele CL, Teuteberg J, Mclean R, MacArthur JW, Woo YJ, Maeda K, Ma M, Nasirov T, Hoteit M, Hilscher MB, Wald J, Mandelbaum T, Olthoff KM, Abt PL, Atluri P, Cevasco M, Mavroudis CD, Fuller S, Lui GK, Kim YY. Mortality and morbidity after combined heart and liver transplantation in the failing Fontan: An updated dual center retrospective study. Clin Transplant 2024; 38:e15302. [PMID: 38567883 DOI: 10.1111/ctr.15302] [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] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION As the adult Fontan population with Fontan associated liver disease continues to increase, more patients are being referred for transplantation, including combined heart and liver transplantation. METHODS We report updated mortality and morbidity outcomes after combined heart and liver transplant in a retrospective cohort series of 40 patients (age 14 to 49 years) with Fontan circulation across two centers from 2006-2022. RESULTS The 30-day, 1-year, 5-year and 10-year survival rate was 90%, 80%, 73% and 73% respectively. Sixty percent of patients met a composite comorbidity of needing either post-transplant mechanical circulatory support, renal replacement therapy or tracheostomy. Cardiopulmonary bypass time > 283 min (4.7 h) and meeting the composite comorbidity were associated with mortality by Kaplan Meier analysis. CONCLUSION Further study to mitigate early mortality and the above comorbidities as well as the high risk of bleeding and vasoplegia in this patient population is warranted.
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Affiliation(s)
- Sumeet S Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan M Ortega-Legaspi
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree R Conrad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christiane L Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rhondalynn Mclean
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John W MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Teimour Nasirov
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marrouf Hoteit
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tal Mandelbaum
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Constantine D Mavroudis
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George K Lui
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yuli Y Kim
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Vaikunth SS, Murphy DJ, Tremmel JA, Schnittger I, Mitchell RS, Maeda K, Rogers IS. Symptomatic Myocardial Bridging in D-Transposition of the Great Arteries Post-Arterial Switch. JACC Case Rep 2023; 8:101730. [PMID: 36860558 PMCID: PMC9969547 DOI: 10.1016/j.jaccas.2022.101730] [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: 09/06/2022] [Revised: 11/17/2022] [Accepted: 12/09/2022] [Indexed: 01/21/2023]
Abstract
We present Stanford's experience with patients post-arterial switch operation presenting with chest pain found to have hemodynamically significant myocardial bridging. The evaluation of symptomatic patients post-arterial switch should not only include assessment for coronary ostial patency but also for nonobstructive coronary conditions such as myocardial bridging. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Sumeet S. Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Division of Cardiology, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Address for correspondence: Dr Sumeet S. Vaikunth, Perelman Center for Advanced Medicine, 11th Floor, South Pavilion, 3400 Civic Center Boulevard, Philadelphia, Pennsylvania 19104-5127, USA.
| | - Daniel J. Murphy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer A. Tremmel
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ingela Schnittger
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Robert Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ian S. Rogers
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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3
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Saef J, Montgomery R, Cedars A, Tang WHW, Rossano JW, Maeda K, Kim YY, Vaikunth SS. Durable Mechanical Circulatory Support in Adult Congenital Heart Disease: Reviewing Clinical Considerations and Experience. J Clin Med 2022; 11:jcm11113200. [PMID: 35683587 PMCID: PMC9181100 DOI: 10.3390/jcm11113200] [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: 04/01/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Adults with congenital heart disease (ACHD) patients are one of the fastest growing populations in cardiology, and heart failure (HF) is the most common cause of morbidity and mortality amongst them. The need for advanced HF therapies in ACHD patients stands to grow substantially. The anatomic considerations for placing durable mechanical circulatory support (MCS) devices in ACHD patients often require specialized approaches. Despite this, increasing evidence suggests that durable MCS can be implanted safely with favorable outcomes in ACHD patients. Expansion of MCS use in ACHD patients is imperative to improve their clinical outcomes. Knowledge of ACHD-specific anatomic and physiologic considerations is crucial to HF programs’ success as they work to provide care to this growing population.
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Affiliation(s)
- Joshua Saef
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Robert Montgomery
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Ari Cedars
- Division of Cardiology, Johns Hopkins Medicine, Baltimore, MD 21287, USA;
| | - Wai H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Yuli Y. Kim
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +215-615-3388
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Vaikunth SS, Chan JL, Woo JP, Bykhovsky MR, Lui GK, Ma M, Romfh AW, Lamberti J, Mastrodicasa D, Fleischmann D, Fischbein MP. Tetralogy of Fallot and Aortic Dissection: Implications in Management. JACC Case Rep 2022; 4:581-586. [PMID: 35615213 PMCID: PMC9125517 DOI: 10.1016/j.jaccas.2022.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 08/11/2021] [Revised: 02/10/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Abstract
We present the case of a 61-year-old man with tetralogy of Fallot postrepair and mechanical aortic valve replacement with an aortic root/ascending/arch aneurysm with chronic type A aortic dissection. He underwent uncomplicated aortic root and total arch replacement. Continued surveillance for aortic aneurysm is necessary in the tetralogy of Fallot population. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Sumeet S. Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joshua L. Chan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer P. Woo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael R. Bykhovsky
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - George K. Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anitra W. Romfh
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - John Lamberti
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA,Address for correspondence: Dr Michael P. Fischbein, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk CVRB, 300 Pasteur Drive, Falk CVRB ULN MC5407, Stanford, California 94305, USA.
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5
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Kim JL, Vaikunth SS, Haeffele C, MacArthur JW. Extracorporeal Membrane Oxygenator as a Bridge to Heart-Liver en bloc Transplant in a Fontan Patient. JTCVS Tech 2022; 12:171-174. [PMID: 35403048 PMCID: PMC8987382 DOI: 10.1016/j.xjtc.2022.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jennifer Lynn Kim
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Christiane Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - John W. MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
- Address for reprints: John W. MacArthur, MD, Cardiothoracic Surgery, Stanford University Hospital, Stanford Hospital and Clinics, 870 Quarry Rd Ext, Palo Alto, CA 94304.
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6
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Vaikunth SS, Leonard MB, Whitehead KK, Goldberg DJ, Rychik J, Zemel BS, Avitabile CM. Deficits in the Functional Muscle-Bone Unit in Youths with Fontan Physiology. J Pediatr 2021; 238:202-207. [PMID: 34214589 PMCID: PMC8634795 DOI: 10.1016/j.jpeds.2021.06.068] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether dual energy X-ray absorptiometry (DXA), a clinically available tool, mirrors the magnitude of deficits in trabecular and cortical bone mineral density (BMD) demonstrated on peripheral quantitative computed tomography in youth with Fontan physiology. STUDY DESIGN We aimed to describe DXA-derived BMD at multiple sites and to investigate the relationship between BMD and leg lean mass, a surrogate for skeletal muscle loading. Subjects with Fontan (n = 46; aged 5-20 years) underwent DXA in a cross-sectional study of growth and bone and muscle health as described previously. Data from the Bone Mineral Density in Childhood Study were used to calculate age-, sex-, and race-specific BMD z-scores of the whole body, lumbar spine, hip, femoral neck, distal one-third radius, ultradistal radius, and leg lean mass z-score (LLMZ). RESULTS Fontan BMD z-scores were significantly lower than reference at all sites-whole body, -0.34 ± 0.85 (P = .01); spine, -0.41 ± 0.96 (P = .008); hip, -0.75 ± 1.1 (P < .001); femoral neck, -0.73 ± 1.0 (P < .001); distal one-third radius, -0.87 ± 1.1 (P < .001); and ultradistal radius. -0.92 ± 1.03 (P < .001)-as was LLMZ (-0.93 ± 1.1; P < .001). Lower LLMZ was associated with lower BMD of the whole body (R2 = 0.40; P < .001), lumbar spine (R2 = 0.16; P = .005), total hip (R2 = 0.32; P < .001), femoral neck (R2 = 0.47; P < .001), and ultradistal radius (R2 = 0.35; P < .001). CONCLUSIONS Patients with Fontan have marked deficits in both cortical (hip, distal one-third radius) and trabecular (lumbar spine, femoral neck, ultradistal radius) BMD. Lower LLMZ is associated with lower BMD and may reflect inadequate skeletal muscle loading. Interventions to increase muscle mass may improve bone accrual.
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Affiliation(s)
- Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B. Leonard
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin K. Whitehead
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S. Zemel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M. Avitabile
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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Vaikunth SS, Haeffele C, McElhinney DB, Lui GK, Romfh AW. Erratum to “The atrial switch patient with a dilated subpulmonic left ventricle” [Int. J. Cardiol. Congenit. Heart Dis. 4 (August 2021) 100153]. International Journal of Cardiology Congenital Heart Disease 2021. [DOI: 10.1016/j.ijcchd.2021.100223] [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: 11/24/2022] Open
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Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in patients with adult congenital heart disease. Many of the most common congenital defects have a high prevalence of HFrEF, including left-sided obstructive lesions (aortic stenosis, coarctation of the aorta, Shone complex), tetralogy of Fallot, Ebstein anomaly, lesions in which there is a systemic right ventricle, and lesions palliated with a Fontan circulation. However, heart failure with preserved ejection fraction (HFpEF) is also prevalent in all these lesions. Comprehensive evaluation includes physical exam, biomarkers, echocardiography and advanced imaging, exercise stress testing, and, in some cases, invasive hemodynamics. Guideline-directed medical therapy for HFrEF can be applied to left-sided lesions and may be considered on an individual basis for systemic right ventricle and single-ventricle patients. Medical therapy is limited for HFpEF. However, in both HFrEF and HFpEF, ventricular dyssynchrony and arrhythmias play an important role, and medications for rhythm control, ablation, and cardiac resynchronization therapy should be considered. Finally, aggressive management of cardiovascular risk factors and comorbidities, including, but not limited to, hypertension, obesity, diabetes, dyslipidemia, and obstructive sleep apnea, cannot be overemphasized.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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9
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Vaikunth SS, Bykhovsky MR, Romfh AW, Haeffele CL, Rogers IS, Dong E, Scribner C, Lui GK. A 40-Year-Old Man With Tricuspid Atresia, Status Post-Fontan, With Severe COVID-19 Pneumonia and Pneumothorax. JACC Case Rep 2021; 3:187-191. [PMID: 33558861 PMCID: PMC7857704 DOI: 10.1016/j.jaccas.2020.10.032] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/26/2020] [Indexed: 12/03/2022]
Abstract
We report a case of COVID-19 in an adult single-ventricle patient post-Fontan—to our knowledge, the first report in this population documenting the use of the latest management recommendations for this novel disease. Additionally, this patient had significant pre-existing ventricular dysfunction, valvular disease, and comorbidities including HIV. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael R Bykhovsky
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anitra W Romfh
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christiane L Haeffele
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ian S Rogers
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Emily Dong
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Caroline Scribner
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
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10
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Vaikunth SS, Higgins JP, Concepcion W, Haeffele C, Wright GE, Chen S, Lui GK, Daugherty T. Does liver biopsy accurately measure fibrosis in Fontan-associated liver disease? A comparison of liver biopsy pre-combined heart and liver transplant and liver explant post-transplant. Clin Transplant 2020; 34:e14120. [PMID: 33053213 DOI: 10.1111/ctr.14120] [Citation(s) in RCA: 21] [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] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/13/2020] [Accepted: 09/30/2020] [Indexed: 01/12/2023]
Abstract
The accuracy of liver biopsy to stage fibrosis due to Fontan-associated liver disease (FALD) remains unclear. We compared the results of biopsy pre-combined heart and liver transplantation (CHLT) to the results of whole liver explant. Liver biopsy and explants from 15 Fontan patients (ages 16-49, median 28 years) were retrospectively reviewed. Staging was as follows: stage 0: no fibrosis, stage 1: pericellular fibrosis, stage 2: bridging fibrosis, and stage 3: regenerative nodules. There is no stage 4. Clinical characteristics including Model of End-stage Liver Disease eXcluding INR and Varices, Ascites, Splenomegaly, and Thrombocytopenia (VAST) scores were collected, and descriptive statistics and Mann-Whitney U tests were used to analyze the data. All patients had biopsies with at least bridging fibrosis, and all had nodularity on explant; transjugular biopsy never overestimated fibrosis. Explant showed higher-grade fibrosis (stage 3) than pre-CHLT biopsy (stage 2) in 6 of 15 patients and equal grade of fibrosis (stage 3) in 9 of 15 patients. Though clinical characteristics varied significantly, VAST score was ≥2 in all but two patients. Transjugular liver biopsy does not overestimate and can underestimate fibrosis in Fontan patients undergoing CHLT, likely due to the patchy nature of fibrosis in FALD.
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Affiliation(s)
- Sumeet S Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John P Higgins
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Waldo Concepcion
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Christiane Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gail E Wright
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - George K Lui
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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11
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Vaikunth SS, Concepcion W, Daugherty T, Fowler M, Lutchman G, Maeda K, Rosenthal DN, Teuteberg J, Woo YJ, Lui GK. Short-term outcomes of en bloc combined heart and liver transplantation in the failing Fontan. Clin Transplant 2019; 33:e13540. [PMID: 30891780 DOI: 10.1111/ctr.13540] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022]
Abstract
Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2-41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end-diastolic pressure was 18/12 mm Hg, respectively. Median Model for End-Stage Liver Disease excluding International Normalized Ratio score was 10 (7-26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178-307) and 287 (227-396) minutes, respectively. Median intensive care and hospital stay were 19 (5-96) and 29 (13-197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post-transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Tami Daugherty
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Fowler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glen Lutchman
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Teuteberg
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - George K Lui
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California.,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
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12
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Vaikunth SS, Bauser-Heaton H, Lui GK, Wise-Faberowski L, Chan FP, Asija R, Hanley FL, McElhinney DB. Repair of Untreated Older Patients With Tetralogy of Fallot With Major Aortopulmonary Collaterals. Ann Thorac Surg 2018; 107:1218-1224. [PMID: 30550802 DOI: 10.1016/j.athoracsur.2018.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/26/2018] [Revised: 10/18/2018] [Accepted: 11/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Our programmatic approach to tetralogy of Fallot with major aortopulmonary collaterals emphasizes single-stage unifocalization with complete intracardiac repair during infancy. Little is known about suitability for complete repair in patients beyond infancy. We sought to analyze outcomes of our approach in older patients with previously untreated tetralogy of Fallot with major aortopulmonary collaterals. METHODS Any patient with this lesion not treated before 2 years of age referred to our center from 2002 to 2017 met inclusion criteria. RESULTS Of 33 patients, 32 were out-of-state (64% international) referrals, and 33% (n = 11) were older than 9 years, had polycythemia, or at least 1 high pressure collateral (>25 mm Hg). Complete repair was achieved in 94% (n = 31) of patients, 82% (n = 27) in one stage and 12% (n = 4) after unifocalization to a central shunt. The median right ventricular-to-aortic pressure ratio was 0.31 after the operation and 0.37 at follow-up. At a median of 4.8 years after repair, 9 patients (19%) underwent reintervention, including 5 conduit and 7 branch pulmonary artery interventions. Three patients also underwent aortic valve replacement. CONCLUSIONS In this selected cohort of older patients with previously unoperated tetralogy of Fallot with major aortopulmonary collaterals, outcomes were comparable with infants undergoing treatment according to our approach. These findings support the notion that patients who are either born in low-resource settings or present to health care providers beyond infancy should be considered candidates and evaluated for complete repair.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California.
| | - Holly Bauser-Heaton
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - George K Lui
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California; Department of Medicine, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - Lisa Wise-Faberowski
- Department of Anesthesiology, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - Frandics P Chan
- Department of Radiology, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - Ritu Asija
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
| | - Doff B McElhinney
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California; Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, California
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13
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Vaikunth SS, Williams RG, Uzunyan MY, Tun H, Barton C, Chang PM. Short-term outcomes following implementation of a dedicated young adult congenital heart disease transition program. CONGENIT HEART DIS 2017; 13:85-91. [PMID: 29152906 DOI: 10.1111/chd.12549] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/21/2017] [Accepted: 10/28/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Transition from pediatric to adult care is a critical time for patients with congenital heart disease. Lapses in care can lead to poor outcomes, including increased mortality. Formal transition clinics have been implemented to improve success of transferring care from pediatric to adult providers; however, data regarding outcomes remain limited. We sought to evaluate outcomes of transfer within a dedicated transition clinic for young adult patients with congenital heart disease. DESIGN, SETTING, AND PATIENTS We performed a retrospective analysis of all 73 patients seen in a dedicated young adult congenital heart disease transition clinic from January 2012 to December 2015 within a single academic institution that delivered pediatric and adult care at separate children's and adult hospitals, respectively. INTERVENTION AND OUTCOME MEASURES Demographic characteristics including congenital heart disease severity, gender, age, presence of comorbidities, presence of cardiac implantable electronic devices, and type of insurance were correlated to success of transfer. Rate of successful transfer was evaluated, and multivariate analysis was performed to determine which demographic variables were favorably associated with transfer. RESULTS Thirty-nine percent of patients successfully transferred from pediatric to adult services during the study period. Severe congenital heart disease (OR 4.44, 95% CI 1.25-15.79, P = .02) and presence of a cardiac implantable electronic device (OR 4.93, 95% CI 1.18-20.58, P = .03) correlated with transfer. Trends favoring successful transfer with presence of comorbidities and private insurance were also noted. CONCLUSIONS Despite a dedicated transition clinic, successful transfer rates remained relatively low though comparable to previously published rates. Severity of disease and presence of implantable devices correlated with successful transfer. Other obstacles to transfer remain and require combined efforts from pediatric and adult care systems, insurance carriers, and policy makers to improve transfer outcomes.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Internal Medicine, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA.,Department of Pediatrics, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Roberta G Williams
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Merujan Y Uzunyan
- Division of Pediatric Cardiology, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Han Tun
- Division of Cardiovascular Medicine, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Cheryl Barton
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Philip M Chang
- Division of Cardiovascular Medicine, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
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14
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Vaikunth SS, Sepulveda JS, Shinbane JS, Chang PM. Isolated Double Chambered Right Ventricle in an Adult Imaged With Magnetic Resonance. World J Pediatr Congenit Heart Surg 2016; 7:758-760. [DOI: 10.1177/2150135116660261] [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: 03/19/2016] [Accepted: 06/14/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Sumeet S. Vaikunth
- Departments of Internal Medicine and Pediatrics, Los Angeles County, University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jose Silva Sepulveda
- Departments of Internal Medicine and Pediatrics, Los Angeles County, University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jerold S. Shinbane
- Division of Cardiovascular Medicine, Los Angeles County, University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Philip M. Chang
- Division of Cardiovascular Medicine, Los Angeles County, University of Southern California Medical Center, Keck School of Medicine of USC, Los Angeles, CA, USA
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15
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Vaikunth SS, Cesari WA, Norwood KV, Satterfield S, Shreve RG, Ryan JP, Lewis JB. Academic achievement and primary care specialty selection of volunteers at a student-run free clinic. Teach Learn Med 2014; 26:129-134. [PMID: 24702548 DOI: 10.1080/10401334.2014.883980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Previous studies have reached conflicting conclusions about the associations between service and academic achievement and service and primary care specialty choice. PURPOSES This study examines the associations between service at a student-run clinic and academic achievement and primary care specialty choice. METHODS Retrospective review of medical student service and statistical analysis of grade point average (GPA), Step 1 and Step 2 Clinical Knowledge (CK) scores, and specialty choice were conducted, as approved by our Institutional Review Board. RESULTS Volunteers, compared to nonvolunteers, had higher GPA (3.59 ± 0.33 vs. 3.40 ± 0.39, p < .001), Step 1 (229 ± 19 vs. 220 ± 21, p < .001), and Step 2 CK (240 ± 18 vs. 230 ± 21, p < .001) scores, but did not pursue primary care specialties at a significantly higher percentage (52% vs. 51%, χ² = .051, p = .82). CONCLUSIONS Further exploration of the associations between service and academic achievement and primary care specialty choice is warranted.
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Affiliation(s)
- Sumeet S Vaikunth
- a Department of Internal Medicine/Pediatrics , University of Southern California , Los Angeles , California , USA
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16
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Vaikunth SS, Weber KT, Bhattacharya SK. Abstract 305: Nebivolol Confers Mitochondria-Targeted Cardioprotection in Isoproterenol-Induced Acute Stressor State. Circ Res 2012. [DOI: 10.1161/res.111.suppl_1.a305] [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] [Indexed: 11/16/2022]
Abstract
Introduction:
Isoproterenol-induced acute stressor state simulates injury from burns or trauma, and results in Ca
2+
overloading and oxidative stress in diverse tissues, including cardiac myocytes and their subsarcolemmal mitochondria (SSM), overwhelming endogenous Zn
2+
-based antioxidant defenses.
We hypothesized
that pretreatment with nebivolol (Nebi), having dual beta-1 antagonistic and novel beta-3 receptor agonistic properties, would prevent Ca
2+
overloading and oxidative stress and upregulate Zn
2+
-based antioxidant defenses, thus enhancing its overall cardioprotective potential in acute stressor state.
Methods:
Eight-week-old male Sprague-Dawley rats received a single subcutaneous dose of isoproterenol (1 mg/kg) and compared to those treated with Nebi (10 mg/kg by gavage) for 10 days prior to isoproterenol. SSM were harvested from cardiac tissue at sacrifice. Total Ca
2+
, Zn
2+
and 8-isoprostane levels in tissue, and mitochondrial permeability transition pore (mPTP) opening, free [Ca
2+
]
m
and H
2
O
2
production in SSM were monitored. Untreated, age-/sex-matched rats served as controls; each group had six rats and data shown as mean±SEM.
Results:
Compared to controls, isoproterenol rats revealed:
(1)
Significantly (*p<0.05) increased cardiac tissue Ca
2+
(8.2±0.8 vs. 13.7±1.0*, nEq/mg fat-free dry tissue (FFDT)), which was abrogated (
#
p<0.05) by Nebi (8.9±0.4
#
);
(2)
Reduced cardiac Zn
2+
(82.8±2.4 vs. 78.5±1.0*, ng/mg FFDT), but restored by Nebi (82.4±0.6
#
);
(3)
Two-fold rise in cardiac 8-isoprostane (111.4±13.7 vs. 232.1±17.2*, pmoles/mg protein), and negated by Nebi (122.3+14.5
#
);
(4)
Greater opening propensity for mPTP that diminished by Nebi;
(5)
Elevated [Ca
2+
]
m
(88.8±2.5 vs. 161.5±1.0*, nM), but normalized by Nebi (93.3±2.7
#
); and
(6)
Increased H
2
O
2
production by SSM (97.4±5.3 vs. 142.8±7.0*, pmoles/mg protein/min), and nullified by Nebi (106.8±9.0
#
).
Conclusions
: Cardioprotection conferred by Nebi, a unique beta-blocker, prevented Ca
2+
overloading and oxidative stress in cardiac tissue and SSM, while simultaneously augmenting antioxidant capacity and promoting mPTP stability. Therapeutic potential of Nebi in patients with acute stressor states remains a provocative possibility that deserves to be explored.
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Affiliation(s)
- Sumeet S Vaikunth
- College of Medicine, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Karl T Weber
- College of Medicine, Univ of Tennessee Health Science Cntr, Memphis, TN
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17
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Abstract
Purpose: To identify the chief complaints and demographics at Clinica Esperanza, a student-run free clinic for an underserved Hispanic population. Methods: A retrospective chart review of patient files from 2005 through 2010 was undertaken, as approved by the University of Tennessee Health Science Center’s Institutional Review Board. Results: From 2005 through 2010, Clinica Esperanza fielded 2551 patient visits, consisting of 951 unique patients, 609 females and 342 males. Mean age was 34 years, and 60% of patients presented once, while 13% followed up for 1 year, 9% for 2 years, 6% for 3, 6% for 4, and 4% for 5. “Pap smear,” “abdominal pain,” and “follow-up lab results” ranked, in order, as the 3 top chief complaints. Discussion: Resulting data have led to several improvements. The clinic has remained open weekly to improve patient continuity. With the top 10 chief complaints identified, they are better addressed. More funding is allocated for speculums and proper training of Pap smear technique. Systematic reporting of lab results is being implemented. Physical therapists and pharmacists now participate to address musculoskeletal and medication-based needs, respectively. A volunteer gastroenterologist has been recruited to provide specialized care for abdominal pain. An electrocardiogram machine is now used to evaluate chest pain. To improve student-patient communication, online language learning modules have been created. Conclusions: Based on these data, improvements in health care services have been made, including better continuity, emphasis on top chief complaints, and provider education in medical Spanish. Future plans include on-site pharmacy, smoother referrals, and similar clinics on the University of Tennessee Health Science Center’s other campuses.
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Affiliation(s)
| | | | - Jim B. Lewis
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mukta Panda
- University of Tennessee Health Science Center, Memphis, TN, USA
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