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Welz F, Schoenrath F, Friedrich A, Wloch A, Stein J, Hennig F, Ott SC, O'Brien B, Falk V, Knosalla C, Just IA. Acute Kidney Injury After Heart Transplantation: Risk Factors and Clinical Outcomes. J Cardiothorac Vasc Anesth 2024; 38:1150-1160. [PMID: 38378323 DOI: 10.1053/j.jvca.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/30/2023] [Accepted: 01/21/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE Acute kidney injury (AKI) requiring renal-replacement therapy (RRT) after heart transplantation (OHT) is common and impairs outcomes. This study aimed to identify independent donor and recipient risk factors associated with RRT after OHT. DESIGN A retrospective data analysis. SETTING Data were collected from clinical routines in a maximum-care university hospital. PARTICIPANTS Patients who underwent OHT. INTERVENTIONS The authors retrospectively analyzed data from 264 patients who underwent OHT between 2012 and 2021; 189 patients were eligible and included in the final analysis. MEASUREMENTS AND MAIN RESULTS The mean age was 48.0 ± 12.3 years, and 71.4% of patients were male. Ninety (47.6%) patients were on long-term mechanical circulatory support (lt-MCS). Posttransplant AKI with RRT occurred in 123 (65.1%) patients. In a multivariate analysis, preoperative body mass index >25 kg/m² (odds ratio [OR] 4.74, p < 0.001), elevated preoperative creatinine levels (OR for each mg/dL increase 3.44, p = 0.004), administration of red blood cell units during transplantation procedure (OR 2.31, p = 0.041) and ischemia time (OR for each hour increase 1.77, p = 0.004) were associated with a higher incidence of RRT. The use of renin-angiotensin-aldosterone system blockers before transplantation was associated with a reduced risk of RRT (OR 0.36, p = 0.013). The risk of mortality was 6.9-fold higher in patients who required RRT (hazard ratio 6.9, 95% CI: 2.1-22.6 p = 0.001). Previous lt-MCS, as well as donor parameters, were not associated with RRT after OHT. CONCLUSIONS The implementation of guideline-directed medical therapy, weight reduction, minimizing ischemia time (ie, organ perfusion systems, workflow optimization), and comprehensive patient blood management potentially influences renal function and outcomes after OHT.
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Affiliation(s)
- Friedrich Welz
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Speciality Network: Infectious Diseases and Respiratory Medicine, Berlin, Germany.
| | - Felix Schoenrath
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Aljona Friedrich
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexa Wloch
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Julia Stein
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Felix Hennig
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Sascha C Ott
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Benjamin O'Brien
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; ETH Zurich, Department of Health Sciences and Technology, Zurich, Switzerland
| | - Christoph Knosalla
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Isabell Anna Just
- Deutsches Herzzentrum der Charité. Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Zhou AL, Jenkins RT, Ruck JM, Shou BL, Larson EL, Casillan AJ, Ha JS, Merlo CA, Bush EL. Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:230-238. [PMID: 37939695 PMCID: PMC10922625 DOI: 10.1097/mat.0000000000002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.
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Affiliation(s)
- Alice L. Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Reed T. Jenkins
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jessica M. Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Benjamin L. Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Emily L. Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Alfred J. Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jinny S. Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital
| | - Errol L. Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
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Carrillo-Gómez DC, Rojas-Perdomo CC, Orozco-Echeverri N, Montes MC, Flórez-Elvira L, López-Pónce de León JD, Olaya-Rojas P, Flórez-Alarcón N, Gómez-Mesa JE. Infections in the first year after heart transplantation in a Latin American country. Transpl Infect Dis 2024; 26:e14166. [PMID: 37846848 DOI: 10.1111/tid.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Heart transplantation is the therapy of choice in patients with advanced heart failure refractory to other medical or surgical management. However, heart transplants are associated with complications that increase posttransplant morbidity and mortality. Infections are one of the most important complications after this procedure. Therefore, infections in the first year after heart transplantation were evaluated. METHODS A retrospective cohort study of infections after heart transplants was conducted in a teaching hospital in Colombia between 2011 and 2019. Patients registered in the institutional heart transplant database (RETRAC) were included in the study. Microbiological isolates and infectious serological data were matched with the identities of heart transplant recipients and data from clinical records of individuals registered in the RETRAC were analyzed. The cumulative incidences of events according to the type of microorganism isolated were estimated using Kaplan-Meier survival analyses. RESULTS Seventy-nine patients were included in the study. Median age was 49 years (37.4-56.3), and 26.58% of patients were women. Eighty-seven infections were documented, of which 55.17% (48) were bacterial, 22.99% (20) were viral, and 12.64% (11) were fungal. Bacterial infections predominated in the first month. In the first year, infections caused 38.96% of hospital admissions and were the second cause of death after heart transplants (25.0%). CONCLUSION Posttransplant infections in the first year of follow-up were frequent. Bacterial infections predominated in the early posttransplant period. Infections, mainly bacterial, were the second most common cause of death and the most common cause of hospitalization in the first year after heart transplantation.
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Affiliation(s)
| | | | | | - Maria C Montes
- Cardiology Service, Fundación Valle del Lili, Cali, Colombia
| | | | - Juan David López-Pónce de León
- Cardiology Service, Heart transplant Unit, Fundación Valle del Lili, Cali, Colombia
- Health Sciences Faculty, Universidad Icesi, Cali, Colombia
| | - Pastor Olaya-Rojas
- Cardiology Service, Heart transplant Unit, Fundación Valle del Lili, Cali, Colombia
| | - Noel Flórez-Alarcón
- Cardiology Service, Heart transplant Unit, Fundación Valle del Lili, Cali, Colombia
- Health Sciences Faculty, Universidad Icesi, Cali, Colombia
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Cotton JL, Suarez-Pierre A, Breithaupt JJ, Yoeli D, Ziogas IA, Choudhury RA, Nydam TL, Pomposelli JJ, Pomfret EA, Adams MA. Survival following liver transplantation: A population-based nested case-control study. Am J Surg 2024; 228:264-272. [PMID: 38867471 DOI: 10.1016/j.amjsurg.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 06/14/2024]
Abstract
BACKGROUND Liver transplantation is the gold standard treatment for end-stage liver disease. This study evaluates post-transplantation survival compared with the general population by quantifying standardized mortality ratios in a nested case-control study. METHODS Controls were noninstitutionalized United States inhabitants from the National Longitudinal Mortality Study. Cases underwent liver transplantation from 1990 to 2007 identified through the Organ Procurement and Transplantation Network database. Propensity matching (5:1, nearest neighbor, caliper 0.1) identified controls based on age, sex, race, and state. The primary endpoint was 10-year survival. RESULTS 62,788 cases were matched to 313,381 controls. The overall standardized mortality ratio was 2.46 (95% CI = 2.44-2.48). The standardized mortality ratio was higher for males (2.59 vs. 2.25) and Hispanic patients (4.80). Younger patients and those transplanted earlier (1990-1995) had higher standardized mortality ratios. CONCLUSIONS Liver recipients have a standardized mortality ratio 2.46 times higher than the general population. Long-term mortality has declined over time.
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Affiliation(s)
- Jake L Cotton
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | | | - Jason J Breithaupt
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dor Yoeli
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ioannis A Ziogas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rashikh A Choudhury
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE) at the University of Colorado Hospital-Anschutz Medical Campus, Aurora, CO, USA
| | - Trevor L Nydam
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE) at the University of Colorado Hospital-Anschutz Medical Campus, Aurora, CO, USA
| | - James J Pomposelli
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE) at the University of Colorado Hospital-Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE) at the University of Colorado Hospital-Anschutz Medical Campus, Aurora, CO, USA
| | - Megan A Adams
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE) at the University of Colorado Hospital-Anschutz Medical Campus, Aurora, CO, USA; Division of Pediatric Transplant Surgery, Children's Hospital of Colorado, Aurora, CO, USA
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5
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Iguidbashian JP, King RW, Carroll AM, Cotton JL, Stuart C, Fullerton DA, Meguid RA, Suarez-Pierre A. Conditional Survival in Lung Transplantation: An Organ Procurement and Transplantation Network Database Analysis. ASAIO J 2023; 69:e333-e341. [PMID: 37191472 DOI: 10.1097/mat.0000000000001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Lung transplantation survival estimates are traditionally reported as fixed 1-, 5-, and 10-year mortality rates. Alternatively, this study aims to demonstrate how conditional survival models can provide useful prognostic information tailored to the time a recipient has already survived from the date of transplantation. Recipient data was obtained from the Organ Procurement and Transplantation Network database. Data from 24,820 adult recipients over age 18 who received a lung transplant between 2002 and 2017 were included in the study. Five-year observed conditional survival estimates were calculated by recipient age, sex, race, transplant indication, transplant type ( i.e. , single or double), and renal function at the time of transplantation. Significant variability exists in conditional survival following lung transplantation. Each specific recipient characteristic significantly impacted conditional survival during at least one time point in the first 5 years. Younger age and double lung transplantation were the two most positive predictors of improved conditional survival consistently throughout the 5-year study period. Conditional survival in lung transplantation recipients changes over time and across recipient characteristics. Hazards of mortality are not fixed and need to be dynamically evaluated as a function of time. Conditional survival calculations can provide more accurate prognostic predictions than unconditional survival estimates.
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Affiliation(s)
- John P Iguidbashian
- From the Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Palmieri V, Montisci A, Vietri MT, Colombo PC, Sala S, Maiello C, Coscioni E, Donatelli F, Napoli C. Artificial intelligence, big data and heart transplantation: Actualities. Int J Med Inform 2023; 176:105110. [PMID: 37285695 DOI: 10.1016/j.ijmedinf.2023.105110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND As diagnostic and prognostic models developed by traditional statistics perform poorly in real-world, artificial intelligence (AI) and Big Data (BD) may improve the supply chain of heart transplantation (HTx), allocation opportunities, correct treatments, and finally optimize HTx outcome. We explored available studies, and discussed opportunities and limits of medical application of AI to the field of HTx. METHOD A systematic overview of studies published up to December 31st, 2022, in English on peer-revied journals, have been identified through PUBMED-MEDLINE-WEB of Science, referring to HTx, AI, BD. Studies were grouped in 4 domains based on main studies' objectives and results: etiology, diagnosis, prognosis, treatment. A systematic attempt was made to evaluate studies by the Prediction model Risk Of Bias ASsessment Tool (PROBAST) and the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD). RESULTS Among the 27 publications selected, none used AI applied to BD. Of the selected studies, 4 fell in the domain of etiology, 6 in the domain of diagnosis, 3 in the domain of treatment, and 17 in that of prognosis, as AI was most frequently used for algorithmic prediction and discrimination of survival, but in retrospective cohorts and registries. AI-based algorithms appeared superior to probabilistic functions to predict patterns, but external validation was rarely employed. Indeed, based on PROBAST, selected studies showed, to some extent, significant risk of bias (especially in the domain of predictors and analysis). In addition, as example of applicability in the real-world, a free-use prediction algorithm developed through AI failed to predict 1-year mortality post-HTx in cases from our center. CONCLUSIONS While AI-based prognostic and diagnostic functions performed better than those developed by traditional statistics, risk of bias, lack of external validation, and relatively poor applicability, may affect AI-based tools. More unbiased research with high quality BD meant for AI, transparency and external validations, are needed to have medical AI as a systematic aid to clinical decision making in HTx.
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Affiliation(s)
- Vittorio Palmieri
- Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Department of Cardiac Surgery and Transplantation, Naples, Italy.
| | - Andrea Montisci
- Division of Cardiothoracic Intensive Care, Cardiothoracic Department, ASST Spedali Civili, Brescia, Italy
| | - Maria Teresa Vietri
- Department of Precision Medicine, "Luigi Vanvitelli" University of Campania School of Medicine, Naples, Italy
| | - Paolo C Colombo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Silvia Sala
- Chair of Anesthesia and Intensive Care, University of Brescia, Brescia, Italy
| | - Ciro Maiello
- Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Department of Cardiac Surgery and Transplantation, Naples, Italy
| | - Enrico Coscioni
- Department of Cardiac Surgery, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Donatelli
- Department of Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy; Chair of Cardiac Surgery, University of Milan, Milan, Italy
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), "Luigi Vanvitelli" University of Campania School of Medicine, Naples, Italy
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Zhou AL, Etchill EW, Shou BL, Whitbread JJ, Barbur I, Giuliano KA, Kilic A. Outcomes after heart transplantation in patients who have undergone a bridge-to-bridge strategy. JTCVS OPEN 2022; 12:255-268. [PMID: 36590736 PMCID: PMC9801290 DOI: 10.1016/j.xjon.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/13/2022] [Accepted: 08/29/2022] [Indexed: 01/04/2023]
Abstract
Objectives We compared posttransplant outcomes between patients bridged from temporary mechanical circulatory support to durable left ventricular assist device before transplant (bridge-to-bridge [BTB] strategy) and patients bridged from temporary mechanical circulatory support directly to transplant (bridge-to-transplant [BTT] strategy). Methods We identified adult heart transplant recipients in the Organ Procurement and Transplantation Network database between 2005 and 2020 who were supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device as a BTB or BTT strategy. Kaplan-Meier survival analysis and Cox regressions were used to assess 1-year, 5-year, and 10-year survival. Posttransplant length of stay and complications were compared as secondary outcomes. Results In total, 201 extracorporeal membrane oxygenation (61 BTB, 140 BTT), 1385 intra-aortic balloon pump (460 BTB, 925 BTT), and 234 temporary ventricular assist device (75 BTB, 159 BTT) patients were identified. For patients supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device, there were no differences in survival between BTB and BTT at 1 and 5 years posttransplant, as well as 10 years posttransplant even after adjusting for baseline characteristics. The extracorporeal membrane oxygenation BTB group had greater rates of acute rejection (32.8% vs 13.6%; P = .002) and lower rates of dialysis (1.6% vs 21.4%; P < .001). For intra-aortic balloon pump and temporary ventricular assist device patients, there were no differences in posttransplant length of stay, acute rejection, airway compromise, stroke, dialysis, or pacemaker insertion between BTB and BTT recipients. Conclusions BTB patients have similar short- and midterm posttransplant survival as BTT patients. Future studies should continue to investigate the tradeoff between prolonged temporary mechanical circulatory support versus transitioning to durable mechanical circulatory support.
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Key Words
- BTB, bridge-to-bridge
- BTT, bridge-to-transplant
- CO, cardiac output
- ECMO, extracorporeal membrane oxygenation
- IABP, intra-aortic balloon pump
- LVAD, left ventricular assist device
- MCS, mechanical circulatory support
- OPTN, Organ Procurement and Transplantation Network
- PA, pulmonary artery
- PCWP, pulmonary capillary wedge pressure
- TAH, total artificial heart
- UNOS, United Network for Organ Sharing
- extracorporeal membrane oxygenation
- heart transplant
- intra-aortic balloon pump
- mPAP, mean pulmonary arterial pressure
- mechanical circulatory support
- tVAD, temporary ventricular assist device
- transplant outcomes
- ventricular assist devices
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Affiliation(s)
- Alice L. Zhou
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Eric W. Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | | | - Iulia Barbur
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Katherine A. Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
- Address for reprints: Ahmet Kilic, MD, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7107, 1800 Orleans St, Baltimore, MD 21287.
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Just IA, Guelfirat M, Leser L, Uecertas A, Kopp Fernandes L, Godde M, Merke N, Stawowy P, Hennig F, Knosalla C, Falk V, Knierim J, Schoenrath F. Diagnostic and Prognostic Value of a TDI-Derived Systolic Wall Motion Analysis as a Screening Modality for Allograft Rejection after Heart Transplantation. Life (Basel) 2021; 11:life11111206. [PMID: 34833082 PMCID: PMC8622239 DOI: 10.3390/life11111206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Despite the risk for complications, allograft surveillance after orthotopic heart transplantation (OHT) is performed by cardiac catheterization and biopsies. We investigated the diagnostic and prognostic value of a TDI-derived systolic wall motion analysis of the posterobasal wall of the left ventricle (Sm) as a screening modality in OHT aftercare. Methods: We examined data of 210 eligible patients who underwent OHT between 2010 and 2020. Forty-four patients who had died within the initial hospital stay were excluded. For 166 patients, baseline and follow-up data were analyzed. The mean age at OHT was 46.2 (±11.4) years; 76.5% were male. Results: Within the observational period, 22 (13.3%) patients died. In total, 170 episodes of acute cellular or humoral rejections occurred (84 ISHLT1R; 13 ISHLT2R; 8 ISHLT3R; 65 AMR), and 29 catheterizations revealed cardiac allograft vasculopathy (5 CAV1; 4 CAV2; 20 CAV3). Individual Sm radial/longitudinal remained stable within the follow-up period (11.5 ± 2.2 cm/s; 10.9 ± 2.1 cm/s). Patients with acute rejections and CAV3 showed significant Sm radial/longitudinal reductions (AMR1: 1.6 ± 1.9 cm/s, confidence interval (CI) 0.77–0.243, p < 0.001; 1.8 ± 2.0 cm/s, CI 0.92–0.267, p < 0.001. ISHLT1R: 1.7 ± 1.8 cm/s, CI 1.32–2.08, p < 0.001; 2.0 ± 1.6 cm/s, CI 1.66–2.34, p < 0.001. CAV3: 1.3 ± 2.5 cm/s, CI 0.23–2.43, p < 0.017; 1.4 ± 2.8 cm/s, CI 0.21–2.66, p < 0.021). Lower Sm was associated with a threefold increase in all-cause mortality (hazard ratio (HR) 3.24, CI 1.2–8.76, p = 0.020; HR 2.92, CI 1.19–7.18, p = 0.019). Overall, Sm-triggered surveillance led to 0.75 invasive diagnostics per patient post-OHT year. Conclusions: Sm remained stable in the post-OHT course. Reductions indicated ISHLT1R, AMR1 and CAV3 and were associated with higher all-cause mortality. Sm-triggered surveillance may be referred to as a safe, high-yield screening modality in OHT aftercare.
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Affiliation(s)
- Isabell A. Just
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Correspondence:
| | - Meryem Guelfirat
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Laura Leser
- Department of Anesthesiology, German Heart Center Berlin, 13353 Berlin, Germany;
| | - Ata Uecertas
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Laurenz Kopp Fernandes
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Maren Godde
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Philipp Stawowy
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Department of Cardiology and Internal Medicine, German Heart Center Berlin, 13353 Berlin, Germany
| | - Felix Hennig
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
- Department of Cardiothorarcic Surgery, Charité, Corpoate Member of Freie Universität Berlin, Humboldt-Universitüt Berlin and Berlin Institute of Health, 13353 Berlin, Germany
- Translational Cardiovascular Technologies, Department of Health Sciences, Eidgenoessische Technische Hochschule (ETH) Zurich, 8092 Zurich, Switzerland
| | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; (M.G.); (A.U.); (L.K.F.); (M.G.); (N.M.); (F.H.); (C.K.); (V.F.); (J.K.); (F.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany;
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Sun JY, Wu R, Xu J, Xue HY, Lu XJ, Ji J. Placental Immune Tolerance and Organ Transplantation: Underlying Interconnections and Clinical Implications. Front Immunol 2021; 12:705950. [PMID: 34413856 PMCID: PMC8370472 DOI: 10.3389/fimmu.2021.705950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/15/2021] [Indexed: 12/22/2022] Open
Abstract
The immune system recognizes and attacks non-self antigens, making up the cornerstone of immunity activity against infection. However, during organ transplantation, the immune system also attacks transplanted organs and leads to immune rejection and transplantation failure. Interestingly, although the embryo and placenta are semi-allografts, like transplanted organs, they can induce maternal tolerance and be free of a vigorous immune response. Also, embryo or placenta-related antibodies might adversely affect subsequent organ transplantation despite the immune tolerance during pregnancy. Therefore, the balance between the immune tolerance in maternal-fetal interface and normal infection defense provides a possible desensitization and tolerance strategy to improve transplantation outcomes. A few studies on mechanisms and clinical applications have been performed to explore the relationship between maternal-fetal immune tolerance and organ transplantation. However, up to now, the mechanisms underlying maternal-fetal immune tolerance remain vague. In this review, we provide an overview on the current understanding of immune tolerance mechanisms underlying the maternal-fetal interface, summarize the interconnection between immune tolerance and organ transplantation, and describe the adverse effect of pregnancy alloimmunization on organ transplantation.
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Affiliation(s)
- Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Digestive Endoscopy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiang Xu
- Department of Rehabilitation, Huai'an Second People's Hospital and The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, China
| | - Hui-Ying Xue
- The Reproductive Center, Huai'an Maternal and Child Health Care Hospital, Xuzhou Medical University, Huai'an, China
| | - Xiao-Jie Lu
- Department of General Surgery, Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiansong Ji
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University/Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, China
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Abstract
PURPOSE OF REVIEW Timely referral of eligible candidates for consideration of advanced therapies, such as a heart transplantation or mechanical circulatory support is essential. The characteristics of heart transplantation candidates have changed significantly over the years, leading to a more complex evaluation process. The present review summarizes recent advances in the evaluation process for heart transplantation eligibility. RECENT FINDINGS The heart transplantation allocation policy was recently reviewed in the USA in an effort to reduce waitlist mortality and to ensure fair geographic allocation of organs to the sickest patients. Moreover, patients with chronic infectious diseases, as well as malignancies, are being currently considered acceptable candidates for transplantation. Listing practices for heart transplantation vary between programmes, with a greater willingness to consider high-risk candidates at higher-volume centres. SUMMARY The ultimate decision to place high-risk candidates on the heart transplantation waitlist should be based on a combination of quantitative and qualitative data analysis informed by clinical judgement, and the chronic shortage of organ donors makes this process an important ethical concern for any society. Future guidelines should discuss approaches to achieve fair organ allocation while preserving improved outcomes after transplantation.
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Affiliation(s)
- Jefferson L Vieira
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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