1
|
Parente A, Milana F, Hajibandeh S, Hajibandeh S, Tirotta F, Cho HD, Kasahara M, Kim KH, Schlegel A. Clinical outcomes after transplantation of domino grafts or standard deceased donor livers: a systematic review and meta-analysis. J Gastroenterol Hepatol 2024; 39:620-629. [PMID: 38228293 DOI: 10.1111/jgh.16476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/01/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND AIM Domino liver transplantation (DLT) utilizes otherwise discarded livers as donor grafts for another recipients. It is unclear whether DLT has less favorable outcomes compared to deceased donor liver transplantation (DDLT). We aimed to assess the outcomes of DLT compared to DDLT. METHODS MEDLINE, Embase, and Web of Science database were searched to identify studies comparing outcomes after DLT with DDLT. Data were pooled using random-effects modeling, evaluating odds ratios (OR) or mean difference (MD) for outcomes including waiting list time, severe hemorrhage, intensive care unit (ICU), length hospital stay (LOS), rejection, renal, vascular, and biliary events, and recipient survival at 1, 3, 5, and 10 years. RESULTS Five studies were identified including 945 patients (DLT = 409, DDLT = 536). The DLT recipients were older compared to the DDLT group (P = 0.04), and both cohorts were comparable regarding lab MELD, hepatocellular carcinoma, and waitlist time. There were no differences in vascular (OR: 1.60, P = 0.39), renal (OR: 0.62, P = 0.24), biliary (OR: 1.51, P = 0.21), severe hemorrhage (OR: 1.09, P = 0.86), rejection (OR: 0.78, P = 0.51), ICU stay (MD: 0.50, P = 0.21), or LOS (MD: 1.68, P = 0.46) between DLT and DDLT. DLT and DDLT were associated with comparable 1-year (78.9% vs 80.4%; OR: 1.03, P = 0.89), 3-year (56.2% vs 54.1%; OR: 1.35, P = 0.07), and 10-year survival (6.5% vs 8.5%; OR: 0.8, P = 0.67) rates. DLT was associated with higher 5-year survival (41.6% vs 36.4%; OR: 1.70; P = 0.003) compared to DDLT, which was not confirmed at sensitivity analysis. CONCLUSION This meta-analysis of the best available evidence (Level 2a) demonstrated that DLT and DDLT have comparable outcomes. As indications for liver transplantation expand, future high-quality research is encouraged to increase the DLT numbers in clinical practice, serving the growing waiting list candidates, with the caveat of uncertain de novo disease transmission risks.
Collapse
Affiliation(s)
- Alessandro Parente
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Flavio Milana
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Fabio Tirotta
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Hwui-Dong Cho
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ki-Hun Kim
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Cabel T, Pascu CM, Ghenea CS, Dumbrava BF, Gunsahin D, Andrunache A, Negoita LM, Panaitescu A, Rinja EM, Pavel C, Plotogea OM, Stan-Ilie M, Sandru V, Mihaila M. Exceptional Liver Transplant Indications: Unveiling the Uncommon Landscape. Diagnostics (Basel) 2024; 14:226. [PMID: 38275473 PMCID: PMC10813978 DOI: 10.3390/diagnostics14020226] [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: 12/06/2023] [Revised: 01/14/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation represents the definitive intervention for various etiologies of liver failure and encompasses a spectrum of rare indications crucial to understanding the diverse landscape of end-stage liver disease, with significantly improved survival rates over the past three decades. Apart from commonly encountered liver transplant indications such as decompensated cirrhosis and liver cancer, several rare diseases can lead to transplantation. Recognition of these rare indications is essential, providing a lifeline to individuals facing complex liver disorders where conventional treatments fail. Collaborative efforts among healthcare experts lead not only to timely interventions but also to the continuous refinement of transplant protocols. This continued evolution in transplant medicine promises hope for those facing diverse and rare liver diseases, marking a paradigm shift in the landscape of liver disease management.
Collapse
Affiliation(s)
- Teodor Cabel
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Cristina Madalina Pascu
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
| | - Catalin Stefan Ghenea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Bogdan Florin Dumbrava
- Department of Gastroenterology, “Sf. Ioan” Emergency Hospital, 014461 Bucharest, Romania
| | - Deniz Gunsahin
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Andreea Andrunache
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
| | - Livia-Marieta Negoita
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Afrodita Panaitescu
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Ecaterina Mihaela Rinja
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Christopher Pavel
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Oana-Mihaela Plotogea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Madalina Stan-Ilie
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Vasile Sandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Mariana Mihaila
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
| |
Collapse
|
3
|
Razvi Y, Porcari A, Di Nora C, Patel RK, Ioannou A, Rauf MU, Masi A, Law S, Chacko L, Rezk T, Ravichandran S, Gilbertson J, Rowczenio D, Blakeney IJ, Kaza N, Hutt DF, Lachmann H, Wechalekar A, Moody W, Lim S, Chue C, Whelan C, Venneri L, Martinez-Naharro A, Merlo M, Sinagra G, Livi U, Hawkins P, Fontana M, Gillmore JD. Cardiac transplantation in transthyretin amyloid cardiomyopathy: Outcomes from three decades of tertiary center experience. Front Cardiovasc Med 2023; 9:1075806. [PMID: 36741843 PMCID: PMC9894650 DOI: 10.3389/fcvm.2022.1075806] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023] Open
Abstract
Aims Transthyretin cardiac amyloidosis (ATTR-CM) is a progressive and fatal cardiomyopathy. Treatment options in patients with advanced ATTR-CM are limited to cardiac transplantation (CT). Despite case series demonstrating comparable outcomes with CT between patients with ATTR-CM and non-amyloid cardiomyopathies, ATTR-CM is considered to be a contraindication to CT in some centers, partly due to a perceived risk of amyloid recurrence in the allograft. We report long-term outcomes of CT in ATTR-CM at two tertiary centers. Materials and methods and Results We retrospectively evaluated ATTR-CM patients across two tertiary centers who underwent transplantation between 1990 and 2020. Pre-transplantation characteristics were determined and outcomes were compared with a cohort of non-transplanted ATTR-CM patients. Fourteen (12 male, 2 female) patients with ATTR-CM underwent CT including 11 with wild-type ATTR-CM and 3 with variant ATTR-CM (ATTRv). Median age at CT was 62 years and median follow up post-CT was 66 months. One, three, and five-year survival was 100, 92, and 90%, respectively and the longest surviving patient was Censored > 19 years post CT. No patients had recurrence of amyloid in the cardiac allograft. Four patients died, including one with ATTRv-CM from complications of leptomeningeal amyloidosis. Survival among the cohort of patients who underwent CT was significantly prolonged compared to UK patients with ATTR-CM generally (p < 0.001) including those diagnosed under age 65 years (p = 0.008) or with early stage cardiomyopathy (p < 0.001). Conclusion CT is well-tolerated, restores functional capacity and improves prognosis in ATTR-CM. The risk of amyloid recurrence in the cardiac allograft appears to be low.
Collapse
Affiliation(s)
- Yousuf Razvi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Aldostefano Porcari
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Rishi K. Patel
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Adam Ioannou
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Muhammad U. Rauf
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ambra Masi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Steven Law
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Liza Chacko
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Tamer Rezk
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Sriram Ravichandran
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Janet Gilbertson
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Dorota Rowczenio
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Iona J. Blakeney
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | | | - David F. Hutt
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Helen Lachmann
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Colin Chue
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Lucia Venneri
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ana Martinez-Naharro
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marco Merlo
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Ugolino Livi
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Philip Hawkins
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Julian D. Gillmore
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| |
Collapse
|
4
|
Theodorakakou F, Fotiou D, Dimopoulos MA, Kastritis E. Solid Organ Transplantation in Amyloidosis. Acta Haematol 2020; 143:352-364. [PMID: 32535598 DOI: 10.1159/000508262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
Amyloidosis comprises a diverse group of diseases characterized by misfolding of precursor proteins which eventually form amyloid aggregates and preceding intermediaries, which are deposited in target tissues causing progressive organ damage. In all forms of amyloidosis, vital organs may fail; depending on the specific amyloidosis type, this may occur rapidly or progress slowly. Beyond therapies to reduce the precursor protein (chemotherapy for light chain [AL] amyloidosis, anti-inflammatory therapy in serum A amyloid-osis [AA], and antisense RNA therapy in transthyretin amyloidosis [ATTR]), organ transplantation may also be a means to reduce amyloidogenic protein, e.g., in types of amyloid-osis in which the variant precursor is produced by the liver. Heart transplantation is a life-saving approach to the treatment of patients with advanced cardiac amyloidosis; however, amyloidosis may still be considered a contraindication to the procedure despite data supporting improved outcomes, similar to patients with other indications. Kidney transplantation is associated with particularly favorable outcomes in patients with amyloidosis, especially if the precursor protein has been eliminated. Overall, outcomes of solid organ transplantation are improving, but more data are needed to refine the selection criteria and the timing for organ transplantation, which should be performed in highly experienced centers involving multidisciplinary teams with close patient follow-up to detect amyloid recurrence.
Collapse
Affiliation(s)
- Foteini Theodorakakou
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A Dimopoulos
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece,
| |
Collapse
|
5
|
Martin AK, Ripoll JG, Wilkey BJ, Jayaraman AL, Fritz AV, Ratzlaff RA, Ramakrishna H. Analysis of Outcomes in Heart Transplantation. J Cardiothorac Vasc Anesth 2020; 34:551-561. [DOI: 10.1053/j.jvca.2019.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022]
|
6
|
Abstract
"Cardiac amyloidosis" is the term commonly used to reflect the deposition of abnormal protein amyloid in the heart. This process can result from several different forms, most commonly from light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis, which in turn can represent wild-type (ATTRwt) or genetic form. Regardless of the origin, cardiac involvement is usually associated with poor prognosis, especially in AL amyloidosis. Although several treatment options, including chemotherapy, exist for different forms of the disease, cardiac transplantation is increasingly considered. However, high mortality on the transplantation list, typical for patients with amyloidosis, and suboptimal post-transplant outcomes are major issues. We are reviewing the literature and summarizing pros and cons of listing patients with amyloidosis for cardiac or combine organ transplant, appropriate work-up, and intermediate and long-term outcomes. Both AL and ATTR amyloidosis are included in this review.
Collapse
|
7
|
Choi HI, Yun TJ, Jung SH, Lee JW, Song GW, Lee SG, Kim KM, Kim JJ. Combined Heart and Liver Transplantation: The Asan Medical Center Experience. KOREAN JOURNAL OF TRANSPLANTATION 2017. [DOI: 10.4285/jkstn.2017.31.2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hyo-In Choi
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
8
|
Navaratnam M, Ng A, Williams GD, Maeda K, Mendoza JM, Concepcion W, Hollander SA, Ramamoorthy C. Perioperative management of pediatric en-bloc combined heart-liver transplants: a case series review. Paediatr Anaesth 2016; 26:976-86. [PMID: 27402424 DOI: 10.1111/pan.12950] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Combined heart and liver transplantation (CHLT) in the pediatric population involves a complex group of patients, many of whom have palliated congenital heart disease (CHD) involving single ventricle physiology. OBJECTIVE The purpose of this study was to describe the perioperative management of pediatric patients undergoing CHLT at a single institution and to identify management strategies that may be used to optimize perioperative care. METHODS We did a retrospective database review of all patients receiving CHLT at a children's hospital between 2006 and 2014. Information collected included preoperative characteristics, intraoperative management, blood transfusions, and postoperative morbidity and mortality. RESULTS Five pediatric CHLTs were performed over an 8-year period. All patients had a history of complex CHD with multiple sternotomies, three of whom had failing Fontan physiology. Patient age ranged from 7 to 23 years and weight from 29.5 to 68.5 kg. All CHLTs were performed using an en-bloc technique where both the donor heart and liver were implanted together on cardiopulmonary bypass (CPB). The median operating room time was 14.25 h, median CPB time was 3.58 h, and median donor ischemia time was 4.13 h. Patients separated from CPB on dopamine, epinephrine, and milrinone infusions and two required inhaled nitric oxide. All patients received a massive intraoperative blood transfusion post CPB with amounts ranging from one to three times the patient's estimated blood volume. The patient who required the most transfusions was in decompensated heart and liver failure preoperatively. Four of the five patients received an antifibrinolytic agent as well as a procoagulant (prothrombin complex concentrate or recombinant activated Factor VII) to assist with hemostasis. There were no 30-day thromboembolic events detected. Postoperatively the median length of mechanical ventilation, ICU stay and stay to hospital discharge was 4, 8, and 37 days, respectively. All patients are alive and free from allograft rejection at this time. CONCLUSION Combined heart and liver transplantation in the pediatric population involves a complex group of patients with unique perioperative challenges. Successful management starts with thorough preoperative planning and communication and involves strategies to deal with massive intraoperative hemorrhage and coagulopathy in addition to protecting and supporting the transplanted heart and liver and meticulous surgical technique. An integrated multidisciplinary team approach is the cornerstone for successful outcomes.
Collapse
Affiliation(s)
- Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ann Ng
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Julianne M Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - Chandra Ramamoorthy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| |
Collapse
|
9
|
Omóbòwálé TO, Oyagbemi AA, Adejumobi OA, Orherhe EV, Amid AS, Adedapo AA, Nottidge HO, Yakubu MA. Preconditioning with Azadirachta indica ameliorates cardiorenal dysfunction through reduction in oxidative stress and extracellular signal regulated protein kinase signalling. J Ayurveda Integr Med 2016; 7:209-217. [PMID: 27894590 PMCID: PMC5192285 DOI: 10.1016/j.jaim.2016.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Azadirachta indica is widely distributed in Africa, Asia and other tropical parts of the world. A. indica (AI) is traditionally used for the treatment of several conditions including cancer, hypertension, heart diseases and skin disorders. Intestinal ischaemia-reperfusion is a common pathway for many diseases and may lead to multiple organ dysfunction syndrome and death. OBJECTIVE In this study, we investigated the ameliorative effects of AI on intestinal ischaemia-reperfusion injury-induced cardiorenal dysfunction. MATERIALS AND METHODS Sixty rats were divided into 6 groups; each containing 10. Corn oil was orally administered to group A (control) rats for 7 days without intestinal ischaemia-reperfusion injury. Group B underwent intestinal ischaemia-reperfusion injury (IIRI) without any pre-treatment. Groups C, D, E and F were pre-treated orally for 7 days with 100 mg/kg AI (100 and (200 mg/kg) vitamin C (100 and 200 mg/kg) respectively and thereafter underwent IIRI on the 8th day. RESULTS The cardiac and renal hydrogen peroxide increased significantly whereas serum xanthine oxidase and myeloperoxidase levels were significantly elevated (p < 0.05) in IIRI only when compared to the control. The cardiac and renal reduced glutathione, glutathione peroxidase, protein thiol, non-protein thiol and serum nitric oxide (NO) decreased (p < 0.05) significantly following IIRI. Immunohistochemical evaluation of cardiac and renal tissues showed reduced expressions of the extracellular signal regulated kinase (ERK1/2) in rats with IIRI only. However, pre-treatment with A. indica and vitamin C significantly reduced markers of oxidative stress and inflammation together with improvement in antioxidant status. Also, reduced serum NO level was normalised in rats pre-treated with A. indica and vitamin C with concomitant higher expressions of cardiac and renal ERK1/2. CONCLUSIONS Together, A. indica and vitamin C prevented IRI-induced cardiorenal dysfunction via reduction in oxidative stress, improvement in antioxidant defence system and increase in the ERK1/2 expressions. Therefore, A. indica can be a useful chemopreventive agent in the prevention and treatment of conditions associated with intestinal ischaemia-reperfusion injury.
Collapse
Affiliation(s)
| | - Ademola Adetokunbo Oyagbemi
- Departments of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Nigeria.
| | | | - Eguonor Vivian Orherhe
- Department of Veterinary Medicine, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
| | - Adetayo Sadudeen Amid
- Department of Veterinary Surgery and Reproduction, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
| | - Adeolu Alex Adedapo
- Departments of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
| | - Helen Olubukola Nottidge
- Department of Veterinary Medicine, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
| | - Momoh Audu Yakubu
- Department of Environmental and Interdisciplinary Sciences, College of Science, Technology and Engineering, Texas Southern University, 3100 Cleburne Avenue, Houston, TX 77004, USA
| |
Collapse
|
10
|
Ankarcrona M, Winblad B, Monteiro C, Fearns C, Powers ET, Johansson J, Westermark GT, Presto J, Ericzon BG, Kelly JW. Current and future treatment of amyloid diseases. J Intern Med 2016; 280:177-202. [PMID: 27165517 PMCID: PMC4956553 DOI: 10.1111/joim.12506] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There are more than 30 human proteins whose aggregation appears to cause degenerative maladies referred to as amyloid diseases or amyloidoses. These disorders are named after the characteristic cross-β-sheet amyloid fibrils that accumulate systemically or are localized to specific organs. In most cases, current treatment is limited to symptomatic approaches and thus disease-modifying therapies are needed. Alzheimer's disease is a neurodegenerative disorder with extracellular amyloid β-peptide (Aβ) fibrils and intracellular tau neurofibrillary tangles as pathological hallmarks. Numerous clinical trials have been conducted with passive and active immunotherapy, and small molecules to inhibit Aβ formation and aggregation or to enhance Aβ clearance; so far such clinical trials have been unsuccessful. Novel strategies are therefore required and here we will discuss the possibility of utilizing the chaperone BRICHOS to prevent Aβ aggregation and toxicity. Type 2 diabetes mellitus is symptomatically treated with insulin. However, the underlying pathology is linked to the aggregation and progressive accumulation of islet amyloid polypeptide as fibrils and oligomers, which are cytotoxic. Several compounds have been shown to inhibit islet amyloid aggregation and cytotoxicity in vitro. Future animal studies and clinical trials have to be conducted to determine their efficacy in vivo. The transthyretin (TTR) amyloidoses are a group of systemic degenerative diseases compromising multiple organ systems, caused by TTR aggregation. Liver transplantation decreases the generation of misfolded TTR and improves the quality of life for a subgroup of this patient population. Compounds that stabilize the natively folded, nonamyloidogenic, tetrameric conformation of TTR have been developed and the drug tafamidis is available as a promising treatment.
Collapse
Affiliation(s)
- M Ankarcrona
- Department of Neurobiology Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, Huddinge, Sweden
| | - B Winblad
- Department of Neurobiology Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, Huddinge, Sweden
| | - C Monteiro
- Department of Chemistry, The Skaggs Institute for Chemical Biology, La Jolla, CA, USA.,Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - C Fearns
- Department of Chemistry, The Skaggs Institute for Chemical Biology, La Jolla, CA, USA.,Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - E T Powers
- Department of Chemistry, The Skaggs Institute for Chemical Biology, La Jolla, CA, USA
| | - J Johansson
- Department of Neurobiology Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, Huddinge, Sweden
| | - G T Westermark
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - J Presto
- Department of Neurobiology Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, Huddinge, Sweden
| | - B-G Ericzon
- Division of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J W Kelly
- Department of Chemistry, The Skaggs Institute for Chemical Biology, La Jolla, CA, USA.,Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| |
Collapse
|
11
|
Beal EW, Mumtaz K, Hayes D, Whitson BA, Black SM. Combined heart-liver transplantation: Indications, outcomes and current experience. Transplant Rev (Orlando) 2016; 30:261-8. [PMID: 27527917 DOI: 10.1016/j.trre.2016.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 04/06/2016] [Accepted: 07/12/2016] [Indexed: 11/15/2022]
Abstract
Combined heart-liver transplantation is a rare, life-saving procedure that treats complex and often fatal diseases including familial amyloidosis polyneuropathy and late stage congenital heart disease status-post previous repair. There were 159 combined heart-liver transplantations performed between January 1, 1988 and October 3, 2014 in the United States. A multitude of potential techniques to be used for combined heart and liver transplant including: orthotopic heart transplant (OHT) and orthotopic liver transplant (OLT) on full cardiopulmonary bypass (CPB), OHT with CPB and OLT with venovenous bypass (VVB), OHT with CPB and OLT without VVB, en-bloc technique and sequential transplantation. Outcomes of combined heart-liver transplant have been demonstrated to be comparable to outcomes of isolated heart and isolated liver transplant. The liver graft may provide some tolerance of other allografts.
Collapse
Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester M Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Transplantation Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| |
Collapse
|
12
|
Bejar D, Colombo PC, Latif F, Yuzefpolskaya M. Infiltrative Cardiomyopathies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:29-38. [PMID: 26244036 PMCID: PMC4498662 DOI: 10.4137/cmc.s19706] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/05/2015] [Accepted: 03/18/2015] [Indexed: 12/15/2022]
Abstract
Infiltrative cardiomyopathies can result from a wide spectrum of both inherited and acquired conditions with varying systemic manifestations. They portend an adverse prognosis, with only a few exceptions (ie, glycogen storage disease), where early diagnosis can result in potentially curative treatment. The extent of cardiac abnormalities varies based on the degree of infiltration and results in increased ventricular wall thickness, chamber dilatation, and disruption of the conduction system. These changes often lead to the development of heart failure, atrioventricular (AV) block, and ventricular arrhythmia. Because these diseases are relatively rare, a high degree of clinical suspicion is important for diagnosis. Electrocardiography and echocardiography are helpful, but advanced techniques including cardiac magnetic resonance (CMR) and nuclear imaging are increasingly preferred. Treatment is dependent on the etiology and extent of the disease and involves medications, device therapy, and, in some cases, organ transplantation. Cardiac amyloid is the archetype of the infiltrative cardiomyopathies and is discussed in great detail in this review.
Collapse
Affiliation(s)
- David Bejar
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Farhana Latif
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | | |
Collapse
|
13
|
Careddu L, Zanfi C, Pantaleo A, Loforte A, Ercolani G, Cescon M, Alvaro N, Pilato E, Marinelli G, Pinna AD. Combined heart-liver transplantation: a single-center experience. Transpl Int 2015; 28:828-34. [PMID: 25711771 DOI: 10.1111/tri.12549] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/07/2015] [Accepted: 02/20/2015] [Indexed: 11/29/2022]
Abstract
Combined orthotopic heart and liver transplantation (CHLT) is a lifesaving procedure for patients with end-stage heart-liver disease. We reviewed the long-term outcome of patients who have undergone CHLT at the University of Bologna, Italy. Fifteen patients with heart and liver failure were placed on the transplant list between November 1999 and March 2012. The pretransplant cardiac diagnoses were familial amyloidosis in 14 patients and chronic heart failure due to chemotherapy with liver failure due to chronic hepatitis in one patient. CHLT was performed as a single combined procedure in 14 hemodynamically stable patients; there was no peri-operative mortality. The survival rates for the CHLT recipients were 93%, 93%, and 82% at 1 month and 1 and 5 years, respectively. Freedom from graft rejection was 100%, 90%, and 36% at 1, 5, and 10 years, respectively, for the heart graft and 100%, 91%, and 86% for the liver graft. The livers of eight recipients were transplanted as a "domino" with mean overall 1-year survival of 93%. Simultaneous heart and liver transplantation is feasible and was achieved in this extremely sick cohort of patients. By adopting the domino technique, we were able to enlarge the donor cohort and include high-risk patients.
Collapse
Affiliation(s)
- Lucio Careddu
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Chiara Zanfi
- Multiorgan Transplantation Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Pantaleo
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anotonio Loforte
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Multiorgan Transplantation Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Matteo Cescon
- Multiorgan Transplantation Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Nicola Alvaro
- Regional Transplant Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emanuele Pilato
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Marinelli
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Daniele Pinna
- Multiorgan Transplantation Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
14
|
Lladó L, Fabregat J, Ramos E, Baliellas C, Roca J, Casasnovas C. Trasplante cardiaco y hepático secuencial por polineuropatía amiloidótica familiar. Med Clin (Barc) 2014; 142:211-4. [DOI: 10.1016/j.medcli.2013.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/24/2013] [Accepted: 10/24/2013] [Indexed: 10/25/2022]
|
15
|
Schaffer JM, Chiu P, Singh SK, Oyer PE, Reitz BA, Mallidi HR. Combined heart-liver transplantation in the MELD era: do waitlisted patients require exception status? Am J Transplant 2014; 14:647-59. [PMID: 24517245 DOI: 10.1111/ajt.12595] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 10/25/2013] [Accepted: 11/15/2013] [Indexed: 01/25/2023]
Abstract
Combined heart-liver transplant (HLT) is a viable therapy for patients with concomitant end-stage heart and liver failure. Using data from the United Network for Organ Sharing database, we examined the cumulative incidences of transplant and mortality in waitlisted candidates for HLT, isolated heart transplant (HRT) and isolated liver transplant (LIV) in the Model for End-Stage Liver Disease era. The incidence of waitlist mortality was higher in HLT candidates than in HRT candidates (p = 0.001, 26% vs. 12% at 1 year) or LIV candidates (p = 0.005, 26% vs. 14% at 1 year). These differences persisted after stratifying by disease severity. Posttransplant survival was not significantly different between HLT and HRT recipients or between HLT and LIV recipients. In a multivariable model, undergoing HLT was associated with enhanced survival for HLT candidates (hazard ratio, 0.41; confidence interval, 0.21-0.79; p = 0.008), but undergoing HRT alone was not. Interestingly, 90% of HLT recipients were allocated an organ locally, compared to 60% of HRT candidates and 73% of LIV candidates (both p < 0.001). These data suggest that the current cardiac and liver allocation systems may underestimate the risk of death for patients with concomitant end-stage heart and liver failure on the HLT waitlist.
Collapse
Affiliation(s)
- J M Schaffer
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, CA
| | | | | | | | | | | |
Collapse
|
16
|
Esplin BL, Gertz MA. Current Trends in Diagnosis and Management of Cardiac Amyloidosis. Curr Probl Cardiol 2013; 38:53-96. [DOI: 10.1016/j.cpcardiol.2012.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
17
|
Nagpal AD, Chamogeorgakis T, Shafii AE, Hanna M, Miller CM, Fung J, Gonzalez-Stawinski GV. Combined Heart and Liver Transplantation: The Cleveland Clinic Experience. Ann Thorac Surg 2013; 95:179-82. [DOI: 10.1016/j.athoracsur.2012.09.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 08/29/2012] [Accepted: 09/04/2012] [Indexed: 11/29/2022]
|
18
|
Nelson LM, Penninga L, Sander K, Hansen PB, Villadsen GE, Rasmussen A, Gustafsson F. Long-term outcome in patients treated with combined heart and liver transplantation for familial amyloidotic cardiomyopathy. Clin Transplant 2012; 27:203-9. [DOI: 10.1111/ctr.12053] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - Luit Penninga
- Department of Surgical Gastroenterology; Rigshospitalet; Copenhagen; Denmark
| | - Kaare Sander
- The Heart Centre; Rigshospitalet; Copenhagen; Denmark
| | | | | | - Allan Rasmussen
- Department of Surgical Gastroenterology; Rigshospitalet; Copenhagen; Denmark
| | | |
Collapse
|
19
|
Benson MD. Liver transplantation and transthyretin amyloidosis. Muscle Nerve 2012; 47:157-62. [PMID: 23169427 DOI: 10.1002/mus.23521] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2012] [Indexed: 12/20/2022]
Abstract
Liver transplantation as a specific treatment of transthyretin amyloidosis was first performed in 1990. The rationale for this treatment was that removal of the source (liver) of the amyloid precursor protein (mutated transthyretin) would stop progression of the disease. Indeed, after orthotopic liver transplantation (OLT), mutant transthyretin (TTR) is rapidly cleared from circulation. In the last 20 years, >2000 familial amyloidotic polyneuropathy (FAP) patients have received liver transplants. For these patients, prospective monitoring has shown prolongation of life compared with FAP patients who have not undergone liver transplantation. The most favorable results have been for FAP patients with the Val30Met TTR mutation. Less favorable results have been seen for patients with other TTR mutations where progression of amyloid tissue deposition has been documented as the result of amyloid fibril formation from normal (wild-type) TTR. Although it is obvious that OLT has benefited many FAP patients, there remains a need for further therapies.
Collapse
Affiliation(s)
- Merrill D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| |
Collapse
|
20
|
Cannon RM, Hughes MG, Jones CM, Eng M, Marvin MR. A review of the United States experience with combined heart-liver transplantation. Transpl Int 2012; 25:1223-8. [PMID: 22937819 DOI: 10.1111/j.1432-2277.2012.01551.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Since first described by Starzl, combined heart and liver transplantation (CHLT) has been a relatively rare event, although utilization has increased in the past decade. This study was undertaken to review the United States experience with this procedure; UNOS data on CHLT was reviewed. CHLT was compared with liver transplantation alone and heart transplantation alone in terms of acute rejection within 12 months, graft survival, and patient survival. Survival was calculated according to Kaplan-Meier and Cox proportional hazards. Continuous variables were compared using Student's t-test and categorical variables with chi-squared. Between 1987 and 2010, there were 97 reported cases of CHLT in the United States. Amyloidosis was the most common indication for both heart (n = 26, 26.8%) and liver (n = 27, 27.8%) transplantation in this cohort. Liver graft survival in the CHLT cohort at 1, 5, and 10 years was 83.4%, 72.8%, and 71.0%, whereas survival of the cardiac allograft was 83.5%, 73.2%, and 71.5%. This was similar to graft survival in liver alone transplantation (79.4%, 71.0%, 65.1%; P = 0.894) and heart transplantation alone (82.6%, 71.9%, 63.2%; P = 0.341). CHLT is a safe and effective procedure, with graft survival rates similar to isolated heart and isolated liver transplantation.
Collapse
Affiliation(s)
- Robert M Cannon
- Division of Transplantation, Department of Surgery, University of Louisville, Louisville, KY 40202, USA
| | | | | | | | | |
Collapse
|
21
|
Rauchfuss F, Breuer M, Dittmar Y, Heise M, Bossert T, Hekmat K, Settmacher U. Implantation of the liver during reperfusion of the heart in combined heart-liver transplantation: own experience and review of the literature. Transplant Proc 2011; 43:2707-2713. [PMID: 21911150 DOI: 10.1016/j.transproceed.2011.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 04/19/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND There are only a few reports about combined heart-liver transplantations. The surgical techniques differ widely, ranging from sequential implantation of the organs to simultaneous transplantations. We report our experience with simultaneous, combined heart-liver transplantations without using a veno-venous bypass demonstrating that this is a feasible surgical technique. METHODS Since 2005, we performed 4 combined heart-liver transplantations by implanting the liver during the reperfusion period of the newly implanted heart. We retrospectively reviewed patient clinical data and outcomes. RESULTS The mean operative time was 534 ± 247 minutes and the ischemia times for heart and liver were 190 ± 72 minutes (cold ischemia time for the heart), 98 ± 96 minutes (warm ischemia time for the heart), 349 ± 101 minutes (cold ischemia time for the liver), and 36.25 ± 3.5 minutes (warm ischemia time for the liver). Three patients were discharged from the hospital after an uneventful clinical course. One patient died due to multi-organ failure during the intensive care unit stay on the 23rd postoperative day. CONCLUSION We suggest that combined, simultaneous heart-liver transplantation without veno-venous bypass is a feasible surgical technique.
Collapse
Affiliation(s)
- F Rauchfuss
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University Jena, Jena, Germany.
| | | | | | | | | | | | | |
Collapse
|
22
|
Barreiros AP, Post F, Hoppe-Lotichius M, Linke RP, Vahl CF, Schäfers HJ, Galle PR, Otto G. Liver transplantation and combined liver-heart transplantation in patients with familial amyloid polyneuropathy: a single-center experience. Liver Transpl 2010; 16:314-23. [PMID: 20209591 DOI: 10.1002/lt.21996] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Liver transplantation (LT) is the only curative option for patients with familial amyloid polyneuropathy (FAP) at present. Twenty patients with FAP underwent LT between May 1998 and June 2007. Transthyretin mutations included predominantly the Val30Met mutation but also 10 other mutations. Seven patients received a pacemaker prior to LT, and because of impairment of mechanical cardiac function, 4 combined heart-liver transplants were performed, 1 simultaneously and 3 sequentially. The first patient, who underwent simultaneous transplantation, died. Seven patients died after LT, with 5 dying within the first year after transplantation. The causes of death were cardiac complications (4 patients), infections (2 patients), and malnutrition (1 patient). One-year survival was 75.0%, and 5-year survival was 64.2%. Gly47Glu and Leu12Pro mutations showed an aggressive clinical manifestation: 2 patients with the Gly47Glu mutation, the youngest patients of all the non-Val30Met patients, suffered from severe cardiac symptoms leading to death despite LT. Two siblings with the Leu12Pro mutation, who presented only with grand mal seizures, died after LT because of sepsis. In conclusion, the clinical course in patients with FAP is very variable. Cardiac symptoms occurred predominantly in patients with non-Val30Met mutations and prompted combined heart-liver transplantation in 4 patients. Although early LT in Val30Met is indicated in order to halt the typical symptoms of polyneuropathy, additional complications occurring predominantly with other mutations may prevail and lead to life-threatening complications or a fatal outcome. Combined heart-liver transplantation should be considered in patients with restrictive cardiomyopathy.
Collapse
Affiliation(s)
- Ana-Paula Barreiros
- Department of Internal Medicine I, Johannes Gutenberg University, Langenbeckstrasse 1, 55101 Mainz, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Combined heart and liver transplantation on cardiopulmonary bypass: report of four cases. Can J Anaesth 2010; 57:355-60. [DOI: 10.1007/s12630-010-9263-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022] Open
|
24
|
Abstract
Amyloidosis is a clinical disorder caused by the extracellular deposition of misfolded, insoluble aggregated protein with a characteristic ss pleated sheet configuration that produces apple-green birefringence under polarized light when stained with Congo red dye. The spectrum of organ involvement can include the kidneys, heart, blood vessels, central and peripheral nervous systems, liver, intestines, lungs, eyes, skin, and bones. Cardiovascular amyloidosis can be primary, a part of systemic amyloidosis, or the result of chronic systemic disease elsewhere in the body. The most common presentations are congestive heart failure because of restrictive cardiomyopathy and conduction abnormalities. Recent developments in imaging techniques and extracardiac tissue sampling have minimized the need for invasive endomyocardial biopsy for amyloidosis. Cardiac amyloidosis management will vary depending on the subtype but consists of supportive treatment of cardiac related symptoms and reducing the amyloid fibrils formation attacking the underlying disease. Despite advances in treatment, the prognosis for patients with amyloidosis is still poor and depends on the underlying disease type. Early diagnosis of cardiac amyloidosis may improve outcomes but requires heightened suspicion and a systematic clinical approach to evaluation. Delays in diagnosis, uncertainties about the relative merits of available therapies, and difficulties in mounting large-scale clinical trials in rare disorders combine to keep cardiac amyloidosis a challenging problem. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
Collapse
Affiliation(s)
- Harit V Desai
- Division of Cardiology, Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY 10595, USA
| | | | | | | |
Collapse
|
25
|
Abstract
BACKGROUND Simultaneous combined orthotopic heart and liver transplantation (CHLTx) remains a lifesaving procedure for the patients suffering from coincident end-stage heart and liver disease and several metabolic disorders. We analyze the long-term outcome of the patients undergoing CHLTx. METHODS Between January 1992 and May 2007, 15 CHLTx were attempted at the Mayo Clinic including two combined heart, liver, and kidney transplantations and one combined heart, lung, and liver transplantations. Pretransplant cardiac diagnoses were familial amyloidosis (11), hemochromatosis (1), restrictive cardiomyopathy and cardiac cirrhosis (1), previously operated congenital heart disease and cardiac cirrhosis (1), and primary pulmonary hypertension with primary biliary cirrhosis (1). RESULTS Heart and liver transplantation were performed as a single combined procedure in 13 (93%) hemodynamically stable patients, and there was no perioperative mortality. Survival rates for the CHLTx recipients at 1 year, 5 years, and 10 years were 100%, 75%, and 60%, respectively, and did not differ from survival after isolated heart transplantation (93%, 83%, and 65%, respectively, P=0.39). Freedom from cardiac allograft rejection (ISHLT > or =grade 2) for CHLTx was 83% at 1 month, did not change with time, and was lower than after isolated heart transplantation (P=0.02). At the mean follow-up of 61.6+/-53.6 months, normal left ventricular ejection fraction and good liver allograft function were demonstrated. Three patients developed end-stage renal failure secondary to calcineurin nephrotoxicity. CONCLUSION Simultaneous heart and liver transplantation is feasible and achieved excellent results for selected patients.
Collapse
|
26
|
Petre S, Shah IA, Gilani N. Review article: gastrointestinal amyloidosis - clinical features, diagnosis and therapy. Aliment Pharmacol Ther 2008; 27:1006-16. [PMID: 18363891 DOI: 10.1111/j.1365-2036.2008.03682.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amyloidosis is one of the unusual diseases about which a physician may not think when it is affecting the patient. During the last three decades, there has been an enormous progress in the understanding of the chemical nature, classification, pathogenesis, clinical features, diagnostic measures and therapy of this disorder. AIM To provide an updated review of amyloidosis affecting the gastrointestinal tract. METHODS Review of current medical literature. RESULTS Amyloid proteins (irrespective of the type) can deposit in various parts of the gastrointestinal tract and liver resulting in symptoms of abdominal pain, dysmotility, diarrhoea, gastrointestinal bleeding, hepatomegaly and even portal hypertension with its associated complications. Definitive diagnosis can only be made by histological examination of the affected organ. Disease modifying treatment with high-dose chemotherapy followed by autologous stem-cell transplantation has shown promise. Liver transplantation is an option for a select group of patients. CONCLUSIONS Suspicion of gastrointestinal amyloidosis in patients without known history of amyloidosis is difficult, but should be considered in those older than 30 years with unexplained diarrhoea, weight loss, autonomic dysfunction, malabsorption or proteinuria. While most gastrointestinal complications are managed symptomatically, causal therapy is reserved for a select few from various subtypes of this disorder.
Collapse
Affiliation(s)
- S Petre
- Department of Gastroenterology, Carl T. Hayden VA Medical Center, Phoenix, AZ 85012, USA
| | | | | |
Collapse
|
27
|
Barrio IM, Mtnez de Guereñu MA, Real MI, Del Campo I, Pérez-Cerdá F, Moreno E. Anesthetic management of a combined heart and liver transplantation in an amyloidotic patient: a case report. Transplant Proc 2007; 39:2458-9. [PMID: 17889217 DOI: 10.1016/j.transproceed.2007.07.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Few cases of combined heart and liver transplantation (CHLT) have been reported for familial amyloidosis. Our first CHLT was performed on a female patient with familial amyloidosis due to a genetic defect in transthyretin, characterized by deposition of amyloid in various organs and tissues. This disease produced autonomic heart dysfunction that preceded the development of clinical manifestations and may be an important factor in determining the optimal timing for liver transplantation. CHLT can be performed successfully, even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications, and worsening of extracardiac and extrahepatic symptoms. Our patient presented severe cardiac dysfunction requiring CHLT. The operative technique is far from being consolidated, despite this, both organs were transplanted in the same day with 2 hours in the intensive care unit (ICU) between surgeries. The outcome of both organs has been favorable. The amyloidotic liver was transplanted to another patient, a sequential (domino) transplantation.
Collapse
Affiliation(s)
- I M Barrio
- Department of Anesthesiology, Hospital Doce de Octubre, Madrid, Spain.
| | | | | | | | | | | |
Collapse
|
28
|
Augustin S, Llige D, Andreu A, González A, Genescà J. Familial amyloidosis in a large Spanish kindred resulting from a D38V mutation in the transthyretin gene. Eur J Clin Invest 2007; 37:673-8. [PMID: 17635579 DOI: 10.1111/j.1365-2362.2007.01836.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transthyretin amyloidosis, also known as familial amyloidotic polyneuropathy, is an autosomal dominant disorder that results from a mutation in the gene encoding plasma transthyretin (TTR). Distinct clinical presentations of the disease have been related so far to different point mutations, polyneuropathy being the predominant clinical feature in the majority of cases. Nevertheless, misdiagnosis of familial forms of amyloidosis is still common. MATERIALS AND METHODS A 71-year-old man was admitted to our hospital for heart failure. He had been previously diagnosed of AL amyloidosis with predominant polyneuropathic, cardiac and laryngeal involvement on the basis of clinical data and amyloid deposition in tissue specimens. During admission, suspicion of transthyretin amyloidosis was raised due to the absence of renal involvement, monoclonal protein and plasma cell dyscrasia. Complete clinical evaluation and sequence analysis of the TTR gene of the patient and his family were performed. RESULTS Gene sequence analysis revealed a rare A-to-T transition in exon 2 resulting in the substitution of aspartic acid by valine at position 38 (D38V) in the index case and in two other members of the family. Clinical study of the kindred showed a predominant late-onset heart involvement with variable polyneuropathy. CONCLUSIONS Here we report a large pedigree from Spain with three members affected by a severe late-onset form of amyloidosis due to a rare D38V TTR mutation. The variations on the natural history of this form of amyloidosis may have important consequences on genetic counselling, follow-up, and therapeutic approaches for these patients.
Collapse
Affiliation(s)
- S Augustin
- Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | | | | | | | | |
Collapse
|
29
|
Garibaldi B, Zaas D. An unusual case of cardiac amyloidosis. J Gen Intern Med 2007; 22:1047-52. [PMID: 17447098 PMCID: PMC2219738 DOI: 10.1007/s11606-007-0207-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 03/17/2007] [Accepted: 03/29/2007] [Indexed: 11/27/2022]
Abstract
Cardiac amyloidosis can result from any of the systemic amyloidoses. The disease is often characterized by a restrictive cardiomyopathy although the particular signs and symptoms depend in part on the underlying cause. In addition to managing the symptoms of heart failure, treatment options vary depending on the etiology of amyloid deposition. It is therefore critical to identify the cause of cardiac amyloidosis before initiating definitive therapy. We present a patient with presumed immunoglobulin (AL) amyloidosis who had a circulating lambda monoclonal protein, but a bone marrow biopsy with kappa predominant plasma cells. This unusual finding called into question the diagnosis of AL amyloidosis and highlights the importance and difficulty of determining the cause of cardiac amyloid deposition before initiating treatment. We review the different forms of cardiac amyloidosis and propose a diagnostic algorithm to help identify the etiology of cardiac amyloid deposition before beginning therapy.
Collapse
Affiliation(s)
- Brian Garibaldi
- Department of Medicine, The Johns Hopkins Hospital, 601 North Caroline Street, Baltimore, Maryland 21287, USA.
| | | |
Collapse
|
30
|
Bernier PL, Grenon M, Ergina P, Schricker T, Chaudhury P, Metrakos P, Lachapelle K. Combined Simultaneous Heart and Liver Transplantation With Complete Cardiopulmonary Bypass Support. Ann Thorac Surg 2007; 83:1544-5. [PMID: 17383383 DOI: 10.1016/j.athoracsur.2006.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Revised: 08/27/2006] [Accepted: 10/04/2006] [Indexed: 10/23/2022]
Abstract
Despite its initial description more than 20 years ago, combined orthotopic heart and liver transplantation is still performed infrequently. We report a 53-year-old man with familial hypertrophic restrictive cardiomyopathy who presented with right heart failure and end-stage liver failure and required combined orthotopic heart and liver transplantation. Rather then using a staged approach, the surgery was performed using a technique of simultaneous implantation supported by cardiopulmonary bypass. The relative merits of using a simultaneous approach are discussed. The patient had an uneventful postoperative course and went home on postoperative day 14.
Collapse
Affiliation(s)
- Pierre-Luc Bernier
- Division of Cardiothoracic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | | | | | | | | | | | | |
Collapse
|
31
|
Maurer MS, Raina A, Hesdorffer C, Bijou R, Colombo P, Deng M, Drusin R, Haythe J, Horn E, Lee SH, Marboe C, Naka Y, Schulman L, Scully B, Shapiro P, Prager K, Radhakrishnan J, Restaino S, Mancini D. Cardiac Transplantation Using Extended-Donor Criteria Organs for Systemic Amyloidosis Complicated by Heart Failure. Transplantation 2007; 83:539-45. [PMID: 17353770 DOI: 10.1097/01.tp.0000255567.80203.bd] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Systemic amyloidosis complicated by heart failure is associated with high cardiovascular morbidity and mortality. Heart transplantation for patients with systemic amyloidosis is controversial due to recurrence of disease in the transplanted organ or progression of disease in other organs. METHODS All patients with systemic amyloidosis and heart failure referred for heart transplant evaluation from 1997 to 2004 were included in this retrospective cohort analysis. An interdisciplinary protocol for cardiac transplantation using extended-donor criteria organs, followed in 6 months by either high-dose chemotherapy and stem cell transplantation for patients with primary (AL) or by orthotopic liver transplantation for familial (ATTR) amyloidosis, was developed. Survival of the transplanted amyloid cohort was compared to survival of those amyloid patients not transplanted and to patients transplanted for other indications. RESULTS A total of 25 patients with systemic amyloidosis and heart failure were included in the study; 12 patients received heart transplants. Amyloid heart transplant recipients were more likely female (58% vs. 8%, P=0.02) and had lower serum creatinine (1.3+/-0.5 vs. 2.0+/-0.7 mg/dL, P=0.01) than nontransplanted amyloid patients. Survival at 1-year after heart transplant evaluation was higher among transplanted patients (75% vs. 23%) compared to patients not transplanted (P=0.001). Short-term survival posttransplant did not differ between transplanted amyloid patients and contemporaneous standard and extended-donor criteria heart transplant patients (P=0.65). CONCLUSIONS Cardiac transplantation for amyloid patients with extended-donor criteria organs followed by either stem cell or liver transplantation is associated with improved survival compared to patients not transplanted. Short- to intermediate-term survival is similar to patients receiving heart transplantation for other indications. This clinical management strategy provides cardiac amyloid patients a novel therapeutic option.
Collapse
Affiliation(s)
- Mathew S Maurer
- Department of Medicine, Divisions of Cardiology, Columbia University Medical Center, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Barshes NR, Udell IW, Joyce DL, Southard RE, O'Mahony CA, Goss JA. A Pooled Analysis of Posttransplant Survival Following Combined Heart-Liver Transplantation. Transplantation 2007; 83:95-8. [PMID: 17220801 DOI: 10.1097/01.tp.0000243731.29657.87] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because no single center has accumulated a large experience with this complex operation, the effectiveness of combined orthotopic heart transplantation (OHT) and orthotopic liver transplantation (OLT) in achieving long-term survival has been unknown. Cases of OHT-OLT were pooled from a U.S. transplant recipient registry and from previously published literature. Aggregate data from these sources was used for survival analysis. Thirty-six patients having undergone OHT-OLT were listed in the national registry; the one- and five-year patient survival rates of these patients were 88% and 78%, respectively. Many patients remain alive at 8+ years after transplantation. An analysis of the pooled results of previously-published cases estimated a one-year patient survival rate of 84%. In selected disease processes, OHT-OLT can correct underlying metabolic deficiencies. While rarely indicated, OHT-OLT is a successful treatment for patients with end-stage heart and liver disease, with survival comparable to that seen after isolated orthotopic heart or orthotopic liver transplantation.
Collapse
Affiliation(s)
- Neal R Barshes
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | | | | | | | | | | |
Collapse
|
33
|
Abstract
Cardiac amyloidosis is a well-known but clinically rare cause of heart failure that has historically been associated with a poor prognosis. Cardiac amyloidosis involves fibril formation from one of several underlying conditions, and the course of illness and prognosis varies among these conditions. Evolving treatment strategies for patients with primary systemic amyloidosis have given this subset of cardiac amyloidosis patients a cause for hope. The identification and appropriate referral of patients in whom this condition is suspected will help to improve the likelihood of successful therapy and long-term survival.
Collapse
Affiliation(s)
- Douglas B Sawyer
- Amyloid Treatment and Research Program, Boston University School of Medicine, 715 Albany Street, K5, Boston, MA 02118, USA
| | | |
Collapse
|
34
|
De Wolf AM. 6/2/06 Perioperative Assessment of the Cardiovascular System in ESLD and Transplantation. Int Anesthesiol Clin 2006; 44:59-78. [PMID: 17033479 DOI: 10.1097/01.aia.0000210818.85287.de] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Andre M De Wolf
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| |
Collapse
|
35
|
Rapezzi C, Perugini E, Salvi F, Grigioni F, Riva L, Cooke RMT, Ferlini A, Rimessi P, Bacchi-Reggiani L, Ciliberti P, Pastorelli F, Leone O, Bartolomei I, Pinna AD, Arpesella G, Branzi A. Phenotypic and genotypic heterogeneity in transthyretin-related cardiac amyloidosis: towards tailoring of therapeutic strategies? Amyloid 2006; 13:143-53. [PMID: 17062380 DOI: 10.1080/13506120600877136] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Transthyretin-related hereditary amyloidosis (ATTR) is genotypically/phenotypically heterogeneous. We investigated myocardial involvement in ATTR in a cohort of patients with a wide range of mutations. Clinical/echocardiographic follow-up of 41 consecutive symptomatic ATTR patients from a single referral center was analyzed according to TTR mutation. Diagnosis was based on histology, immunohistochemistry and genotyping. Median follow up was 40 months (range 8-120). Among the 12 different mutations identified, Val30Met was found in 10 patients and Glu89Gln in seven. Compared with Val30Met, Glu89Gln was associated with higher LV mass index, lower left ventricular ejection fraction and shorter E-wave deceleration time. All Glu89Gln carriers had cardiomyopathy, which was more severe (for left ventricular thickness, left ventricular mass and restrictive pathophysiology) than in the six affected Val30Met patients. Glu89Gln was independently associated with higher risk of major cardiovascular events among cardiomyopathy patients. This follow-up study of ATTR patients carrying a wide range of mutations indicates that (1) cardiac involvement is a very important component of phenotypic expression; and (2) genotype is an important source of heterogeneity in myocardial involvement, with Glu89Gln being associated with a severe, heart-driven prognosis. We think that combined heart-liver transplantation could be considered for Glu89Gln carriers with established, morphologically severe cardiomyopathy.
Collapse
Affiliation(s)
- Claudio Rapezzi
- Institute of Cardiology, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
|
37
|
Delahaye N, Rouzet F, Sarda L, Tamas C, Dinanian S, Plante-Bordeneuve V, Adams D, Samuel D, Merlet P, Syrota A, Slama MS, Le Guludec D. Impact of liver transplantation on cardiac autonomic denervation in familial amyloid polyneuropathy. Medicine (Baltimore) 2006; 85:229-238. [PMID: 16862048 DOI: 10.1097/01.md.0000232559.22098.c3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Familial amyloid polyneuropathy (FAP) is a rare and severe hereditary form of amyloidosis, due to the deposition of a genetic variant transthyretin essentially produced by the liver, and characterized by both sensorimotor and autonomic neuropathy. Liver transplantation (LT) is the most effective treatment to stop the progression of the disease. Cardiac amyloid infiltration is usually associated with cardiac denervation, restrictive cardiomyopathy, conduction disturbances, and sometimes sudden death. Whether the cardiac involvement related to amyloid deposition may be altered after LT remains unclear. We conducted the present study to define the outcome of cardiac involvement after LT in 31 patients with FAP (age, 39 +/- 12 yr). Patients were evaluated before and after LT (24 +/- 15 mo). Cardiac sympathetic denervation was assessed by both iodine-123 metaiodobenzylguanidine (MIBG) scintigraphy and heart rate variability (HRV) analysis. The scintigraphic importance of sympathetic denervation was evaluated globally on planar imaging using heart-to-mediastinum activity ratio (H/M) measured 4 hours after injection, and regionally using single-photon emission tomography (SPET) imaging. Amyloid myocardial infiltration was assessed by echocardiography. Diffuse sympathetic denervation was found when using cardiac MIBG planar imaging in patients evaluated before LT and compared with 12 control subjects (H/M: 1.45 +/- 0.29 vs. 1.98 +/- 0.35, p < 0.001). On SPET images, defects were diffuse in 12 patients and focal in 19 patients, with predominance at the inferior and apical segments. No change in sympathetic innervation was found in patients after LT as assessed either with planar imaging (H/M after LT: 1.46 +/- 0.28, p = not significant vs. H/M before LT) or with SPET imaging. HRV nonspectral indexes showed that the standard deviation of all cycles was significantly lower in patients compared with control subjects, and remained unchanged after LT. Conduction disturbances and ventricular arrhythmias were associated with low cardiac MIBG uptake, and progressed after LT. The left ventricular wall was slightly thickened in patients, and a further increase was observed after LT (posterior wall from 9.2 +/- 1.8 to 10.1 +/- 2.3 mm, p = 0.02; septal wall from 10.6 +/- 2.7 to 12.1 +/- 4, p = 0.046). Neurologic status stabilized in 26 patients, but worsened in the 5 patients who had the most severe cardiac sympathetic denervation before LT as measured by MIBG imaging. The magnitude of the cardiac sympathetic denervation remained stable 2 years after LT in patients with FAP, whereas the cardiac amyloid infiltration progressed. The importance of cardiac sympathetic denervation found in FAP patients before LT was associated with a neurologic worsening after LT.
Collapse
Affiliation(s)
- Nicolas Delahaye
- From Service de Médecine Nucléaire (ND, FR, LS, PM, DLG), Hôpital Bichat, AP-HP, Paris; SHFJ (LS, CT, AS), DRM, DSV-CEA, Orsay; Service de Cardiologie (SD, MSS), Hôpital A. Béclère, AP-HP, Paris; Service de Neurologie (VPB, DA), Hôpital Bicêtre, AP-HP, Paris; Service de Chirurgie Hépatique (DS), Hôpital P. Brousse, AP-HP, Paris, France
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Sakashita N, Ando Y, Haraoka K, Terazaki H, Yamashita T, Nakamura M, Takeya M. Severe congestive heart failure with cardiac liver cirrhosis 10 years after orthotopic liver transplantation for familial amyloidotic polyneuropathy. Pathol Int 2006; 56:408-12. [PMID: 16792551 DOI: 10.1111/j.1440-1827.2006.01978.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Reported herein is an autopsy case of familial amyloidotic polyneuropathy (FAP) with cardiac liver cirrhosis associated with amyloid cardiomyopathy after liver transplantation. At 47 years of age a Japanese woman with a transthyretin Val30Met mutation and sensorimotor polyneuropathy underwent liver transplantation; no postoperative deterioration related to the graft or polyneuropathy occurred. However, cardiovascular dysfunction associated with amyloid deposition gradually worsened. Pacemaker implantation and diuretics were ineffective against the heart failure; 10 years after transplantation the patient died. Autopsy revealed massive pleural and pericardial effusions and amyloid cardiomyopathy, especially in the right atrium and cardiac conduction system. Amyloid deposition was slight in all organs except the heart, but liver cirrhosis with reversed lobulation and centrilobular hemorrhagic necrosis was prominent. There was no histological evidence for chronic liver graft rejection. These findings suggest that liver transplantation effectively stopped amyloid deposition and ameliorated clinical FAP symptoms but that amyloid cardiomyopathy after liver transplantation in advanced clinical stages may lead to severe congestive heart failure and cardiac liver cirrhosis.
Collapse
Affiliation(s)
- Naomi Sakashita
- Department of Cell Pathology, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan.
| | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
More than three decades of clinical experience in cardiac transplantation resulted in the spread of the procedure worldwide with a wealth of knowledge and advancements. Developments included liberalization of recipient and donor selection criteria, improved surgical techniques, novel immunosuppressive drugs and protocols, new rejection surveillance techniques, and better understanding of the pathophysiology of cardiac allograft vasculopathy to direct interventions for prevention and treatment.
Collapse
Affiliation(s)
- Abdulaziz Al-khaldi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA.
| | | |
Collapse
|
40
|
Abstract
PURPOSE OF REVIEW Recent papers relevant to the preoperative evaluation and optimization of patients with severe liver disease will be discussed. The emphasis will be placed on cardiovascular, pulmonary, and renal complications. Other aspects such as preoperative management of hepatitis B and C, other infectious issues, and liver cancer will not be discussed because this rarely involves the anesthesiologist. RECENT FINDINGS Dobutamine stress echocardiography has been the cornerstone of cardiac evaluation of liver transplant candidates. Combining liver transplantation with cardiac procedures has been shown to be feasible. While mild hepatopulmonary syndrome is well-tolerated, severe hepatopulmonary syndrome carries a fairly high mortality rate. New treatment modalities of severe portopulmonary hypertension have been introduced, and may have advantages over epoprostenol administration. Hepatic hydrothorax requires similar therapy to ascites [repeated thoracentesis or paracentesis, and transjugular intrahepatic portosystemic shunt (TIPS)], but refractory hydrothorax may require other interventions. Hepatorenal syndrome may improve by increasing renal blood flow through the use of vasoconstrictors (vasopressin, norepinephrine) in combination with albumin administration. Interventional radiologists can now change the flow through an established TIPS. Hepatic encephalopathy may result in some irreversible changes in the brain. It remains difficult to predict whether a patient with acute fulminant failure will recover spontaneously. Support devices that include hepatocytes show early promising results. The coagulation changes in living donors are incompletely understood. Finally, autonomic neuropathy as a complication of severe liver disease results in more hemodynamic instability. SUMMARY Recent advances in preoperative evaluation and optimization are presented and discussed.
Collapse
Affiliation(s)
- Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611-2908, USA.
| |
Collapse
|
41
|
|