Regression of Tricuspid Valve Regurgitation After Lung Transplant: A Single-Center Experience

BACKGROUND

Although tricuspid regurgitation (TR) is common in candidates for lung transplant, no data or established guidelines exist regarding the need for surgical repair at the time of transplant. We aimed to evaluate the natural course of TR by assessing the incidence and extent of TR regression among patients who did not undergo tricuspid valve repair (TVR) concomitantly with lung transplant.

METHODS

We retrospectively identified adult patients who underwent lung transplant without TVR at our institution from 2001 through 2017. Pretransplant and posttransplant echocardiograms were reviewed to assess severity of TR, tricuspid annular plane systolic excursion, central venous pressure, mean pulmonary arterial pressure, and right ventricular size and function.

RESULTS

Among 553 included patients, 324 (58.7%) were men, the mean (SD) age was 61.9 years (12.7), and 417 (75.4%) had a double lung transplant. TR before transplant was reported as trivial in 265 patients (47.9%), mild in 235 (42.5%), moderate in 40 (7.2%), and severe in 13 (2.4%). After transplant, TR improved significantly overall (P < .001). TR improved in 193 patients: 158 patients (81.9%) by 1 grade and 35 patients (18.1%) by 2 or more grades. Additionally, of 53 patients with pretransplant moderate or severe TR, 44 (83%) had improvement to mild, trivial, or no TR. After transplant, 12 patients (2.2%) had no remaining TR.

CONCLUSION

The severity of TR improved or showed no change in most patients after lung transplant, which obviates the need for TVR among most lung transplant recipients.

Combined cardiac surgery procedures and liver transplant: a single-center experience

OBJECTIVE

Morbidity and mortality rates associated with liver transplant are high for patients with concomitant heart disease. Traditionally, such cases were considered contraindications for transplant. The objective of our study was to assess the outcome of combined surgical approaches.

METHODS

A prospectively maintained database was analyzed of patients undergoing cardiac surgery and liver transplant at our institution. Twelve identified patients underwent combined cardiac operation and liver transplant. A control group was created (n = 24) with the same selection criteria.

RESULTS

Median patient age was 64.94 years in the combined group vs 63.80 in the control, and in both groups, 58% were male. Left ventricular ejection fraction (0.60), body mass index (30.1), and median (range) score of the Model for End-stage Liver Disease (18 [9-33]) were the same in both groups. The cardiac operations combined with liver transplant were coronary artery bypass grafting, valve replacement procedures, and ascending thoracic aortic aneurysm repair. Piggyback liver transplant was performed for all patients. Survival periods of 1, 5, and 10 years for control vs combined cases were 90 vs 62%, 79 vs 55%, and 70 vs 45%, respectively (P = 0.03).

CONCLUSION

Concomitant cardiac procedure and liver transplant is a valid treatment option and should be considered with risk stratification criteria of the patient with end-stage liver disease and cardiac surgical pathologic characteristics.

A Successful Endovascular Treatment of an Ischemic Stroke following Cardiac Surgery

Ischemic stroke following cardiac surgery is one of the devastating complications that surgeons may encounter, and may lead to serious disabilities for the patient. The clinical course of such a complication may be prolonged if it is not treated properly. Making a quick decision when choosing a revascularization method is very helpful in this matter. Effective treatment options are usually limited. Neurointerventional maneuvers have recently emerged as a possible therapeutic modality in this field. We present the case of a 52-year-old woman who had open heart surgery in Queen Alia Heart Institute, Jordan, to replace a severely stenotic rheumatic mitral valve and repair a leaking tricuspid valve. Her surgery went smoothly with no major event. However, she developed a massive ischemic stroke during her recovery period despite being on adequate anticoagulation therapy. Urgent radiological work-up confirmed the diagnosis of ischemic stroke in the territory of the right middle cerebral artery. We chose a neuro-interventional method for her treatment, and mechanical thrombectomy was performed with a successful outcome and no apparent complications.

A Successful Endovascular Treatment of an Ischemic Stroke following Cardiac Surgery

Ischemic stroke following cardiac surgery is one of the devastating complications that surgeons may encounter, and may lead to serious disabilities for the patient. The clinical course of such a complication may be prolonged if it is not treated properly. Making a quick decision when choosing a revascularization method is very helpful in this matter. Effective treatment options are usually limited. Neurointerventional maneuvers have recently emerged as a possible therapeutic modality in this field. We present the case of a 52-year-old woman who had open heart surgery in Queen Alia Heart Institute, Jordan, to replace a severely stenotic rheumatic mitral valve and repair a leaking tricuspid valve. Her surgery went smoothly with no major event. However, she developed a massive ischemic stroke during her recovery period despite being on adequate anticoagulation therapy. Urgent radiological work-up confirmed the diagnosis of ischemic stroke in the territory of the right middle cerebral artery. We chose a neuro-interventional method for her treatment, and mechanical thrombectomy was performed with a successful outcome and no apparent complications.

Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis

BACKGROUND

We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited.

METHODS

A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A random-effect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant.

RESULTS

Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p = 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p = 0.06). Patients undergoing pCABG were 14% (0% to 55%; p = 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p = 0.014), the stroke rates were comparable in both cohorts (p = 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p = 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p = 0.36).

CONCLUSIONS

Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.