RESUMEN
BACKGROUND: Heart transplantation is an established treatment for advanced heart failure. Primary allograft dysfunction (PGD) is reported in up to 40% of transplants and is associated with a poor outcome. METHODS: As part of Heart Evaluation and Retrieval for Transplantation study, an investigation of the assessment of donor hearts for transplantation, we proposed a clinical definition for cardiac PGD comprising severely impaired systolic function affecting one or both ventricles accompanied by hypotension, low cardiac output, and high filling pressures occurring in the first 72 hours (in the absence of hyper acute rejection and technical surgical factors, such as cardiac tamponade). Here, we examine the prospective application of this definition to 290 heart transplants. We compared the clinical outcome of PGD and non-PGD cases. RESULTS: Ninety-four of 290 transplants developed PGD (32.4%). Inotrope use (score) was higher in the PGD group at 24, 48, and 72 hours after transplantation (P < 0.01). In the PGD group, there was a greater requirement for, intra-aortic balloon pump (50% vs 15%, P < 0.01), mechanical support (27% vs 0%, P < 0.01), and renal replacement therapy (61% vs 26%, P < 0.01). Intensive care stay was longer for recipients with PGD (median 14 vs 5 days, P < 0.01) and early mortality was higher (37% vs 4% at 30 days, 42% vs 8% at 1 year, P < 0.01). CONCLUSIONS: In conclusion, our definition of PGD could be applied in a national multicenter study, and the cases it defined had more frequent complications and higher mortality.
Asunto(s)
Gasto Cardíaco Bajo/clasificación , Gasto Cardíaco Bajo/diagnóstico , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/efectos adversos , Disfunción Primaria del Injerto/clasificación , Disfunción Primaria del Injerto/diagnóstico , Terminología como Asunto , Adulto , Gasto Cardíaco Bajo/etiología , Gasto Cardíaco Bajo/fisiopatología , Gasto Cardíaco Bajo/terapia , Cardiotónicos/uso terapéutico , Femenino , Insuficiencia Cardíaca/mortalidad , Trasplante de Corazón/mortalidad , Hemodinámica , Humanos , Unidades de Cuidados Intensivos , Contrapulsador Intraaórtico , Tiempo de Internación , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Disfunción Primaria del Injerto/etiología , Disfunción Primaria del Injerto/mortalidad , Disfunción Primaria del Injerto/fisiopatología , Disfunción Primaria del Injerto/terapia , Estudios Prospectivos , Terapia de Reemplazo Renal , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Reino UnidoRESUMEN
OBJECTIVE: Primary graft failure is the most common cause of mortality early after heart transplantation. The availability of relatively low-cost short-term mechanical support devices has altered the management of primary graft failure but there are few data on clinical outcome. Here, we describe the UK experience with Levitronix CentriMag support following heart transplantation across multiple centres. METHODS: Data for all adult heart transplants and all CentriMag devices used within 30 days of heart transplantation in the UK between November 2003 and July 2008 were collected. Transplant characteristics were compared for those who did and did not receive CentriMag support, and device outcomes and survival rates were summarised. RESULTS: A total of 572 heart transplants were performed in this period. As many as 38 patients (6.6%) were implanted with CentriMag devices for primary graft failure. Four patients received extracorporeal membrane oxygenation concurrently and were excluded from further analysis. There were no significant differences in transplant characteristics between the patients who received CentriMag support and those who did not. Twelve patients were explanted; nine survived but three died shortly afterwards. Five underwent acute retransplantation; two survived and three died. Seventeen patients died on support. The 30-day and 1-year survival rates were 50% (95% confidence interval (CI) 32-65%) and 32% (95% CI 18-48%), respectively. Patients who previously had a bridge-to-transplant ventricular assist device (VAD) had significantly better survival than those who did not (1-year survival 71% vs 22%, p = 0.029). CONCLUSIONS: Primary graft failure remains an important early complication of heart transplantation. Levitronix CentriMag support led to the salvage of 32% of patients with severe allograft failure.
Asunto(s)
Rechazo de Injerto/terapia , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Corazón Auxiliar/estadística & datos numéricos , Adulto , Métodos Epidemiológicos , Femenino , Rechazo de Injerto/epidemiología , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/mortalidad , Corazón Auxiliar/efectos adversos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Terapia Recuperativa/métodos , Donantes de Tejidos , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
Demand for donor hearts exceeds supply, and a significant number of patients die while awaiting transplantation. Within the pool of currently unused potential donor hearts, a proportion may be suitable for transplantation but are declined due to anticipated poor function. Despite current assessment methods, in some donor hearts accepted for transplantation early graft failure develops in the recipient. Current methods of assessment are inadequate, and there is a potential for biomarkers to improve identification of satisfactory hearts for transplantation or hearts destined to fail in the recipient. Biomarkers are routinely used to diagnose and risk-stratify myocardial infarction, acute coronary syndromes, and heart failure. Some of these might facilitate donor heart assessment. Cardiac troponins, cytokines, inflammatory markers, natriuretic peptides, and intracellular proteins may each have discriminant value. This review details the current status of biomarkers in the assessment of donor hearts.
Asunto(s)
Biomarcadores/metabolismo , Trasplante de Corazón/métodos , Obtención de Tejidos y Órganos/métodos , Calcitonina/metabolismo , Selección de Donante , Electrocardiografía/métodos , Insuficiencia Cardíaca/terapia , Humanos , Interleucina-6/metabolismo , Péptido Natriurético Encefálico/metabolismo , Riesgo , Donantes de Tejidos/provisión & distribución , Troponina/metabolismo , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
OBJECTIVES: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in subarachnoid haemorrhage, brainstem death (BSD) and heart failure. We examined the relationship between NT-proBNP and cardiac functional status after BSD and left ventricular (LV) BNP precursor gene expression. METHODS: We assayed NT-proBNP in the serum of potential heart donors investigated with pulmonary artery flotation catheters, transthoracic echocardiography and cardiac troponin (cTn) I and T. After 6.9 h of optimisation, haemodynamic studies were repeated to determine haemodynamic functional suitability for transplantation. Median (interquartile range (IQR)) NT-proBNP levels are reported according to initially measured dichotomised pulmonary capillary wedge pressure (PCWP), cardiac index (CI), indexed cardiac power output (CPOi), left ventricular ejection fraction (LVEF), wall motion score (WMS), extravascular lung water index (EVLWI), cTnT and cTnI and end-management functional suitability. LV biopsies were snap-frozen, mRNA extracted and reverse-transcribed, allowing performance of Taqman real-time polymerase chain reaction assays of mRNA-BNP precursor. RESULTS: There were 79 subjects. Median NT-proBNP was 121 pg ml(-1) (range 5-4139) and levels correlated with time from coning (p<0.01, r=-0.379). Higher NT-proBNP was found in donors with PCWP >14 mmHg; 504 (120-1544) versus 101 (38-285); p=0.01; CI <2.4 l min(-1) m(-2) 410 (123-1511) versus 95 (37-264); p=0.001; CPOi <0.5 Wm(-2) 256 (78-694) versus 105 (37-315); p=0.02; LVEF <50% 231 (75-499) versus 72 (36-177); p=0.04; WMS >2; 343 (80-673) versus 99 (37-236); p=0.01; cTnT >0.1 microg ml(-1) 499 (127-967) versus 80 (36-173); p<0.001 and cTnI >1 mg ml(-1) 410 (97-684) versus 88 (36-190); p<0.01 and in hearts functionally unsuitable at end-optimisation; 189 (74-522) versus 85 (39-243); p=0.02. Hearts functionally suitable for transplantation expressed significantly less mRNA encoding for BNP precursor (0.19-fold; p=0.01). CONCLUSION: During or after BSD, NT-proBNP is released and the heart is a likely source. Higher NT-proBNP levels are associated with donor heart dysfunction and a failure to achieve haemodynamic functional suitability criteria. This supports the hypothesis that biomarkers, including NT-proBNP, may be useful in donor heart assessment.
Asunto(s)
Trasplante de Corazón , Corazón/fisiología , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Donantes de Tejidos , Adolescente , Adulto , Anciano , Biomarcadores/sangre , Muerte Encefálica/sangre , Gasto Cardíaco , Causas de Muerte , Selección de Donante , Femenino , Expresión Génica , Ventrículos Cardíacos/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/genética , Fragmentos de Péptidos/genética , ARN Mensajero/genética , Volumen Sistólico , Recolección de Tejidos y Órganos , Adulto JovenRESUMEN
Thoracic endovascular aortic reconstruction (TEVAR) is increasingly used in the management of descending aortic pathology including aneurysms, dissections and transaction. When treating aortic arch pathology, hybrid procedures have been devised, in which major supra-aortic arteries are translocated using a variety of techniques. Such hybrid procedures offer an attractive alternative to open arch procedures in frail elderly patients in whom the risks of open repair are considerable. We describe a surgical bail-out procedure which was used during a hybrid aortic arch replacement when endovascular aneurysm exclusion could not be achieved.
Asunto(s)
Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Circulación Cerebrovascular , Terapia Recuperativa , Anciano de 80 o más Años , Anastomosis Quirúrgica , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Puente Cardiopulmonar , Humanos , Masculino , Stents , Esternotomía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Following the acute changes of lung resection surgery, does the ratio of intrathoracic blood volume (ITBV) to global end diastolic volume (GEDV) remain constant? If it does this could validate a single thermo dilution (STD) technique in the measurement of extravascular lung water index (EVLWI) in patients undergoing lung resection surgery. EVLWI was derived using both double dye technique (DDT) and single thermo dilution technique (STD) in four patients undergoing thoracotomy selected for major lung resection surgery. Regular measurements were made for up to 12 h after surgery. After the first two hours following lung resection surgery, the ratio of blood volume ITBV/GEDV shows little variation for up to 12 h. EVLWI measurements measured by STD correlate well with those of DDT. This preliminary study suggests that EVLWI measurements by STD could be used to measure changes in EVLW following major lung resection. An assessment of EVLW could be useful in early diagnosis, management and treatments of the devastating condition of postoperative acute lung injury.