RESUMEN
OBJECTIVE: Despite small single-center reports demonstrating acceptable outcomes using donor hearts with left ventricular dysfunction, 19% of potential donor hearts are currently unused exclusively because of left ventricular dysfunction. We investigated modern long-term survival of transplanted donor hearts with left ventricular dysfunction using a large, diverse cohort. METHODS: Using the United Network for Organ Sharing database, we reviewed all adult heart transplants between January 2000 and March 2016. Baseline and postoperative characteristics and Kaplan-Meier survival curves were compared. A covariates-adjusted Cox regression model was developed to estimate post-transplant mortality. To address observed variation in patient profile across donor ejection fraction, a propensity score was built using Cox predictors as covariates in a generalized multiple linear regression model. All the variables in the original Cox model were included. For each recipient, a predicted donor ejection fraction was generated and exported as a new balancing score that was used in a subsequent Cox model. Cubic spline analysis suggested that at most 3 and perhaps no ejection fraction categories were appropriate. Therefore, in 1 Cox model we added donor ejection fraction as a grouped variable (using the spline-directed categories) and in the other as a continuous variable. RESULTS: A total of 31,712 donor hearts were transplanted during the study period. A total of 742 donor hearts were excluded for no recorded left ventricular ejection fraction, and 20 donor hearts were excluded for left ventricular ejection fraction less than 20%. Donor hearts with reduced left ventricular ejection fraction were from younger donors, more commonly male donors, and donors with lower body mass index than normal donor hearts. Recipients of donor hearts with reduced left ventricular ejection fraction were more likely to be on mechanical ventilation. Kaplan-Meier curves revealed no significant differences in recipient survival up to 15 years of follow-up (P = .694 log-rank test). Cox regression analysis showed that after adjustment for propensity variation, transplant year, and region, ejection fraction had no statistically significant impact on mortality when analyzed as a categoric or continuous variable. Left ventricular ejection fraction at approximately 1 year after transplantation was normal for all groups. CONCLUSIONS: Carefully selected donor hearts with even markedly diminished left ventricular ejection fraction can be transplanted with long-term survival equivalent to normal donor hearts and therefore should not be excluded from consideration on the basis of depressed left ventricular ejection fraction alone. Functional recovery of even the most impaired donor hearts in this study suggests that studies of left ventricular function in the setting of brain death should be interpreted cautiously.
Asunto(s)
Selección de Donante , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/métodos , Volumen Sistólico , Donantes de Tejidos , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda , Adolescente , Adulto , Anciano , Femenino , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/mortalidad , Adulto JovenRESUMEN
PURPOSE: Computed tomography (CT) scans are a significant source of radiation to patients. It was hypothesized that technical success and complication rates would not be significantly changed by radically lowering the CT dose during lung biopsies with an ultra-low-dose (ULD) protocol. MATERIALS AND METHODS: A total of 100 consecutive patients aged 11-89 years who underwent biopsies of lung lesions were evaluated. Technical parameters were altered halfway through the study from the standard dose (140 kV localizing/100 kV subsequent guiding scans with auto-mA) to a ULD protocol (100 kV, 7.5 mAs) as part of a quality initiative. ULD studies were evaluated subjectively for image quality on a five-point scale. Patients' body mass indexes, total estimated radiation doses (dose-length product), technical success rates, and complications were compared between the standard-dose and the ULD groups. RESULTS: Average radiation dose was reduced from 677.5 mGy·cm for the standard-dose group to 18.3 mGy·cm for the ULD group (P < .0001). In the ULD group, image quality was rated as adequate or better in 96% of cases. Pneumothoraces necessitating chest tube placements occurred in 10% and 6% of cases in the ULD and standard dose groups, respectively (P = .715). Technical success rates of 92% and 98% were obtained in the ULD and standard dose groups, respectively (P = .362). CONCLUSIONS: Radiation dose to the chest during CT-guided percutaneous lung biopsies is reduced greater than 95% versus a standard protocol through the use of a ULD CT protocol without decreasing technical success or patient safety.
Asunto(s)
Biopsia/métodos , Enfermedades Pulmonares/diagnóstico , Traumatismos por Radiación/prevención & control , Radiografía Intervencional , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biopsia/efectos adversos , Carga Corporal (Radioterapia) , Índice de Masa Corporal , California , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dosis de Radiación , Traumatismos por Radiación/etiología , Radiografía Intervencional/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X/efectos adversos , Adulto JovenRESUMEN
PURPOSE: To compare the sensitivity of magnetic resonance (MR) susceptibility-weighted imaging (SWI) with conventional MR sequences and computed tomography (CT) in the detection of hemorrhage in an acute infarct. MATERIALS AND METHODS: A series of 84 patients suspected of having acute strokes had both CT and MR imaging (MRI) scans with diffusion-weighted imaging (DWI) and SWI. The SWI sequence is a new high-resolution three-dimensional (3D) imaging technique that amplifies phase to enhance the magnitude contrast. RESULTS: Thirty-eight of 84 cases showed abnormal DWI consistent with acute infarct. Of the 38, SWI showed evidence of hemorrhage in 16 cases, compared to eight cases with spin echo (SE) T2, seven cases with fluid attentuated inversion recovery (FLAIR), and only five cases with CT. In a subset of 17 cases of acute infarct who had both two-dimensional gradient recalled echo (2D-GRE) T2*-weighted imaging and SWI, in addition to conventional MRI, evidence of hemorrhage was seen in 10 cases using SWI, compared to seven cases with 2D-GRE T2*. CONCLUSION: SWI proved to be a powerful new approach for visualizing hemorrhage in acute stroke compared to CT and conventional MRI methods.