Is liver transplantation a risk factor for cardiovascular disease? A meta-analysis of observational studies.

Up to two-thirds of patients develop metabolic syndrome within the first 5 years after orthotopic liver transplantation (OLT). However, data on overall cardiovascular (CV) morbidity and mortality among OLT recipients and particularly those who develop metabolic syndrome remain elusive. A literature search using MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and meeting abstracts (along with their bibliographies) was performed to identify studies. Data on ischemic CV events were extracted from each study and were used for pooled analyses. Overall pooled estimates and 95% confidence intervals (CIs) for the incidence of CV events and deaths were obtained with a random effects model. Twelve observational studies reporting CV outcomes for 4792 post-OLT recipients who were followed for 28,783 person-years were included. Pooled estimates showed that the 10-year risk of developing CV events among the post-OLT recipients was 13.6% (95% CI = 9%-8.1%). Pooled estimates from case-control studies showed that the post-OLT group had an approximately 64% greater risk of experiencing CV events than controls (standardized incidence ratio = 1.64, 95% CI = 1.18-2.20). Among OLT recipients, those with metabolic syndrome were approximately 4 times more likely to have a CV event [odds ratio (OR) = 4.01, 95% CI = 1.94-8.32] without any significant increase in all-cause mortality (OR = 1.15, 95% CI = 0.63-2.10). In conclusion, this systematic review suggests that OLT recipients and particularly those with metabolic syndrome have a high risk for CV events. However, the literature is limited and lacks high-quality studies. Future prospective studies are warranted to confirm these findings and determine whether aggressive risk-reduction strategies can attenuate the increased CV risk seen in this population.

Cumulative risk of cardiovascular events after orthotopic liver transplantation.

As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion = 44%, Caucasian proportion = 84%, median follow-up = 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) = 1.2, addition of 95% confidence interval (CI) = 1.1-1.3, P = 0.006], male sex (OR = 2.0, 95% CI = 1.2-3.3, P = 0.01), posttransplant diabetes (OR = 2.0, 95% CI = 1.3-3.3, P = 0.003), posttransplant hypertension (OR = 1.8, 95% CI = 1.1-3.0, P = 0.02), and mycophenolate mofetil (OR = 2.0, 95% CI = 1.3-3.2, P = 0.003). Among post-OLT patients, the cumulative risk at 5 years of 13.5%, respectively. In conclusion, cardiac complications after liver transplantation are common (Approximately 10% of patients experience 1 or move cv events). Patients with posttransplant hypertension and diabetes, which are modifiable risk factors, are approximately twice as likely to experience a CV event.

Unusual cause of acute mitral regurgitation: idiopathic hypereosinophilic syndrome.

Idiopathic hypereosinophilic syndrome (HES) is a rare multisystem condition characterized by dysregulated overproduction of eosinophils. Cardiac involvement in HES is characterized by necrosis from infiltration of eosinophils and thrombus formation and, in the late stage, by fibrosis and chronic valvular regurgitation. We report a very unusual presentation of idiopathic HES with acute mitral regurgitation due to papillary muscle rupture. The transesophageal echocardiogram was suggestive of a flail posterior leaflet and suspicious for endocarditis. Intraoperatively, papillary muscle rupture was seen and the patient underwent mitral valve replacement. The pathologic examination of the valve revealed eosinophilic infiltration of the papillary muscle. The patient was treated with steroids and responded well clinically.

Impact of blood transfusion on short- and long-term mortality in patients with ST-segment elevation myocardial infarction.

OBJECTIVES: We sought to examine the short- and long-term outcomes of blood transfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: The short- and long-term consequences of blood transfusion in anemic patients with recent STEMI remain controversial. METHODS: We evaluated 30-day, 6-month, and 1-year all-cause mortality among 4,131 STEMI patients enrolled in the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) IIb trial. Patients were categorized according to whether they received a blood transfusion during hospitalization. Cox proportional hazards survival models with transfusion as a time-dependent covariate were conducted for the whole and for the propensity-matched groups. Additionally, a series of sensitivity analyses assessed the magnitude of hidden bias that would need to be present to explain the associations actually observed. RESULTS: Death at 30 days (13.7% vs. 5.5%), 6 months (19.7% vs. 6.9%), and 1 year (21.8% vs. 8.7%) was significantly higher for transfused patients than for nontransfused patients, respectively. After adjusting for over 25 baseline characteristics, nadir hemoglobin, and propensity score for transfusion, and using transfusion as a time-dependent covariate, transfusion remained significantly associated with increased risk of mortality at 30 days (hazard ratio [HR]: 3.89, 95% confidence interval [CI]: 2.66 to 5.68, p < 0.001), 6 months (HR: 3.63, 95% CI: 2.67 to 4.95, p < 0.001), and 1 year (HR: 3.03, 95% CI: 2.25 to 4.08, p < 0.001). Similar results were observed in the propensity-matched patients. CONCLUSIONS: Blood transfusion is associated with increased short- and long-term mortality in the setting of STEMI.

Predictors of difficult carotid stenting as determined by aortic arch angiography.

OBJECTIVE: Although different aortic arch classifications exist to help determine carotid artery stenting (CAS) difficulty, they are not validated. We compared quantitative angiographic characteristics of aortic arch between easy and difficult CAS. METHODS: We defined difficult procedures as requiring the longest fluoroscopy time (FT) (90th percentile) and easy procedures as the shortest FT (10th percentile) from our CAS database. We excluded patients undergoing additional procedures, intraprocedural complications or those with difficult vascular access. RESULTS: We analyzed 24 patients with difficult CAS (median fluoroscopy time of 58 minutes) and 24 with easy CAS (median fluoroscopy time of 19 minutes). The two groups were similar with respect to demographics, comorbidities and clinical presentation at the time of CAS. Patients with difficult procedures had a longer distance from the origin of treated artery to the beginning of the descending aorta (D1; 50 +/- 17 mm vs. 40 +/- 16 mm; p = 0.04), severe tortuosity (T) of the common carotid and internal carotid vessels (T; 50.0% vs. 16.7%; p = 0.03) and a trend in the presence of a Type 3 arch (33.3% vs. 25.0%; p = 0.18) and angulated takeoff (20.8% vs. 4.3%; p = 0.19). There was no difference in the severity of stenosis or index lesion calcification, ulceration and eccentricity between the two groups. On multivariate analysis, independent predictors of procedural difficulty were D1 (odds ratio 1.04 per mm; 95% CI, 1.01-1.09; p = 0.04), and T (odds ratio 4.77; 95% CI 1.3-42.9; p = 0.03). CONCLUSIONS: Distance from the origin of the treated artery to the beginning of the D1 and target vessel T determine prolonged fluoroscopy time during CAS.