Male-female differences in thoracic aortic diameters at presentation of acute type A aortic dissection.

Background: Acute type A aortic dissection (ATAAD) is a highly lethal event, associated with aortic dilatation. It is not well known if patient height, weight or sex impact the thoracic aortic diameter (TAA) at ATAAD. The study aim was to identify male-female differences in TAA at ATAAD presentation. Methods: This retrospective cross-sectional study analysed all adult patients who presented with ATAAD between 2007 and 2017 in two tertiary care centres and underwent contrast enhanced computed tomography (CTA) before surgery. Absolute aortic diameters were measured at the sinus of Valsalva (SoV), ascending (AA) and descending thoracic aorta (DA) using double oblique reconstruction, and indexed for body surface area (ASI) and height (AHI). Z-scores were calculated using the Campens formula. Results: In total, 59 % (181/308) of ATAAD patients had CT-scans eligible for measurements, with 82 female and 99 male patients. Females were significantly older than males (65.5 ± 12.4 years versus 60.3 ± 2.3, p = 0.024). Female patients had larger absolute AA diameters than male patients (51.0 mm [47.0-57.0] versus 49.0 mm [45.0-53.0], p = 0.023), and larger ASI and AHI at all three levels. Z-scores for the SoV and AA were significantly higher for female patients (2.99 ± 1.66 versus 1.34 ± 1.77, p < 0.001 and 5.27 [4.38-6.26] versus 4.06 [3.14-5.02], p < 0.001). After adjustment for important clinical factors, female sex remained associated with greater maximal TAA (p = 0.019). Conclusion: Female ATAAD patients had larger absolute ascending aortic diameters than males, implying a distinct timing in disease presentation or selection bias. Translational studies on the aortic wall and studies on growth patterns should further elucidate these sex differences.

Listing criteria for heart transplantation in the Netherlands.

The updated listing criteria for heart transplantation are presented on behalf of the three heart transplant centres in the Netherlands. Given the shortage of donor hearts, selection of those patients who may expect to have the greatest benefit from a scarce societal resource in terms of life expectancy and quality of life is inevitable. The indication for heart transplantation includes end-stage heart disease not remediable by more conservative measures, accompanied by severe physical limitation while on optimal medical therapy, including ICD/CRT­D. Assessment of this condition requires cardiopulmonary stress testing, prognostic stratification and invasive haemodynamic measurements. Timely referral to a tertiary centre is essential for an optimal outcome. Chronic mechanical circulatory support is being used more and more as an alternative to heart transplantation and to bridge the progressively longer waiting time for heart transplantation and, thus, has become an important treatment option for patients with advanced heart failure.

Care for the organ transplant recipient on the intensive care unit.

All transplant recipients receive tacrolimus, mycophenolate and glucocorticoids and these drugs have many side-effects and drug-drug interactions. Common complications include surgical complications, infections, rejection and acute kidney injury. Infections as CMV and PJP can be prevented with prophylactic treatment. Given the complexity of organ transplant recipients a multi-disciplinary team of intensivists, surgeons, pharmacists and transplant specialists is essential. After heart transplantation a temporary pacemaker is required until the conduction system recovers. Stiffening of the heart and increased cardiac markers indicate rejection. An endomyocardial biopsy is performed via the right jugular vein, necessitating its preservation. For lung transplant patients, early intervention for aspiration is warranted to prevent chronic rejection. Risk of any infection is high, requiring active surveillance and intensive treatment, mainly of fungal infections. The liver is immunotolerant requiring lower immunosuppression. Transplantation surgery is often accompanied by massive blood loss and coagulopathy. Other complications include portal vein or hepatic artery thrombosis and biliary leakage or stenosis. Kidney transplant recipients have a high risk of cardiovascular disease and posttransplant anemia should be treated liberally. After postmortal transplantation, delayed graft function is common and dialysis is continued. Ureteral anastomosis complications can be diagnosed with ultrasound.

Waiting list mortality and the potential of donation after circulatory death heart transplantations in the Netherlands.

BACKGROUND: With more patients qualifying for heart transplantation (HT) and fewer hearts being transplanted, it is vital to look for other options. To date, only organs from brain-dead donors have been used for HT in the Netherlands. We investigated waiting list mortality in all Dutch HT centres and the potential of donation after circulatory death (DCD) HT in the Netherlands. METHODS: Two different cohorts were evaluated. One cohort was defined as patients who were newly listed or were already on the waiting list for HT between January 2013 and December 2017. Follow-up continued until September 2018 and waiting list mortality was calculated. A second cohort of all DCD donors in the Netherlands (lung, liver, kidney and pancreas) between January 2013 and December 2017 was used to calculate the potential of DCD HT. RESULTS: Out of 395 patients on the waiting list for HT, 196 (50%) received transplants after a median waiting time of 2.6 years. In total, 15% died while on the waiting list before a suitable donor heart became available. We identified 1006 DCD donors. After applying exclusion criteria and an age limit of 50 years, 122 potential heart donors remained. This number increased to 220 when the age limit was extended to 57 years. CONCLUSION: Waiting list mortality in the Netherlands is high. HT using organs from DCD donors has great potential in the Netherlands and could lead to a reduction in waiting list mortality. Cardiac screening will eventually determine the true potential.

A Multicenter Study on Long-Term Outcomes After Lung Transplantation Comparing Donation After Circulatory Death and Donation After Brain Death.

The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one-to-one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long-term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.

Aortic root reoperations after pulmonary autograft implantation.

OBJECTIVE: To report the results of aortic root reoperations after pulmonary autograft implantation. METHODS: All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. RESULTS: From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technical difficulties encountered included bleeding at the sternal re-entry in 5 patients. No 30-day mortality occurred. The postoperative complications included reexploration for persistent blood loss in 3 patients and cerebrovascular accident in 3 patients. Two patients died during the follow-up period. The survival rate after reoperation was 94% (standard error, 4.1%) at 5 years. CONCLUSIONS: An increasing number of patients requires reoperation after pulmonary autograft implantation. These reoperations can be done with very low mortality and morbidity and excellent follow-up results.

Evolution of allograft aortic valve replacement over 13 years: results of 275 procedures.

OBJECTIVE: We describe our center's experience with the use of allografts for aortic valve or root replacement, illustrating the impact on outcome of the changes made in surgical and preservation techniques. METHODS: Between 4/1987 and 1/2001 275 allografts were used in 267 consecutive patients to replace the aortic valve or root. All patients were prospectively followed over time. Mean patient age was 46 years (SD 16; range 0.06-83), male/female ratio was 201/74. Prior cardiac operations took place in 73 patients; 49 patients presented with active endocarditis. Pre-operative NYHA-class was III in 51%. Initially, the subcoronary technique was used (SC; N=95) while in recent years root replacement (ARR; N=180) became the technique of choice. Seven fresh (two pulmonary and five aortic) and 268 cryopreserved (four pulmonary and 264 aortic; 35 glycerol and 233 DMSO) allografts were implanted. Concomitant procedures took place in 133 (48%). RESULTS: Operative mortality was 5.5% (N=15) and during follow-up (99% complete) 29 more patients died. Overall cumulative survival was 73% (95% CI 65-81%) at 9 years postoperative and significantly better for SC compared to ARR patients (P=0.005). Freedom from allograft-related reoperation (N=34) was 77% (95% CI 69-85) at 9 years, and worse in the SC compared to ARR group due to increased early technical failure (P=0.03). Freedom from reoperation for structural valve deterioration (SVD; N=22) was 81% (95% CI 73-89) at 9 years and did not differ between SC and ARR (P=0.51). Independent predictors of degenerative SVD were younger patient age (HR 0.93 with age as continuous variable; 95% CI 0.90-0.97), older donor age (HR 1.06 with age as a continuous variable; 95% CI 1.00-1.11), larger allograft diameter (HR 1.38; 95% CI 1.11-1.71) and the use of pulmonary allografts (HR 10.72; 95% CI 3.88-29.63). Calculated median time to reoperation for structural valve deterioration ranged from 23 years in a 65-year-old patient to 12 years in a 25-year-old. CONCLUSIONS: Aortic valve replacement with allografts yields adequate midterm results. Although important changes have been made over the years to improve durability, allografts still have a limited life span especially in young patients.

[The application of electric heart assist devices in 3 patients with end-stage heart failure as a bridge to transplantation]. / Toepassing van een elektrisch steunhart bij 3 patiënten met terminaal hartfalen als overbrugging naar transplantatie.

Left-ventricular assist devices have already gained an international place in the treatment of end-stage heart failure. It is expected that in future they will be increasingly used as a temporary bridging following the recovery from heart failure and to a lesser extent as a bridge to heart transplantation. Three patients with end-stage heart failure, men aged 68, 57 and 49 years, received a left-ventricular assist device (LVAD) as a bridge to transplantation. The device chosen was a Heartmate Vented Electric System (ThermoCardiosystems; Woburn, Massachusetts, US). In this system a pump is implanted under the diaphragm and connected to the apex of the left ventricle and the pars ascendens aortae. The first two patients reached the time of transplantation and used the LVAD for 367 and 416 days respectively. The third patient died after the pump had been implanted, due to progressive right-ventricle failure. The first patient died shortly after the heart transplantation.

Dysphagia lusoria: clinical aspects, manometric findings, diagnosis, and therapy.

OBJECTIVE: The lusorian artery is a rare anomaly of the right subclavian artery. This artery arises from the aortic arch distal of the left subclavian artery, crossing the midline behind the esophagus. Normally this anomaly causes no symptoms. Sometimes dysphagia first appears above the age of 40 yr. METHODS: In the period of 1992-1997, the diagnosis of an aberrant right subclavian artery was made in five patients with dysphagia who were referred to a small community hospital. A sixth patient had a right-sided aorta with an aberrant left subclavian artery. RESULTS: Endoscopy revealed a pulsating impression in the esophagus of three patients. Four patients had coexisting esophageal abnormalities. Barium contrast examination of the esophagus showed a characteristic diagonal impression at the level of the fourth thoracic vertebra in all patients. Computed tomography and angiography confirmed the diagnosis and excluded aneurysms. Manometric investigation of the esophagus revealed nonspecific abnormalities in five patients. Drug treatment was sufficient in three patients (mean follow-up, 6.2 yr). Three patients were operated upon because of persistent dysphagia. Through a cervical approach the artery was ligated near its root and connected with the right carotid artery. Postoperatively two patients became symptom-free, the other patient still has intermittent dysphagia. CONCLUSION: Dysphagia can be caused by a rare anomaly of the subclavian artery. The diagnosis can be overlooked at endoscopy, but barium contrast study of the esophagus will reveal the abnormality. In patients with coexisting esophageal abnormalities the finding may be incidental and specific conservative treatment may be sufficient. Manometry cannot be used to diagnose this condition or to predict surgical outcome. When the symptoms are intractable, surgical correction should be considered even if coexisting esophageal abnormalities are present.

Use of Markov series and Monte Carlo simulation in predicting replacement valve performances.

BACKGROUND AND AIMS OF THE STUDY: Several different biological, bioprosthetic and mechanical devices are available for heart valve replacement. We present a quantitative methodology to estimate the (event-free) life-expectancy and lifetime risk of valve-related events for individual patients after implantation of any one of these valve types. METHODS: We modelled the age-dependent prognosis of a patient after aortic valve replacement with a discrete-time Markov model and Monte-Carlo simulation to estimate (event-free) life-expectancy and life-time risk of valve-related events, respectively. Quantitative estimates to parameterize these models used hypothetical devices and presumed data were based on a limited review of published literature. RESULTS: This decision-analytical approach allowed an estimation of the overall and event-free life-expectancy as well as the lifetime risk of valve-related events after implantation of different types of prosthetic heart valve in the aortic position. In the current, hypothetical model, one valve type excelled for all age groups in terms of life expectancy and life-time risk of valve-related events. The choice of the second-best alternative varied according to patient age and comorbidity. Sensitivity analyses showed results to be especially dependent on the durability of the replacement valve and surgical risk. CONCLUSIONS: This methodological approach is very flexible, and its quantitative results may guide decision making, if increasing quantitative information on heart valve prosthesis performance becomes available in future. Markov models and Monte Carlo simulation may be used to obtain a better understanding of the effect that different types of prosthetic heart valves have on patient prognosis, while quantitative results may help cardiologists and cardiac surgeons to choose a specific valve type for an individual patient.