Cirrhotic cardiomyopathy: Predictors of major adverse cardiac events and assessment of reversibility after liver transplant.

BACKGROUND: Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM), initially described in 2005 and revised in 2019, is a source of MACE in patients after OLT. We sought to identify CCM-related predictors of MACE at one-year follow-up after OLT and assess for reversibility of CCM post-OLT. METHODS: This is a retrospective study of adult patients who underwent OLT between 2009 and 2019. All patients had transthoracic echocardiography pre-and post-OLT. Patients with a left ventricular ejection fraction <50 % pre-OLT were excluded. MACE was defined as death, myocardial infarction, congestive heart failure hospitalization, or cardiac arrest. RESULTS: In total, 131 patients were included in this study, of whom 103 and 23 patients met the 2005 and 2019 criteria, respectively. During the follow-up period, 42 patients had MACE and these patients were more likely to have ascites (p = 0.003), hepatorenal syndrome (p = 0.019), and CCM per 2005 criteria (p = 0.023). There were no significant differences between pre-OLT CCM per 2019 criteria (19 % vs 17 %, p = 0.758) or MELD-Na score (21.24 vs 19.40, p = 0.166) for MACE post-OLT. Per the 2005 criteria, 35 of 103 patients recovered and these patients were less likely to have MACE post-OLT (p = 0.012). Per the 2019 criteria, 13 of 23 patients recovered post-OLT but this low number precluded further statistics. CONCLUSION: The 2005 Montreal criteria for CCM were an independent predictor of MACE at one-year follow-up post-OLT while the 2019 CCC criteria for CCM were not. In addition, the 2005 Montreal criteria were more prevalent when compared to 2019 CCC criteria. Finally, the 2005 Montreal criteria were reversible post-OLT 34 % of the time compared to the 2019 CCC criteria which were reversible 57 % of the time.

Comparison of and Frequency of Mortality, Left Ventricular Assist Device Implantation, Ventricular Arrhythmias, and Heart Transplantation in Patients With Familial Versus Nonfamilial Idiopathic Dilated Cardiomyopathy.

We postulated that familial idiopathic dilated cardiomyopathy (F-IDC) is associated with a worse prognosis than nonfamilial IDC (nonF-IDC). Patients with F-IDC had either a strong family history and/or proved genetic mutations. We studied long-term prognosis (mean follow-up: 6.1 ± 4.1 years) of 162 patients with IDC (age: 55.5 ± 17.9 years, men: 57.8%, 50% F-IDC) with an implantable cardioverter-defibrillator or cardiac resynchronization therapy. The primary end point was a composite of death, left ventricular (LV) assist device implant, or heart transplantation. The secondary end point was a ventricular arrhythmia event. There was no significant difference in the prevalence of diabetes, hypertension, New York Heart Association class, medical therapy, and years of follow-up between the F-IDC and nonF-IDC groups. Patients with F-IDC were younger than patients with nonF-IDC (49.1 ± 17.0 years vs 61.6 ± 16.5 years, p <0.001). Mean LV ejection fraction was significantly lower in F-IDC group than in the nonF-IDC group (26 ± 12% vs 31 ± 12%, p = 0.022). The primary end point was achieved in 54 patients in F-IDC group (66.7%) versus 19 in the nonF-IDC group (23.5%) (p <0.001). The Kaplan-Meier survival estimates for the composite end point and for ventricular arrhythmia were significantly lower in the F-IDC versus nonF-IDC (log-rank p ≤0.001 and 0.04, respectively). F-IDC was the only multivariable predictor of the primary composite end point (hazard ratio 3.419 [95% confidence interval 1.845 to 6.334], p <0.001). The likelihood of LV remodeling manifested by LV ejection fraction improvement (≥10%) was significantly lower in F-IDC than nonF-IDC (27.1% vs 44.8%, p = 0.042). In conclusion, F-IDC is a predictor of mortality, need for LV assist device, or heart transplantation. F-IDC is associated with significantly lower event-free survival for primary end point and ventricular arrhythmia than nonF-IDC. F-IDC has significantly lower likelihood of LV reverse remodeling than nonF-IDC.

Association Between Trauma Center Level and Outcomes of Adult Patients with Motorcycle Crash-Related Injuries in the United States.

BACKGROUND: Motorcycle crash-related injury mechanism is a criterion in the Centers for Disease Control and Prevention field triage guidelines of injured patients, with a recommendation to transport affected patients to a trauma center need not be the highest level. OBJECTIVE: This study examines the evidence behind this recommendation because severe injuries can result from motorcycle crashes and patients can benefit from treatment at higher-level trauma centers. METHODS: This retrospective cohort study used the National Trauma Data Bank 2015 dataset. We conducted descriptive analyses (univariate and bivariate) followed by adjusted multivariate analysis to examine the association between trauma center designation levels and survival to hospital discharge. RESULTS: A total of 28,821 patients with motorcycle injuries were included. Most patients were men (n = 25,361; 88%) and aged between 16 and 64 years (n = 26,989; 93.6%). Survival rates were higher in level II (n = 10,658; 95.3%) and III (n = 2,129; 95.5%) trauma centers compared to level I centers (n = 14,498; 94.6%). After adjusting for confounders, decreased survival to hospital discharge was noted for patients treated at level III trauma centers compared to those at level I centers (odds ratio 0.543; 95% confidence interval 0.390-0.729). No difference in survival was noted between level I and II centers. CONCLUSIONS: Patients with motorcycle crash-related injuries treated at higher-level trauma center (I or II) had increased survival. This warrants a re-evaluation and adjustment of the field triage criterion for such patients. Examining the evidence behind field triage guidelines in trauma systems is needed for improved patient outcomes.

A Rare Case of Isolated Ureteral Diaphragmatic Herniation: Case Report and Review of Literature.

Diaphragmatic ureteral hernias are rare causes of ipsilateral renal obstruction. Management strategies varies from conservative to ureteral stenting to operative herniorraphy and reduction. We present a case of a 71-year-old man who was found to have an incidental right ureteral diaphragmatic herniation causing an asymptomatic kidney obstruction. He was managed conservatively with no evidence of increased hydronephrosis on serial imaging and no deterioration of biochemical renal function. We review all similar cases published in the literature and discuss the optimal treatment strategies.