Effect of hypertension, diabetes, and smoking on development of renal dysfunction after heart transplantation.

BACKGROUND: Renal dysfunction is a serious problem after heart transplantation (HT). The objective of this study was to determine the cardiovascular risk factors associated with medium- to long-term dysfunction after HT. MATERIALS AND METHODS: We studied 247 consecutive patients who underwent HT between January 2000 and September 2006 who survived for at least 6 months. We excluded patients receiving combination transplants, those undergoing repeat HT, and pediatric patients undergoing HT. Mean (SD) follow-up was 72 (42) months. We defined renal dysfunction as serum creatinine concentration greater than 1.4 mg/dL during follow-up. Patients were considered to be smokers if they had smoked during the six months before HT, to have hypertension if they required drugs for blood pressure control, and to have diabetes if they required insulin therapy. Statistical tests included the t test and the chi(2) tests. We performed Cox regression analysis using significant or nearly significant values in the univariate analysis. RESULTS: Mean (SD) age of the patients who underwent HT was 52 (10) years, and 217 (87.9%) were men. Renal dysfunction was detected during follow-up in 135 (54.5%) patients. The significant variables at univariate analysis were smoking (61.4% vs. 43.2%; P = .01) and previous renal dysfunction (94.1% vs 52.7%; P = .001). Nearly significant variables were the presence of hypertension before HT (63.8% vs 51.1%; P = .09) and after HT (58.2% vs 44.8%; P = .082). At multivariate analysis, pre-HT smoking and previous renal dysfunction were significant correlates (P = .04 and P = .01, respectively). CONCLUSIONS: Renal dysfunction is common after HT. In our analysis, the best predictors were pre-HT dysfunction and smoking. Less important factors were advanced age and post-HT hypertension.

Influence of traditional cardiovascular risk factors in the recipient on the development of cardiac allograft vasculopathy after heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the leading cause of death heart transplant (HT) recipients after the first year. We assessed the influence of cardiovascular risk factors (CVRFs) in HT recipients on the development of CAV after 1 year of follow-up. MATERIALS AND METHODS: From 2001 to 2005, we studied 72 patients who received a HT and survived for at least 1 years. All patients underwent coronary arteriography and intravascular ultrasonography at 1 year after HT. Cardiac allograft vasculopathy was defined as intimal proliferation of 0.5 mm or more. The analyzed CVRFs were age, sex, body mass index, diabetes mellitus, hypertension, dyslipidemia, and smoking. We also considered the heart disease that was the reason for HT. The statistical tests used in the univariate analysis were the t and chi(2) tests. Logistic regression was performed with the variables obtained at univariate analysis. RESULTS: Mean (SD) recipient age at HT was 51 (9) years. Eighty patients (90.5%) were men. Dyslipidemia was significantly associated with a greater incidence of CAV at 1 year (68.3% vs 41.9%; P = .03). Ischemia, as opposed to all other causes, was also significantly associated with CAV (69.4% vs 44.4%; P = .03). Older age, hypertension, smoking history, and high body mass index were associated with a higher incidence of CAV, albeit without statistical significance. At multivariate analysis, dyslipidemia was the most significant CVRF (P = .045) for the development of CAV. CONCLUSIONS: Recipient dyslipidemia is a risk factor for the development of CAV in HT. The remaining traditional CVRFs are more weakly associated with CAV. After HT close monitoring of recipients with pretransplantation CVRFs is essential for early detection of CAV.

[Major complications in the recovery unit following heart transplant: incidence and risk factors]. / Incidencia y predictores de complicaciones graves tras el trasplante cardiaco en la Unidad de Reanimación.

OBJECTIVE: To assess the incidence of major complications in the postoperative recovery unit and to analyze the associated recipient, donor, and surgical risk factors. MATERIAL AND METHODS: We studied a series of consecutive orthotopic heart transplants carried out in our hospital from 2001 through 2007. Patients who experienced major complications during their stay in the recovery ward were compared with those who did not. Exitus, primary graft failure, severe infection, and need for hemodialysis were considered major complications. RESULTS: One hundred fifty-two patients were enrolled. The mean stay in the recovery unit was 3 days (range, 225-5 days). Thirty-nine patients (26%) developed major complications in the recovery unit and 113 did not. The complications were primary graft failure (20%), infection (12%), and acute renal failure (53%). Patients with and without major complications were significantly different with respect to mean (SD) age (55 [6] vs 50 [12] years, respectively; P=.001), presence of diabetes mellitus (41% vs 14%, P=.0001), classification in New York Heart Association functional class IV/IV status (54% vs 34%, P=.05), emergency transplantation (46% vs 18%, P=.001), mean cardiopulmonary bypass time (145 [66] vs 119 [35], P=.03), pretransplant use of an intra-aortic balloon pump (15% vs 6%, P=.04). Multivariate analysis demonstrated an association between major complications and emergency transplantation (OR, 5.67; P=.001), recipient age over 55 years (OR, 2.99; P=.027), and diabetes mellitus (OR, 2.86; P=.048). CONCLUSIONS: The incidence of major complications in our postoperative recovery unit was 26%. The most common complications were primary graft failure, infection, and acute renal failure. Emergency transplantation, older age, and a diagnosis of diabetes mellitus in the recipient were predictors of complication.

Normalization of the heart rate response to exercise 6 months after cardiac transplantation.

INTRODUCTION: Heart transplant recipients show an abnormal heart rate (HR) response to exercise due to complete cardiac denervation after surgery. They present elevated resting HR, minimal increase in HR during exercise, with maximal HR reached during the recovery period. The objective of this study was to study the frequency of normalization of the abnormal HR in the first 6 months after transplantation. MATERIALS AND METHODS: We prospectively studied 27 heart transplant recipients who underwent treadmill exercise tests at 2 and 6 months after heart transplantation (HT). HR responses to exercise were classified as normal or abnormal, depending on achieving all of the following criteria: (1) increased HR for each minute of exercise, (2) highest HR at the peak exercise intensity, and (3) decreased HR for each minute of the recovery period. The HR response at 2 months was compared with the results at 6 months post-HT. RESULTS: At 2 months post-HT, 96.3% of the patients showed abnormal HR responses to exercise. Four months later, 11 patients (40.7%) had normalized HR responses (P<.001), which also involved a significant decrease in the time to achieve the highest HR after exercise (124.4±63.8 seconds in the first test and 55.6±44.6 seconds in the second). A significant improvement in exercise capacity and chronotropic competence was also shown in tests performed at 6 months after surgery. CONCLUSIONS: We observed important improvements in HR responses to exercise at 6 months after HT, which may represent early functional cardiac reinnervation.

Exercise tolerance after beta blockade in recent cardiac transplant recipients.

OBJECTIVE: Exercise capacity has been shown to be reduced among cardiac transplant recipients. This observation is directly connected to both the transplanted heart's dependence on circulating catecholamines and the abnormal sympathoadrenal response to exercise in these patients. Taking into account this background, there is reluctance to use beta-blockers after heart transplantation. Nevertheless, this point remains controversial. Our aim was to examine exercise tolerance after an oral dose of atenolol early after cardiac transplantation. MATERIALS AND METHODS: Eighteen nonrejecting, otherwise health, cardiac transplant recipients were included in this study at a mean of 61.9 +/- 25.6 days after surgery; 13 were men. Patients performed controlled exercise to a symptom-limited maximum before and 2 hours after taking an oral dose of atenolol. Heart rate, blood pressure, exercise time, and metabolic equivalent units (METS) were recorded at rest as well as during and after exercise. We compared results depending on taking atenolol. RESULTS: Resting (101.7 +/- 14.5 vs 84 +/- 12.4 bpm; P = .001) and peak heart rates (128.5 +/- 12.9 vs 100.7 +/- 16 bpm; P = .001) were significantly higher before than after beta blockade. Resting systolic blood pressure was slightly higher before compared with after beta blockade (129.3 +/- 23.6 vs 122.2 +/- 20.3 mm Hg; P = .103). However, there was neither a significant difference in the length of exercise (3.17 +/- 1.96 vs 3.40 +/- 2.48 minutes; P = .918) nor in the estimated oxygen consumption (METS; 5.07 +/- 1.8 vs 5.31 +/- 2.2; P = .229). Furthermore, no patient reported a greater degree of tiredness after beta blockade. CONCLUSIONS: This study showed little adverse effect on exercise tolerance by beta blockade in recently transplanted patients. Atenolol seemed to be safe in this context.

Incidencia y predictores de complicaciones graves tras el trasplantecardiaco en la Unidad de Reanimación / Major complications in the recovery unit following heart transplant: incidence and risk factors

OBJETIVO: Determinar las complicaciones durante elpostoperatorio en Reanimación y analizar qué variablesdel receptor, donante y quirúrgicas se asocian a complicacionesmayores.MATERIAL Y MÉTODO: Analizamos una serie de trasplantescardiacos ortotópicos consecutivos realizados ennuestro centro entre 2001-2007. Se compararon pacientesque no presentaron complicaciones mayores (CM) durantela estancia en Reanimación (Grupo 1) con los que sí lasdesarrollaron (Grupo 2). Se consideró CM el exitus, falloprimario del injerto (FPI), infección grave y necesidad dehemodiálisis.RESULTADOS: Incluimos 152 pacientes cuyo tiempo depermanencia en Reanimación fue de 3 (2,25-5) días. Cientotrece pacientes no presentaron CM en Reanimación(Grupo 1), mientras que 39 pacientes (26%) sí desarrollaroncomplicaciones (Grupo 2): FPI (20%), infección (12%)y disfunción renal grave (5,3%). Observamos diferenciassignificativas entre los grupos respecto a edad (50 ± 12 vs55 ± 6; p = 0,001), diabetes (14 vs. 41%; p = 0,0001), clasefuncional New York Heart Association IV/IV (34 vs. 54%;p = 0,04), trasplante urgente (18 vs 46%; p = 0,001), tiempode circulación extracorpórea (119 ± 35 vs. 145 ± 66minutos; p = 0,03), balón de contrapulsación pretrasplante(6 vs 15%; p = 0,04). El análisis multivariado demostróasociación entre las CM y el trasplante urgente (OR: 5,67;p = 0,001), receptor mayor de 55 años (OR: 2,99;p = 0,027) y diabético (OR: 2,86; p = 0,048).CONCLUSIONES: Un 26% de los pacientes cardiacosdesarrollaron CM en Reanimación. Las más frecuentesfueron el FPI, la infección y la disfunción renal grave. Sonvariables predictivas independientes de su aparición eltrasplante urgente, edad y diabetes mellitus del receptor (AU)

OBJECTIVE: To assess the incidence of majorcomplications in the postoperative recovery unit andto analyze the associated recipient, donor, and surgicalrisk factors.MATERIAL AND METHODS: We studied a series ofconsecutive orthotopic heart transplants carried out inour hospital from 2001 through 2007. Patients whoexperienced major complications during their stay in therecovery ward were compared with those who did not.Exitus, primary graft failure, severe infection, and needfor hemodialysis were considered major complications.RESULTS: One hundred fifty-two patients were enrolled.The mean stay in the recovery unit was 3 days (range,2.25-5 days). Thirty-nine patients (26%) developed majorcomplications in the recovery unit and 113 did not. Thecomplications were primary graft failure (20%), infection(12%), and acute renal failure (5.3%). Patients with andwithout major complications were significantly differentwith respect to mean (SD) age (55 [6] vs 50 [12] years,respectively; P=.001), presence of diabetes mellitus (41%vs 14%, P=.0001), classification in New York HeartAssociation functional class IV/IV status (54% vs 34%,P=.05), emergency transplantation (46% vs 18%, P=.001),mean cardiopulmonary bypass time (145 [66] vs 119 [35],P=.03), pretransplant use of an intra-aortic balloon pump(15% vs 6%, P=.04). Multivariate analysis demonstratedan association between major complications andemergency transplantation (OR, 5.67; P=.001), recipientage over 55 years (OR, 2.99; P=.027), and diabetesmellitus (OR, 2.86; P=.048).CONCLUSIONS: The incidence of major complicationsin our postoperative recovery unit was 26%. The mostcommon complications were primary graft failure,infection, and acute renal failure. Emergencytransplantation, older age, and a diagnosis of diabetesmellitus in the recipient were predictors of complication (AU)