Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 19 de 19
Filter
Add more filters

Country/Region as subject
Affiliation country
Publication year range
1.
Am J Transplant ; 23(10): 1570-1579, 2023 10.
Article in English | MEDLINE | ID: mdl-37442277

ABSTRACT

Experience in donation after circulatory-determined death (DCD) heart transplantation (HTx) is expanding. There is limited information on the functional outcomes of DCD HTx recipients. We sought to evaluate functional outcomes in our cohort of DCD recipients. We performed a single-center, retrospective, observational cohort study comparing outcomes in consecutive DCD and donation after brain death (DBD) HTx recipients between 2015 and 2019. Primary outcome was allograft function by echocardiography at 12 and 24 months. Secondary outcomes included incidence of cardiac allograft vasculopathy, treated rejection, renal function, and survival. Seventy-seven DCD and 153 DBD recipients were included. There was no difference in left ventricular ejection fraction at 12 months (59% vs 59%, P = .57) and 24 months (58% vs 58%, P = .87). There was no significant difference in right ventricular function at 12 and 24 months. Unadjusted survival between DCD and DBD recipients at 5 years (85.7% DCD and 81% DBD recipients; P = .45) was similar. There were no significant differences in incidence of cardiac allograft vasculopathy (odds ratio 1.59, P = .21, 95% confidence interval 0.77-3.3) or treated rejection (odds ratio 0.60, P = .12, 95% confidence interval 0.32-1.15) between DBD and DCD recipients. Post-transplant renal function was similar at 1 and 2 years. In conclusion, cardiac allografts from DCD donors perform similarly to a contemporary population of DBD allografts in the medium term.


Subject(s)
Heart Transplantation , Tissue and Organ Procurement , Humans , Graft Survival , Retrospective Studies , Incidence , Stroke Volume , Ventricular Function, Left , Tissue Donors , Brain Death , Heart Transplantation/adverse effects , Allografts , Death
2.
J Card Fail ; 29(5): 834-840, 2023 05.
Article in English | MEDLINE | ID: mdl-36521726

ABSTRACT

BACKGROUND: Heart transplantation (HTx) after donation after circulatory death (DCD) is an expanding practice but is associated with increased warm ischemic time. The impact of DCD HTx on cardiac mechanics and myocardial fibrosis has not been reported. We aimed to compare cardiac mechanics and myocardial fibrosis using cardiovascular magnetic resonance (CMR) imaging in donation after brain death (DBD) and DCD HTx recipients and healthy controls. METHODS AND RESULTS: Consecutive HTx recipients between March 2015 and March 2021 who underwent routine surveillance CMR imaging were included. Cardiac mechanics were assessed using CMR feature tracking to compute global longitudinal strain, global circumferential strain, and right ventricular free-wall longitudinal myocardial strain. Fibrosis was assessed using late gadolinium enhancement imaging and estimation of extracellular volume. There were 82 (DBD n = 42, DCD n = 40) HTx recipients (aged 53 years, interquartile range 41-59 years, 24% female) who underwent CMR imaging at median of 9 months (interquartile range 6-14 months) after transplantation. HTx recipients had increased extracellular volume (29.7 ± 3.6%) compared with normal ranges (25.9%, interquartile range 25.4-26.5). Myocardial strain was impaired after transplantation compared with controls (global longitudinal strain -12.6 ± 3.1% vs -17.2 ± 1.8%, P < .0001; global circumferential strain -16.9 ± 3.1% vs -19.2 ± 2.0%, P = .002; right ventricular free-wall longitudinal strain -15.7 ± 4.5% vs -21.6 ± 4.7%, P < .0001). There were no differences in fibrosis burden (extracellular volume 30.6 ± 4.4% vs 29.2 ± 3.2%; P = .39) or cardiac mechanics (global longitudinal strain -13.1 ± 3.0% vs -12.1 ± 3.1%, P = .14; global circumferential strain -17.3 ± 2.9% vs -16.6 ± 3.1%, P = .27; right ventricular free-wall longitudinal strain -15.9 ± 4.9% vs -15.5 ± 4.1%, P = .71) between DCD and DBD HTx. CONCLUSIONS: HTx recipients have impaired cardiac mechanics compared with controls, with increased myocardial fibrosis. There were no differences in early CMR imaging characteristics between DBD and DCD heart transplants, providing further evidence that DCD and DBD HTx outcomes are comparable.


Subject(s)
Cardiomyopathies , Heart Failure , Heart Transplantation , Humans , Female , Male , Contrast Media , Gadolinium , Heart Failure/diagnostic imaging , Heart Failure/surgery , Heart Transplantation/adverse effects , Fibrosis , Retrospective Studies , Tissue Donors
3.
J Card Surg ; 37(12): 5362-5370, 2022 Dec.
Article in English | MEDLINE | ID: mdl-36403276

ABSTRACT

BACKGROUND AND AIM OF THE STUDY: An atrioesophageal fistula is a devastating complication of ablation for atrial fibrillation. For the surgeon facing this dreaded complication, it may be a 'once in a lifetime' case. This review aims to describe the clinical problem and evaluate the outcome of different surgical techniques to start guiding cardiothoracic surgeons toward those which offer the best chance of survival. METHODS: An electronic search retrieved 125 articles containing 195 cases of atrioesophageal fistula secondary to atrial fibrillation ablation. Reports of pericardio-esophageal or mediastino-esophageal fistula were excluded. RESULTS: The median age was 61 and 143 (73%) cases occurred in males. Fever (n = 147; 75%) and neurological dysfunction (n = 151; 77%) were the most common symptoms. The median time from ablation to symptom onset was 21 days (interquartile range: 12-28). The most sensitive thoracic imaging modality was computed tomography (n = 135/153; 90%). Immediate deterioration occurred during 11/58 (19%) oesophago-gastro-duodenoscopies. Mortality was lower in patients who had surgery (39%) compared with endoscopic intervention (94%) or conservative management (97%). Patients who had atrial repair combined with esophageal repair or oesophagectomy were more likely to survive than those who had atrial repair alone (OR 6.97; p < .001). Isolation of the esophageal aspect of the fistula conferred an additional survival benefit (OR 5.85; p = .02). CONCLUSIONS: Fever, neurological symptoms, and chest pain in the context of recent ablation should prompt immediate evaluation. Urgent CT thorax should be arranged and repeated if initially unremarkable. Esophageal instrumentation should be avoided due to the risk of catastrophic air embolism or massive hemorrhage. The best way forward is emergency surgical repair; the combination which offers the best survival benefit is atrial repair combined with esophageal surgery and isolation of the esophageal aspect of the fistula.


Subject(s)
Atrial Fibrillation , Catheter Ablation , Esophageal Fistula , Humans , Male , Middle Aged , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Atrial Fibrillation/complications , Catheter Ablation/adverse effects , Esophageal Fistula/diagnosis , Esophageal Fistula/etiology , Esophageal Fistula/surgery , Heart Atria/diagnostic imaging , Heart Atria/surgery , Female
4.
Pediatr Transplant ; 23(6): e13536, 2019 09.
Article in English | MEDLINE | ID: mdl-31273913

ABSTRACT

This is a report of a unique DCD paediatric heart transplant whereby normothermic regional perfusion was used to assess DCD heart function after death followed by ex situ heart perfusion of the graft during transportation from donor to recipient hospitals. The DCD donor was a 9-year-old boy weighing 84 kg. The recipient was 7-year-old boy with failing Fontan circulation and weighed 23 kg. It was an ABO-compatible heart transplantation. The DCD heart was reperfused and assessed using normothermic regional perfusion followed by portable ex situ heart perfusion during transportation. The orthotopic heart transplantation was successful with good graft function and no evidence of rejection on endomyocardial biopsy at 30 days post-transplant. At 1-year follow-up, excellent graft function is maintained, and he is attending school with a good quality of life. DCD heart transplantation in children is a promising solution to reducing paediatric waiting times. The case demonstrates the feasibility of using normothermic regional perfusion in the donor and ex situ heart perfusion during graft transportation. This combination allowed a functional assessment whilst minimizing warm ischaemia resulting in a successful outcome. More research and long-term follow-up are needed in order to benefit from the huge potential that paediatric DCD heart transplantation has to offer.


Subject(s)
Fontan Procedure , Heart Diseases/surgery , Heart Transplantation , Tissue Donors , Tissue and Organ Procurement/methods , Animals , Biopsy , Cattle , Child , Graft Survival , Humans , Immunosuppressive Agents/therapeutic use , Male , Organ Preservation/methods , Pediatrics , Perfusion , Pericardium/pathology , Treatment Outcome
5.
J Heart Lung Transplant ; 41(9): 1294-1302, 2022 09.
Article in English | MEDLINE | ID: mdl-35811221

ABSTRACT

BACKGROUND: Ex-situ heart perfusion (ESHP) is commonly used for the reanimation and preservation of hearts following donation after circulatory determined death (DCD). The only commercially available existing ESHP device promotes perfusate lactate levels for assessment of heart viability. The reliability of this marker is yet to be confirmed for DCD heart transplantation. METHODS: This is a single center, retrospective study examining DCD heart transplants from March 1, 2015 to June 30, 2020. Recipients were divided into 2 groups dependent upon their requirement for or absence of mechanical circulatory support post-transplant. Lactate profiles obtained during ESHP were analyzed. Hearts were procured using the direct procurement and perfusion (DPP) method. RESULTS: Fifty-one DCD heart transplant recipients were studied, of which 20 (39%) were dependent on mechanical circulatory support (MCS) following transplantation, (2% Ventricular Assist Device (VAD), 16% Extra Corporeal Membrane Oxygenation (ECMO) and 21% Intra-aortic balloon pumps (IABP). There was no difference in arterial lactate profiles on ESHP at any time point for those dependent upon MCS support (MCS) and those that were not (no MCS) post-transplant. After 3 hours of ESHP, the arterial lactate was >5mmol/L in 80% upon MCS vs 62% no MCS, p = .30. There was also no difference in ESHP rising arterial lactate concentrations, (15% MCS vs 13% non MCS, p = 1.00). CONCLUSION: For DCD hearts transplants retrieved using the DPP technique, lactate profiles do not seem to be a reliable predictor of mechanical circulatory support requirement post-transplant.


Subject(s)
Heart Transplantation , Tissue and Organ Procurement , Heart Transplantation/methods , Humans , Lactic Acid , Perfusion/methods , Reproducibility of Results , Retrospective Studies , Tissue Donors
6.
J Heart Lung Transplant ; 39(12): 1366-1371, 2020 12.
Article in English | MEDLINE | ID: mdl-32958407

ABSTRACT

Combined heart-lung transplantation is the optimal treatment option for many patients with end-stage heart failure and fixed severe pulmonary hypertension. It offers the only possibility of long-term survival and a return to a normal quality of life. Unfortunately, it is rarely performed because of donor organ allocation policies. We present the case of a critically ill 24-year-old man, who after waiting for >100 days in-hospital on the urgent transplant list, deteriorated further and underwent the first successful heart-lung transplant with organs from a donation after circulatory death.


Subject(s)
Heart Defects, Congenital/surgery , Heart-Lung Transplantation/methods , Tissue Donors , Tissue and Organ Procurement/methods , Adult , Humans , Male , Quality of Life , Young Adult
7.
J Heart Lung Transplant ; 39(12): 1463-1475, 2020 12.
Article in English | MEDLINE | ID: mdl-33248525

ABSTRACT

BACKGROUND: In an effort to address the increasing demand for heart transplantation within the United Kingdom (UK), we established a clinical program of heart transplantation from donation after circulatory-determined death (DCD) donors in 2015. After 5 years, we report the clinical early outcomes and impact of the program. METHODS: This is a single-center, retrospective, matched, observational cohort study comparing outcomes of hearts transplanted from DCD donors from March 1, 2015 to February 29, 2020 with those from matched donation after brain death (DBD) donors at Royal Papworth Hospital (RPH) (Cambridge, UK). DCD hearts were either retrieved using thoracoabdominal normothermic regional perfusion or the direct procurement and perfusion technique. All DBD hearts were procured using standard cold static storage. The primary outcomes were recipient 30-day and 1-year survival. RESULTS: During the 5-year study, DCD heart donation increased overall heart transplant activity by 48% (79 for DCD and 164 for DBD). There was no difference in survival at 30 days (97% for DCD vs 99% for DBD, p = 1.00) or 1 year (91% for DCD vs 89% for DBD, p = 0.72). There was no difference in the length of stay in the intensive care unit (7 for DCD vs 6 for DBD days, p = 0.24) or in the hospital (24 for DCD vs 25 for DBD days, p = 0.84). CONCLUSIONS: DCD heart donation increased overall heart transplant activity at RPH by 48%, with no difference in 30-day or 1-year survival in comparison with conventional DBD heart transplantations. DCD heart donation is set to make a dramatic difference in the number of patients who can benefit from heart transplantation.


Subject(s)
Heart Transplantation/methods , Tissue Donors , Tissue and Organ Procurement/methods , Adult , Female , Follow-Up Studies , Graft Survival , Humans , Male , Middle Aged , Retrospective Studies , Time Factors , United Kingdom
8.
Eur J Cardiothorac Surg ; 55(3): 468-475, 2019 Mar 01.
Article in English | MEDLINE | ID: mdl-30239643

ABSTRACT

OBJECTIVES: Heart transplantation represents the most effective therapy that is currently available for end-stage heart failure. Despite the shortage of organ donors, many donor hearts are not accepted for transplantation due to poor function. Targeted donor management may increase the donor heart utilization rate. The aim of this study is to analyse a 2-year experience of early donor management through the 'scout programme' by a high-volume national cardiothoracic organ retrieval team. METHODS: A prospective cohort study was carried out between 2013 and 2015 on consecutive donation from brain-dead donors. A member of the cardiothoracic retrieval team travelled to the intensive care unit of the donor hospital to assist with early management. RESULTS: One hundred and seventy-eight cardiac donors were enrolled; 106 (59.5%) were 'scouted', and 72 (40.5%) were 'non-scouted'. Donor heart utilization rate in the 'scouted' group was 47.2% (50/106) compared with 30.6% (22/72) in the 'non-scouted' group (P = 0.03). On logistic regression analysis, early donor management by the scouts independently predicted donor heart utilization. The time in the operating theatre from donor arrival to skin incision was significantly reduced in the 'scouted' group. No differences were found in the 30-day graft failure rate or the 30-day, 1-year and 2-year survival rates of the recipients between the 2 groups. CONCLUSIONS: Early donor management delivered by the cardiothoracic retrieval team significantly increased the donor heart utilization rate from existing donors. Moreover, the time in the operating theatre from donor heart arrival to skin incision was significantly reduced.


Subject(s)
Heart Failure/surgery , Heart Transplantation/statistics & numerical data , Procedures and Techniques Utilization/statistics & numerical data , Tissue Donors/supply & distribution , Tissue and Organ Procurement/organization & administration , Tissue and Organ Procurement/statistics & numerical data , Adult , Female , Humans , Male , Middle Aged , Prospective Studies , Time Factors , Young Adult
9.
Ann Cardiothorac Surg ; 7(1): 75-81, 2018 Jan.
Article in English | MEDLINE | ID: mdl-29492385

ABSTRACT

Fifty years since the first successful human heart transplant from a non-heart beating donor, this concept of heart transplantation from donation after circulatory determined death (DCD) promises to be one of the most exciting developments in heart transplantation. Heart transplantation has established itself as the best therapeutic option for patients with end-stage heart failure, with the opportunity to provide these patients with a near-normal quality of life. However, this treatment is severely limited by the availability of suitable donor hearts. In recent times, heart transplantation has been limited to using donor hearts from donors following brain stem death. The use of donor hearts from DCD had been thought to be associated with high risk and poor outcomes until recent developments in organ perfusion and retrieval techniques have shown that this valuable resource may provide an answer to the global shortage of suitable donor hearts. With established DCD heart transplant programmes reporting encouraging results, this technique has been shown to be comparable to the current gold standard of donation after brain death (DBD) heart transplantation.

10.
J Heart Lung Transplant ; 37(7): 865-869, 2018 07.
Article in English | MEDLINE | ID: mdl-29731238

ABSTRACT

Heart transplantation from donation after circulatory-determined-death (DCD) donors is emerging as an additional avenue to increase heart transplant activity. Previous methods of DCD heart retrieval include direct procurement and cold storage, direct procurement, and machine perfusion and normothermic regional perfusion, followed by machine perfusion during transportation. Herein we report a further technique resulting in successful DCD heart transplantation utilizing normothermic regional perfusion and permitting functional assessment followed by cold storage.


Subject(s)
Death , Heart Transplantation , Organ Preservation/methods , Tissue and Organ Procurement , Adult , Cold Temperature , Female , Humans , Male , Middle Aged , Perfusion
11.
J Heart Lung Transplant ; 36(12): 1311-1318, 2017 Dec.
Article in English | MEDLINE | ID: mdl-29173394

ABSTRACT

BACKGROUND: The requirement for heart transplantation is increasing, vastly outgrowing the supply of hearts available from donation after brain death (DBD) donors. Transplanting hearts after donation after circulatory-determined death (DCD) may be a viable additive alternative to DBD donors. This study compared outcomes from the largest single-center experience of DCD heart transplantation against matched DBD heart transplants. METHODS: DCD hearts were retrieved using normothermic regional perfusion (NRP) or direct procurement and perfusion (DPP). During NRP, perfusion was restored to the arrested heart within the donor with the exclusion of the cerebral circulation, whereas DPP hearts were removed directly. All hearts were maintained on machine perfusion during transportation. A retrospective cohort of DBD heart transplants, matched for donor and recipient characteristics, was used as a comparison group. The primary outcome measure of this study (set by the United Kingdom regulatory body) was 90-day survival. RESULTS: There were 28 DCD heart transplants performed during the 25-month study period. Survival at 90 days was not significantly different between DCD and matched DBD transplant recipients (DCD, 92%; DBD, 96%; p = 1.0). Hospital length of stay, treated rejection episodes, allograft function, and 1-year survival (DCD, 86%; DBD, 88%; p = 0.98) were comparable between groups. The method of retrieval (NRP or DPP) was not associated with a difference in outcome. CONCLUSIONS: These results suggest that heart transplantation from DCD heart donation provides comparable short-term outcomes to traditional DBD heart transplants and can serve to increase heart transplant activity in well-selected patients.


Subject(s)
Heart Transplantation/mortality , Perfusion/methods , Registries , Tissue Donors , Tissue and Organ Procurement/methods , Adolescent , Adult , Brain Death , Female , Graft Survival , Humans , Male , Middle Aged , Retrospective Studies , Survival Rate/trends , Transplantation, Homologous , United Kingdom/epidemiology , Young Adult
12.
J Heart Lung Transplant ; 35(12): 1443-1452, 2016 12.
Article in English | MEDLINE | ID: mdl-27916176

ABSTRACT

BACKGROUND: After a severe shortage of brain-dead donors, the demand for heart transplantation has never been greater. In an attempt to increase organ supply, abdominal and lung transplant programs have turned to the donation after circulatory-determined death (DCD) donor. However, because heart function cannot be assessed after circulatory death, DCD heart transplantation was deemed high risk and never adopted routinely. We report a novel method of functional assessment of the DCD heart resulting in a successful clinical program. METHODS: Normothermic regional perfusion (NRP) was used to restore function to the arrested DCD heart within the donor after exclusion of the cerebral circulation. After weaning from support, DCD hearts underwent functional assessment with cardiac-output studies, echocardiography, and pressure-volume loops. In the feasibility phase, hearts were transported perfused before evaluation of function in modified working mode extracorporeally. After the establishment of a reliable assessment technique, hearts with demonstrable good function were then selected for clinical transplantation. RESULTS: NRP was instituted in 13 adult DCD donors, median age of 33 years (interquartile range [IQR], 28-38 years), after a median ischemic time from withdrawal to perfusion of 24 minutes (IQR, 21-29; range, 17-146 minutes). Two of 4 hearts in the feasibility phase were unsuitable for transplantation after functional assessment. Nine DCD hearts were transplanted in the clinical phase, with 100% survival. The median intensive care duration was 5 days (IQR, 4-5 days), with 2 patients requiring mechanical support. There were no episodes of rejection (total, 1,436 patient-days; range, 48-297). During the same period, we performed 20 standard heart transplants using brain-dead donors. CONCLUSIONS: NRP allows rapid reperfusion and functional assessment of the DCD donor heart, ensuring only viable hearts are selected for transplantation. This technique minimizes the risk of primary graft dysfunction and maximizes confidence in DCD heart transplantation, realizing a 45% increase in our heart transplant activity.


Subject(s)
Heart Transplantation , Adult , Humans , Perfusion , Tissue Donors , Tissue and Organ Procurement
13.
Eur J Cardiothorac Surg ; 48(5): 642-53, 2015 Nov.
Article in English | MEDLINE | ID: mdl-26254467

ABSTRACT

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.


Subject(s)
Empyema, Pleural , Thoracic Surgery, Video-Assisted , Adult , Child , Consensus , Empyema, Pleural/diagnosis , Empyema, Pleural/surgery , Humans
14.
Asian Cardiovasc Thorac Ann ; 23(5): 535-42, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25698796

ABSTRACT

BACKGROUND: We sought to determine the incidence of hospital death due to surgical compromise of the coronary ostia in aortic valve replacement. The mechanism of coronary ostium blockage was also investigated. METHODS: A retrospective review was conducted of prospectively collected clinical data and autopsy findings in 322 patients who died in hospital after aortic valve replacement with or without concomitant procedures in a single institution from January 1998 to March 2013. RESULTS: Over the 15-year period, more than 17 surgeons performed 7507 aortic valve replacements with or without other procedures. The mean age of the patients was 70.8 ± 11.78 years and 63% were male. Bioprosthetic valves were used in 75%, mechanical valves in 24.7%, and homografts in only 0.3%. Early mortality for all patients (combined, emergency, and redo procedures) was 4.29% (mean logistic EuroSCORE 10.7). There were 322 deaths after procedures involving the aortic valve. Autopsy examinations were carried out in all patients and showed that 3.4% (n = 11) of deaths were at least partly attributed to encroachment on one or both coronary ostia. Causes of ostial compromise included the valve sutures, the valve sewing ring, and the aortotomy suture line. CONCLUSIONS: Coronary ostial compromise in aortic valve replacement is a very rare but real problem occurring in at least 0.15% of aortic valve replacements and contributing to or directly causing one in every 29 aortic valve replacement deaths. Surgeons should have a high level of awareness of the risk of this rare but fatal and avoidable complication.


Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Coronary Stenosis/etiology , Heart Valve Prosthesis Implantation/mortality , Heart Valve Prosthesis Implantation/methods , Postoperative Complications/etiology , Aged , Aged, 80 and over , Aortic Valve/pathology , Aortic Valve Stenosis/mortality , Autopsy , Coronary Stenosis/mortality , Coronary Stenosis/pathology , Female , Heart Valve Prosthesis , Humans , Male , Postoperative Complications/mortality , Postoperative Complications/pathology , Retrospective Studies
16.
Interact Cardiovasc Thorac Surg ; 19(3): 419-24, 2014 Sep.
Article in English | MEDLINE | ID: mdl-24939960

ABSTRACT

OBJECTIVES: Mesenteric ischaemia (MesI) remains a rare but lethal complication following cardiac surgery. Previously identified risk factors for MesI mortality (age, poor left ventricular (LV) function, cardiopulmonary bypass time and blood loss) are non-specific and cannot necessarily be modified. This study aims to identify potentially modifiable risk factors for MesI mortality through analysis of peri- and intraoperative perfusion data. METHODS: Patients who underwent cardiac surgery between 2006 and 2011 at Papworth Hospital were retrospectively divided into 3 outcome categories: death caused by MesI; death due to other causes and survival to discharge. A published MesI risk calculator was used to estimate risk of MesI for each patient and then to create 3 cohorts of matched patients from each outcome group. Pre-, intra- and postoperative variables were collected and conditional logistic regression methods were used to identify parameters associated specifically with MesI deaths after cardiac surgery. RESULTS: A total of 10 409 patients underwent cardiac surgery between 2006 and 2011. The incidence of MesI was 0.3% (30 patients). Two hundred and sixty-one patients died of non-MesI causes and 10 118 survived. It was possible to identify 25 patients in each group at equivalent risk of MesI. The following parameters were found to be associated with MesI mortality: recent myocardial infarction [odds ratio (OR) 4.98, 95% confidence interval (CI) 1.58-15.71, P = 0.01], standard EuroSCORE (OR 1.12, 95% CI 1.03-1.21, P = 0.01), vasopressor dose on bypass (OR 1.28, 95% CI 1.04-1.57, P = 0.02), metaraminol dose on bypass (OR 1.52, 95% CI 1.12-2.06, P = 0.01) and lowest documented mean arterial pressure (OR 0.90, 95% CI 0.83-0.97, P = 0.01). No other intraoperative perfusion-related parameters (e.g. flow, average activated clotting time or pressure) were associated with MesI mortality. CONCLUSIONS: Our study not only confirms previously known predictive factors, but also demonstrates a new association between intraoperative vasopressor use and MesI mortality.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Mesenteric Ischemia/etiology , Perfusion , Aged , Aged, 80 and over , Cardiac Surgical Procedures/mortality , Cause of Death , England , Female , Hospital Mortality , Humans , Incidence , Logistic Models , Male , Mesenteric Ischemia/diagnosis , Mesenteric Ischemia/mortality , Odds Ratio , Perfusion/adverse effects , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Vasoconstrictor Agents/therapeutic use
17.
Interact Cardiovasc Thorac Surg ; 16(6): 725-30, 2013 Jun.
Article in English | MEDLINE | ID: mdl-23429568

ABSTRACT

OBJECTIVES: Many centres in the UK carry out routine chest X-ray (CXR) and/or electrocardiogram (ECG) when patients attend follow-up clinic after cardiac surgery. Current evidence to support this practice is weak. This study investigated the appropriateness of carrying out these investigations in the absence of clinical indication. METHODS: All patients attending routine 6- to 8-week follow-up clinic after cardiac surgery in this hospital were prospectively reviewed over a 6-month period (October 2011-April 2012). Two groups were identified for comparison. Group A comprised patients who had CXR and/or ECG requested routinely, and those in Group B had the investigations only when clinically indicated. A proforma was designed to screen each patient for cardiac and respiratory symptoms, predischarge CXR abnormalities and the presence of atrial fibrillation/flutter postoperatively. Management alterations based on the findings from the investigations were noted. Patients who had thoracic, major aortic, or heart transplant surgery were excluded from the audit. RESULTS: Three hundred and fifty patients were reviewed: 250 were in Group A and 100 in Group B. No patient had a significant management alteration in the absence of an indication for the tests. There were no differences in outcome between the two groups. In Group A, 111 (45%) patients had CXR and ECG done without indication and no abnormality was detected. In Group B, 52 patients had no indication for either tests and were thus not tested. None of these patients required readmission/intervention following discharge from clinic. Overall, 271 patients had CXR carried out, with only 83 being indicated. This led to a management alteration in 33 patients (12% overall, 40% if indicated). Two hundred and eighty-six patients had ECG carried out with 140 indicated. Management was altered in 122 patients (43% overall, 87% if indicated). The correlation between the clinical indication-based investigation and the resulting change in patient management was found to be significant (Goodman-Kruskal Gamma: 0.99, P = 0.000 for both investigations). CONCLUSIONS: There is a strong correlation between clinical indication for CXR and/or ECG and management alterations. These investigations should be performed during the routine follow-up of adult cardiac surgical patients using a patient-centred approach based on signs and symptoms.


Subject(s)
Cardiac Surgical Procedures , Electrocardiography , Outpatient Clinics, Hospital , Postoperative Complications/diagnosis , Radiography, Thoracic , Cardiac Surgical Procedures/adverse effects , Humans , Patient-Centered Care , Postoperative Care , Postoperative Complications/diagnostic imaging , Predictive Value of Tests , Prospective Studies , Time Factors , Unnecessary Procedures
18.
Interact Cardiovasc Thorac Surg ; 17(1): 116-9, 2013 Jul.
Article in English | MEDLINE | ID: mdl-23592726

ABSTRACT

OBJECTIVES: Death in low-risk cardiac surgical patients provides a simple and accessible method by which modifiable causes of death can be identified. In the first FIASCO study published in 2009, local potentially modifiable causes of preventable death in low-risk patients with a logistic EuroSCORE of 0-2 undergoing cardiac surgery were inadequate myocardial protection and lack of clarity in the chain of responsibility. As a result, myocardial protection was improved, and a formalized system introduced to ensure clarity of the chain of responsibility in the care of all cardiac surgical patients. The purpose of the current study was to re-audit outcomes in low-risk patients to see if improvements have been achieved. METHODS: Patients with a logistic EuroSCORE of 0-2 who had cardiac surgery from January 2006 to August 2012 were included. Data were prospectively collected and retrospectively analysed. The case notes of patients who died in hospital were subject to internal and external review and classified according to preventability. RESULTS: Two thousand five hundred and forty-nine patients with a logistic EuroSCORE of 0-2 underwent cardiac surgery during the study period. Seven deaths occurred in truly low-risk patients, giving a mortality of 0.27%. Of the seven, three were considered preventable and four non-preventable. Mortality was marginally lower than in our previous study (0.37%), and no death occurred as a result of inadequate myocardial protection or communication failures. CONCLUSION: We postulate that the regular study of such events in all institutions may unmask systemic errors that can be remedied to prevent or reduce future occurrences. We encourage all units to use this methodology to detect any similarly modifiable factors in their practice.


Subject(s)
Cardiac Surgical Procedures/mortality , Medical Errors/mortality , Postoperative Complications/mortality , Cause of Death , Hospital Mortality , Humans , Logistic Models , Medical Audit , Medical Errors/prevention & control , Patient Safety , Postoperative Complications/prevention & control , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome
19.
Hosp Pract (1995) ; 40(3): 71-9, 2012 Aug.
Article in English | MEDLINE | ID: mdl-23086096

ABSTRACT

Chronic thromboembolic pulmonary hypertension (CTEPH) is the only cause of pulmonary hypertension for which there is a potential cure, which is in the form of pulmonary endarterectomy. There is a strong link between pulmonary embolism (PE) and the development of CTEPH. Although CTEPH was initially believed to be a rare complication, this belief has been reconsidered following several studies suggesting that up to 8.8% of patients develop CTEPH within the 2 years after PE. However, considering the incidence of PE, there is a significant discrepancy in the number of patients who are diagnosed, referred, and treated for CTEPH. Potential reasons for this include its often vague clinical presentation, the variable association of CTEPH with PE, and discrepancies when interpreting imaging studies. Underdiagnosis of CTEPH is preventing patients from accessing potentially curative therapy. Increased awareness about this condition is an important initial step to improving diagnostic rates and treatment.


Subject(s)
Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/etiology , Pulmonary Embolism/complications , Pulmonary Embolism/diagnosis , Chronic Disease , Diagnostic Imaging , Endarterectomy/methods , Humans , Hypertension, Pulmonary/epidemiology , Hypertension, Pulmonary/surgery , Incidence , Prevalence , Pulmonary Embolism/epidemiology , Pulmonary Embolism/surgery , Risk Factors
SELECTION OF CITATIONS
SEARCH DETAIL