Risk stratification of best medical therapy for acute uncomplicated type B intramural hematoma.

OBJECTIVES: Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making. METHODS: Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure. RESULTS: In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR â€‹= â€‹1.99 CI â€‹= â€‹1.16-3.40, p â€‹= â€‹0.012), initial IMH thickness (HR â€‹= â€‹3.29, CI â€‹= â€‹1.28-8.46, p â€‹= â€‹0.013) and presence of focal contrast enhancement (HR â€‹= â€‹3.12, CI â€‹= â€‹1.49-6.54, p â€‹= â€‹0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 â€‹+ â€‹Max IMH thickness (mm)∗1.1918 â€‹+ â€‹PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score â€‹< â€‹4.12, compared with only 35.1% in those with a risk score â€‹â‰§ â€‹4.12. CONCLUSIONS: In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention.

Aortic remodeling after endovascular aortic repair and tailored distal entry tears exclusion in Crawford type III or IV dissection aneurysm.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm. METHODS: All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years. RESULTS: The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage. CONCLUSION: Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm.

Effects of Slowness, Frailty, Insufficient Intake, and Delirium in Patients Following Cardiac Surgery: A Cohort Study.

BACKGROUND: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery. OBJECTIVES: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes. METHODS: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients. RESULTS: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6). CONCLUSIONS: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes.

Endovascular Repair for Retrograde Type A Intramural Haematoma with Intimal Tear in the Descending Thoracic Aorta.

OBJECTIVE: The current treatment for acute retrograde type A intramural haematoma (IMH) remains challenging. Aortic remodelling in both the ascending aorta (AA) and descending thoracic aorta (DTA) was evaluated and the 30 day and mid term outcomes were determined in patients who underwent thoracic endovascular aneurysm repair (TEVAR) for retrograde type A IMH with a primary intimal tear or ulcer like projection in the DTA METHODS: This was a retrospective, multicentre observational study. Clinical data, including post-operative mortality and adverse event, aorta related re-intervention, aortic remodelling, and the survival rate of 18 non-consecutive patients with acute retrograde type A IMH undergoing TEVAR between June 2006 and March 2018 were reviewed. RESULTS: The median age at repair was 58.1 years (range 38-86) and 14 (78%) were men. Eight patients (44%) presented with haemopericardium, and 10 (56%) underwent TEVAR within 24 h. The mean IMH thickness and AA diameter were 10.4 ± 3.6 and 45.7 ± 4.6 mm, respectively. Among all patients with acute retrograde type A IMH, 11 patients presented with classical type B aortic dissection and seven with type B IMH. All procedures were technically successful. The median follow up was 28.7 months (range 7-78). No 30 day mortality was observed. Three patients developed post-procedure adverse events. Of these, two patients had neurological events, with one each having cerebrovascular and spinal cord infarction individually, and the third patient required long term haemodialysis with ventilator support. The overall survival rate was 100%. The maximum diameter of the AA and the IMH in the AA significantly decreased after TEVAR. Aortic remodelling was also observed in the DTA along the length of TEVAR coverage. CONCLUSION: In selected patients with acute retrograde type A IMH, TEVAR offered a treatment alternative to open surgical grafting and medical follow up.

Long-term outcomes of surgical treatment for intravascular leiomyomatosis.

BACKGROUND: Intravascular leiomyomatosis (IVL) is relatively rare. The optimal surgical method and long-term outcomes are not completely understood. METHODS: Medical records between 2007 and 2017 in our hospital were analyzed to identify IVL cases with surgical intervention. Their medical records, operative details, and follow-up were collected by chart review and telephone communication. RESULTS: Eight patients with IVL were included in the study, accounting for 0.26% of all uterine leiomyoma cases. Primary IVL was confined to pelvic cavity in three patients, extended to the inferior vena cava (IVC) below renal vein in one, reached IVC and right atrium in three, and reached main pulmonary artery in one. One-stage operation was performed for seven patients. Cardiopulmonary bypass was done in four patients, and aortic cross-clamp and temporary circulatory arrest was performed in two patients. None of the four patients with intrapulmonary tumors received concomitant pulmonary tumor resection. There was no operative mortality and four morbidities, including ureter injury (2), bladder injury (1), and femoral vein thrombosis (1). During follow-up, two patients exhibited local recurrence of the tumor in the pelvis, and one patient had rapidly growing intrapulmonary tumor three months post-operatively. Intrapulmonary tumors in the other three patients remained stationary at 6, 84, and 120 months post-operatively. CONCLUSION: One-stage operation to completely remove IVL is feasible and with good long-term outcomes, which is recommended if the patient can tolerate the operation. Concomitant intrapulmonary tumors can be followed up watchfully except when associated with pleural effusion or the pathology indicating trend of increasing malignancy.

Impact of Fatigue Characteristics on Quality of Life in Patients After Heart Transplantation.

BACKGROUND: Fatigue has been identified as a major symptom in heart transplant (HTx) patients; however, researchers have not examined the role of fatigue characteristics (ie, intensity, interference, and duration) in the quality of life (QOL) of HTx patients. OBJECTIVE: The aim of this study was to explore differences in physical and mental aspects of QOL by patient characteristics, as well as the association between fatigue characteristics and QOL in HTx patients after considering other confounding factors (symptom distress and psychological distress). METHODS: A cross-sectional study was conducted in which patients completed the Transplant Symptom Frequency and Symptom Distress Scale, the Fatigue Symptom Inventory, the Hospital Anxiety and Depression Scale, and the 12-item Short-Form Health Survey. Multiple regressions were used to identify factors significantly related to QOL. RESULTS: A total of 126 patients reported moderate levels of fatigue intensity, mild fatigue interference, and low QOL scores in the physical and mental domains. Patients with better physical and cardiac function and lower symptom distress and fatigue interference had better scores on the physical aspect of QOL (explaining 30.7% of the variance); patients with lower fatigue interference, anxiety, and depression had better scores on the mental aspect of QOL (explaining 50% of the variance). CONCLUSIONS: Fatigue interference had a greater influence on QOL domains than fatigue intensity. The degree to which fatigue interferes with daily life should be assessed, and suitable interventions should be introduced in clinical settings to help patients manage their fatigue and improve their QOL.

A Novel Bubble-Mixture Method to Improve Dynamic Images in Carbon Dioxide Angiography.

PURPOSE: To present a novel method of preparing carbon dioxide (CO2) for contrast enhancement. TECHNIQUE: CO2 angiography can often produce poor image enhancement, especially in dependent vessels due to buoyancy of the gas. A new technique for premixing the CO2 gas with the patient's blood and dispersing it into the bubble mixture before injection was developed. Comparative dynamic images showed bubble-mixed CO2 angiography had less fragmentation, more even distribution, and more sustainability than the same volume of pure CO2. CONCLUSION: The alteration of CO2 gas toward a semiliquid form demonstrates an easy and reproducible concept to improve the dynamic image quality of traditional CO2 angiography.

Crossover chimney technique to preserve the internal iliac artery during endovascular repair of iliac or aortoiliac aneurysms: midterm results.

PURPOSE: To report our midterm results of the crossover chimney technique to preserve the internal iliac artery (IIA) in patients with aortoiliac aneurysms (AIA) and isolated common iliac artery aneurysms (CIAA). METHODS: Between May 2012 and January 2014, 14 consecutive patients (mean age 77.3 years; all men) with 17 AIA, isolated CIAAs, or abdominal aortic aneurysms with short CIAs underwent elective endovascular aneurysm repair (EVAR) with the crossover chimney technique to preserve the IIA. Follow-up assessment, including computed tomographic angiography or duplex ultrasound, was performed at 1, 6, and 12 months and annually thereafter. RESULTS: Technical success, defined as successful preservation of IIA without intraoperative type I or III endoleak, was 100%. Over a mean 14.3 months (range 6-21), primary patency was 92.8%. There was no early or late procedure-related mortality. Among the 17 iliac aneurysms excluded, the sac diameter significantly (at least 5 mm) decreased in 3, decreased <5 mm in 10, and did not change in 4. CONCLUSION: The crossover chimney technique is a simple and safe alternative for IIA endovascular revascularization with high technical success and acceptable midterm patency.

Injection of autologous bone marrow cells in hyaluronan hydrogel improves cardiac performance after infarction in pigs.

Intramyocardial injection of bone marrow mononuclear cells (MNCs) with hyaluronan (HA) hydrogel is beneficial to the ischemic heart in a rat model of myocardial infarction (MI). However, the therapeutic efficacy and safety must be addressed in large animals before moving onto a clinical trial. Therefore, the effect of combined treatment on MI was investigated in pigs. Coronary artery ligation was performed in minipigs to induce MI followed by an intramyocardial injection of normal saline (n = 7), HA (n = 7), normal saline with 1 × 10(8) freshly isolated MNCs (n = 8), or HA with 1 × 10(8) MNCs (HA-MNC; n = 7), with a sham-operated group serving as a control (n = 7). The response of each experimental group was estimated by echocardiography, ventricular catheterization, and histological analysis. Although injection of HA or MNCs slightly elevated left ventricular ejection fraction, the combined HA-MNC injection showed a significant increase in left ventricular ejection fraction, contractility, infarct size, and neovascularization. Importantly, injection of MNCs with HA also promoted MNC retention and MNC differentiation into vascular lineage cells in pigs. Therefore, this study not only provides evidence but also raises the possibility of using a combined HA-MNC injection as a promising therapy for heart repair.

Heart transplantation in endstage rheumatic heart disease-experience of an endemic area.

BACKGROUND: Rheumatic heart disease (RHD) remains a significant cause of cardiovascular disease in developing countries. The nonsuppurative cardiovascular sequel of group A streptococcal infection is sustained inflammatory and immune reactions toward the myocardium and valves. This study attempted to determine the long-term outcome of heart transplantation in endstage RHD patients.Methods and Results:The 23 patients with endstage RHD at National Taiwan University Hospital between June 1987 and March 2012 were enrolled. In the same period, 226 dilated cardiomyopathy (DCM) patients were enrolled as the control group. The RHD group experienced more right ventricular failure and higher central venous pressure than the control group, which resulted in impaired liver and kidney function. The RHD patients had a lower 15-year survival rate than the DCM patients after transplantation (22.7% vs. 45.7%, P=0.038) and higher incidence of tricuspid regurgitation than the control group (32.2% vs. 11.4%). No differences existed between the groups for the mitral regurgitation rate (RHD 37.7% vs. DCM 29.4%, P=0.562). CONCLUSIONS: Preoperatively, the RHD patients suffered more tricuspid regurgitation than the control group. The aortic and mitral valves in both groups functioned well over the long term. Heart transplantation for endstage RHD had a long-term survival rate that was inferior to that for DCM patients.

Hyaluronan enhances bone marrow cell therapy for myocardial repair after infarction.

Hyaluronan (HA) has been shown to play an important role during early heart development and promote angiogenesis under various physiological and pathological conditions. In recent years, stem cell therapy, which may reduce cardiomyocyte apoptosis, increase neovascularization, and prevent cardiac fibrosis, has emerged as a promising approach to treat myocardial infarction (MI). However, effective delivery of stem cells for cardiac therapy remains a major challenge. In this study, we tested whether transplanting a combination of HA and allogeneic bone marrow mononuclear cells (MNCs) promotes cell therapy efficacy and thus improves cardiac performance after MI in rats. We showed that HA provided a favorable microenvironment for cell adhesion, proliferation, and vascular differentiation in MNC culture. Following MI in rats, compared with the injection of HA alone or MNC alone, injection of both HA and MNCs significantly reduced inflammatory cell infiltration, cardiomyocyte apoptosis, and infarct size and also improved cell retention, angiogenesis, and arteriogenesis, and thus the overall cardiac performance. Ultimately, HA/MNC treatment improved vasculature engraftment of transplanted cells in the infarcted region. Together, our results indicate that combining the biocompatible material HA with bone marrow stem cells exerts a therapeutic effect on heart repair and may further provide potential treatment for ischemic diseases.

Comparison the prognostic value of galectin-3 and serum markers of cardiac extracellular matrix turnover in patients with chronic systolic heart failure.

BACKGROUND: Galectin-3 (Gal-3) shows the ability of survival prediction in heart failure (HF) patients. However, Gal-3 is strongly associated with serum markers of cardiac extracellular matrix (ECM) turnover. The aim of this study is to compare the impact of Gal-3 and serum markers of cardiac ECM turnover on prognostic prediction of chronic systolic HF patients. METHODS: Serum Gal-3, brain natriuretic peptide (BNP), extracellular matrix including type I and III aminoterminal propeptide of procollagen (PINP and PIIINP), matrix metalloproteinase-2, 9 (MMP-2, 9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) were analyzed. Cox regression analysis was used for survival analysis. RESULTS: A total of 105 (81 male) patients were enrolled. During 980±346 days follow-up, 17 patients died and 36 episodes of HF admission happened. Mortality of these patients was significantly associated with the log PIIINP (ß= 15.380; P=0.042), log TIMP-1(ß= 44.530; P=0.003), log MMP-2 (ß= 554.336; P<0.001), log BNP (ß= 28.273; P=0.034). Log Gal-3 (ß= 7.484; P=0.066) is borderline associated with mortality. Mortality or first HF admission of these patients was significantly associated with the log TIMP-1(ß= 16.496; P=0.006), log MMP-2 (ß= 221.864; P<0.001), log BNP (ß= 5.999; P=0.034). Log Gal-3 (ß= 4.486; P=0.095) only showed borderline significance. In several models adjusting clinical parameters, log MMP-2 was significantly associated with clinical outcome. In contrast, log Gal-3 was not. CONCLUSION: The prognostic strength of MMP-2 to clinical outcome prediction in HF patients is stronger than Gal-3.

Outcomes following endovascular or open repair for ruptured abdominal aortic aneurysm in a Chinese population.

To determine whether emergent endovascular repair (eEVAR) can be an alternative for anatomically suitable ruptured abdominal aortic aneurysms (RAAA) in a Chinese population compared to open aneurysm repair (OAR), 36 patients with RAAA undergoing either OAR or eEVAR in National Taiwan University Hospital from 2005 to 2012 were analyzed retrospectively. Thirty-five (97.2 %) patients were treated. Among them, 20 (57.1 %) were treated by OAR and 15 (42.9 %) by eEVAR. The overall 30-day survival rate was 77.1 %. There was no significant difference in 30-day mortality rate (OAR 15.0 % vs. eEVAR 33.3 %, p = 0.201) and midterm mortality rate (OAR 20.0 % vs. eEVAR 46.7 %, p = 0.093) between these two groups. On univariate analysis, free peritoneal rupture (p < 0.001), pre-operative shock (p = 0.001) and female gender (p = 0.016) are related to a higher 30-day mortality rate, while free peritoneal rupture (p = 0.012) and pre-operative shock (p = 0.030) are associated with a higher midterm mortality rate in both repair techniques. On multivariate analysis, free peritoneal rupture was associated with higher 30-day (OR 26.0, 95 % CI 2.2-295.6, p = 0.009) and midterm (OR 13.1, 95 % CI 1.2-37.6, p = 0.032) mortality rates. In patients with RAAA, there is no significant difference in 30-day mortality and midterm mortality between eEVAR and OAR groups in our study. eEVAR could be an alternative therapy for anatomically suitable RAAA in a Chinese population.

One-stage hybrid repair to thoracoabdominal aortic aneurysm.

BACKGROUND: Open repair of a thoracoabdominal aortic aneurysm (TAAA) is associated with high rates of morbidity and mortality. This study reviewed the midterm outcomes of hybrid TAAA repair in high-risk patients at our institution. METHODS: The clinical data of patients undergoing 1-stage hybrid repair of a TAAA between June 2007 and June 2011 were retrospectively analyzed. This study represents our experience with 10 patients at a single center who underwent 1-stage visceral hybrid procedures for complex thoracoabdominal aortic pathologies. There were 9 men and 1 woman with a median age of 65.7 years. The average preoperative European System for Cardiac Operative Risk Evaluation II score was 34.1%. RESULTS: The technical success rate with completion was 100%. No procedure was abandoned because of any aortic event. The 30-day mortality rate in this study was 10%. Overall major perioperative complication rates were 20%. Major complications included renal impairment requiring permanent support in 1 patient (10%) and paraplegia in 1 patient (10%). At a median follow-up of 20.1 months (range, 0.3-39 months), the overall survival rate was 70%. The primary graft patency rate was 96.8% (32/33). Only 1 renal artery graft was occluded. CONCLUSIONS: The midterm results in selected high-risk patients with TAAA undergoing 1-stage hybrid repair were encouraging. When open repair is hazardous and branched stent grafting is not an option, hybrid repair is a viable treatment alternative. However, larger study cohorts and longer durations of follow-up are necessary to provide data on the durability of aortic stent grafts and visceral artery reconstruction.

Transapical endovascular repair with a table-tailored endograft to treat ascending aortic dissection.

Current endografts, which were designed primarily for the descending aorta, have significant limitations when used in the ascending aorta. We report our initial experience using the transapical endovascular approach to treat an ascending aortic dissection with a table-tailored commercial stent graft.

Clinical Applications of Extracorporeal Membranous Oxygenation: A Mini-Review.

UNLABELLED: The clinical usage of extracorporeal membranous oxygenation began more than 40 years ago. Although the indications for its use have expanded over the years, it has been challenging to conduct randomized controlled trials to prove that extracorporeal membranous oxygenation is more effective than traditional approaches. Through a review of retrospective reports and data from registries, we attempted to evaluate the appropriateness of its application for acute respiratory distress syndrome, cardiopulmonary resuscitation, postcardiotomy cardiogenic shock, and sepsis. Our investigation revealed that using extracorporeal membranous oxygenation when readily available is appropriate for all patients with cardiopulmonary resuscitation or postcardiotomy cardiogenic shock, and for selected patients with acute respiratory distress syndrome or sepsis. KEY WORDS: Acute respiratory distress syndrome; Cardiopulmonary resuscitation; Extracorporeal membranous oxygenation; Postcardiotomy cardiogenic shock; Sepsis.

Crossover chimney technique to preserve the internal iliac artery in abdominal aortic aneurysm with common iliac artery aneurysms.

PURPOSE: To report a new technique to preserve the internal iliac artery (IIA) in cases of aortoiliac aneurysms. TECHNIQUE: Under bilateral common femoral artery (CFA) exposure, a crossover sheath was inserted from the contralateral CFA to the ipsilateral IIA involved in the common iliac artery (CIA) aneurysm. A Viabahn stent-graft was positioned 2 cm inside the IIA. The main body abdominal stent-graft was inserted through the ipsilateral CFA with distal sealing in the external iliac artery (EIA). The gate was cannulated, and the limb extension was positioned in the contralateral CIA near the IIA orifice. After the first Viabahn deployment, a second device was deployed with a minimum 1-cm overlap inside the first Viabahn and 2 mm distal to the limb extension. For bilateral CIA aneurysms, the Viabahn and extension limb were landed in the EIA with IIA embolization. In the past year, this technique has been used in 5 patients with success. There was no acute branch occlusion or type I endoleak from the IIA or chimney graft gutters on imaging studies up to 6 months. CONCLUSION: This technique is easy to use and avoids the brachial access of the sandwich technique and the additional cost of an iliac branch device.

Usefulness of magnetocardiography to detect coronary artery disease and cardiac allograft vasculopathy.

BACKGROUND: Electrophysiological information as well as anatomic information are important for the detection of coronary artery lesions. The aim of this study was to assess the efficacy of resting magnetocardiography (MCG) in stable coronary artery disease (CAD) and cardiac allograft vasculopathy (CAV). METHODS AND RESULTS: MCG and coronary angiography were performed within 1 month in 75 patients with suspected CAD and in 26 subjects after orthotopic heart transplantation (OHT). Plaque volumes were additionally measured on intravascular ultrasound in OHT recipients. The spatially distributed QT(c) interval maps were constructed with 64-channel MCG. A T-wave propagation map and QT(c) heterogeneity index including QT(c) dispersion and smoothness index of QT(c) (SI-QT(c)) were derived for ischemia detection and localization. CAD patients had higher QT(c) dispersion and SI-QT(c). Receiver operating characteristic curve analysis identified SI-QT(c) ≥9 ms, QT(c) dispersion ≥79 ms as the optimal cut-off for detecting CAD (diagnostic accuracy, 0.7953, 0.7819), better than T-wave propagation (0.6594, P<0.05). There was no significant difference of QT(c) dispersion between CAD and OHT subjects. In OHT recipients, QT(c) dispersion positively correlated with plaque volume, and SI-QT(c) progressively increased after transplantation. Using T-wave propagation mapping, regionally increased dispersion could be demonstrated in CAD patients, but increased dispersion was noted in fewer OHT recipients. CONCLUSIONS: MCG is clinically feasible as a non-invasive tool for diagnosis of CAD, and could be used as a surrogate marker of CAV.

Extracorporeal rescue for early and late graft failure after cardiac transplantation: short result and long-term followup.

OBJECTIVES: Graft failure after heart transplantation led to poor outcomes. We tried to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) rescue in graft survival after transplantation. METHODS: A retrospective review of 385 consecutive heart transplants revealed 46 patients of graft failure requiring ECMO rescue (48 episodes). The pretransplant and ECMO-related variables were evaluated. RESULTS: The median age was 37.7 ± 18.8 years, and the median support time was 155 ± 145 hours. Success rate was 47.9% (23/48). Pretransplant ECMO use was 25% (12/48) and they had 58.3% mortality. The success rate in "early" graft failures was 51.4% (18/35) and 50% for "late" graft failure. The ischemic time with graft failure (178 ± 70 min) was significantly longer than that without graft failure. Preoperative status and the longer ischemic time may be the major factors for failure. Long-term 5-year survival demonstrated significant survival difference between graft failure and nongraft failure. No survival difference was shown between "early" and "late" graft failure. CONCLUSIONS: Graft failure still carried high mortality if advanced circulatory support was required. Early graft failure and late graft failure had similar outcomes. Further investigation of the risk factors shows that ECMO does play a role of rescue in catastrophic conditions.

Myocardial Flow Assessment After Heart Transplantation Using Dynamic Cadmium-Zinc-Telluride Single-Photon Emission Computed Tomography With 201Tl and 99mTc Tracers and Validated by 13N-NH3 Positron Emission Tomography.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse form of vasculopathy and is the most common cause of long-term cardiovascular mortality in heart transplant patients. This study aimed to investigate the diagnostic performance of 99mTc and 201Tl tracers in the assessment of CAV using cadmium-zinc-telluride (CZT) single-photon emission computed tomography (SPECT) for myocardial blood flow (MBF) and myocardial flow reserve (MFR) quantification, which was further validated using 13 N-NH3 positron emission tomography (PET). METHODS: Thirty-eight patients with prior heart transplantation who underwent CZT SPECT and 13 N-NH3 PET dynamic scans were included in this study. CZT SPECT with 99mTc-sestamibi was used in the first 19 patients and 201Tl-chloride for the remaining patients. To determine the diagnostic accuracy of angiographically defined moderate-to-severe CAV, the analysis included patients who underwent angiographic examinations within 1 year of their second scan. RESULTS: There were no significant differences in the patient characteristics between the 201Tl and 99mTc tracer groups. Both 201Tl and 99mTc CZT SPECT-derived stress MBF and MFR values globally and in 3 coronary territories showed good correlations with 13 N-NH3 PET. The 201Tl and 99mTc cohorts did not differ significantly in the correlation coefficients of CZT SPECT versus PET for MBF and MFR, except for stress MBF (201Tl:0.95 versus 99mTc:0.80, P=0.03). 201Tl and 99mTc CZT SPECT were satisfactory for detecting PET MFR <2.0 (201Tl area under the curve, 0.92 [0.71-0.99], 99mTc area under the curve, 0.87 [0.64-0.97]) and angiographically defined moderate-to-severe CAV, and CZT SPECT results were comparable to that of 13 N-NH3 PET (CZT area under the curve, 0.90 [0.70-0.99], PET area under the curve, 0.86 [0.64-0.97]). CONCLUSIONS: This small study suggests that CZT SPECT using 201Tl and 99mTc tracers showed comparable MBF and MFR, and the results correlated well with those of 13 N-NH3 PET. Hence, CZT SPECT with 201Tl or 99mTc tracers can be used to detect moderate-to-severe CAV in patients with prior heart transplantation. However, validation using larger studies is warranted.