Repair of the complete atrioventricular septal defect-impact of postoperative moderate or more regurgitation.

OBJECTIVES: To study the risk factors for mortality, moderate or more left atrioventricular valve regurgitation (LAVVR) and reoperation after the surgical repair of complete atrioventricular septal defect (cAVSD) in a single centre. METHODS: The current study is a retrospective review of patients who underwent surgical repair of cAVSD between 2000 and 2021. Patients with unbalanced ventricles not amenable to biventricular repair, double outlet right ventricle and malpositioned great arteries were excluded. The clinical predictors of outcome for end points were analysed with univariate and multivariable Cox regression analysis or Fine-Gray modelling for competing risks. Time-dependent end points were estimated using the Kaplan-Meier curve analysis and cumulative incidence curves. RESULTS: The median follow-up time was 2.3 years. Among 220 consecutive patients were 10 (4.6%) operative and 21 late mortalities (9.6%). A total of 26 patients were identified to have immediate postoperative moderate or more regurgitation and 10 of them ultimately died. By multivariable analysis prematurity and having more than moderate regurgitation immediately after the operation were identified as predictors of overall mortality (P = 0.003, P = 0.012). Five- and ten-year survival rates were lower for patients with immediate postoperative moderate or more LAVVR {51.9% [confidence interval (CI): 27.5-71.7%]} when compared to patients without moderate or more regurgitation [93.2% (CI: 87.1-96.4%) and 91.3% (CI: 83.6-95.5%)]. CONCLUSIONS: The patients who undergo cAVSD repair remain subjected to a heavy burden of disease related to postoperative residual LAVVR. Immediate postoperative moderate or more LAVVR contributes significantly to overall mortality. Whether a second run of bypass can decrease this observed mortality should be investigated.

Successful Reuse of a Donor Heart.

At a time when transplantable organs are in a shortage, few cases have noted the reuse of donor hearts in a second recipient in an effort to expand the donor network. Here, we present a case in which an O Rh-positive donor heart was first transplanted into a B Rh-positive recipient and later successfully retransplanted into a second O Rh-positive recipient 10 days after the initial transplant at the same medical center. On postoperative day 1, the first recipient, a 21-year-old man with nonischemic cardiomyopathy, sustained a devastating cerebrovascular accident with progression to brain death. With preserved left ventricle and mildly depressed right ventricle function, the heart was allocated to the second recipient, a 63-year-old male patient with familial restrictive cardiomyopathy. The bicaval technique was used, and the total ischemic time was 100 minutes. His postoperative course was uncomplicated with no evidence of rejection on 3 endomyocardial biopsies. Follow-up transthoracic echocardiogram revealed a left ventricular ejection fraction of 60% to 70%. Seven months posttransplant, the second recipient was doing well with appropriate left and right ventricular function. With careful organ selection, short ischemic time, and proper postoperative care, retransplant of donor hearts may be an option for select patients in need of heart transplant.

Simultaneous heart-kidney transplant in patients with borderline estimated glomerular filtration rate without dialysis dependency.

BACKGROUND: Appropriate patient selection for simultaneous heart-kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging. METHODS: From the United Network for Organ Sharing database (2003-2020), we identified 5678 adults with an estimated pre-transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre-transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching. RESULTS: The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p < .001). After matching, 1 and 5-year survival was 87.7% (95% confidence interval [CI] 83.3-91.0) and 80.0% (95% CI 74.2-84.6) after sHK, and 87.3% (95% CI 85.2-89.1) and 71.8% (95% CI 68.4-74.9) after heart transplant alone (p = .04). In the subgroup analysis, sHK was associated with a 5-year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p = .05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p = .45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis-dependent after transplant within 5-year follow-up (10.2%, 95% CI 8.0-12.6 vs. 3.8%, 95% CI 1.7-7.1, p = .004). The 5-year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively. CONCLUSION: Among propensity-matched patients without pre-transplant dialysis, compared to heart transplants alone, sHK had improved 5-year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2 . One-year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system.

Evaluating age-based eligibility thresholds for heart re-transplantation - an analysis of the united network for organ sharing database.

BACKGROUND: Risk-adjusted survival after late heart re-transplantation may be comparable to primary transplant, but the efficacy of re-transplantation in older candidates is not established. We evaluated outcomes after heart re-transplantation in recipients > 60 years. METHODS: We identified 1026 adult patients undergoing isolated heart re-transplantation between 2003 and 2020 from the United Network for Organ Sharing database. Older recipients (> 60 years, n=177) were compared to younger recipients (≤ 60 years, n=849). Five and ten-year post-transplant survival was estimated using the Kalpan-Meier method and adjusted with multivariable Cox models. RESULTS: Older recipients were more likely to be male and have diabetes or previous malignancies with higher baseline creatinine. They also more frequently required pre-transplant ECMO (11.9% vs. 6.8%, p=0.02) and received re-transplantation due to primary graft failure (13.6% vs. 8.5%, p=0.03). After the transplant, older recipients had a higher incidence of stroke (6.8% vs. 2.6%, p=0.01) and dialysis requirements (20.3% vs. 13.2%) before discharge (both p<0.05), and more frequently died from malignancy-related causes (16.3% vs. 3.9%, p<0.001). After adjustment, recipient age >60 was associated with an increased risk of both 5-year (HR 1.42, 95% CI 1.02-2.01, p=0.04) and 10-year mortality (HR 1.72, 95% CI 1.20-2.45, p=0.003). Restricted cubic spline showed a non-linear relationship between recipient age and 10-year mortality. CONCLUSIONS: Heart re-transplantation in recipients > 60 years has inferior outcomes compared to younger recipients. Strict patient selection and close follow-up are warranted to ensure the appropriate utilization of donor hearts and to improve long-term outcomes.

Heart transplant recipient 1-year outcomes during the COVID-19 pandemic.

The COVID-19 pandemic initially brought forth considerable challenges to the field of heart transplantation. To prevent the spread of the virus and protect immunocompromised recipients, our center made the following modifications to post-transplant outpatient management: eliminating early coronary angiograms, video visits for postoperative months 7, 9, and 11, and home blood draws for immunosuppression adjustments. To assess if these changes have impacted patient outcomes, the current study examines 1-year outcomes for patients transplanted during the pandemic. Between March and September 2020, we assessed 50 heart transplant patients transplanted during the pandemic. These patients were compared to patients who were transplanted during the same months between 2011 and 2019 (n = 482). Endpoints included subsequent 1-year survival, freedom from cardiac allograft vasculopathy, any-treated rejection, acute cellular rejection, antibody-mediated rejection, nonfatal major adverse cardiac events (NF-MACE), and hospital and ICU length of stay. Patients transplanted during the pandemic had similar 1-year endpoints compared to those of patients transplanted from years prior apart from 1-year freedom from NF-MACE which was significantly higher for patients transplanted during the pandemic. Despite necessary changes being made to outpatient management of heart transplant recipients, heart transplantation continues to be safe and effective with similar 1-year outcomes to years prior.

Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis.

INTRODUCTION: Cannabinoid hyperemesis syndrome (CHS) is a condition that is being recognized and treated more frequently in emergency departments (EDs) across the United States. Currently, ED providers rely on antiemetics, antipsychotics and benzodiazepines to alleviate the symptoms. Topical capsaicin, a transient receptor potential vanilloid 1 (TRPV1) agonist, has been proposed in recent years as a low-cost and effective alternative to the traditional antiemetic regimen when treating CHS. The aim of this systematic review and meta-analysis is to demonstrate the reliability and the gaps of what is known about this treatment modality. METHODS: Articles were extracted from PubMed, SCOPUS, and Google Scholar databases. Publication dates ranged from the inception of the databases to October 2020. Initial searches found 328 studies. After careful review and screening by two investigators, 7 studies met the inclusion criteria and were included for our meta-analysis. Variables that were evaluated included the prevalence of hospital admissions for patients treated with capsaicin, time to relief of symptoms after capsaicin administration, and ED length of stay (LOS). I-square and Q-statistic values were used to assess heterogeneity. RESULTS: Among the 7 studies, there was a total of 106 patients. Two studies reported time to resolution of symptoms following capsaicin administration and ED LOS. Means for these outcomes were 325 (95% CI 234-787) and 379 (95% CI 10-747) minutes respectively. I-square was 44%, and Q-statistic was 11 with 6 degrees of freedom, with a p-value of 0.1. DISCUSSION: With acceptable time to resolution of symptoms after topical administration and ED LOS, capsaicin appears to be an effective treatment option for symptomatic relief of CHS. Further randomized controlled trials should be conducted to examine if it is the more efficacious and efficient treatment for CHS across various care settings.

Heart transplantation in the era of the SARS-CoV-2 pandemic: Is it safe and feasible?

As the SARS-CoV-2-pandemic continues to unfold, the number of heart transplants completed in the United States has been declining steadily. The current case series examines the immediate short-term outcomes of seven heart transplant recipients transplanted during the SARS-CoV-2 pandemic. We hope to illustrate that with proper preparation, planning, and testing, heart transplantation can be continued during a pandemic. We assessed 7 patients transplanted from March 4, 2020, to April 15, 2020. The following endpoints were noted: in-hospital survival, in-hospital freedom from rejection, in-hospital nonfatal major cardiac adverse events (NF-MACE), severe primary graft dysfunction, hospital length of stay, and ICU length of stay. There were no expirations throughout the hospital admission. In addition, there were no patients with NF-MACE or treated rejection, and 1 patient developed severe primary graft dysfunction. Average length of stay was 17.2 days with a standard deviation of 5.9 days. ICU length of stay was 7.7 days with a standard deviation of 2.3 days. Despite the decreasing trend in completed heart transplants due to SARS-CoV-2, heart transplantation appears to be feasible in the immediate short term. Further follow-up is needed, however, to assess the impact of SARS-CoV-2 on post-heart transplant outcomes months after transplantation.