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1.
Ned Tijdschr Tandheelkd ; 128(2): 87-88, 2021 Feb.
Artigo em Holandês | MEDLINE | ID: mdl-33605257

RESUMO

A heart transplant procedure is performed on patients who have an end-stage heart disease (severe failure) for whom no other treatment is left. Patients need to take immunosuppressive drugs for the rest of their lives to prevent the rejection of a transplanted heart. A recent overview of scientific literature shows a higher risk of gingival hyperplasia, periodontal conditions, the presence of Candida species and oral malignancies compared to healthy individuals. The association between a heart transplant and dental caries is unclear. A frequent periodical dental check and professional dental cleaning is recommended for heart transplant patients.


Assuntos
Cárie Dentária , Placa Dentária , Transplante de Coração , Doenças Periodontais , Cárie Dentária/epidemiologia , Cárie Dentária/prevenção & controle , Transplante de Coração/efeitos adversos , Humanos , Saúde Bucal , Doenças Periodontais/epidemiologia
2.
Int J Mol Sci ; 22(2)2021 Jan 13.
Artigo em Inglês | MEDLINE | ID: mdl-33451076

RESUMO

Porcine heart xenotransplantation is a potential treatment for patients with end-stage heart failure. To understand molecular mechanisms of graft rejection after heart transplantation, we transplanted a 31-day-old alpha-1,3-galactosyltransferase knockout (GTKO) porcine heart to a five-year-old cynomolgus monkey. Histological and transcriptome analyses were conducted on xenografted cardiac tissue at rejection (nine days after transplantation). The recipient monkey's blood parameters were analyzed on days -7, -3, 1, 4, and 7. Validation was conducted by quantitative real-time PCR (qPCR) with selected genes. A non-transplanted GTKO porcine heart from an age-matched litter was used as a control. The recipient monkey showed systemic inflammatory responses, and the rejected cardiac graft indicated myocardial infarction and cardiac fibrosis. The transplanted heart exhibited a total of 3748 differentially expressed genes compared to the non-transplanted heart transcriptome, with 2443 upregulated and 1305 downregulated genes. Key biological pathways involved at the terminal stage of graft rejection were cardiomyopathies, extracellular interactions, and ion channel activities. The results of qPCR evaluation were in agreement with the transcriptome data. Transcriptome analysis of porcine cardiac tissue at graft rejection reveals dysregulation of the key molecules and signaling pathways, which play relevant roles on structural and functional integrities of the heart.


Assuntos
Rejeição de Enxerto , Transplante de Coração , Transplante Heterólogo , Animais , Biomarcadores , Biologia Computacional/métodos , Feminino , Expressão Gênica , Perfilação da Expressão Gênica , Ontologia Genética , Rejeição de Enxerto/genética , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Haplorrinos , Transplante de Coração/efeitos adversos , Imunossupressores/farmacologia , Masculino , Anotação de Sequência Molecular , Suínos , Transcriptoma , Transplante Heterólogo/efeitos adversos
3.
J Thorac Cardiovasc Surg ; 161(3): 1048-1059.e3, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33485653

RESUMO

OBJECTIVES: Right heart hemodynamic management is critical, because many post-heart transplantation (HTx) complications are related to right ventricular (RV) failure. However, current guidelines on size and sex matching rely primarily on weight matching, with recent literature using total ventricular mass (TVM), which places less emphasis on the impact of RV mass (RVM) matching. The aim of the present study was to analyze the relationship of RVM matching and survival after HTx. METHODS: We performed the retrospective analysis using the UNOS database of adult HTx performed between January 1997 and December 2017. Previously validated equations were used to calculate TVM and RVM. The percent difference in ventricular mass in the donor and recipient pair was used for the size mismatch. All donor-recipient pairs were divided into 4 RVM groups by their mismatch ratio. We analyzed RVM matching and explored how RVM undersizing impacted outcomes. The primary outcome measure was 1-year survival; secondary outcomes measured included stroke and dialysis within 1 year and functional status. RESULTS: A total of 38,740 donor-recipient pairs were included in our study. The 4 RVM match groupings were as follows: <0%, 0% to 20%, 20% to 40%, and >40%. Utilization of donors who were older and of female sex resulted in greater RVM undersizing. Survival analysis demonstrated patients with RVM undersizing had worse 1-year survival (P < .001). RVM undersizing was an independent predictor of higher 1-year mortality (hazard ratio, 1.23; 95% confidence interval, 1.11 to 1.34; P < .001). RVM undersizing was also associated with higher rates of dialysis within 1-year of transplantation and poorer postoperative functional status. CONCLUSIONS: RVM undersizing is an independent predictor for worse 1-year survival. Donors who are older and female have lower absolute predicted RVM and may be predisposed to RVM undersizing. RVM-undersized transplantation requires careful risk/benefit considerations.


Assuntos
Seleção do Doador , Transplante de Coração/mortalidade , Disfunção Ventricular Direita/mortalidade , Função Ventricular Direita , Adulto , Fatores Etários , Bases de Dados Factuais , Técnicas de Apoio para a Decisão , Feminino , Transplante de Coração/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/fisiopatologia
6.
BMC Infect Dis ; 21(1): 89, 2021 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-33472599

RESUMO

BACKGROUND: There are limited data on Coronavirus disease 2019 (COVID-19) in solid organ transplant patients, especially in heart transplant recipients, with only a few case reports and case series described so far. Heart transplant recipients may be at particular high risk due to their comorbidities and immunosuppressed state. CASE PRESENTATION: This report describes the clinical course and the challenging management of early COVID-19 infection in two heart transplant recipients who tested positive for the SARS-CoV-2 virus in the perioperative period of the transplant procedure. The two patients developed a severe form of the disease and ultimately died despite the initiation of an antiviral monotherapy with hydroxychloroquine coupled with the interruption of mycophenolate mofetil. CONCLUSIONS: These two cases illustrate the severity and poor prognosis of COVID-19 in the perioperative period of a heart transplant. Thorough screening of donors and recipients is mandatory, and the issue of asymptomatic carriers needs to be addressed.


Assuntos
/complicações , Transplante de Coração/efeitos adversos , Antimaláricos/uso terapêutico , Antivirais/uso terapêutico , Comorbidade , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Transplantados
8.
Cardiovasc Pathol ; 50: 107266, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32814149

RESUMO

We report a case of a 75-year-old female post orthotopic heart transplantation, who presented to the emergency department with a six-week history of shortness of breath, hand tremor and ultimately delirium. She had lobular breast carcinoma more than 5 years prior to her heart transplant, treated by lumpectomy followed by anthracycline based chemotherapy. The reason for her heart transplant was heart failure that was suspected to be from anthracycline cardiomyopathy, however, her explanted heart actually showed cardiac sarcoidosis. She was placed on long-term immunosuppression with tacrolimus, mycophenolate mofetil and prednisone. Two years after her heart transplant, she underwent bilateral mastectomies for recurrent breast cancer. Her neurological workup, including brain imaging (CT, MRI, LP and EEG) did not show any structural abnormalities, ischemia, mass or neurosarcoidosis as cause for delirium. Tacrolimus was held due to renal dysfunction and hemolytic anemia, and then she developed signs of right heart failure so an endomyocardial biopsy was carried out for suspected allograft rejection. The biopsy did not show any evidence of cellular or antibody medicated rejection; however, it demonstrated infiltration by bland appearing cells with signet ring morphology cells many of which showed intracytoplasmic mucin. The cells were strongly positive with cytokeratins AE1/3, CK7 and mammaglobin. The morphology and immunoprofile were consistent with metastatic lobular breast carcinoma and this was thought to be the cause of her clinical presentation with delirium, hemolytic anemia and renal dysfunction as a paraneoplastic syndrome.


Assuntos
Carcinoma Lobular/secundário , Insuficiência Cardíaca/cirurgia , Neoplasias Cardíacas/secundário , Transplante de Coração , Miocárdio/patologia , Idoso , Antraciclinas/efeitos adversos , Antibióticos Antineoplásicos/efeitos adversos , Biópsia , Carcinoma Lobular/complicações , Carcinoma Lobular/terapia , Cardiomiopatias/induzido quimicamente , Cardiotoxicidade , Quimioterapia Adjuvante , Feminino , Insuficiência Cardíaca/etiologia , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/terapia , Transplante de Coração/efeitos adversos , Humanos , Síndromes Paraneoplásicas/etiologia , Valor Preditivo dos Testes , Fatores de Risco , Sarcoidose/complicações
9.
AJR Am J Roentgenol ; 215(4): 828-833, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32783558

RESUMO

OBJECTIVE. The purpose of this study was to evaluate the feasibility, image quality, and radiation dose of high-pitch coronary CT angiography (CCTA) in orthotopic heart transplant (OHT) recipients. SUBJECTS AND METHODS. Twenty-two consecutive OHT recipients (16 men, six women; median age, 66.5 years [interquartile range, 51.3-70.3 years]; median heart rate, 91 beats/min [interquartile range, 79.3-97.3 beats/min]) underwent CCTA with a third-generation dual-source CT scanner in high-pitch mode to rule out coronary allograft vasculopathy. Data acquisition was triggered at 30% of the R-R interval. Two independent observers blindly assessed image quality on a per-segment, per-vessel, and per-patient basis using a 4-point scale (4, excellent; 1, not evaluative). Scores 2-4 indicated diagnostic quality. Studies were compared with previously performed retrospective ECG-gated examinations, when available. Interobserver agreement on the image quality was assessed with kappa statistics. Radiation dose was recorded. RESULTS. A total of 322 coronary segments were evaluated. Diagnostic image quality was observed in 97.5% of the segments. Interobserver agreement for image quality assessment was very good on a per-patient (κ = 0.82), per-vessel (κ = 0.83), and per-segment basis (κ = 0.89). The median per-patient image quality score was 4.0 (3.0-4.0) for the entire coronary tree. A comparison of image quality scores between high-pitch and retrospective ECG-gated CCTA examinations showed no significant differences, but the estimated mean radiation dose was significantly lower for the high-pitch mode (median dose-length product, 31.6 mGy × cm [interquartile range, 23.1-38.8 mGy × cm] vs 736.5 mGy × cm [interquartile range, 655.5-845.7 mGy × cm], p < 0.001). CONCLUSION. Performing single-heartbeat high-pitch CCTA during the systolic phase of the cardiac cycle in OHT recipients results in diagnostic image quality in coronary angiograms at very low radiation dose.


Assuntos
Angiografia por Tomografia Computadorizada , Estenose Coronária/diagnóstico por imagem , Transplante de Coração/efeitos adversos , Processamento de Imagem Assistida por Computador , Idoso , Estudos de Coortes , Estenose Coronária/etiologia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doses de Radiação , Reprodutibilidade dos Testes , Sístole
10.
J Interv Cardiol ; 2020: 9835151, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32733172

RESUMO

Background: Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. Purpose: The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods: In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. Results: In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion: The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.


Assuntos
Aloenxertos , Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias , Aloenxertos/irrigação sanguínea , Aloenxertos/patologia , Desenho Assistido por Computador , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Feminino , Transplante de Coração/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Reprodutibilidade dos Testes , Medição de Risco/métodos
11.
Nat Commun ; 11(1): 4289, 2020 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-32855397

RESUMO

Older organs represent an untapped potential to close the gap between demand and supply in organ transplantation but are associated with age-specific responses to injury and increased immunogenicity, thereby aggravating transplant outcomes. Here we show that cell-free mitochondrial DNA (cf-mt-DNA) released by senescent cells accumulates with aging and augments immunogenicity. Ischemia reperfusion injury induces a systemic increase of cf-mt-DNA that promotes dendritic cell-mediated, age-specific inflammatory responses. Comparable events are observed clinically, with the levels of cf-mt-DNA elevated in older deceased organ donors, and with the isolated cf-mt-DNA capable of activating human dendritic cells. In experimental models, treatment of old donor animals with senolytics clear senescent cells and diminish cf-mt-DNA release, thereby dampening age-specific immune responses and prolonging the survival of old cardiac allografts comparable to young donor organs. Collectively, we identify accumulating cf-mt-DNA as a key factor in inflamm-aging and present senolytics as a potential approach to improve transplant outcomes and availability.


Assuntos
DNA Mitocondrial/efeitos adversos , Dasatinibe/farmacologia , Inflamação/prevenção & controle , Transplante de Órgãos/métodos , Quercetina/farmacologia , Adulto , Envelhecimento/fisiologia , Animais , Diferenciação Celular , Ácidos Nucleicos Livres , Senescência Celular/efeitos dos fármacos , Senescência Celular/fisiologia , Citocinas/metabolismo , DNA Mitocondrial/metabolismo , Células Dendríticas/imunologia , Células Dendríticas/fisiologia , Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Humanos , Inflamação/etiologia , Masculino , Camundongos Endogâmicos C57BL , Camundongos Endogâmicos DBA , Pessoa de Meia-Idade , Transplante de Órgãos/efeitos adversos , Traumatismo por Reperfusão/genética , Traumatismo por Reperfusão/imunologia , Doadores de Tecidos
12.
Kardiologiia ; 60(6): 880, 2020 Jul 07.
Artigo em Russo | MEDLINE | ID: mdl-32720616

RESUMO

Aim To evaluate incidence of arterial hypertension (AH) in the posttransplantation period and to identify risk factors for this complication.Materials and methods From January, 2010 through December, 2017, 96 heart transplantations (HT) (70 men and 26 women aged 46.5±13.9 years) were performed. During the first month following HT, 8 recipients died and were excluded from the analysis. The retrospective evaluation of results included 88 patients followed up for more than one year.Results For the entire post-HT period (maximum 92 months), AH was observed in 75 of 88 (85%) recipients. Post-HT AH was correlated with male gender (r=0.24; p=0.031), history of smoking before HT (r=0.45; p<0.001), history of ischemic heart disease (IHD) (r=0.28; p=0.01), older age (r=0.35; p=0.001), higher body weight index (r=0.37; p=0.0005), creatinine level (r=0.37; p=0.001), and low-density lipoprotein cholesterol level (r=0.27; p=0.04). Interrelations with other AH risk factors were not found. Most patients developed AH within the first two years after HT. During the first year, AH was diagnosed in 60% (53 of 88) of patients (relapse, 85% (n=29); newly diagnosed, 45% (n=24), p=0.0003). At two years, AH was detected in 79% (46 of 58) of patients (relapse, 53% (n=18); newly diagnosed, 53% (n=28), p=0.9). All recipients received an adequate antihypertensive therapy. 40-63% of patients required a single-drug therapy at different points of follow-up; from 29 to 45% of patients required a two-drug therapy, and 5-15% of patients required three or more drugs. During all 5 years of treatment, most patients used angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (70-87%) and slow calcium channel blockers (SCCB) (48-53%). The presence of AH following HT was associated with development of all cardiovascular events (CVE; r=0.31; p=0.012) whereas persistent AH, which required a combination antihypertensive treatment, was associated with a high mortality (r=0.61; p=0.015).Conclusion AH is a frequent complication of HT (85%), which is newly diagnosed in most patients during the first two years. AH incidence was higher for male recipients with a history of IHD, hypertension, and smoking. Approximately half of patients required only a single-drug antihypertensive therapy. After HT, the most frequently prescribed drugs included ACE inhibitors or ARBs and SCCBs (70-87% and 48-53%, respectively, depending on the time elapsed after HT). Persistent AH requiring a treatment with two or more antihypertensive drugs was associated with development of all CVEs and a higher long-term mortality.


Assuntos
Transplante de Coração , Hipertensão , Adulto , Inibidores da Enzima Conversora de Angiotensina , Anti-Hipertensivos , Feminino , Transplante de Coração/efeitos adversos , Humanos , Hipertensão/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
13.
Front Immunol ; 11: 1392, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32612614

RESUMO

Since December 2019, the ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly affected solid organ transplantation (SOT) worldwide and has become a threat to the lives of SOT recipients. Here, we have reviewed, condensed, and organized the available information on COVID-19 to provide recommendations to transplant healthcare workers. Our review of reported cases shows that the symptoms of SOT patients with COVID-19 are similar to those of the normal population, but their severity and outcomes are worse. Thus far, there is no evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) directly causes permanent damage to kidney, liver, or heart allografts.


Assuntos
Infecções por Coronavirus/patologia , Transplante de Coração/efeitos adversos , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Pneumonia Viral/patologia , Adulto , Idoso , Betacoronavirus , Infecções por Coronavirus/transmissão , Feminino , Coração/virologia , Humanos , Rim/patologia , Rim/virologia , Fígado/patologia , Fígado/virologia , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Pandemias , Pneumonia Viral/transmissão , Transplantados/estatística & dados numéricos
14.
J Card Surg ; 35(10): 2847-2852, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32683723

RESUMO

BACKGROUND: With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. CASE PRESENTATION: A 65-year-old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function. CONCLUSION: Potential fatal complications caused by catheter or wire entrapment in the right-sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.


Assuntos
Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Coração Artificial/efeitos adversos , Coração Auxiliar/efeitos adversos , Disfunção Primária do Enxerto/etiologia , Síndrome da Veia Cava Superior/etiologia , Síndrome da Veia Cava Superior/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Veia Cava Superior/cirurgia , Idoso , Constrição Patológica/cirurgia , Humanos , Masculino , Radiografia Intervencionista , Cirurgia Assistida por Computador/métodos , Resultado do Tratamento , Veia Cava Superior/patologia
15.
Circ Heart Fail ; 13(7): e006840, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32660322

RESUMO

Biomarkers have a well-defined role in the diagnosis and management of chronic heart failure, but their role in patients with left ventricular assist devices and cardiac transplant is uncertain. In this review, we summarize the available literature in this patient population, with a focus on clinical application. Some ubiquitous biomarkers, for example, natriuretic peptides and cardiac troponin, may assist in the diagnosis of left ventricular assist device complications and transplant rejection. Novel biomarkers focused on specific pathological processes, such as left ventricular assist device thrombosis and profiling of leukocyte activation, continue to be developed and show promise in altering the management of the advanced heart failure patient. Few biomarkers at this time have been assessed with sufficient scrutiny to warrant broad, universal application, but encouraging limited data and large potential for impact should prompt ongoing investigation.


Assuntos
Biomarcadores/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/terapia , Doença Crônica , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Implantação de Prótese/efeitos adversos
16.
Pediatr Cardiol ; 41(5): 962-971, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32556487

RESUMO

BACKGROUND: Care of pediatric heart transplant recipients relies upon serial invasive hemodynamic evaluation, generally performed under the artificial conditions created by anesthesia and supportive ventilation. OBJECTIVES: This study aimed to evaluate the hemodynamic impacts of different anesthetic and ventilatory strategies. METHODS: We compared retrospectively the cardiac index, right- and left-sided filling pressures, and pulmonary and systemic vascular resistances of all clinically well and rejection-free heart transplant recipients catheterized from 2005 through 2017. Effects of spontaneous versus positive pressure ventilation and of sedation versus general anesthesia were tested with generalized linear mixed models for repeated measures using robust sandwich estimators of the covariance matrices. Least squared means showed adjusted mean outcome values, controlled for appropriate confounders. RESULTS: 720 catheterizations from 101 recipients met inclusion criteria. Adjusted cardiac index was 3.14 L/min/m2 (95% CI 3.01-3.67) among spontaneously breathing and 2.71 L/min/m2 (95% CI 2.56-2.86) among ventilated recipients (p < 0.0001). With spontaneous breathing, left filling pressures were lower (9.9 vs 11.0 mmHg, p = 0.030) and systemic vascular resistances were higher (24.0 vs 20.5 Woods units, p < 0.0001). After isolating sedated from anesthetized spontaneously breathing patients, the observed differences in filling pressures and resistances emerged as a function of sedation versus general anesthesia rather than of spontaneous versus positive pressure ventilation. CONCLUSION: In pediatric heart transplant recipients, positive pressure ventilation reduces cardiac output but does not alter filling pressures or vascular resistances. Moderate sedation yields lower left filling pressures and higher systemic vascular resistances than does general anesthesia. Differences are quantitatively small.


Assuntos
Anestesia/efeitos adversos , Cateterismo Cardíaco/métodos , Sedação Profunda/efeitos adversos , Respiração com Pressão Positiva/efeitos adversos , Resistência Vascular , Adolescente , Anestesia/estatística & dados numéricos , Criança , Sedação Profunda/estatística & dados numéricos , Feminino , Transplante de Coração/efeitos adversos , Humanos , Masculino , Respiração com Pressão Positiva/estatística & dados numéricos , Estudos Retrospectivos , Transplantados/estatística & dados numéricos
17.
Curr Opin Cardiol ; 35(4): 368-375, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32398603

RESUMO

PURPOSE OF REVIEW: Systemic hypertension (HTN) is a common complication arising in the heart transplant recipient. This article aims to review the most current literature and update readers on the epidemiology, pathophysiology and management of HTN in heart transplant patients. RECENT FINDINGS: In contrast to the general nontransplant hypertensive patient population, traditional risk factors, including family history of HTN, obesity and diabetes, play a minor role in the genesis of posttransplant HTN. Dysregulation in sodium and water balance, vascular stiffness, endothelial dysfunction, abnormal cardiorenal neural reflexes resulting from immunosuppression and cardiac denervation seem to be the predominant factors leading to postheart transplant HTN. Calcineurin inhibitors induced nephrotoxicity and steroid use further contributes to posttransplant HTN. SUMMARY: Owing to the paucity of data, particularly randomized controlled trials to guide the evaluation and management of HTN in the cardiac transplant patients, much of the available data come from the renal transplant population. The choice of antihypertensive should be based on timing related to transplantation and patient's comorbidities. Although calcium channel blockers and loop diuretics are the preferred agents in the early postheart transplant period, angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers may be beneficial in the late postheart transplant period especially in the setting of diabetes and in the presence of proteinuria.


Assuntos
Transplante de Coração/efeitos adversos , Hipertensão/tratamento farmacológico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Humanos
18.
Transplant Proc ; 52(5): 1394-1396, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32387081

RESUMO

BACKGROUND: Pediatric end-stage heart disease is surgically managed by heart transplantation. A major complication of primary transplantation (PTx) is coronary allograft vasculopathy (CAV), a form of accelerated atherosclerosis. Retransplantation (RTx) has been the management of CAV; however, there is limited comprehensive literature on this subject. Here we report 25 years of single-center experience in managing CAV with RTx and place it in the context of recent studies. METHODS: A retrospective cohort study was undertaken on patients who underwent PTx <18 years old and subsequent RTx due to CAV at the Heart Institute (InCor) University of São Paulo Medical School between 1992 and 2018. The maintenance immunosuppression protocol was double immunosuppression. For both PTx and RTx, quantitative and qualitative analyses were conducted for transplantation indication, donor/recipient demographics, post-transplant survival, rejection, infection, and immunosuppression. RESULTS: Between 1992 and 2018, 200 children underwent heart transplantation. Ten re-transplantations were performed, for which 7 (70%) were for CAV. Ages at RTx ranged from 11.5 to 29.3 years (19.1 ± 5.68 years; median 18.2 years). The mean time between PTx and RTx was 12.9 ± 3.4 years (median 13.4 years). The Kaplan-Meier survival rate at 1 month, 3 years, and 5 years was 85.7%, 71.5%, and 47.6%, respectively. CONCLUSION: Cardiac RTx can be a management option for CAV in patients who have undergone PTx in childhood with double immunosuppression therapy.


Assuntos
Doença da Artéria Coronariana/etiologia , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Reoperação , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Doença da Artéria Coronariana/cirurgia , Feminino , Cardiopatias/cirurgia , Transplante de Coração/mortalidade , Humanos , Masculino , Reoperação/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
19.
Am J Transplant ; 20(7): 1787-1794, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32400087

RESUMO

In the context of a rapidly evolving pandemic, multiple organizations have released guidelines stating that all organs from potential deceased donors with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection should be deferred, including from otherwise medically eligible donors found to have mild or asymptomatic SARS-CoV-2 discovered on routine donor screening. In this article, we critically examine the available data on the risk of transmission of SARS-CoV-2 through organ transplantation. The isolation of SARS-CoV-2 from nonlung clinical specimens, the detection of SARS-CoV-2 in autopsy specimens, previous experience with the related coronaviruses SARS-CoV and MERS-CoV, and the vast experience with other common RNA respiratory viruses are all addressed. Taken together, these data provide little evidence to suggest the presence of intact transmissible SARS-CoV in organs that can potentially be transplanted, specifically liver and heart. Other considerations including ethical, financial, societal, and logistical concerns are also addressed. We conclude that, for selected patients with high waitlist mortality, transplant programs should consider accepting heart or liver transplants from deceased donors with SARS-CoV-2 infection.


Assuntos
Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/normas , Obtenção de Tecidos e Órgãos/tendências , Betacoronavirus , Ética Médica , Coração/virologia , Transplante de Coração/efeitos adversos , Transplante de Coração/tendências , Humanos , Fígado/virologia , Transplante de Fígado/efeitos adversos , Transplante de Fígado/tendências , Pulmão/virologia , Exposição Ocupacional , Síndrome Respiratória Aguda Grave/prevenção & controle , Obtenção de Tecidos e Órgãos/ética , Listas de Espera
20.
Expert Opin Pharmacother ; 21(11): 1367-1376, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32401066

RESUMO

INTRODUCTION: Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Its peculiar pathophysiology involves multifactorial pathways including immune-mediated and metabolic risk factors, which are associated with the development of specific pathological lesions. The often diffuse and chronic nature of the disease reduces the effectiveness of revascularization procedures, and pharmacological prevention of the disease is the sole therapeutic approach with some proven efficacy. AREAS COVERED: In this article, after briefly outlining the risk factors for CAV, the authors revise the potential pharmacological approaches that may reduce the burden of CAV. While several therapies have shown convincing efficacy in terms of CAV prevention diagnosed by coronary imaging, very few have been reported to improve prognosis with any meaningful level of evidence. EXPERT OPINION: The authors believe that a customizable approach is necessary for clinical practice given the currently available evidence. Furthermore, it is important, in the future, to address the glaring therapeutic gap of an effective treatment against donor-specific antibodies, whose effect on endothelial injury is currently one of the major mechanisms of CAV development and for which no pharmacological treatment is currently available.


Assuntos
Aloenxertos/efeitos dos fármacos , Inibidores de Calcineurina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Transplante de Coração/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Imunossupressores/uso terapêutico , Aloenxertos/irrigação sanguínea , Aloenxertos/imunologia , Aloenxertos/patologia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Antioxidantes/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/imunologia , Doença da Artéria Coronariana/patologia , Humanos , Inibidores da Agregação de Plaquetas/uso terapêutico , Fatores de Risco , Resultado do Tratamento
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