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1.
Ann Thorac Surg ; 109(3): 649-660, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32115073

RESUMO

BACKGROUND: The field of mechanical circulatory support has been impacted by the approval of new continuous-flow left ventricular assist devices (LVADs) and changes to the United States heart allocation system. METHODS: Primary isolated continuous-flow LVAD implants in The Society of Thoracic Surgeons Intermacs registry from January 2014 through September 2019 were evaluated. Survival and freedom from major adverse events were compared between axial-flow, centrifugal-flow with hybrid levitation (CF-HL), and centrifugal-flow with full magnetic levitation (CF-FML) devices. RESULTS: Of 2603 devices implanted in 2014, 1824 (70.1%) were axial flow and 1213 (46.6%) were destination therapy (DT); through September 2019, 1752 devices were implanted, but only 37 (2.1%) were axial flow and 1230 (70.2%) were DT. Implants were performed in 13,016 patients between 2014 and 2018. Patients receiving implants in 2017-2018 compared with 2014-2016 were more likely to be at Intermacs profile 1 (17.1% vs 14.3%, P < .001) and to have preimplant temporary mechanical circulatory support (34.8% vs 29.3%, P < .001). Overall survival and freedom from major adverse events were higher with CF-FML devices. In multivariable analysis of survival between CF-HL and CF-FML, device type was not a significant early hazard, but the use of CF-HL devices had a late hazard ratio for death of 3.01 (P < .001). CONCLUSIONS: Over the past 5 years, centrifugal-flow LVADs have become the dominant technology and DT the most common implant strategy. While outcomes with CF-FML devices are promising, comparisons with other devices from nonrandomized registry studies should be made with caution.


Assuntos
Coração Auxiliar/estatística & dados numéricos , Adulto , Feminino , Transplante de Coração/mortalidade , Transplante de Coração/estatística & dados numéricos , Coração Auxiliar/efeitos adversos , Coração Auxiliar/tendências , Humanos , Estimativa de Kaplan-Meier , Masculino , Readmissão do Paciente , Desenho de Prótese , Alocação de Recursos/métodos , Alocação de Recursos/estatística & dados numéricos , Sociedades Médicas , Cirurgia Torácica , Estados Unidos , Listas de Espera
2.
Transplant Proc ; 52(2): 575-576, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035681

RESUMO

BACKGROUND: Severe right ventricular failure (RVF) has a significant incidence among cardiac transplant patients. It is a serious complication and an independent risk factor for postoperative mortality. In this setting, ventricular assist devices (VADs) must be considered if conservative medical management fails. This study sought to examine our series of patients with early RVF after heart transplantation requiring VAD support. METHOD: We analyzed consecutive, adult heart transplant recipients at a third level intensive care unit who underwent transplantation from January 2011 to March 2019 requiring post-transplant mechanical circulatory support for RVF. Demographic characteristics, clinical data, complications, and survival rates were collected. RESULTS: Ten patients were included. Median age was 50 years (range, 31.7-57). Eight patients (80%) were male. The most frequent indication for heart transplantation was ischemic heart disease (4 patients) followed by dilated cardiomyopathy and congenital heart disease (2 patients). Preoperative pulmonary hypertension was present in 6 patients. Three patients required a VAD before transplant. Whole survival rate was 60%. After heart transplantation, 7 patients required renal replacement therapy, 2 patients suffered a hemorrhagic stroke, and 5 patients needed a tracheostomy for long-term ventilation. CONCLUSION: Patients who develop RVF after transplantation have an increased incidence of complications and high mortality after surgery. VADs could be implanted immediately after heart transplantation in high-risk patients.


Assuntos
Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Transplante de Coração/efeitos adversos , Coração Auxiliar , Adulto , Feminino , Insuficiência Cardíaca/epidemiologia , Transplante de Coração/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
3.
Transplant Proc ; 52(2): 577-579, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32046860

RESUMO

BACKGROUND: Heart failure is the leading cause of death in grown-up congenital heart disease patients (GUCH). Although heart transplantation (OHT) remains the gold standard in end-stage heart failure, the ratio of GUCH patients undergoing this procedure remains low. OBJECTIVE: Describe the cohort of GUCH patients undergoing heart transplantation at a third-level hospital. METHODS: A retrospective review of GUCH patients undergoing OHT between 1997 and 2019 was conducted at a single tertiary university hospital. We included different preoperative (demographic and clinical data, cardiac catheterization data from the last routine hemodynamic monitoring) and postoperative variables (complications, survival). RESULTS: Fourteen patients were enrolled. The median age was 25.5 years (range, 20.7-32.2). Eight patients (57.1%) were male. The median preoperative left ventricular ejection fraction was 37% (range, 22.5%-55%). As for preoperative hemodynamic evaluation, the median for the mean arterial pulmonary pressure was 19 mm Hg (range, 12-22.5), for the capillary wedge pressure was 16 mm Hg (range, 13.5-19.5), and for pulmonary vascular resistance was 1.83 Wood units (range, 1-4). After OHT, 6 patients (42.9%) suffered an infection, the most common of which was respiratory (3 out of 6). Four patients (28.6%) needed renal replacement therapy, and 4 patients (28.6%) presented liver failure. Four patients (28.6%) developed graft failure, thus requiring mechanical support with extracorporeal membrane oxygenation during a median of 6 days (range, 1-17.5). Survival rate of patients under extracorporeal membrane oxygenation was 50%, and overall survival rate was 78.6%. CONCLUSION: OHT represents a good option for GUCH patients, with good overall survival rates.


Assuntos
Cardiopatias Congênitas/cirurgia , Transplante de Coração , Adulto , Estudos de Coortes , Feminino , Cardiopatias Congênitas/mortalidade , Transplante de Coração/mortalidade , Humanos , Masculino , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
4.
Transplant Proc ; 52(2): 580-583, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32057502

RESUMO

BACKGROUND: Pulmonary arterial hypertension (PAH) represents a marker of bad prognosis in left heart disease. Nonetheless, the effect on survival after heart transplant remains controversial. The objective was to study the impact of preoperative PAH on survival in patients undergoing elective heart transplant. METHODS: A retrospective study of 173 transplant recipients was conducted at a single hospital from January 2009 to December 2018. Congenital etiology and emergent heart transplant were exclusion criteria as well as those patients without enough data in the hemodynamic study. Two groups were considered: A (without PAH) and B (with HTP). PAH was classified as mild (mean pulmonary arterial pressure [mPAP] 25-34 mm Hg, pulmonary vascular resistance [PVR] 2.5-3.4 Wood units and/or transpulmonary gradient [TPG] 13-16 mm Hg), moderate (mPAP 35-44 mm Hg, PVR 3.5-4.9 Wood units and/or TPG 17-19 mm Hg), and severe (mPAP > 44 mm Hg, PVR > 4.9 Wood units and/or TPG > 19 mm Hg). RESULTS: A total of 102 patients were enrolled; 71.6% were male and average age was 52.3 (SD, 10.02) years. The main etiology was ischemic cardiomyopathy; 13.7% underwent previous heart operations. A total of 61 patients (59.8%) had PAH prior to heart transplant: 25 mild, 34 moderate, and 2 severe. Mean overall survival after transplant was 79.9 (SD, 5.68) months, without differences between the 2 groups (P = .82). One-month survival was 89% (the main cause of mortality was primary graft dysfunction), and 1-year survival was 78%. Four patients required mechanical circulatory support during early post-transplant period. CONCLUSIONS: Preoperative PAH does not have a significant impact on survival in elective heart transplant.


Assuntos
Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/cirurgia , Transplante de Coração/mortalidade , Hipertensão Pulmonar/complicações , Adulto , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
5.
J Thorac Cardiovasc Surg ; 159(3): 865-896, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31983522
6.
Transplant Proc ; 51(10): 3424-3427, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810509

RESUMO

BACKGROUND: Pulmonary function tests (PFTs) are often impaired in patients with advanced heart failure. There is limited data about their impact on survival after heart transplantation (HT). We sought to assess the prevalence and type of PFT abnormalities in patients on HT waiting list and their impact on outcomes. METHODS: We performed a retrospective analysis of a prospective registry of consecutive patients undergoing HT between 2012 and 2018. Patients were classified into 4 groups according to pre-HT PFT results: 1. normal pattern: forced vital capacity (FVC) ≥ 80% and forced expiratory volume in 1 second (FEV1) to FVC ratio (FEV1/FVC) ≥ 0.7; 2. obstructive: FEV1/FVC < 0.7; 3. nonobstructive: FEV1/FVC ≥ 0.7 and FVC < 80% when total lung capacity value was not available; and 4. restrictive: FEV1/FVC ≥ 0.7 and total lung capacity < 80%. The prevalence of impaired carbon monoxide diffusing capacity corrected for hemoglobin < 80% and FEV1 < 70% was also analyzed. High-urgency HT patients and those referred from other centers without quantitative pulmonary evaluation were excluded. RESULTS: Among 123 patients who underwent HT, 83 patients with complete PFT were included. Median follow-up was 2.7 ± 1.9 years. Of these, 29 (34.9%) had an obstructive pattern, 20 (24.1%) a nonobstructive, 18 (21.7%) a restrictive, and 16 (19.3%) a normal pattern. Fifty-one (61.4%) patients had FEV1 < 70% and 58 (69.9%) a carbon monoxide diffusing capacity corrected for hemoglobin < 80%. There was a tendency to lower survival in all altered PFT groups compared with normal (P = .054) but not within the other groups. Patients with an impaired FEV1 had significantly higher mortality than patients with normal values (P = .008). Area under receiver operating characteristic curve for FEV1 was 0.73 (95% confidence interval [0.60-0.86]). A cutoff value of FEV1 (60.5) predicts mortality with 66% sensitivity and 64% specificity. CONCLUSIONS: PFT alterations have a very high prevalence on HT waiting list patients. Patients with impaired FEV1 had worse outcomes after heart transplantation.


Assuntos
Insuficiência Cardíaca/complicações , Transplante de Coração , Pneumopatias/complicações , Adulto , Feminino , Transplante de Coração/mortalidade , Humanos , Pulmão/fisiopatologia , Pneumopatias/epidemiologia , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prevalência , Curva ROC , Testes de Função Respiratória , Estudos Retrospectivos
7.
Transplant Proc ; 51(10): 3395-3398, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810507

RESUMO

BACKGROUND: Renal function is a major consideration for orthotopic heart transplantation (OHT) and left ventricular assist device (LVAD) therapy. We compared serial changes in renal function and outcomes between patients who underwent OHT and LVAD therapy over 12 months. METHODS: Forty-five and 58 consecutive patients who underwent LVAD implantation (all bridge to transplant or candidacy) and OHT from April 2014 to November 2016 were included. Six of these patients were in both LVAD and OHT cohorts. Survival analysis was calculated using Kaplan Meier and log rank methods. Univariate analysis of data was performed using χ2, Mann-Whitney, Kruskal-Wallis, and Wilcoxon signed rank tests where appropriate. Comparisons of the renal function to baseline were conducted using generalized estimating equations. RESULTS: Renal function had a biphasic course among the LVAD cohort, increasing at 30 days but reducing at 6 and 12 months. Meanwhile, estimated glomerular filtration rate (eGFR) was seen to progressively decline among OHT recipients. Altogether, eGFR was significantly higher at 6 and 12 months among the LVAD cohort compared to OHT (68.3 vs 59.4, P = .046; 68.3 vs 50.4, P = .015). Compared to the baseline average, eGFR had risen among the LVAD patients (P = .031) but had decreased among the OHT group (P < .001) at 12 months. No significant difference in survival was seen at 1 year (84.4% vs 81.0%; P = .540) and 2 years (78.3% vs 78.8%, P = .687) between the cohorts. CONCLUSION: Despite poorer baseline renal function, LVAD therapy was associated with comparable survival and better renal outcomes compared to OHT at 12 months. Renal impairment may favor the use of LVAD therapy over OHT in the short term.


Assuntos
Insuficiência Cardíaca/complicações , Transplante de Coração , Coração Auxiliar , Insuficiência Renal/complicações , Resultado do Tratamento , Adulto , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Transplante de Coração/mortalidade , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/mortalidade , Estudos Retrospectivos , Análise de Sobrevida
8.
J Am Coll Cardiol ; 74(24): 3026-3035, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31865970

RESUMO

BACKGROUND: Heart transplant recipients are at high risk for mortality, with traditional risk scores performing modestly in predicting post-transplant survival, underscoring the importance of as yet unidentified factors in determining prognosis. In this analysis, the association between PM2.5 exposure levels and survival after heart transplantation were investigated. OBJECTIVES: This study sought to study the association between PM2.5 exposure and mortality following heart transplantation. METHODS: On the basis of the zip code of residence, mortality data in patients who underwent heart transplantation (2004 to 2015) in the United Network for Organ Sharing (UNOS) database were linked with validated estimates of fine particulate matter concentrations (particles with diameter <2.5 µm [PM2.5]; 1 × 1-km grids) for each calendar year during which a UNOS cardiac transplant recipient was at risk for death. Cox proportional hazard models were used to estimate the relationship between exposure and overall mortality adjusting for recipient, donor, and neighborhood variables. RESULTS: A total of 21,800 patients with 86,713 patient-years of follow-up was included. Mean age at transplantation was 52.6 ± 12.6 years, 75% were male, 69% were white, and 39% had ischemic etiology of heart failure. Mean annual exposure to PM2.5 was 10.6 ± 2.3 µg/m3. At a median follow-up of 4.8 (95% confidence interval: 2.0 to 7.8) years, 5,208 patients (23.9%) had died. The estimated mortality hazard ratio, per 10 µg/m3 increment increase in annual PM2.5 exposure was 1.43 (95% confidence interval: 1.21 to 1.49). After adjusting for 30 recipient, donor, and neighborhood variables, the estimated mortality hazard ratio per 10 µg/m3 increment in annual exposure to PM2.5 was 1.26 (95% confidence interval: 1.11 to 1.43) relative increase in hazard of mortality. This association was consistent across subgroups. CONCLUSIONS: This study provides evidence linking air pollution with mortality after heart transplantation. These results suggest an important influence of a key environmental factor in outcomes following heart transplantation, and supports the need for further studies in this population.


Assuntos
Poluição do Ar/efeitos adversos , Transplante de Coração/mortalidade , Material Particulado/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
9.
Cardiovasc Ther ; 2019: 9482797, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31772620

RESUMO

Introduction: Cardiovascular diseases are the number one cause of death globally contributing to 37% of all global deaths. A common complication of cardiovascular disease is heart failure, where, in such cases, the only solution would be to conduct a heart transplant. Every 10 minutes a new patient is added to the transplant waiting list. However, a shortage of human donors and the short window of time available to find a correct match and transplant the donors' heart to the recipient means that numerous challenges are faced by the patient even before the operation could be done, reducing their chances of living even further. Methods: This review aims to evaluate the application of the Organ Care System (OCSTM) in improving the efficiency of heart storage based on journal articles obtained from PubMed, Elsevier Clinical Key, and Science Direct. Results: Studies have shown that OCS is capable of extending the ischemic time 120 minutes longer than conventional methods without any detrimental effect on the recipient nor donor's safety. Based on the PROTECT I and PROCEED II study, 93% of transplantation recipients using the OCS system passed through the 30-day mortality period. Discussion: OCS is able to prolong the ischemic time of donors' hearts by perfusing the organ at 34°C in a beating state, potentially reducing the detrimental effect of cold storage and providing additional assessment options. Another clear advantage is the implanting surgeon can assess the quality of the donor heart before surgery as well as providing a time safety buffer in unanticipated circumstances that will reduce the mortality risk of transplant recipients.


Assuntos
Seleção do Doador , Transplante de Coração/métodos , Soluções para Preservação de Órgãos/uso terapêutico , Preservação de Órgãos , Perfusão , Doadores de Tecidos/provisão & distribução , Listas de Espera , Animais , Sobrevivência de Enxerto , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Humanos , Preservação de Órgãos/efeitos adversos , Preservação de Órgãos/mortalidade , Soluções para Preservação de Órgãos/efeitos adversos , Perfusão/efeitos adversos , Perfusão/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Sobrevivência de Tecidos , Resultado do Tratamento
10.
Transplant Proc ; 51(10): 3409-3411, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31733803

RESUMO

Heart transplantation is the definitive management for select patients with end-stage heart failure. Owing to an ongoing organ donor shortage, organs are sometimes allocated from distant locales. These organs may be perceived as less desirable because of donor risk factors and ischemic times. We compared survival after heart transplantation by donors originating from British Columbia (BC), other Canadian provinces, and the United States. This retrospective cohort analysis included all patients transplanted in BC between December 1, 1988, and October 21, 2014, and excluded those with missing data or retransplantation. Among 382 patients, 297 (77.7%) recipients and 238 (62.3%) donors were male. The median recipient age was 54.6 years (interquartile range, 46.0-61.0 years) and the median donor age was 33 years (interquartile range, 22-46 years). Overall 10-year survival was 62.1% (95% confidence interval, 56.3-67.4). There was no difference in 10-year survival when comparing donors from BC, other Canadian provinces, and the United States despite significantly lower median ischemic times in donors from BC. Donor location was not predictive of mortality after controlling for recipient age, donor age, and cold ischemic time. Donor origin did not impact 10-year survival after heart transplantation despite increased ischemic time, suggesting that distant donors result in similar outcomes in BC.


Assuntos
Isquemia Fria , Insuficiência Cardíaca/cirurgia , Transplante de Coração/mortalidade , Doadores de Tecidos , Adulto , Canadá , Estudos de Coortes , Feminino , Sobrevivência de Enxerto , Transplante de Coração/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
11.
JAMA ; 322(18): 1789-1798, 2019 11 12.
Artigo em Inglês | MEDLINE | ID: mdl-31714985

RESUMO

Importance: In the United States, the number of deceased donor hearts available for transplant is limited. As a proxy for medical urgency, the US heart allocation system ranks heart transplant candidates largely according to the supportive therapy prescribed by transplant centers. Objective: To determine if there is a significant association between transplant center and survival benefit in the US heart allocation system. Design, Setting, and Participants: Observational study of 29 199 adult candidates for heart transplant listed on the national transplant registry from January 2006 through December 2015 with follow-up complete through August 2018. Exposures: Transplant center. Main Outcomes and Measures: The survival benefit associated with heart transplant as defined by the difference between survival after heart transplant and waiting list survival without transplant at 5 years. Each transplant center's mean survival benefit was estimated using a mixed-effects proportional hazards model with transplant as a time-dependent covariate, adjusted for year of transplant, donor quality, ischemic time, and candidate status. Results: Of 29 199 candidates (mean age, 52 years; 26% women) on the transplant waiting list at 113 centers, 19 815 (68%) underwent heart transplant. Among heart transplant recipients, 5389 (27%) died or underwent another transplant operation during the study period. Of the 9384 candidates who did not undergo heart transplant, 5669 (60%) died (2644 while on the waiting list and 3025 after being delisted). Estimated 5-year survival was 77% (interquartile range [IQR], 74% to 80%) among transplant recipients and 33% (IQR, 17% to 51%) among those who did not undergo heart transplant, which is a survival benefit of 44% (IQR, 27% to 59%). Survival benefit ranged from 30% to 55% across centers and 31 centers (27%) had significantly higher survival benefit than the mean and 30 centers (27%) had significantly lower survival benefit than the mean. Compared with low survival benefit centers, high survival benefit centers performed heart transplant for patients with lower estimated expected waiting list survival without transplant (29% at high survival benefit centers vs 39% at low survival benefit centers; survival difference, -10% [95% CI, -12% to -8.1%]), although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers (77.6% vs 77.1%, respectively; survival difference, 0.5% [95% CI, -1.3% to 2.3%]). Overall, for every 10% decrease in estimated transplant candidate waiting list survival at a given center, there was an increase of 6.2% (95% CI, 5.2% to 7.3%) in the 5-year survival benefit associated with heart transplant. Conclusions and Relevance: In this registry-based study of US heart transplant candidates, transplant center was associated with the survival benefit of transplant. Although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers, compared with centers with survival benefit significantly below the mean, centers with survival benefit significantly above the mean performed heart transplant for recipients who had significantly lower estimated expected 5-year waiting list survival without transplant.


Assuntos
Transplante de Coração/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidade do Paciente , Qualidade da Assistência à Saúde , Sistema de Registros , Alocação de Recursos , Análise de Sobrevida , Estados Unidos/epidemiologia , Listas de Espera
12.
Transplant Proc ; 51(9): 2962-2966, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31607616

RESUMO

INTRODUCTION: Preoperative liver and renal dysfunction remain surgical risk factors for both postoperative morbidity and mortality. The Model of End-Stage Liver Disease Excluding INR (international normalized ratio), or MELD-XI, score calculation may help as a predictor in patients with advanced heart failure. We analyzed the impact of progressive elevated MELD-XI values among recipients of heart transplant at our institution. METHODS: The data of a total of 425 consecutive adult patients who underwent heart transplantation, between January 2000 and August 2018, have been reviewed and divided into 3 cohorts according to preoperative MELD-XI calculations (MELD-XI < 11; MELD-XI 11-18; and MELD-XI > 18). Early and late outcomes have been analyzed. RESULTS: Patients with a MELD-XI score > 18 had a more critical clinical condition preoperatively and had a higher risk of early mortality (hazard ratio [HR] 1.45 [1.11-1.67], P < .001). They showed high risk for postoperative dialysis (HR 2.8 [1.5-5.3], P < .001), rethoracothomy for bleeding (HR 2.1 [1.2-4.1], P = .001), prolonged time of mechanical ventilation, time of intensive care unit stay (HR 2.2 [1.3-3.8], P = .005), and graft failure requiring mechanical circulatory support (HR 1.9 [1.1-3.3], P = .003). After risk adjustment per MELD-XI cohort, ischemic dilated cardiomyopathy, redo operation, and cold ischemic time > 240 minutes resulted in being the strongest predictors of early mortality (P < .001). The 5-year and 10-year survival for MELD-XI > 18 cohort was 63% and 47% vs 72% and 59% in the control group (MELD-XI < 18) (log-rank, P < .001). CONCLUSIONS: Patients with an elevated preoperative MELD-XI profile presented more comorbidities and significantly lower survival. This suggests the MELD-XI score may provide further insight into appropriate recipient and eventual donor selection. Renal insufficiency and congestive hepatopathy should be properly optimized before heart transplantation.


Assuntos
Doença Hepática Terminal/complicações , Transplante de Coração , Nefropatias/complicações , Índice de Gravidade de Doença , Adulto , Estudos de Coortes , Doença Hepática Terminal/mortalidade , Feminino , Transplante de Coração/mortalidade , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco
13.
Cardiovasc Diabetol ; 18(1): 118, 2019 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526382

RESUMO

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality following heart transplantation (HT). Reduced cardiovascular mortality and morbidity have been reported in non-HT patients treated with metformin. Given the high prevalence of type 2 diabetes mellitus (T2DM) in HT patients, we investigated the association between metformin therapy and cardiovascular outcomes after HT. METHODS: The study population comprised 103 DM patients who had undergone HT between 1994 and 2018 and were prospectively followed-up. We excluded from the study patients with type 1 diabetes mellitus. Fifty-five HT patients (53%) in the cohort were treated with metformin. Clinical data were recorded on prospectively designed forms. The primary outcomes included CAV, survival, and the combined end-point of CAV or cardiovascular mortality. RESULTS: Kaplan-Meier survival analysis showed that the CAV rate at 20 years of follow-up was lower in DM patients treated with metformin than in those who were not (30 vs. 65%; log-rank p = 0.044). Similarly, the combined risk of CAV or cardiovascular mortality was lower in the metformin-treated patients than in those not receiving metformin (32 vs. 68%; log rank p = 0.01). Consistently, multivariate analysis adjusted for age and comorbidities showed that metformin therapy was independently associated with a significant 90% reduction (95% confidence interval 0.02-0.46, p = 0.003) in the risk for the development of CAV, and a 91% reduction (95% confidence interval 0.02-0.42; p = 0.003) in the risk for CAV or cardiovascular mortality. CONCLUSIONS: In diabetic HT patients, metformin therapy is independently associated with a significant reduction in the long-term risk for CAV and the combined end-point of CAV or cardiovascular mortality after HT.


Assuntos
Doença da Artéria Coronariana/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Insuficiência Cardíaca/cirurgia , Transplante de Coração/efeitos adversos , Hipoglicemiantes/uso terapêutico , Metformina/uso terapêutico , Adulto , Causas de Morte , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Transplante de Coração/mortalidade , Humanos , Hipoglicemiantes/efeitos adversos , Masculino , Metformina/efeitos adversos , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
Pediatr Cardiol ; 40(8): 1655-1662, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31506731

RESUMO

We sought to better define the demographics and characteristics of post-transplant lymphoproliferative disorders (PTLD) in a cohort of paediatric OHT patients from a developing country. Data were collected from the Heart Institute, Sao Paulo, for all paediatric OHT recipients from October 1992 to October 2018. Group differences between the PTLD and non-PTLD cohorts were assessed by Fisher exact and Mann-Whitney U tests. Kaplan-Meier curves analysed the survival in each group. Data were reviewed for 202 paediatric OHT recipients. Overall 1-, 5- and 10-year survival for the entire cohort was 76.5%, 68.3% and 62.9%; 24 patients (11.9%) developed PTLD at a median 3.1 years (IQR 0.8-9.0) after OHT. Cases were evenly spread over the follow-up period, with PTLD diagnosed in 9.8% (n = 137) of patients who were alive at 3 years, 15.3% (n = 78) of patients who were alive at 5 years and 29.3% (n = 41) of patients who were alive at 10 years. The commonest form of PTLD was diffuse large B cell lymphoma (n = 9), and most patients received rituximab with immunosuppression and chemotherapy as treatment (n = 15). We identified no increased risk in mortality amongst the PTLD vs. non-PTLD cohorts in multivariate analysis (P = 0.365). PTLD after paediatric OHT had acceptable outcomes. However, risk factors for PTLD were not identified and warrant further investigation.


Assuntos
Transplante de Coração/efeitos adversos , Transtornos Linfoproliferativos/mortalidade , Brasil , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Transplante de Coração/mortalidade , Humanos , Lactente , Transtornos Linfoproliferativos/diagnóstico , Transtornos Linfoproliferativos/etiologia , Masculino , Prevalência , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida
15.
J Card Surg ; 34(10): 994-1003, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31374593

RESUMO

BACKGROUND: The impact of center volume on heart transplantation is widely recognized and serves as a benchmark for certification and reimbursement. STUDY AIMS: Study sociodemographic variables associated with access to high-volume centers and substantiate the importance of extending access to underserved populations. METHODS: This study focused on adults undergoing heart transplantation between 2006 and 2015. Centers were clustered into terciles (>25, 14-25, or <14 transplants per year) and factors associated with receiving care in different terciles were identified through multinomial regression. RESULTS: During the study period, 18 725 patients were transplanted at 145 centers. Younger age (<30 years) (P = .005), lower educational level (P < .001), and government-based insurance (P < .001) were associated to lower odds of receiving care at a high-volume center. These centers had higher risk recipients and accepted organs from higher risk donors, when compared to intermediate- and low-volume centers. Receiving care at high (odds ratio [OR], 1.212; P = .017) and intermediate-volume centers (OR, 1.304; P = .001) was associated with greater odds of 1-year survival when compared with low-volume centers. CONCLUSION: Social, demographic, and geographic factors affect access to high- and intermediate-volume centers. High-volume centers tolerate more risk while providing excellent survival. Awareness of this impact should prompt an extension of access to care for underserved patient populations.


Assuntos
Transplante de Coração/mortalidade , Vigilância da População , Sistema de Registros , Medição de Risco/métodos , Doadores de Tecidos , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Transplante Homólogo , Resultado do Tratamento , Estados Unidos/epidemiologia
16.
Methodist Debakey Cardiovasc J ; 15(2): 145-148, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31384378

RESUMO

Steady advances in the diagnosis and management of congenital heart disease over the last few decades has resulted in a growing population of adults with congenital heart disease (ACHD). Consequently, there has been a parallel increase in the number of ACHD patients plagued with end-stage heart failure. Even so, the transplantation rate for these patients has remained low, at about 3% of all adult heart transplants. This review discusses the scope of transplantation for ACHD, including indications and contraindications, specific challenges and nuances, and post-transplant outcomes.


Assuntos
Cardiopatias Congênitas/cirurgia , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Adulto , Fatores Etários , Tomada de Decisão Clínica , Progressão da Doença , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Humanos , Seleção de Pacientes , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Listas de Espera
17.
J Cardiothorac Surg ; 14(1): 138, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331354

RESUMO

BACKGROUND: The donor's mode of brain death (BD), being associated with impairment of myocardial function and hemodynamic performance, impacts the prognosis of the heart transplantation (HTx) recipient. METHODS: All patients who underwent HTx between 1996 and 2017 were categorized according to donor's BD mechanism: traumatic BD (TBD) versus non-traumatic BD (NTBD). RESULTS: The TBD group included 105 recipients, and the NTBD group, 85 recipients. Kaplan-Meier survival analysis showed that overall survival was significantly higher for recipients of TBD hearts (10-year survival 58.1 vs. 37.6%, p = 0.044). Consistently, multivariate analysis showed that TBD was independently associated with a significant 43% reduction in mortality [95% confidence interval (CI) 0.42-0.75, p = 0.033]. Rejection rate was lower in the TBD group (total rejection score 0.44 ± 0.32 vs. 0.51 ± 0.38, p = 0.04; any rejection score 0.38 ± 0.26 vs. 0.45 ± 0.31, p = 0.030), and freedom from cardiac allograft vasculopathy (CAV) was significantly higher in recipients of traumatic vs. non-traumatic donors (10 years: 82.9 vs. 62.4%, log-rank p-value = 0.024). Multivariate analysis showed a significant 42% reduction in CAV [hazard ratio (HR) = 0.58, 95% CI 0.51-0.85, p = 0.022). CONCLUSION: Mode of brain death significantly impacts HTx outcomes, with TBD being associated with reduced mortality, rejections and CAV.


Assuntos
Morte Encefálica , Seleção do Doador/métodos , Transplante de Coração , Doadores de Tecidos , Ferimentos e Lesões , Adulto , Idoso , Idoso de 80 Anos ou mais , Seleção do Doador/normas , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Cardiopatias/epidemiologia , Cardiopatias/etiologia , Cardiopatias/prevenção & controle , Transplante de Coração/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Melhoria de Qualidade , Taxa de Sobrevida
18.
Interact Cardiovasc Thorac Surg ; 29(4): 576-582, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31280304

RESUMO

OBJECTIVES: The aim of this study was to evaluate the impact of overall and older-recipient-specific centre volumes on outcomes of orthotopic heart transplant (OHT) in older recipients. METHODS: Patients aged ≥60 years undergoing OHT were identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was 1-year post-OHT mortality. Secondary outcomes included the incidence and impact on 1-year survival of postoperative complications including infection, renal failure requiring dialysis and stroke. Patients were divided into equal size tertiles based on overall and older-recipient-specific OHT centre volumes. RESULTS: A total of 5373 older recipients were identified. Mean overall and older-recipient-specific volumes were 27.5 ± 19.5 and 9.4 ± 7.3 OHT/year, respectively. Although overall and older-recipient-specific low-volume centres were at higher risk of mortality in separate multivariable analysis, only older-recipient-specific volume contributed significantly to post-OHT mortality in the combined multivariable analysis (P < 0.05). In the receiver operating characteristic analysis, an older-recipient-specific volume of 8 OHTs/year was identified as the most discriminative volume threshold for mortality (area under the receiver operating characteristic curve = 0.68). Although low older-recipient-specific volume centres did not have significantly higher incidences of postoperative complications, they had significantly worse 1-year survival rates compared to higher volume centres in patients with postoperative infection or dialysis (each P < 0.01). CONCLUSIONS: This large-cohort analysis demonstrates that older-recipient-specific centre volume contributes to post-OHT outcomes in the older recipients more significantly than overall volume. This may be a consequence of higher older-recipient-specific volume centres to better manage specific complications in this patient population.


Assuntos
Transplante de Coração/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso , Estudos de Coortes , Feminino , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento
19.
J Card Surg ; 34(10): 927-932, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31269296

RESUMO

BACKGROUND: Patients undergoing heart transplantation (HT) frequently receive perioperative red blood cell (RBC) transfusions, but the impact of perioperative transfusion on clinical outcomes after HT remains unclear. METHODS: All adult HTs performed in Korea between 2007 and 2016 were analyzed using data from the National Health Insurance Service. Patients were classified into four groups based on the number of RBC units transfused during hospital admission for HT: 0, 1 to 2, 3 to 5, and greater than or equal to 6 units. In-hospital and long-term mortality rates were compared among the groups. RESULTS: In total, 833 adults HTs were included in the study. The overall in-hospital mortality rate was 8.4% (70 of 833), with no mortality occurring in patients who received no transfusion. The in-hospital mortality rate was higher in patients requiring greater than or equal to 6 units (25.1%) than in patients who received 1 to 2 units (0.3%) and 3 to 5 units (2.7%; P < .001). Patients who received greater than or equal to 6 units of RBCs had a significantly higher risk of all-cause mortality after HT compared to patients who received no transfusion (hazard ratio [95% confidence interval], 5.99 [1.46-24.56]; P = .012). Long-term survival rate was also lower in patients who received transfusions of greater than or equal to 6 units of RBCs than in patients who received no transfusion (P < .001). CONCLUSIONS: Perioperative transfusion of greater than or equal to 6 units of RBCs may be associated with an increased risk of in-hospital and long-term mortality after HT.


Assuntos
Transfusão de Eritrócitos/métodos , Cardiopatias/cirurgia , Transplante de Coração/mortalidade , Assistência Perioperatória/métodos , Vigilância da População , Adulto , Feminino , Seguimentos , Cardiopatias/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , República da Coreia/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto Jovem
20.
Am J Surg ; 218(4): 737-743, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31353032

RESUMO

BACKGROUND: Aging and loss of estrogen suppress immune function, potentially improving survival after orthotopic heart transplant (OHT). The effect of female aging on OHT outcomes is unknown. METHODS: Between 1995 and 2015, 41,299 adult OHT recipients (24.3% women) were studied using a retrospective multi-institutional cohort. Patients were stratified by age and gender into premenopausal (18-39 years), perimenopausal (40-49 years), and postmenopausal (≥50 years) groups. Kaplan-Meier survival analyses and risk-adjusted models examined gender differences across groups at one, five, and ten years. RESULTS: Kaplan-Meier survival was equivalent for postmenopausal women and men, and lower for premenopausal women than men at all time points (p ≤ 0.05). Postmenopausal women had higher risk-adjusted five-year survival than premenopausal women (AOR 1.61, 95% CI 1.15-2.25, p = 0.006). CONCLUSIONS: Premenopausal women have lower unadjusted survival than men after OHT. Post-menopausal women have significantly better five-year survival than pre-menopausal women. Menopause may contribute to improved survival after OHT.


Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Transplante de Coração/mortalidade , Adolescente , Adulto , Fatores Etários , Débito Cardíaco , Estrogênios , Feminino , Insuficiência Cardíaca/imunologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Taxa de Sobrevida , Adulto Jovem
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