Predictive factors for anemia six and twelve months after orthotopic liver transplantation.

BACKGROUND: The aim of our study was to determine the prevalence and predictive factors for post-transplant anemia (PTA) at 6 (M6) and 12 (M12) months after orthotopic liver-transplant (OLT) in a cohort of 97 consecutive patients. METHODS: Anemia was defined at M6 and M12 according to the World Health Organization criteria, i.e., a hemoglobin level of <12 g/dL for women and <13 g/dL for men. Immunosuppression relied on tacrolimus and steroids with or without mycophenolate mofetil. RESULTS: Anemia was present in 64.5%, 50%, and 52.8% of patients before OLT and at M6 and M12, respectively. Of the anemic patients, 33% (M6) and 30.3% (M12) received recombinant erythropoietin therapy. In multivariate analysis, the independent predictive factors for anemia at M6 were mean corpuscular volume (<85 fl) at day 7, daily steroid dosage (<0.3 mg/kg), serum creatinine (>130 micromol/L), and hemoglobin level (<11 g/dL) 1 month after OLT (M1). Independent predictive factors for anemia at M12 were daily steroid dosage at M1 (<0.3 mg/kg), hematocrit at M1 (<33%), red blood cell count at M6 (<3.75 T/L), daily dosage at M1 of cyclosporine and tacrolimus, and OLT for causes other than alcohol abuse. CONCLUSION: Anemia is highly prevalent within the first year post-OLT. This deserves further investigation and appropriate treatment.

Clinical significance of early thrombosis after prosthetic mitral valve replacement: a postoperative monocentric study of 680 patients.

OBJECTIVES: The aim of this study was to evaluate the incidence of early thrombosis, its prognostic significance, and the therapeutic implications. BACKGROUND: Transesophageal echocardiography (TEE) is the method of choice for detecting symptomless early postoperative thrombosis of prosthetic valves. However, the clinical significance is not yet known. METHODS: Between June 1994 and December 2000, 680 consecutive patients underwent TEE on day 9 after mechanical mitral valve replacement, to search for early thrombosis. Initially, end points were the in-hospital outcome and treatment. Patients were also evaluated 34 +/- 22 months after surgery. RESULTS: Sixty-four early thrombi were detected (9.4%). Two early obstructive were treated by redo-surgery. Sixty-two nonobstructive benefited from medical treatment. The patients were allocated into two groups as a function of the maximum size of thrombus: <5 mm in 29 patients (group A) and > or =5 mm in 35 (group B). During early follow-up, we observed one complicated course in group A and eight in group B. In the long-term survey, three complications were noted in group A and 11 in group B. Incidence of early (p = 0.027) and long-term (p = 0.04) complications were significantly different in the two subsets. CONCLUSIONS: This study confirms the incidence of early thrombi after mechanical mitral valve replacement detected by TEE. A small (<5 mm) nonobstructive thrombus seems benign, and our experience argues in favor of medical treatment. Prognosis appears more serious for large thrombi. Medically aggressive therapy and further surgery should be considered in cases of obstructive thrombosis or large and mobile nonobstructive thrombosis.

Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases.

OBJECTIVES: This study was designed to analyze the results of fibrinolytic treatment (FT) in a large single-center group of patients with prosthetic heart valve thrombosis (PHVT). BACKGROUND: Fibrinolytic treatment of PHVT represents an alternative to surgery, but is still controversial because of the risk of embolism. METHODS: A total of 110 consecutive patients presenting with 127 instances of PHVT received FT between 1978 and 2001. The diagnosis of PHVT was established mainly by fluoroscopy and/or echocardiography. The first fibrinolytic agent used was streptokinase (SK) in 49 cases, urokinase (UK) in 41 cases, and recombinant tissue-type plasminogen activator (rtPA) in 37 cases. A second FT was consecutively infused in 38 patients (30%) and a third FT in 11 others. The efficacy of FT was assessed from hemodynamic parameters derived from echographic examinations as well as on clinical grounds. RESULTS: Complete resolution of hemodynamic abnormalities was seen in 90/127 patients, partial resolution in 22/127 patients, and no change in 15/127 patients after one or more consecutive fibrinolytic regimens. When SK or rtPA were used as the first fibrinolytic agent, they appeared significantly superior to UK in terms of valve reopening. Fifteen patients died. Severe hemorrhagic complications were observed in six patients. Nineteen documented embolic events occurred during FT. Finally, PHVT recurred in 24 patients, 17 of whom were retreated with lytic agents. CONCLUSIONS: These results indicate that FT is effective in most cases of PHVT, regardless of prosthesis or site involved. However, embolism, hemorrhage, and death were not uncommon after lytic therapy of left-sided PHVT, limiting its application to patients at high risk with alternative treatment.

Improvement of left ventricular wall synchronization with multisite ventricular pacing in heart failure: a prospective study using Doppler tissue imaging.

UNLABELLED: We sought to assess right, left and biventricular pacing effects on myocardial function by using pulsed-Doppler tissue imaging (DTI) and automated border detection (ABD) techniques which provide electromechanical delay (EMD) assessment of the different left ventricular walls. METHODS: 15 patients (67+/-7 years) with drug-resistant primitive dilated cardiomyopathy and QRS> or =140 ms received a pacemaker for multisite ventricular pacing. Echocardiography was performed after 1 month of biventricular pacing (BVP). Echocardiographic measurements were recorded during spontaneous rhythm (SpR), right ventricular pacing (RVP), left ventricular pacing (LVP) and BVP. RESULTS: LV ejection fraction was statistically similar between the four rhythms. BVP showed a significant EMD decrease for the lateral LV wall vs. SpR, RVP and even LVP. LVP resulted in significantly longer aortic pre-ejection time vs. BVP while the EMD temporal dispersion (time between the shortest regional EMD and the longest one) was similar in the two modes. CONCLUSIONS: BVP and LVP substantially reduce the EMD temporal dispersion of the four LV walls, but with a longer aortic pre-ejection time for LVP. In RVP, LVP and BVP, the septal LV wall is always activated later than during SpR. BVP and LVP are associated with a mitral regurgitation reduction.

Cardiac magnetic resonance imaging for the diagnosis of patients presenting with chest pain, raised troponin, and unobstructed coronary arteries.

To evaluate the incremental diagnostic and prognostic value of cardiac magnetic resonance (CMR) in patients with chest pain, raised troponin and unobstructed coronary arteries, and to compare subsequent event rates between diagnostic groups. 130 patients (mean age: 54 ± 17) presenting with troponin-positive acute chest pain and unobstructed coronary arteries were included. All patients were managed according to European Society of Cardiology guidelines, including echocardiography, and had CMR within 6.2 ± 5.3 days of presentation. During follow-up, major adverse cardiovascular events (MACE) were recorded. CMR provided a diagnosis in 100 of 130 patients (76.9%), with the remaining 30 (23.1%) having a normal examination. CMR diagnosed 37 (28.5%) acute myocardial infarctions, 34 (26.1%) myocarditis, 28 (21.5%) apical ballooning syndromes and 1 (0.8%) hypertrophic cardiomyopathy. When a single diagnosis was suspected by the referring physician, CMR validated this diagnosis in 32 patients (76.2%). CMR provided a formal diagnosis in 61 patients (69.3%) in which the clinical diagnosis was uncertain between at least two possibilities. CMR corrected a wrong diagnosis in 10 patients (7.7%). CMR-suggested diagnosis led to a modification of therapy in 42 patients (32.3%). Median follow-up was 34 months (interquartile range 24-49) in 124 patients. Sixteen patients (12.9%) experienced MACE. MACE rate was not different between patients with a conclusive CMR and normal CMR. In patients with acute troponin-positive chest pain and unobstructed coronary arteries, early CMR has important diagnostic and therapeutic implications. However its association with occurrence of MACE during mid term follow-up was not obvious.