16 research outputs found
Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis
Development of cardiac allograft vasculopathy represents
the major determinant of long-term survival in patients after
heart transplantation. Due to graft denervation, these
patients seldom present with classic symptoms of angina
pectoris, and the first clinical presentations are progressive
heart failure or sudden cardiac death. Although coronary
angiography remains the routine technique for coronary
artery disease detection, it is not sensitive enough for
screening purposes. This is especially the case in the first
year after transplantation when diffuse and concentric vascular
changes can be easily detected only by intravascular
ultrasound. The treatment of the established vasculopathy
is disappointing, so the primary effort should be directed
toward early prevention and diagnosis. Due to diffuse vascular
changes, revascularization procedures are restricted
only to a relatively small proportion of patients with favorable
coronary anatomy. Percutaneous coronary intervention
is preferred over surgical revascularization since it leads to
better acute results and patient survival. Although there is
no proven long-term advantage of drug-eluting stents for
the treatment of in-stent restenosis, they are preferred over
bare-metal stents. Severe vasculopathy has a poor prognosis
and the only definitive treatment is retransplantation.
This article reviews the present knowledge on the pathogenesis,
diagnosis, treatment, and prognosis of cardiac allograft
vasculopathy
Primjena ručne metode intrakrdijalnih elektrograma odgovarajuća je zamjena ehokardiografskoj atrioventrikulskoj i inter-ventrikulskoj optimizaciji resinkronizacijskoga elektrostimulatora srca
Some manufacturers do not provide automated intracardiac electrogram method (IEGM) systems for atrioventricular (AV) and interventricular (VV) delay optimization in cardiac resynchronization therapy (CRT). We aimed to evaluate the accuracy of manual IEGM method in 48 patients previously implanted with Medtronic Syncra CRT. All patients underwent standard device interrogation followed by CRT optimization by IEGM method and by echocardiography one month after implantation. The patient mean age was 60.7±11.8 years and there were 33 (68.8%) males. After CRT implantation, the left ventricular ejection fraction increased from 28.0±7.9% to 39.1±11.0% (p<0.001). Optimal aortic flow Velocity Time Integral (aVTI) was obtained when VV was set to 20-50 ms left ventricular pre-activation. There was a strong correlation between VV values determined by echocardiography and IEGM (R=0.823, p<0.001). We found no significant difference in AV, VV and aVTI values between echocardiography and IEGM method. However, IEGM was significantly less time-consuming than echocardiography [20 (10-28) vs. 40 (35-60) minutes, p<0.001]. Manual IEGM method may be good alternative to echocardiography and automated IEGM method. It also emphasizes the need for implementation of automated IEGM systems in as many CRT devices as possible.Neki proizvođači nemaju automatski sustav intrakardijalnog elektrokardiograma (IEGM) za atrioventrikulsku (AV) i in-terventrikulsku (VV) optimizaciju u srčanoj resinkronizacijskoj terapiji (CRT). Cilj ovoga istraživanja bio je procijeniti točnost ručnog namještanja IEGM kod bolesnika s ugrađenom CRT. U istraživanje je bilo uključeno 48 bolesnika kojima je prethodno ugrađen Medtronic Syncra CRT. Jedan mjesec nakon ugradnje svim bolesnicima je učinjena standardna kontrola elektrostimulatora, nakon čega je učinjena optimizacija CRT, prvo metodom IEGM, a potom ultrazvučno. Srednja dob bolesnika bila je 60,7±11,8 godina; bila su 33 (68,8%) muškarca. Nakon ugradnje CRT, ejekcijska frakcija lijeve klijetke narasla je s 28,0±7,9% na 39,1±11,0% (p<0,001). Najveći integral brzine protoka nad aortnom valvulom (aVTI) dobiven je pri VV intervalu od 20-50 ms lijeve preekscitacije. Utvrđena je snažna korelacija između trajanja VV intervala dobivenog ultrazvučno i IEGM (R=0,823, p<0,001). Nismo našli statistički značajnu razliku između vrijednosti AV, VV i aVTI dobivenih ultrazvučno i metodom IEGM. Ipak, metoda IEGM zahtijeva bitno manje vremena od ultrazvučne metode [20 (10-28) prema 40 (35- 60) minuta, p<0,001]. Naše istraživanje pokazuje da ručna metoda IEGM može biti dobra alter-nativa ehokardiografskoj optimizaciji i automatskoj metodi IEGM. Također ukazuje na potrebu omogućavanja automatske IEGM optimizacije kod što više CRT uređaja
Paracorporeal right ventricular assist device for acute and chronic right heart failure in carriers of durable left ventricular assist devices
Pretransplant and perioperative predictors of early heart transplantation outcomes
Aim To identify predictors of 3-month mortality after heart transplantation
in a Croatian academic center.
Methods A retrospective review of institutional database identified
117 heart transplantations from January 2008 to July 2014. Two children
<14 years were excluded from the study. The remaining 115
patients were dichotomized into survivors and non-survivors adjudicated
at 3-months postoperatively, and their demographic, clinical,
and longitudinal hemodynamic data were analyzed.
Results 3-month survival after heart transplantation was 86%. Nonsurvivors
were older (59 ± 8 vs 50 ± 14 years, P = 0.009), more likely
to have previous cardiac surgery (44% vs 19%; odds ratio [OR] 3.28,
95% confidence interval [CI] 1.08-9.90; P = 0.029), lower body mass
index (BMI) (25 ± 4 vs 28 ± 2 kg/m2, P = 0.001), and be diabetics (44%
vs 23%; OR 2.57, 95% CI 0.86-7.66; P = 0.083). Creatinine clearance
was marginally superior among survivors (59 ± 19 vs 48 ± 20 mL/
min, P = 0.059). Donor age and sex did not affect outcomes. Nonsurvivors
were more likely to have had ischemic cardiomyopathy
(69% vs 32%, P = 0.010). Postoperative utilization of epinephrine as a
second line inotropic agent was a strong predictor of mortality (63%
vs 7%; OR 21.91; 95% CI 6.15-78.06; P < 0.001). Serum lactate concentrations
were consistently higher among non-survivors, with the
difference being most pronounced 2 hours after cardiopulmonary
bypass (9.8 ± 3.5 vs 5.2 ± 3.2 mmol/L, P < 0.001). The donor hearts
exhibited inferior early hemodynamics in non-survivors (cardiac index
3.0 ± 1.0 vs 4.0 ± 1.1 L/min/m2, P = 0.001), stroke volume (49 ± 24
vs 59 ± 19 mL, P = 0.063), and left and right ventricular stroke work
indices (18 ± 8 vs 30 ± 11 g/beat/m2, P < 0.001 and 5 ± 3 vs 7 ± 4 g/
beat/m2, P = 0.060, respectively). Non-survivors were more likely to
require postoperative re-sternotomy (50% vs 12%; OR 7.25, 95% CI
2.29-22.92; P < 0.001), renal replacement therapy (RRT) (69% vs 9%;
OR 22.00, 95% CI 6.24-77.54; P < 0.001), and mechanical circulatory
assistance (MCS) (44% vs 5%; OR 14.62, 95% CI 3.84-55.62; P < 0.001).
Binary logistic regression revealed recipient age (P = 0.024), serum
lactates 2 hours after CPB (P = 0.007), and epinephrine use on postoperative
day 1 (P = 0.007) to be independently associated with
3-month mortality.
Conclusion Pretransplant predictors of adverse outcome after
heart transplantation were recipient age, lower BMI, ischemic cardiomyopathy,
reoperation and diabetes. Postoperative predictors
of mortality were inferior donor heart hemodynamics, epinephrine
use, and serum lactate concentrations. Non-survivors were more
likely to require re-sternotomy, MCS, and RRT