Predisposing factors for late mortality in heart transplant patients

Background: Because of the growing prevalence of terminal heart failure on the one hand and organ shortage on the other hand, an optimal care of heart transplant recipients based on the knowledge of potential risk factors not only early, but also in a long-term course after heart transplantation is of great importance. Therefore, the aim of the present study was to identify predisposing factors for late mortality in this patient collective.Methods: Data from long-term heart transplant patients collected during follow-up visits in the current center were retrospectively analyzed. Clinical, laboratory, including immune monitoring and apparative examination results were studied with regard to all-cause mortality.Results: One hundred and seventy-two patients after heart transplantation (mean: 13.2 ± 6.4 years) were divided into two groups: survivors (n = 133) and non-survivors (n = 39). In comparison with survivors, non-survivors were characterized by significantly more pronounced renal insufficiency with more frequent dialysis, anemia and worse functional status. Additionally, non-survivors obtained hearts from relevantly more obese donors. In a multivariate Cox regression analysis the following parameters were shown to be independent risk factors for increased mortality: CD4 percentage < 42%, C-reactive protein ≥ 0.5 mg/dL, presence of rejections requiring therapies in the past, onset of cardiac allograft vasculopathy < 5 years following heart transplantation and no use of beta-blockers.Conclusions: Low CD4+ cell percentages, sustained inflammation, relevant organ rejections, early onset of transplant vasculopathy and no use of beta-blockers are risk factors for higher mortality in a long-term follow-up after heart transplantation

Surgery of secondary mitral insufficiency in patients with impaired left ventricular function

<p>Abstract</p> <p>Background</p> <p>Secondary mitral insufficiency (SMI) is an indicator of a poor prognosis in patients with ischemic and dilated cardiomyopathies. Numerous studies corroborated that mitral valve (MV) surgery improves survival and may be an alternative to heart transplantation in this group of patients.</p> <p>The aim of the study was to retrospectively analyze the early and mid-term clinical results after MV repair resp. replacement in patients with moderate-severe to severe SMI and left ventricular ejection fraction (LVEF) below 35%.</p> <p>Methods</p> <p>We investigated 40 patients with poor LVEF (mean, 28 ± 5%) and SMI who underwent MV repair (n = 26) resp. replacement (n = 14) at the University Hospital Muenster from January 1994 to December 2005. All patients were on maximized heart failure medication. 6 pts. had prior coronary artery bypass grafts (CABG). Twenty-seven patients were in New York Heart Association (NYHA) class III and 13 were in class IV. Eight patients were initially considered for transplantation. During the operation, 14 pts had CABG for incidental disease and 8 had tricuspid valve repair. Follow-up included echocardiography, ECG, and physician's examination and was completed in 90% among survivors. Additionally, the late results were compared with the survival after orthotope heart transplantation (oHTX) in adults with ischemic or dilated cardiomyopathies matched to the same age and time period (148 patients).</p> <p>Results</p> <p>Three operative deaths (7.5%) occurred as a result of left ventricular failure in one and multiorgan failure in two patients. There were 14 late deaths, 2 to 67 months after MV procedure. Progress of heart failure was the main cause of death. 18 patients who were still alive took part on the follow-up examination. At a mean follow-up of 50 ± 34 (2–112) months the NYHA class improved significantly from 3.2 ± 0.5 to 2.2 ± 0.4 (p < 0.001). The LVEF improved significantly from 29 ± 5% to 39 ± 16 (p < 0.05). There were no differences in survival after MV repair or replacement. The 1-, 3-, 5-year survival rates in the study group were 80%, 58% and 55% respectively. In the group of patients after oHTX the survival was accordingly 72%, 68%, 66% (p > 0.05).</p> <p>Conclusion</p> <p>High risk mitral valve surgery in patients with cardiomyopathy and SMI offers a real mid-term alternative method of treatment of patients in drug refractory heart failure with similar survival in comparison to heart transplantation.</p

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19

Objectives: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). Design: Multicenter retrospective, observational study. Setting: Ten tertiary referral university and community hospitals. Participants: Patients with confirmed severe COVID-19-related ARDS. Interventions: Venovenous or venoarterial ECMO. Measurements and Main Results: One hundred thirty-two patients (mean age 51.1 +/- 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 +/- 4.4, mean pH was 7.23 +/- 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 +/- 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 +/- 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. Conclusions: The present findings suggested that about half of adult patients with severe COVID-19 -related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. (C) 2021 The Authors. Published by Elsevier Inc.Peer reviewe

Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation With and Without Intra-Aortic Balloon Pump

Publisher Copyright: © 2022 The Author(s)Objectives: To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). Design: A retrospective multicenter registry study. Setting: At 19 cardiac surgery units. Participants: A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). Measurements and Main Results: The overall series mean age was 63 +/- 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMOIABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, inhospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). Conclusions: This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock. (C) 2022 The Author(s). Published by Elsevier Inc.Peer reviewe

Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis

Background: It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Methods: A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. Results: The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08–1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04–1.76, I2 21%). Conclusions: Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO

Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Background: The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA. Methods: This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO. Results: Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157-1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (= 1.6 mmol/L, 45.0%; adjusted OR 2.489, 95%CI 1.374-4.505). When 261 patients with arterial lactate at VA-ECMO weaning = 1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate >= 1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate. Conclusions: Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19

ObjectivesThe authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)–related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO).DesignMulticenter retrospective, observational study.SettingTen tertiary referral university and community hospitals.ParticipantsPatients with confirmed severe COVID-19–related ARDS.InterventionsVenovenous or venoarterial ECMO.Measurements and Main ResultsOne hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19–related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality.ConclusionsThe present findings suggested that about half of adult patients with severe COVID-19–related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. Clinical Trial Registration: identifier, NCT04383678.</p

Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation in Patients Aged 70 Years or Older

Background. There is uncertainty whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) should be used in older patients with cardiopulmonary failure after cardiac surgery.Methods. This was a retrospective multicenter study of 781 patients who required postcardiotomy VA-ECMO for cardiopulmonary failure after adult cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. A parallel systematic review with meta-analysis of the literature was performed.Results. The hospital mortality in the overall Post-cardiotomy Venoarterial Extracorporeal Membrane Oxygenation (PC-ECMO) series was 64.4%. A total of 255 patients were 70 years old or older (32.7%), and their hospital mortality was significantly higher than in younger patients (76.1% vs 58.7%; adjusted odds ratio, 2.199; 95% confidence interval [CI], 1.536 to 3.149). Arterial lactate level greater than 6 mmol/L before starting VA-ECMO was the only predictor of hospital mortality among patients 70 years old or older in univariate analysis (82.6% vs 70.4%; P = .029). Meta-analysis of current and previous studies showed that early mortality after postcardiotomy VA-ECMO was significantly higher in patients aged 70 years or older compared with younger patients (odds ratio, 2.09; 95% CI, 1.59 to 2.75; 5 studies including 1547 patients; I-2, 5.9%). The pooled early mortality rate among patients aged 70 years or older was 78.8% (95% CI, 74.1 to 83.5; 6 studies including 617 patients; I-2, 41.8%). Two studies reported 1-year mortality (including hospital mortality) of 79.9% and 75.6%, respectively, in patients 70 years old or older.Conclusions. Advanced age should not be considered a contraindication for postcardiotomy VA-ECMO. However, in view of the high risk of early mortality, meaningful scrutiny is needed before using VA-ECMO after cardiac surgery in older patients. (C) 2019 by The Society of Thoracic Surgeon

Influence in changes of blood pressure variability on the renin angiotensin system in chronically instrumented, alert rats

Titelblatt und Inhaltsverzeichnis Einleitung Zielsetzung Material und Methoden Ergebnisse Diskussion Zusammenfassung LiteraturverzeichnisHintergrund: Physiologische Schwankungen des Blutdrucks mit einer Frequenz von 0.1 Herz können die Fähigkeit der Nieren zur Autoregulation des renalen Blutfluss umgehen. Der Einfluss solcher plötzlichen Veränderungen des renalen Perfusionsdrucks auf die Blutdruckregulation z.B. durch das Renin Angiotensin System sind derzeit unbekannt. Daher haben wir den Einfluss solcher Blutdruckoszillationen auf die Plasma Renin Aktivität und die Renin mRNA Spiegel in der Niere währen der Initialphase des renovaskulären Hypertonus studiert. Methoden und Ergebnisse: 30 männlich SD Ratten (zufällig den folgenden Protokollen zugeordnet) wurden zur Messung des systemische Blutdrucks chronisch instrumentiert. Eine aufblasbare Manschette wurde benutzt um den renalen Perfusionsdruck über 24 Stunden in sich frei bewegenden Ratten zu senken und um Blutdruckoszillationen zu erzeugen. Am Ende des Versuches wurden Blutproben zur Bestimmung der Plasma Renin Aktivität entnommen, die Nieren entnommen und der Renin mRNA Gehalt mittels eines Northern Blots bestimmt. Eine Reduktion des renalen Perfusionsdrucks verdoppelte die Plasma Renin Aktivität und den Renin mRNA Gehalt. Die Überlagerung von 0.1-Hz. Oszillationen auf den reduzierten renalen Perfusionsdruck schwäche den Blutdruckanstieg ab und führte zu einem weniger stark ausgeprägtem Anstieg der Plasma Renin Aktivität und der Renin mRNA Spiegel. In einer zweiten Versuchsserie wurden 30 männliche SD zufällig den gleichen Versuchsprotokollen wie oben erwähnt zugeordnet. Zuvor waren diese Tiere aber mit einer salzreichen Diät ernährt worden. Die hohe Salzaufnahme hatte keine Effekt auf den systemischen Blutdruck, die Plasma Renin Aktivität und die Renin mRNA Spiegel unter Kontrollbedingungen und bei einem auf 80 mmHg reduziertem renalen Perfusionsdruck. Die Effekte der überlagerten 0.1 Hz Blutdruckoszillationen wurden aber durch die hohe Salzaufnahme abgeschwächt. In einer dritten Versuchsreihe wurden 40 SD Ratten wie oben beschrieben chronisch instrumentiert. Der renale Perfusionsdruck wurde für 24 Stunden auf 90, 80 und 70 mmHg abgesenkt und die Plasma Renin Aktivität und der Renin mRNA Gehalt bestimmt. Eine Reduktion des renalen Perfusionsdrucks führte zu einem fast linearen Anstieg des systemischen Blutdrucks und der Plasma Renin Aktivität. Der Renin mRNA Gehalt war verglichen mit der Kontrollgruppe signifikant erhöht, wenn der renale Perfusionsdruck auf 90 mmHg abgesenkt wurde. Eine weitere Senkung des renalen Perfusionsdrucks führte zu keinem weitern Anstieg der Renin mRNA Spiegel mehr. In einer vierten Versuchsserie wurden 40 SD Ratten zufällig den vorher erwähnten Protokollen zugeordnet. Zuvor wurden die Tiere jedoch salzreich ernährt. Eine salzreiche Ernährung schwächte den bei reduziertem renalen Perfusionsdruck beobachteten Anstieg von Plasma Renin Aktivität und Renin mRNA Gehalt ab. Der Renin mRNA Gehalt war verglichen mit der Kontrollgruppe erst signifikant erhöht, wenn der renale Perfusionsdruck auf 80 mmHg abgesenkt wurde. Eine weitere Senkung des renalen Perfusionsdrucks führte zu keinem weitern Anstieg der Renin mRNA Spiegel mehr. Schlussfolgerung: Blutdruckfluktuationen schwächen den in der Initialphase der renovaskulären Hypertonie beobachteten Blutdruckanstieg ab, indem Sie zu einem geringeren Anstieg der Plasma Renin Aktiviät und des Renin mRNA Gehaltes führen. Der Renin mRNA Gehalt reagiert dichotom auf eine Reduktion des renalen Perfusionsdrucks. Durch eine salzreiche Ernährung kann der Schwellenwert dieses System zu niedrigern Werten hin verschoben werden.Background: Physiological blood pressure (BP) fluctuations with frequencies of 0.1 Hz can override renal blood flow autoregulation. The influence of such immediate changes in renal perfusion pressure (RPP) on daily BP regulation, e.g. via PRA and Renin mRNA, however, is unknown. Thus, we studied the effects of such RPP oscillations on renal Rennin mRNA levels, Plasma Renin Activity (PRA) and on systemic BP during the onset of renal hypertension. Methods and Results: 30 male SD rats (randomly assigned to each of the following protocols) were chronically instrumented for the measurement of systemic BP. An inflatable cuff was used to reduce and to oscillate RPP over 24 hours in the freely moving rat. At the end of the experiment blood samples for PRA were drawn, animals were scarified, kidneys were harvested and Renin mRNA was detected by northern blot analysis. Reducing RPP to 80 mm Hg doubled PRA and Renin mRNA levels. Superimposing 0.1-Hz oscillations (± 10 mmHg) onto the reduced RPP blunted hypertension and PRA as well as Renin mRNA levels were significantly reduced at this experimental protocol. In a second set of experiments 30 male SD rats were randomly assigned to the same protocols as mentioned above but prior to the experiments a high sodium diet was fed to the animals. High sodium intake had no effect on PB, PRA and rennin mRNA levels under control condition and when RPP was reduced to 80 mmHg. But the effects of 0.1 Hz BP oscillations on systemic BP, PRA and Renin mRNA were attenuated when a high sodium diet was fed prior to the experiments. In a third set of experiments 40 male SD rats were chronically instrumented as described above. RPP was reduced to 90, 80 and 70 mmHg for 24 hours and PRA as well as Renin mRNA were estimated at the end of the experiment. Reduction of RPP led to an almost linear increase of BP and PRA. Renin mRNA levels were significantly higher when RPP was reduced to 90 mmHg compared to control levels. A further decrease in RPP did not lead to a further increase in Renin mRNA levels. In a fourth set of experiments 40 male SD rats were randomly assigned to the same protocols as mentioned above but prior to the experiments a high sodium diet was fed to the animals. High sodium intake attenuated the increase in BP and PRA observed after reduction of RPP. Renin mRNA levels increased significantly when RPP was set to 80 mmHg. A further decrease in RPP did not lead to a further increase in Renin mRNA levels. Conclusions: BP fluctuations induce a reduction in PRA and Renin mRNA levels and markedly attenuate the acute development of renovascular hypertension. Renin mRNA levels reveal a dichotomic response to a reduction of RPP. A high sodium intake reduces the threshold pressure of this system

Current management and perspectives in the treatment of ventricular assist device-specific infections.

Occurrence of ventricular assist device (VAD)-specific infections is a serious complication that can jeopardize on the long run the effectiveness of VAD therapy. In the light of ongoing shortage of organ available for heart transplantation there will be in the next future an increase necessity of conservative strategies. A multidisciplinary approach including cardiac surgeons, cardiologist, infectious disease (ID) consultant and nuclear medicine physicians should be the first step for the diagnosis and treatment of VAD-specific infections. Early detection of infections and consequently early treatment with innovative strategies may help physicians to improve outcomes