Joint Arthroplasties other than the Hip in Solid Organ Transplant Recipients

Transplantation Surgery has undergone a great development during the last thirty years and the survival of solid organ recipients has increased dramatically. Osteo-articular diseases such as osteoporosis, fractures, avascular bone necrosis and osteoarthritis are relatively common in these patients and joint arthroplasty may be required. The outcome of hip arthroplasty in patients with osteonecrosis of the femoral head after renal transplantation has been studied and documented by many researchers. However, the results of joint arthroplasties other than the hip in solid organs recipients were only infrequently reported in the literature. A systematic review of the English literature was conducted in order to investigate the outcome of joint arthroplasties other than the hip in kidney, liver or heart transplant recipients. Nine pertinent articles including 51 knee arthroplasties, 8 shoulder arthroplasties and 1 ankle arthroplasty were found. These articles reported well to excellent results with a complication rate and spectrum comparable with those reported in nontransplant patients

Pathological assessment of end-stage heart failure in explanted hearts in correlation with hemodynamics in patients undergoing orthotopic heart transplantation

Background: To date, there has been little research, if any, on the pathological correlates of end-stage heart failure in the explanted hearts of orthotopic heart transplant (OHT) recipients in correlation with the patients' hemodynamics. We sought to compare the gross and histopathological parameters in hearts explanted-native or previously transplanted-from patients with end-stage heart failure with the clinical hemodynamics parameters at the time of OHT. Methods: Forty patients undergoing OHT were enrolled in this study and divided into two groups according to whether they suffered from ischemic (ICMP) or nonischemic cardiomyopathy (NICMP). All study patients were treated with OHT for end-stage heart failure at The University of Texas Health Science Center at Houston. The pathological investigations of the hearts were focused on the study of the underlying cause of heart failure leading the patient to OHT; on the quantification of the extent and severity of fibrosis, hypertrophy, and myocytolysis; and on validating a semiquantitative grading scale. Analyses of multiple sections of the explanted hearts were carried out. The heart weights were recorded and compared with the grades of fibrosis, hypertrophy of cardiomyocytes, and myocytolysis. The grades of fibrosis, hypertrophy, and myocytolysis were evaluated in right and left ventricles and atria (with areas of confluent infarction excluded). The pathological parameters were correlated with the patients' clinical parameters. Results: Twenty-two patients (20 men, 2 women, mean age\ub1S.E.M., 62.3\ub12.2 years) suffered from ICMP and 18 patients (9 men, 9 women, mean age\ub1S.E.M., 56.3\ub12.8 years) from NICMP. All the clinical and pathological measured variables were comparable between the two groups, except for pulmonary vascular resistance, which was higher in the NICMP group of patients, and the grade of myocytolysis, which was significantly higher in the ICMP vs. NICMP group. Most of the clinical and pathological variables were overall linearly correlated. Conclusions: Both ICMP and NICMP groups of end-stage heart failure requiring OHT presented high grades of fibrosis, hypertrophy, and myocytolysis. Heart failure is the final common pathway of a variety of primary cardiovascular diseases regardless of the ischemic or nonischemic nature of the cardiomyopathy

HeartMate II left ventricular assist device implantation in patients with advanced hepatic dysfunction

PubMed ID: 24641429Background We sought to determine the outcomes for patients with advanced hepatic dysfunction undergoing HeartMate II left ventricular assist device (LVAD) implantation. Methods Between November 1, 2003 and December 1, 2012, we implanted the HeartMate II continuous-flow LVAD in 338 patients, either for bridging to heart transplantation or for destination therapy. Twenty-three of these patients (19 men and 4 women; mean age, 47 ± 16 years) had advanced hepatic dysfunction, as characterized by alanine aminotransferase (ALT) or aspartate transaminase (AST) levels five times normal; serum total bilirubin levels three times normal; and/or necessity for a liver biopsy before or during device implantation. Of this group, 17 patients received the LVAD as a bridge to transplantation, and six patients received it for destination therapy. Results Nine of the 23 patients required either a transjugular or a core liver biopsy during LVAD implantation. Three patients died within the first postoperative month; the 20 surviving patients had significant improvements in their hepatic parameters. The ALT decreased from 238 ± 296 to 27 ± 13 U/L (p = 0.022), AST decreased from 209 ± 199 to 29 ± 8 U/L (p = 0.009), and total bilirubin level decreased from 6.9 ± 6.0 to 0.6 ± 0.1 mg/dL (p = 0.044). The serum albumin level increased from 3.2 ± 0.6 to 4.3 ± 0.3 g/dL (p = 0.003), and creatinine clearance increased from 77.6 ± 35.2 to 110.2 ± 35.7 mL/min/1.73 m2 (p = 0.101). Conclusion Continuous-flow LVAD support may significantly improve hepatic function, allowing patients with poor preimplant liver function to become better candidates for heart transplantation. © 2013 Wiley Periodicals, Inc

Left ventricular noncompaction cardiomyopathy in end-stage heart failure patients undergoing orthotopic heart transplantation

Background Previous studies reported that left ventricular noncompaction (LVNC) is a cardiomyopathy, familial or sporadic, arising from arrest of the normal process of trabecular remodeling during embryonic development. The diagnosis is usually made by echocardiography, but to date, there has been little research on the occurrence and clinicopathological features of LVNC in the explanted hearts of orthotopic heart transplant (OHT) recipients. Design The clinical, echocardiographic, and pathologic findings were reviewed for evidence of LVNC, diagnosed by echocardiographic criteria, in 105 patients with end-stage heart failure (HF) undergoing OHT. Analyses of multiple sections of the explanted hearts were carried out. The hearts were evaluated for grades (0, negative; 1, mild/occasional foci; 2, moderate/multiple foci; 3, severe/extensive, diffuse) of fibrosis, reactive and replacement, hypertrophy, myocytolysis in left ventricle, right ventricle, interventricular septum, and atria. Absolute measurements of noncompacted and compacted portions of the left ventricle wall and noncompacted/compacted ratios were calculated. Results Isolated LVNC was observed in 0 of 54 ischemic cardiomyopathy and in 4 of 51 (7.8%) nonischemic cardiomyopathy patients \u2014 2 men and 2 women, with a mean age \ub1 SEM of 34.2 \ub1 6.9 years. The echocardiogram disclosed marked left ventricular dilatation, prominent trabeculations, and left ventricle ejection fraction < 20%. Mural thrombi were seen in 3 of 4 (75%) patients. The heart weight mean \ub1 SEM was 468 \ub1 55.3 g (range, 340\u2013600 g); noncompacted myocardium was 22 \ub1 5.8 mm, compacted myocardium was 13.2 \ub1 3.5 mm, and noncompacted/compacted ratio was 1.7/1 \ub1 0.2. The total scores of hypetrophy, myocytolysis, and fibrosis were as follows: left ventricle, 7.7 \ub1 0.2; right ventricle, 6.2 \ub1 0.5; interventricular septum, 6.7 \ub1 0.2; and atria, 7.5 \ub1 0.3. Conclusions LVNC is an unusual form of nonischemic cardiomyopathy in patients suffering from end-stage HF undergoing OHT. The variability in the noncompacted/compacted ratio and discordance between the echocardiographic and pathological findings points to the need for further clarification of diagnostic imaging and diagnostic criteria for LVNC. Further studies in larger series, correlating the anatomoclinical and genetic variables, also would improve our understanding of LVNC as a cause of advanced HF leading to OHT

Continuous aortic flow augmentation - A pilot study of hemodynamic and renal responses to a novel percutaneous intervention in decompensated heart failure

Background - Diminished aortic flow may induce adverse downstream vascular and renal signals. Investigations in a heart failure animal model have shown that continuous aortic flow augmentation ( CAFA) achieves hemodynamic improvement and ventricular unloading, which suggests a novel therapeutic approach to patients with heart failure exacerbation that is inadequately responsive to medical therapy. Methods and Results - We studied 24 patients ( 12 in Europe and 12 in the United States) with heart failure exacerbation and persistent hemodynamic derangement despite intravenous diuretic and inotropic and/or vasodilator treatment. CAFA ( mean +/- SD 1.34 +/- 0.12 L/min) was achieved through percutaneous ( n = 19) or surgical ( n = 5) insertion of the Cancion system, which consists of inflow and outflow cannulas and a magnetically levitated and driven centrifugal pump. Hemodynamic improvement was observed within 1 hour. Systemic vascular resistance decreased from 1413 +/- 453 to 1136 +/- 381 dyne (.) s (.) cm(-5) at 72 hours ( P = 0.0008). Pulmonary capillary wedge pressure decreased from 28.5 +/- 4.9 to 19.8 +/- 7.0 mm Hg ( P < 0.0001), and cardiac index ( excluding augmented aortic flow) increased from 1.97 +/- 0.44 to 2.27 +/- 0.43 L (.) min(-1) (.) m(-2) ( P = 0.0013). Serum creatinine trended downward during treatment ( overall P = 0.095). There were 8 complications during treatment, 7 of which were self-limited. Hemodynamics remained improved 24 hours after CAFA discontinuation. Conclusions - In patients with heart failure and persistent hemodynamic derangement despite intravenous inotropic and/or vasodilator therapy, CAFA improved hemodynamics, with a reduction in serum creatinine. CAFA represents a promising, novel mode of treatment for patients who are inadequately responsive to medical therapy. The clinical impact of the observed hemodynamic improvement is currently being explored in a prospective, randomized, controlled trial