This is invited commentary to the following article:
Kilic, A., Conte, J. V., Shah, A. S., & Yuh, D. D. (2012). Orthotopic heart transplantation in patients with metabolic risk factors. Annals of Thoracic Surgery, 93(3), 718-724

Cavarocchi, Nicholas C.

Mather, Paul

This is invited commentary to the following article:
Kilic, A., Conte, J. V., Shah, A. S., \u26 Yuh, D. D. (2012). Orthotopic heart transplantation in patients with metabolic risk factors. Annals of Thoracic Surgery, 93(3), 718-724

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Invited Commentary on: Orthotopic Heart Transplantation in Patients With Metabolic Risk Factors

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Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Surgery Faculty Papers Department of Surgery3-2012Invited Commentary on: Orthotopic HeartTransplantation in Patients With Metabolic RiskFactorsNicholas C. CavarocchiDepartment of Surgery, Thomas Jefferson University, nicholas.cavarocchi@jefferson.eduPaul MatherAdvanced Heart Failure and Cardiac Transplant Center, Jefferson Heart Institute, Thomas Jefferson University,paul.mather@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/surgeryfpPart of the Cardiology Commons, Endocrinology, Diabetes, and Metabolism Commons, and theSurgery CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Surgery Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationCavarocchi, Nicholas C. and Mather, Paul, "Invited Commentary on: Orthotopic HeartTransplantation in Patients With Metabolic Risk Factors" (2012). Department of Surgery FacultyPapers. Paper 58.http://jdc.jefferson.edu/surgeryfp/58As submitted to: Annals of Thoracic Surgery  And later published as: Invited Commentary on: Orthotopic Heart Transplantation in Patients With Metabolic Risk Factors  Volume 93, Issue 3, March 2012, Pages 724-725 DOI: 10.1016/j.athoracsur.2012.01.024  Cavarocchi, N. C., & Mather, P. (2012). Invited commentary. Annals of Thoracic Surgery, 93(3), 724-725.Invited Commentary Obesity affects ~50-60% of a nation’s population and can be associated with insulin resistance and the metabolic syndrome (MetS).1 The prevalence of the MetS in the global population is ~ 20-30% and people with metabolic syndrome (MetS) are twice as likely to die of cardiovascular disease.2 As more advanced heart failure patients are presented for evaluation for heart transplantation such risk factors are often overlooked or marginalized in an effort to provide care. Kilic et al. queried the UNOS database to evaluate the impact of risk factors for MetS and their effect on mortality after Orthotopic heart transplantation (OHT). Their work demonstrated that increasing number of metabolic risk factors contributed to increased mortality and decreased survival in OHT patients. But are the metabolic risk factors reviewed from the UNOS database in this review substantial enough to define them as the metabolic syndrome? The definition for MetS for use in clinical practice include central obesity measured by waist circumference (WC), plus any two of the following: raised triglyceride (TG) >150 mg/dl; reduced HDL cholesterol <40 mg>/dl, systolic blood pressure > 130; raised fasting blood sugar(BS) or type 2 diabetes mellitus.3 The World Health Organization (WHO), The Europe group for the study of Insulin Resistance (SGIR), The National Cholesterol Education Program (NCEP:ATP111), The American Association of Clinical Endocrinology (AACE), the International Diabetic Federation (IDF), and the AHA/NHLBI have attempted to incorporate all the different parameters used to define metabolic syndrome. The core manifestations of the metabolic syndrome (MetS) which prevail throughout all definitions remain central obesity and insulin resistance, key data missing from the UNOS database.4, 5 The UNOS database does not contain waist circumference, TG, HDL or BS data; the authors substituted BMI > 30 kg/m2 for obesity, history of hypertension and diabetes for risk factors to evaluate for MetS. Although there is a well defined gradient relationship between the level of BMI and probability of the MetS, most obese individuals do not have MetS and conversely most patients with MetS are not obese or overweight. Central obesity, measured simply by waist circumference, is more indicative of the MetS then BMI across all BMI groups for both men and women.5 Overall adiposity defined by BMI is not a surrogate marker for insulin resistance. Despite the sample size and their significant finding that multiple metabolic risk factors in OHT are associated with mortality, this study does not use standard accepted definitions of MetS. The core manifestations of the MetS, central obesity and insulin resistance, were not reported in this review due to the lack of data available in the database. To optimize long term survival for these patients, clinicians should carefully evaluate candidates for acceptance for transplant, envision steroid sparing immunosuppression protocols, and acknowledge and create an algorithm for post OHT physical rehabilitation to minimize the development of the MetS. A prospective treatment plan will mitigate and hopefully improve long term survival and quality of life in patients with metabolic risk factors. Nicholas C. Cavarocchi, MD Paul Mather, MD Associate Professor of Surgery Professor of Medicine Director, Advanced Heart Failure and Cardiac Transplant Center at the Jefferson Heart Institute, Jefferson Medical College of Thomas Jefferson University 925 Chestnut Street Suite 323A Philadelphia, PA 19107 Thomas Jefferson University Dept. of Surgery 1025 Walnut St. Ste.605E Philadelphia, Pa. 19107 Nicholas.cavarocchi@jefferson.edu References  1. Wild S, Roglic G, Green A et al. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27(5): 1047-53 2. Diabetes Atlas, second edition, International Diabetes Federation, 2003 3. Alberti KG, Eckel RH, Grundy SM et al. Harmonizing the metabolic syndrome: a joint statement. Circulation 2009, 120: 1640-1645 4. Carr DB, Utzchneider KM, Hull RL et al. Intra-abdominal fat is a major determinant of the NCEP/ATP111 criteria for the metabolic syndrome. Diabetes 2004; 53(8):2087-94 5. Pouilot MC, Despres JP, Lemieux S et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994:73:460-8  

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Invited Commentary on: Orthotopic Heart Transplantation in Patients With Metabolic Risk Factors

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