Trasplante cardíaco

Alterations in Fibrin Structure in Patients with Liver Diseases.

Semin Thromb Hemost. 2016 Jun;42(4):389-96

Authors: Lisman T, Ariëns RA

Abstract
The hemostatic balance in patients with liver diseases is relatively well preserved due to concomitant alterations in pro- and antihemostatic pathways. Thrombin generation studies support the notion of hemostatic competence in liver diseases, but in such tests alterations in fibrinogen level and function are not taken into account. We have recently studied structural and functional properties of the fibrin clot in patients with liver diseases. Although we have confirmed previous findings that hypersialylation of the fibrinogen molecule in patients with liver diseases contributes to a defective fibrinogen-to-fibrin conversion, we have found that once the clot has been formed, it has a thrombogenic nature as assessed by permeability assays. These thrombogenic properties of the fibrin clot in cirrhosis relate to incompletely characterized intrinsic changes in the fibrinogen molecule, which may include oxidation and hypersialylation. In addition, in patients with nonalcoholic fatty liver disease thrombogenic properties of the fibrin clot are not only due to liver disease but also to obesity and the metabolic syndrome. During liver transplantation, the clot normalizes and becomes increasingly permeable, and the functional properties of the fibrin clot are markedly normalized by fibrinogen concentrate, when added to plasma samples in vitro. These new insights in the functional properties of the fibrin clot in patients with liver diseases facilitate a more rational approach to treatment and prevention of both bleeding and thrombotic complications.

PMID: 27071046 [PubMed - indexed for MEDLINE]

Prevention of TLR9 Pathway in Warm Ischemia in Porcine Donor Liver after Cardiac Death.

Cell Physiol Biochem. 2017 Mar 27;41(4):1547-1554

Authors: Shao Z, Jiao B, Yi D, Liu T, Pan Q, Cheng Y, Liu H

Abstract
OBJECTIVE: To investigate effect of warm ischemia after cardiac death on activation of TLR9 pathway in porcine liver.
METHODS: Donor of cardiac death (DCD) model was established with Duroc, Landrace, Large White crossbred pigs. Liver tissues from the animals were harvested at 0, 5, 10, 15, 25 and 30 minutes after warm ischemia for analysis of expression of TLR9, IRF7, IFN-β, and TNF-α at mRNA and protein levels by real-time PCR and western blot, respectively, and for assessment of NF-κB/DNA binding activity by western blot detection of p65 protein.
RESULTS: Ischemia induced TLR9, IRF7, IFN-β, and TNF-α expression at both mRNA and protein levels in an ischemic time dependent manner. Among them, expression of TNF-α and IFN- β was induced later than TLR9 and IRF7 did. Ischemia also enhanced NF-κB binding to DNA in the DCD liver tissue. Pretreatment with iCpG specifically blocked activation of TLR9 pathway triggered by ischemia in liver and protected the animals from ischemia-caused liver tissue damage.
CONCLUSION: Warm ischemia activates TLR9 pathways in the porcine liver tissue. Blocking TLR9 pathway could offer protection from ischemia-caused liver tissue in DCD liver transplantation.

PMID: 28334710 [PubMed - as supplied by publisher]

Cardiovascular Parameters to 2 years After Kidney Transplantation Following Early Switch to Everolimus Without Calcineurin Inhibitor Therapy: An Analysis of the Randomized ELEVATE Study.

Transplantation. 2017 Mar 22;:

Authors: Holdaas H, de Fijter JW, Cruzado JM, Massari P, Nashan B, Kanellis J, Witzke O, Gutierrez-Dalmau A, Turkmen A, Wang Z, Lopez P, Bernhardt P, Kochuparampil J, van der Giet M, Murbraech K, ELEVATE Study Group

Abstract
BACKGROUND: Mammalian target of rapamycin (mTOR) inhibitors may confer cardioprotective advantages but clinical data are limited.
METHODS: In the open-label ELEVATE trial, kidney transplant patients were randomized at 10-14 weeks posttransplant to convert from calcineurin inhibitor (CNI) to everolimus or remain on standard CNI therapy. Prespecified endpoints included left ventricular mass index (LVMi) and, in a subpopulation of patients, arterial stiffness as measured by pulse wave velocity (PWV).
RESULTS: The mean change in LVMi from randomization was similar with everolimus versus CNI (month 24: -4.37 g/m versus -5.26 g/m; mean difference 0.89 [p=0.392]). At month 24, LVH was present in 41.7% versus 37.7% of everolimus and CNI patients, respectively. Mean PWV remained stable with both everolimus (mean change from randomization to month 12: -0.24 m/s; month 24: -0.03 m/s) or CNI (month 12: 0.11 m/s; month 24: 0.16 m/s). The change in mean ambulatory night time blood pressure from randomization showed a benefit for diastolic pressure at month 12 (p=0.039) but not month 24. Major adverse cardiac events occurred in 1.1% and 4.2% of everolimus-treated and CNI-treated patients, respectively by month 12 (p=0.018) and 2.3% (8/353) and 4.5% by month 24 (p=0.145).
CONCLUSIONS: Overall, these data do not suggest a clinically relevant effect on cardiac endpoints following early conversion from CNI to a CNI-free everolimus-based regimen.

PMID: 28333860 [PubMed - as supplied by publisher]

Improving Decision Making for Advanced Heart Failure Patients and Caregivers.

J Nurs Adm. 2017 Apr;47(4):190-191

Authors: McIlvennan CK

Abstract
In this month's Magnet® Perspectives column, Colleen K. McIlvennan, DNP, ANP, lead nurse practitioner, Advanced Heart Failure and Transplantation at the University of Colorado, discusses her groundbreaking research encompassing patients' and caregivers' emotional, rational, and fundamental beliefs when considering a left ventricular assist device (LVAD). Results have led to the development of 2 innovative decision aids that are currently in use by LVAD programs across the United States and Canada. Dr McIlvennan's efforts led to a $2 million grant from the Patient-Centered Outcomes Research Institute, as well as national recognition from the American Heart Association and the Heart Failure Society of America. Last year, she received the 2016 National Magnet Nurse of the Year® Award in the Empirical Outcomes category. In addition to sharing her findings, Dr McIlvennan examines the value of performing research in a Magnet-recognized organization.

PMID: 28333785 [PubMed - in process]

Accelerated Total Lymphoid Irradiation-containing Salvage Regimen for Patients With Refractory and Relapsed Hodgkin Lymphoma: 20 Years of Experience.

Int J Radiat Oncol Biol Phys. 2017 Apr 01;97(5):1066-1076

Authors: Rimner A, Lovie S, Hsu M, Chelius M, Zhang Z, Chau K, Moskowitz AJ, Matasar M, Moskowitz CH, Yahalom J

Abstract
PURPOSE: We report the long-term results of integrated accelerated involved field radiation therapy (IFRT) followed by total lymphoid irradiation (TLI) as part of the high-dose salvage regimen followed by autologous bone marrow transplantation or autologous stem cell transplantation in patients with relapsed or refractory Hodgkin lymphoma (HL).
METHODS AND MATERIALS: From November 1985 to July 2008, 186 previously unirradiated patients with relapsed or refractory HL underwent salvage therapy on 4 consecutive institutional review board-approved protocols. All patients had biopsy-proven primary refractory or relapsed HL. After standard-dose salvage chemotherapy (SC), accelerated IFRT (18-20 Gy) was given to relapsed or refractory sites, followed by TLI (15-18 Gy) and high-dose chemotherapy. Overall survival (OS) and event-free survival (EFS) were analyzed by Cox analysis and disease-specific survival (DSS) by competing-risk regression.
RESULTS: With a median follow-up period of 57 months among survivors, 5- and 10-year OS rates were 68% and 56%, respectively; 5- and 10-year EFS rates were 62% and 56%, respectively; and 5- and 10-year cumulative incidences of HL-related deaths were 21% and 29%, respectively. On multivariate analysis, complete response to SC was independently associated with improved OS and EFS. Primary refractory disease and extranodal disease were independently associated with poor DSS. Eight patients had grade 3 or higher cardiac toxicity, with 3 deaths. Second malignancies developed in 10 patients, 5 of whom died.
CONCLUSIONS: Accelerated IFRT followed by TLI and high-dose chemotherapy is an effective, feasible, and safe salvage strategy for patients with relapsed or refractory HL with excellent long-term OS, EFS, and DSS. Complete response to SC is the most important prognostic factor.

PMID: 28332991 [PubMed - in process]

The Effects of Center Volume on Mortality in Pediatric Heart Transplantation- The Rest of the Story.

Am J Transplant. 2017 Mar 23;:

Authors: Canter CE

Abstract
Paul Harvey was an American radio commentator in the latter part of the twentieth century. He would present vignettes and would finish them with the tag line "now you know the rest of the story". In this issue Rana, et al (1) have analyzed the effects of center transplant volume on outcomes with pediatric heart transplantation. Instead of focusing on outcomes after transplantation, their primary aim was to analyze center volume effects on waitlist mortality- the rest of the story. This article is protected by copyright. All rights reserved.

PMID: 28332766 [PubMed - as supplied by publisher]

Office orthostatic blood pressure measurements and ambulatory blood pressure monitoring in the prediction of autonomic dysfunction.

Clin Hypertens. 2017;23:3

Authors: Alquadan KF, Singhania G, Koratala A, Ejaz AA

Abstract
BACKGROUND: In this retrospective analysis we investigated the predictive performance of orthostatic hypotension (OH) and ambulatory blood pressure monitoring (ABP) to predict autonomic dysfunction.
METHODS: Statistical associations among the candidate variables were investigated and comparisons of predictive performances were performed using Receiver Operating Characteristics (ROC) curves.
RESULTS: Ninety-four patients were included for analysis. No significant correlations could be demonstrated between OH and components of ABP (reversal of circadian pattern, postprandial hypotension and heart rate variability), nor between OH and autonomic reflex screen. Reversal of circadian pattern did not demonstrate significant correlation (r = 0.12, p = 0.237) with autonomic reflex screen, but postprandial hypotension (r = 0.39, p = 0.003) and heart rate variability (r = 0.27, p = 0.009) demonstrated significant correlations. Postprandial hypotension was associated with a five-fold (OR 4.83, CI95% 1.6-14.4, p = 0.005) increased risk and heart rate variability with a four-fold (OR 3.75, CI95% 1.3-10.6, p = 0.013) increased risk for autonomic dysfunction. Per ROC curves, heart rate variability (0.671, CI95% 0.53-0.81, p = 0.025) and postprandial hypotension (0.668, CI95% 0.52-0.72, p = 0.027) were among the best predictors of autonomic dysfunction in routine clinical practice.
CONCLUSION: Postprandial hypotension and heart rate variability on ambulatory blood pressure monitoring are among the best predictors of autonomic dysfunction in routine clinical practice.

PMID: 28331633 [PubMed - in process]

Pulmonary Thromboendarterectomy for Pulmonary Hypertension Before Considering Transplant.

Ochsner J. 2017;17(1):66-70

Authors: Kooperkamp H, Mehta I, Fary D, Bates M

Abstract
BACKGROUND: In cases of chronic thromboembolic pulmonary hypertension (CTEPH), referral for possible surgical intervention is important because surgery can be curative. Surgery necessitates cardiopulmonary bypass and deep circulatory arrest with pulmonary thrombectomy and bilateral endarterectomy (PTE). If surgery fails, lung transplant is the next best surgical option. Medical treatment is also an important adjunct.
CASE REPORT: A 35-year-old female presented 3 months after a pulmonary embolus was found to be completely occluding her left pulmonary artery. She was found to have pulmonary hypertension with a pulmonary artery pressure of 81/33 mmHg, with a mean pressure of 52 mmHg. The right atrial pressure was also severely elevated at 29 mmHg, and her echocardiogram revealed severe tricuspid regurgitation and severe right ventricular dysfunction. She underwent PTE and postoperatively was followed by the heart failure team. Her 6-minute walk distance improved from 396 meters at 1 month to 670 meters at 7 months, and her pulmonary artery pressure improved significantly to 55/17 mmHg with a mean pressure of 31 mmHg. The patient's right atrial pressure also improved significantly from 29 mmHg to 13 mmHg.
CONCLUSION: CTEPH is likely underrecognized, and patients with pulmonary hypertension or a history of pulmonary embolism should be screened for CTEPH. This case illustrates the surgical treatment for CTEPH and discusses alternative and adjunctive treatments. Residual pulmonary hypertension after PTE occurs in approximately 35% of patients. Overall, 4-year mortality rates after surgery appear to be approximately 15%, and mortality rates correlate with the postoperative pulmonary vascular resistance. Recognition of chronic pulmonary thromboembolic disease as the etiology of pulmonary hypertension warrants evaluation for surgery.

PMID: 28331450 [PubMed - in process]

Pacemaker Use Following Heart Transplantation.

Ochsner J. 2017;17(1):20-24

Authors: Mallidi HR, Bates M

Abstract
BACKGROUND: The incidence of permanent pacemaker implantation after orthotopic heart transplantation has been reported to be 2%-24%. Transplanted hearts usually exhibit sinus rhythm in the operating room following reperfusion, and most patients do not exhibit significant arrhythmias during the postoperative period. However, among the patients who do exhibit abnormalities, pacemakers may be implanted for early sinus node dysfunction but are rarely used after 6 months. Permanent pacing is often required for atrioventricular block. A different cohort of transplant patients presents later with bradycardia requiring pacemaker implantation, reported to occur in approximately 1.5% of patients. The objectives of this study were to investigate the indications for pacemaker implantation, compare the need for pacemakers following bicaval vs biatrial anastomosis, and examine the long-term outcomes of heart transplant patients who received pacemakers.
METHODS: For this retrospective, case-cohort, single-institution study, patients were identified from clinical research and administrative transplant databases. Information was supplemented with review of the medical records. Standard statistical techniques were used, with chi-square testing for categorical variables and the 2-tailed t test for continuous variables. Survival was compared with the use of log-rank methods.
RESULTS: Between January 1968 and February 2008, 1,450 heart transplants were performed at Stanford University. Eighty-four patients (5.8%) were identified as having had a pacemaker implanted. Of these patients, 65.5% (55) had the device implanted within 30 days of transplantation, and 34.5% (29) had late implantation. The mean survival of patients who had an early pacemaker implant was 6.4 years compared to 7.7 years for those with a late pacemaker implant (P<0.05). Sinus node dysfunction and heart block were the most common indications for pacemaker implantation. Starting in 1997, a bicaval technique was used for implantation. The incidence of pacemaker implantation by technique was 2.0% for bicaval and 9.1% for biatrial (P=0.001). Significantly more rejection episodes occurred in the pacemaker group (2.67 ± 2.18) compared with the no-pacemaker group (2.01 ± 2.05) (P<0.05).
CONCLUSION: Our results show a decreased pacemaker need after bicaval anastomosis and that more patients who needed a pacemaker after transplantation had a pretransplant diagnosis of ischemic cardiomyopathy. In our cohort, the need for a permanent pacemaker was also associated with older donor grafts and an increase in the number of treated rejection episodes.

PMID: 28331443 [PubMed - in process]

The influence of surgical technique on early posttransplant atrial fibrillation - comparison of biatrial, bicaval, and total orthotopic heart transplantation.

Ther Clin Risk Manag. 2017;13:287-297

Authors: Rivinius R, Helmschrott M, Ruhparwar A, Erbel C, Gleissner CA, Darche FF, Thomas D, Bruckner T, Katus HA, Doesch AO

Abstract
PURPOSE: Early posttransplant atrial fibrillation (AF) has been associated with worse clinical outcomes after heart transplantation (HTX). The type of surgical technique may constitute a relevant risk factor for AF.
PATIENTS AND METHODS: This retrospective single-center study included 530 adult patients. Patients were stratified by surgical technique (biatrial, bicaval, or total orthotopic HTX) and early posttransplant heart rhythm (AF or sinus rhythm). Univariate and multivariate analyses were performed to evaluate risk factors for AF.
RESULTS: A total of 161 patients received biatrial HTX (30.4%), 115 bicaval HTX (21.7%), and 254 total orthotopic HTX (47.9%). Sixty-one of 530 patients developed early posttransplant AF (11.5%). Patients with AF showed a statistically inferior 5-year survival compared to those with sinus rhythm (P<0.0001). Total orthotopic HTX had the lowest rate of AF (total orthotopic HTX [6.3%], bicaval HTX [14.8%], biatrial HTX [17.4%], P=0.0012). Multivariate analysis showed pretransplant valvular heart disease (P=0.0372), posttransplant enlarged left atrium (P=0.0066), posttransplant mitral regurgitation (P=0.0370), and non-total orthotopic HTX (P=0.0112) as risk factors for AF.
CONCLUSION: Early posttransplant AF was associated with increased mortality (P<0.0001). Total orthotopic HTX showed the lowest rate of AF compared to biatrial or bicaval HTX (P=0.0012).

PMID: 28331331 [PubMed - in process]

Significance and Value of Endomyocardial Biopsy Based on Our Own Experience.

Circ J. 2017 Mar 22;:

Authors: Ishibashi-Ueda H, Matsuyama TA, Ohta-Ogo K, Ikeda Y

Abstract
Endomyocardial biopsy (EMB) has been established in parallel with the development of percutaneous catheter technology for the diagnosis of cardiac diseases. It was developed in the early 1960 s in Japan by Drs. Konno, Sakakibara and Sekiguchi of Tokyo Women's Medical University. EMB is a valuable and useful, but invasive, modality for making a definite diagnosis in diseases such as myocarditis and secondary cardiomyopathies, which are often difficult to diagnose by imaging modality alone. In the field of heart transplantation, the histology of EMB helps monitor rejection to allografts. In cases of chronic heart failure, fibrosis and degeneration of cardiomyocytes are very important findings of heart remodeling. Recently, molecular biology technology has been applied to EMB specimens to get more detailed information. However, we must also recognize that EMB is an invasive examination that should not be performed without skillful cardiac catheterization experience to avoid complications. In this review as a message from pathologists, we present key cardiac histopathology using EMB, in a way that allows one to imagine whole cardiac pathological conditions. We also describe the current role of EMB and its significance in order to encourage young cardiologists to perform EMB to see another world of pathology.

PMID: 28331134 [PubMed - as supplied by publisher]

Reduction in Heart Failure Hospitalizations With Ambulatory Hemodynamic Monitoring Seen in Clinical Trials Is Maintained in the 'Real World'.

J Am Coll Cardiol. 2017 Mar 09;:

Authors: Desai AS, Bhimaraj A, Bharmi R, Jermyn R, Bhatt K, Shavelle D, Redfield MM, Hull R, Pelzel JA, Davis K, Dalal N, Adamson PB, Heywood JT

Abstract
BACKGROUND: In the CHAMPION trial, heart failure hospitalization (HFH) rates were lower in patients managed with guidance from an implantable pulmonary artery pressure (PAP) sensor compared to usual care.
OBJECTIVES: To examine the effectiveness of ambulatory hemodynamic monitoring in reducing HFH outside the clinical trial setting.
METHODS: We conducted a retrospective cohort study using US Medicare claims data from patients undergoing PAP sensor implantation between 6/1/2014 and 12/31/2015. Rates of HFH during predefined periods before and after implantation were compared using the Andersen-Gill extension to the Cox proportional hazards model while accounting for the competing risk of death, ventricular assist device (VAD), or cardiac transplantation. Comprehensive HF-related costs were compared over the same periods.
RESULTS: Among 1114 implanted patients, there were 1020 HFH in the 6 months before, compared with 381 HFH, 139 deaths, and 17 VAD/transplants in the 6 months after implantation (HR 0.55, 95%CI 0.49-0.61, p < 0.001). This lower rate of HFH was associated with a 6-month comprehensive HF cost reduction of $7,433 per patient (95%CI, $7,000-7,884) and was robust in analyses restricted to 6-month survivors. Similar reductions in HFH and costs were noted in the subset of 480 patients with complete data available for 12 months before and after implantation (HR 0.66, 95%CI 0.57-0.76, P<0.001).
CONCLUSIONS: As in clinical trials, use of ambulatory hemodynamic monitoring in clinical practice reduces HFH and comprehensive HF costs. These benefits are sustained to one year and support the 'real world' effectiveness of this approach to HF management.

PMID: 28330751 [PubMed - as supplied by publisher]

Layered Fibrotic Plaques Are the Predominant Component in Cardiac Allograft Vasculopathy: Systematic Findings and Risk Stratification by OCT.

JACC Cardiovasc Imaging. 2017 Mar 10;:

Authors: Clemmensen TS, Holm NR, Eiskjær H, Løgstrup BB, Christiansen EH, Dijkstra J, Barkholt TØ, Terkelsen CJ, Maeng M, Poulsen SH

Abstract
OBJECTIVES: The aims of this study were to characterize cardiac allograft vasculopathy (CAV) phenotypes using optical coherence tomography (OCT) and to evaluate the prognostic significance of OCT-determined CAV severity.
BACKGROUND: Intravascular OCT enables in vivo characterization of CAV microstructure after heart transplantation.
METHODS: Sixty-two patients undergoing heart transplantation were enrolled at routine angiography from September 2013 through October 2015 and prospectively followed until censoring on May 27, 2016. Optical coherence tomographic acquisitions aimed for the longest possible pull-backs, including proximal segments of all 3 major vessels. Plaques and bright spots were analyzed by delineating circumferential borders and measuring the angulation of total circumference. Layers were contoured for absolute and relative estimates. Nonfatal CAV progression (NFCP) during follow-up was registered. NFCP included occluded vessels or severe (≥70%) new angiographic coronary stenosis or percutaneous coronary intervention.
RESULTS: A total of 172 vessels were categorized as follows: no CAV, n = 111; mild to moderate CAV (<70% stenosis), n = 40; and severe CAV (≥70% stenosis), n = 21. Layered fibrotic plaque (LFP) was the most prevalent plaque component, and the extent increased with angiographic CAV severity (p < 0.01). During follow-up, 22 of 172 vessels (13%) experienced NFCP. Median follow-up was 633 days (interquartile range: 432 to 808 days). The extent of LFP (hazard ratio: 5.0; 95% confidence interval: 2.1 to 12.4; p < 0.0001) and the extent of bright spots (hazard ratio: 6.2; 95% confidence interval: 2.4 to 15.8, p < 0.001) were strong predictors of NFCP. By combining LFP and bright spots, a strong NFCP predictive model was obtained (hazard ratio: 8.9; 95% confidence interval: 2.6 to 29.9; p < 0.0001).
CONCLUSIONS: OCT enables the detection of CAV-associated plaque compositions and allows early detection and differentiation of vessel wall disease not visible on angiography. LFP was the most prevalent plaque component, was strongly associated with NFCP, and may be associated with stepwise CAV progression caused by organizing mural thrombi. (The GRAFT Study: Evaluation of Graft Function, Rejection and Cardiac Allograft Vasculopathy in First Heart Transplant Recipients; NCT02077764).

PMID: 28330670 [PubMed - as supplied by publisher]

Shedding Light on Cardiac Allograft Vasculopathy: OCT to Predict Progression of Disease.

JACC Cardiovasc Imaging. 2017 Mar 10;:

Authors: Baran DA

PMID: 28330652 [PubMed - as supplied by publisher]

Equivalency of Saphenous Vein and Arterial Composite Grafts: 5-Year Angiography and Midterm Clinical Follow-Up.

Ann Thorac Surg. 2016 Aug;102(2):580-8

Authors: Hwang HY, Lee KH, Han JW, Kim KB

Abstract
BACKGROUND: We compared 5-year graft patency rates and midterm clinical outcomes of saphenous vein (SV) composite grafts with those of total arterial (TA) composite grafts in patients who underwent off-pump coronary artery bypass graft surgery (OPCAB).
METHODS: Three hundred sixty-three patients who underwent OPCAB using composite grafts based on the left internal thoracic artery were studied. The SV was used as a second (connected to the left internal thoracic artery) or a third (connected to the second arterial graft) composite graft in 90 patients (SV group); TA composite grafting was performed in 273 patients (TA group). Follow-up was complete in 96.4% of patients (350 of 363), with a median follow-up of 82 months. Five-year graft patency rates and long-term clinical outcomes were compared. A propensity score-matched analysis was also performed to minimize differences in preoperative and intraoperative variables (n = 69 in each group).
RESULTS: There were no differences in operative mortality and postoperative complications between the SV group and TA group. Actuarial 5-year patency rates of the venous and arterial composite grafts were 89.3% and 89.5%, respectively (p = 0.958). Those were also similar between the two propensity score-matched SV and TA groups (90.5% and 89.3%, respectively; p = 0.759). Five-year overall survival and freedom from major adverse cardiac and cerebrovascular events were 88.5% and 85.6%, respectively. Those were similar between the two groups before and after propensity score matching.
CONCLUSIONS: The SV composite grafts were equivalent to arterial composite grafts in terms of 5-year graft patency rates and midterm clinical outcomes.

PMID: 27209611 [PubMed - indexed for MEDLINE]

Surgical Results and Outcomes After Reimplantation for the Management of Anomalous Aortic Origin of the Right Coronary Artery.

Ann Thorac Surg. 2016 Jul;102(1):192-8

Authors: Law T, Dunne B, Stamp N, Ho KM, Andrews D

Abstract
BACKGROUND: Anomalous aortic origin of the right coronary artery (AAORCA) has been reported to cause myocardial ischemia, leading to angina, dyspnea, and decreased exercise tolerance. Reimplantation is a repair technique devised to exclude the abnormal intramural portion of the anomalous artery and avoid the known late attrition of saphenous vein grafts. Our study aims to evaluate the medium-term clinical outcomes with this technique.
METHODS: A retrospective review was made of patients who underwent repair of AAORCA by reimplantation between 2002 and 2014 in two institutions in Western Australia. Follow-up computed tomography coronary angiography was used to assess the status of the reimplanted right coronary artery (RCA). Data on survival, freedom from symptoms, cardiac events, and cardiac interventions were also analyzed.
RESULTS: Of the 16 patients (aged 17 to 70 years old), 14 (88%) were symptomatic before surgery, with angina (50%) and exertional dyspnea (56%) being the most common symptoms. Surgical reimplantation was successful in 15 patients (94%) without operative mortality. One patient required saphenous vein bypass grafting of the RCA intraoperatively after presumed failed repair and difficulty weaning from cardiopulmonary bypass. All patients who had successful reimplantation of AAORCA were symptom-free after surgery, and none had subsequent cardiac events attributable to the RCA or required further interventions. Ten patients (67%) had computed tomography coronary angiography after surgery; none had stenosis, kinking, or compression of the RCA by the pulmonary artery. Two further patients (including the patient who underwent saphenous vein grafting for presumed failed reimplantation) underwent conventional angiography, which demonstrated patent reimplantations.
CONCLUSIONS: To the best of our knowledge, this is the largest reported series of anomalous RCA managed by surgical reimplantation. Our results suggest that this technique is safe and has excellent medium to long-term results regarding symptom-free survival.

PMID: 27112655 [PubMed - indexed for MEDLINE]

Limitations to Chronic Right Ventricular Assist Device Support.

Ann Thorac Surg. 2016 Aug;102(2):651-8

Authors: Karimov JH, Sunagawa G, Horvath D, Fukamachi K, Starling RC, Moazami N

Abstract
Failure of the right ventricle represents a significant clinical problem and may have different causes, with rates varying between 5% and 50% in patients supported by a left ventricular assist device (LVAD). However, treatment options and device development for right ventricular failure (RVF) have significantly lagged behind those for LVADs. Newer technologies designed or adapted for RV support are needed to provide adequate long-term circulatory support. In this review, we discuss (1) the significance of RVF and its physiologic implications, (2) device constraints affecting treatment options for RVF, and (3) implantable VADs potentially available for RV support.

PMID: 27106620 [PubMed - indexed for MEDLINE]

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