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Marzia Leacche

Publications and source records attributed to Marzia Leacche.

At least 19 recordsLinked to original sources
PubMed2006

Does off-pump coronary revascularization reduce the release of the cerebral markers, S-100beta and NSE?

OBJECTIVES: The aims of this study were to (1) compare the release of S-100 beta and NSE in off-pump coronary artery bypass grafting (CABG) versus on-pump surgery; (2) investigate whether the S-100 beta and NSE serum concentrations correlate with cardiopulmonary bypass (CPB) duration. MATERIALS AND METHODS: Between October 2002 and May 2004, 42 patients undergoing first time CABG surgery were enrolled in the study. The exclusion criteria were: LVEF<35%, age>70 years, previous myocardial infarction, REDO surgery, the presence of valvular heart disease and/or cerebrovascular disease, abnormal preoperative carotid vessels angiography, coronary artery disease involving the distal circumflex artery, renal dysfunction, coagulopathy. The patients were randomly assigned either to undergo on-pump CABG surgery [group I, n=24 patients] or off-pump CABG [group II, n=18 patients]. Blood was not re-transfused from the cardiotomy suction. All patients presenting haemolysis were excluded from the study. RESULTS: The preoperative S-100beta was 0.13+/-0.08 (microg/l) and NSE 7+/-1.5 (microg/l) in group I and 0.12+/-0.1 (microg/l) and 6.9+/-2.7 (microg/l), respectively in group II. Six hours after the surgery, S-100beta in patients of group I reached a maximum level of 1.38+/-0.4 (microg/l) and NSE of 17.7+/-6.5 (microg/l) compared to 0.5+/-0.11 (microg/l) [S-100B] and NSE 8.6+/-4.2 (microg/l) in group II (p=0.001). Three (12%) patients in group I and none (0%) in group II suffered postoperative delirium, p=0.247. No strokes occurred linear regression analysis revealed a strong correlation between cardiopulmonary bypass duration and S-100beta and NSE peak levels, p<0.0021 (r(2)=0.36) and p<0.0001 (r=0.81), respectively. CONCLUSION: Coronary artery bypass surgery with CPB causes a significantly greater increase in NSE and S-100beta serum levels than off-pump surgery and correlates with CPB duration.

Aged↗
PubMed2006

Mitral valve surgery simultaneous to coronary revascularization in patients with end-stage ischemic cardiomyopathy.

Mitral valve regurgitation (MVR), occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction, predicts a poor outcome in terms of survival and morbidity. Between 1995 and 2003, 180 consecutive patients with impaired LV function and chronic ischemic MVR underwent cardiac surgery. Fifty-four patients (group I), MVR (grade III-IV) underwent simultaneous MV surgery and coronary artery bypass grafting (CABG); 40 patients (group II), MVR (grade II-III), and 86 patients (group III), MVR (grade I-II), underwent CABG alone. In group I, MV repair was performed in 36 patients (group IA) and MV replacement in 18 (group IB). The incidence of hospital death was similar between groups. The actuarial event-free survival was significantly lower in group than in groups II and III (P = 0.0045) and I (P = 0.038). The overall actuarial survival was significantly higher in group IA than in group IB (P = 0.027). Postoperatively, the LV ejection fraction (P < 0.001), LV end-diastolic diameter (P < 0.001), LV end-systolic diameter (P < 0.01), and cardiac index (P < 0.001) improved significantly in group I. The regurgitation fraction decreased significantly in Groups I and III after surgery (P < 0.001 and P = 0.003, respectively). Both MV repair and replacement that preserves subvalvular apparatus in patients with end-stage ischemic myocardiopathy offer an acceptable outcome. Mitral valve repair simultaneous to CABG improves significantly the LV function and its geometry. In patients with mild to moderate mitral regurgitation, CABG alone may be performed with good overall survival, but with lower event-free survival than those undergoing concomitant mitral valve repair.

Aged↗
PubMed2006

Perioperative and clinical-angiographic late outcome of total arterial myocardial revascularization according to different composite original graft techniques.

Total arterial myocardial revascularization (TAMR) is advisable because of the excellent long-term patency of arterial conduits. We present early and midterm outcomes of five different surgical configurations for TAMR. Between January 1998 and May 2004, 112 patients (aged 56.5 +/- 4.5 years, 20% female) with three-vessel disease underwent TAMR. The internal mammary arteries (IMAs) were harvested in a sketelonized fashion. The surgical techniques for TAMR consisted in Y or T composite grafts (n = 88, 78%) constructed between the in situ right IMA (RIMA) and the free left IMA (LIMA) graft (n = 58) or the radial artery (n = 30) (RA) in three different configurations. The other techniques consisted in T- and inverted T-graft (n = 24, 22%) constructed between the RA conduit and the free LIMA graft in two different configurations. The mean follow-up time was 40 +/- 23 months. Postoperative angiographic control was performed in 76/111 (70%) patients. Overall, 472 arterial anastomoses (average 4.2 per patient) were performed. One (0.9%) patient, undergoing the inverted T-graft technique, died on postoperative day 2. Another patient (0.9%), undergoing the lambda-graft technique using both IMAs and RA, suffered a new myocardial infarction probably due to RA conduit vasospasm. One week after surgery, after the transthoracic echocardiographic Doppler with adenosine provocative test, the coronary flow reserve (CFR) at the LIMA and RIMA main stems were 2 +/- 0.4 and 2.4 +/- 0.3, respectively. At 12-month follow-up, after adenosine provocative test, the CFRs at the LIMA and RIMA stems were significantly higher than the values at 1 week after surgery within the same group; (LIMA)CFR (1 week) 2.4 +/- 0.3 (12 months) vs 2 +/- 04 (1 week), P = 0.002; (RIMA)CFR 2.58 +/- 0.4 vs 2.4 +/- 0.3, P = 0.001. The CFR at the RIMA main stem was higher in all measurements within the same group than in the LIMA main stem, but not significantly. In one patient undergoing the lambda-graft technique using both IMAs, the RIMA was found to have a string sign. Postoperative angiography in 50 patients showed that the patency rate for the LIMA was 100%, for the RIMA 97.3%, and for the RA 96.7%. Angiography at 3-year follow-up in 76 patients documented excellent patency rates of the LIMA (97.4%), RIMA (95%), and RA (87%). Survival at 7 years was 92.5%, event-free survival 89.3%, and freedom from angina 94%. Total arterial myocardial revascularization using different surgical configurations is safe and effective. The use of composite arterial grafts provides excellent clinical and angiographic results, with a low rate of angina recurrence and late cardiac events. These configurations allow for complete arterial revascularization.

Adult↗
PubMed2006

Predicting survival in patients requiring renal replacement therapy after cardiac surgery.

BACKGROUND: We sought to develop and internally validate a prediction score for all-cause in-hospital mortality in patients who have acute renal failure and require renal replacement therapy after cardiac surgery. METHODS: From January 1992 to July 2001, 136 of 14,000 patients (0.9%) had acute renal failure requiring renal replacement therapy after cardiac surgery. Multivariate logistic regression analysis, based on pre-renal replacement therapy variables, was used to construct a predictive score for all causes of in-hospital mortality. Subsequently, the score was validated in 27 patients who underwent surgery between August 2001 and March 2003. RESULTS: In-hospital mortality was 58% (79 of 136). From the logistic regression model, we assigned a score (range, 0 to 6) based on the presence of independent predictors of operative mortality (preoperative creatinine < or = 1.5 mg/dL [odds ratio (OR) = 5.0], hypertension [OR = 4.4], predialysis coma [OR = 9.6], sepsis [OR = 6.4], and total bilirubin > or = 2 mg/dL [OR = 5.6]). Higher scores strongly predicted mortality: patients who scored 3 or higher before the initiation dialysis (n = 54), had a mortality rate of 94% (51 of 54). In contrast, patients who scored 1 or less on this scale (n = 36), had a mortality of 16% (6 of 36). In the validation cohort, the sensitivity of the new score at the cutoff of 2 or fewer points versus 3 or more points was 0.71, the specificity was 0.90, the positive predictive value was 0.92, and the negative predictive value was 0.64. CONCLUSIONS: The prediction score represents a simple and accurate tool for predicting in-hospital mortality associated with renal replacement therapy for cardiac surgery patients before the institution of this resource-intensive treatment.

Acute Kidney Injury↗
PubMed2005

Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease.

OBJECTIVES: The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. BACKGROUND: With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. METHODS: We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality. RESULTS: There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. CONCLUSIONS: Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Aged↗
PubMed2005

Postinfarction ventricular septal defect with pseudoaneurysm repair after failed percutaneous closure.

Ventricular septal defect with intramyocardial dissection of the ventricular free wall is a rare complication of myocardial infarction associated with poor prognosis. We describe a patient who developed a ventricular septal defect with intramyocardial dissection of the right ventricular free wall. Initially the patient was successfully stabilized by the placement of a percutaneous closure device. The placement of the device allowed initial hemodynamic recovery of the patient and subsequent definitive surgical repair. This case illustrates the importance of collaboration between interventional cardiologists and cardiac surgeons in the treatment of complex postinfarction ventricular septal defects.

Aneurysm, False↗
PubMed2005

Impact of concomitant coronary artery bypass grafting on hospital survival after aortic root replacement.

BACKGROUND: We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk. METHODS: Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%). RESULTS: Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p < 0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor. CONCLUSIONS: Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Adult↗
PubMed2005

Skeletonized bilateral internal mammary arteries for non-elective surgical revascularization in unstable angina.

OBJECTIVE: The aim of this study was to evaluate the feasibility, safety and outcome of skeletonized bilateral internal mammary arteries (BIMA) in patients with unstable angina (UA) undergoing non-elective myocardial revascularization. METHODS: Between January 1997 and December 2003, 758 patients, mean age 62+/-12 years, underwent non-elective coronary artery bypass grafting (CABG) for unstable angina. Two hundred and five (27%) were operated emergently and 503 (73%) urgently. BIMA were employed in 320 (42%) patients (Group B) and isolated left IMA and/or saphenous vein grafts in the remaining 438 (58%) patients (Group M). RESULTS: In-hospital mortality (B = 5.9% and M = 5.3%), and perioperative myocardial infarction (B = 2.2%; M = 1.96%) were similar between the two groups (P = ns). Actuarial survival at 1, 3 and 7 years was 98.7, 97.5 and 96.2% in B and 99, 94.3 and 88.4% in M (P < 0.05 at 7 years follow-up). At 7 years follow-up, the event-free cardiac survival (92 vs. 87%, P = 0.021), angina-free survival (98.6 vs. 94%, P = 0.039), reoperation-free cardiac survival (98 vs. 95%, P = 0.04) and infarct-free cardiac survival (98.7 vs. 96%, P = 0.05) were better in Group B. Multivariate analysis identified age > 65 years (P = 0.02), LVEF < 35% (P = 0.01), > 1 ischemic irreversible area (P = 0.03) as independent predictors for late deaths, while the use of the LIMA (P=0.006) and both mammary arteries (P=0.001) decreased the risk of late deaths. CONCLUSIONS: The use of BIMA in non-elective CABG for UA is safe and effective. Mid-term outcome, however, are superior with improved freedom from cardiac death, from coronary reintervention and from myocardial infarction.

Aged↗
PubMed2005

Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach.

OBJECTIVES: This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate. METHODS: Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest. RESULTS: There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively. CONCLUSION: An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

Actuarial Analysis↗
PubMed2005

Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: a two-center study.

OBJECTIVE: Left ventricular assist device (LVAD) insertion after anterior wall myocardial infarction complicated by cardiogenic shock is an accepted modality of support in select patients. Results of primary revascularization for these patients are poor. We seek to determine the outcomes of patients with myocardial infarction and shock who undergo LVAD insertion alone versus surgical revascularization before LVAD insertion. METHODS: Seventy-four patients at 2 institutions underwent LVAD implantation for myocardial infarction and shock over a 12-year period. Twenty-eight underwent direct LVAD placement, and 46 underwent revascularization through coronary artery bypass grafting before LVAD placement. Variables examined included patient demographics, myocardial infarction-LVAD interval, bridge to transplantation, early mortality (< or = 30 days), survival after LVAD placement, and posttransplantation survivals. RESULTS: There were no differences in demographics between the 2 groups. The group undergoing revascularization before LVAD placement had a lower bridge to transplantation, higher early mortality, and lower overall 6- and 12-month survivals after LVAD placement compared with the group undergoing direct LVAD placement (45.50% vs 70.40%, P = .041; 39.10% vs 14.30%, P = .020; 89.3% and 82.1% vs 54.4% and 52.2%, respectively, P = .006). Posttransplantation survival and LVAD explantation rates were equivalent in both groups. CONCLUSIONS: Coronary artery bypass grafting before LVAD insertion for cardiogenic shock complicating myocardial infarction adversely affects survival. Confirmation of these findings would require conducting a large, multicenter, randomized clinical trial comparing revascularization versus LVAD support as primary therapy in this setting.

Coronary Artery Bypass↗
PubMed2005

Valve replacement in women of childbearing age: influences on mother, fetus and neonate.

BACKGROUND AND AIM OF THE STUDY: Currently, there is no clear consensus on the optimal type of cardiac valve prosthesis that should be placed in women of childbearing age. The risks of reoperative surgery for bioprosthetic valves must be weighed against those of anticoagulation therapy required for mechanical valves. Bioprosthetic valves placed in women of childbearing age are not necessarily superior to mechanical valves in terms of maternal or fetal outcomes. METHODS: A retrospective analysis was performed of early and late outcome in 103 women of childbearing age (mean age 28.3 +/- 5.1 years; range: 18-35 years) who underwent mechanical (n = 63) or biological (n = 40) valve replacement between January 1982 and July 2002. RESULTS: Eleven of the 40 women (28%) with biological valves had 19 pregnancies (13 vaginal births; three caesarean sections). Twelve of the 63 women (19%) with mechanical valves had 37 pregnancies (nine vaginal births, four caesarean sections). All of the women with mechanical valves became pregnant while receiving warfarin, and were subsequently placed on heparin or enoxaparin. No bleeding complications or birth defects were observed in either group. The incidence of miscarriages (32% (12/37) versus 11% (2/19), p = 0.09) and therapeutic abortions (32.4% (12/37) versus 5.3% (1/19), p = 0.06) were greater in the group with mechanical valves than with bioprosthetic valves. Freedom from reoperation at five and 10 years for biological versus mechanical valves was 79% versus 90%, and 38% versus 82%, respectively (p < 0.01), with no reoperative mortality. CONCLUSION: Biological valves are recommended in women of childbearing age, despite the fact that no birth defects were seen in children born to women with mechanical valves on warfarin, because the teratogenic effects of warfarin may be masked by the high rate of miscarriages and therapeutic abortions in this group.

Adolescent↗
PubMed2004

Outcomes in patients with normal serum creatinine and with artificial renal support for acute renal failure developing after coronary artery bypass grafting.

This retrospective study of cardiac surgical patients with normal serum creatinine who developed acute renal failure requiring artificial renal support was undertaken to (1) determine the prevalence of acute renal failure and hospital mortality in this subgroup, (2) identify the independent predictors of early mortality, and (3) determine long-term survival and prognosis.

Acute Kidney Injury↗
PubMed2004

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg.

BACKGROUND: The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. METHODS: Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 +/- 2.9 years (range 2 months-10.7 years). RESULTS: The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II (p = 0.95). Major associated cardiac malformations (p < 0.001) and pulmonary hypertension (p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 +/- 1.2 versus 1.2 +/- 1 in group II (p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 (p < 0.001), postoperative LAVVR greater than or equal to 2 (p = 0.006), major associated cardiac malformations (p = 0.00034), associated LAVV malformations (p = 0.0044), and non or partial LAVV cleft closure (p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar (p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg (p = 0.022) according to the log-rank test. Weight less than 5 kg (p = 0.023, beta = -0.6) was one of the predictors for reoperation due to severe LAVVR in this series. CONCLUSIONS: We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.

Cardiac Surgical Procedures↗
PubMed2004

Surgical management of complications of percutaneous coronary rotational atherectomy interventions.

Percutaneous coronary interventions have progressed from angioplasty and intracoronary stents to the more aggressive rotational atherectomy devices. These technically complex procedures are typically performed on the more diseased anatomy, which causes the likelihood of complications to be more common. In this report, we present our experience with three unusual complications and their surgical management.

Aged↗
PubMed2004

Left anterior descending coronary endarterectomy: early and late results in 196 consecutive patients.

BACKGROUND: With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized. METHODS: Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations. RESULTS: All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years. CONCLUSIONS: Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.

Adult↗
PubMed2004

Severity of intraoperative tricuspid regurgitation predicts poor late survival following cardiac transplantation.

BACKGROUND: This study evaluates the significance of tricuspid regurgitation (TR) on long-term survival as detected by intraoperative transesophageal echocardiography at the time of orthotopic heart transplantation. Although significant (2+ to 4+) TR after orthotopic heart transplantation is rare, its influence on long-term survival is unknown, warranting further investigation. METHODS: Between January 1992 and July 2001, 181 consecutive patients underwent orthotopic heart transplantation. Tricuspid regurgitation was graded by intraoperative transesophageal echocardiography after final separation from cardiopulmonary bypass in 130 of 181 patients (72%). RESULTS: Although 80% (104/130) of patients had either no (0, n = 77) or trace (1+, n = 27) TR, 9% (12/130 patients) had mild (2+), 10% (13/130 patients) had moderate (3+), and 0.8% (1/130 patients) had severe (4+) TR. The severity correlated strongly with the presence of right ventricular dysfunction (p < 0.001). In a multivariate regression model, gender mismatch (p = 0.002) and right ventricular dysfunction (p < 0.001) were independent predictors for equal to or greater than mild (2+ to 4+) TR (p = 0.015). Although the degree of recipient pulmonary vascular resistance did not influence the grade (p = 0.600), higher pulmonary vascular resistance tended to increase the severity of TR in the setting of prolonged donor ischemic times (p = 0.054). Proportional hazards regression analysis demonstrated significantly decreased survival for patients with mild or greater (2+ to 4+) TR detected by transesophageal echocardiography at the time of transplantation (p < 0.001) and RV dysfunction (p = 0.023). CONCLUSIONS: Even mild (> or = 2+) TR identified by transesophageal echocardiography at the time of orthotopic heart transplant predicts poor late survival, suggesting a possible role for concomitant tricuspid valve repair at the time of transplant. Whether or not tricuspid valve repair will improve long-term survival is unknown.

Acute Kidney Injury↗
PubMed2004

Risk factors and outcomes for 'vasoplegia syndrome' following cardiac transplantation.

OBJECTIVE: Vasoplegia syndrome after orthotopic heart transplantation (OHT) is a rare but highly lethal syndrome of unknown etiology, characterized by severe refractory hypotension, metabolic acidosis, and decreased systemic vascular resistance (SVR). The objective of this retrospective study was to identify the risk factors contributing to the development of vasoplegia syndrome after OHT in order to provide potential algorithms for its management. METHODS: Between October 1992 and July 2001, 187 consecutive patients underwent OHT. Complete pre- and post-data were available in 147 patients (78%). Mean age was 49+/-11 years, 82% (120/147) were male, and donor ischemic time was 117+/-62 min. Twenty-eight of 147 (19%) developed vasoplegia syndrome, defined as SVR <800 dyns per cm(5) with serum bicarbonate <20 mEq/l. RESULTS: Patients who developed vasoplegia syndrome demonstrated greater hospital mortality (25 vs. 9%, P=0.031) compared to those who did not. Multivariate logistic regression identified pre-operative use of intravenous heparin (OR 2.8, CI 1-7.4, P=0.039) and body surface area >1.9 m(2) (OR 7, CI 0.98-50, P=0.052) as independent predictors for the development of post-operative vasoplegia syndrome. Pre-operative use of inotropic support conferred protection against the development of post-operative vasoplegia syndrome (OR 0.25, CI 0.08-0.79, P=0.018). Pre-operative use of ACE inhibitors was not associated with increased risk (55 vs. 59%, P=0.441). CONCLUSIONS: Vasoplegia syndrome following OHT is associated with high early mortality. The development of a risk stratification profile may help in patient selection as well as the post-operative management of vasoplegia syndrome following OHT.

Acidosis↗