Digoxin's effect on mortality and hospitalization in heart failure: implications of the DIG study. Digitalis Investigation Group.
Explore the source record for details and available documents.
Canada↗
Biomedical subjects
R E Hobbs
Publications and source records attributed to R E Hobbs.
Does distance between home and transplantation center adversely affect patient outcomes after heart transplantation?
BACKGROUND: The emergence of heart transplantation referral centers, in an era of cost-conscious managed care programs, frequently leads to long-distance patient consultation and care. The purpose of this project was to review one center's experience regarding the effect of long distances from home to transplantation hospital on outcomes. METHODS: Three hundred twelve adult, noninternational, transplant recipients surviving at least 3 months were assessed for 10 events: rejection episodes, number of endomyocardial biopsies, emergency department visits, hospital admissions, return to full-time work or school, infections, coronary allograft vasculopathy, malignancies, retransplantation, and death. Presence of a locally involved physician was also determined. Distance from the transplantation center was analyzed in three discrete groups: 0 to 150 miles (n = 207), 151 to 300 miles (n = 69), and >300 miles (n = 36). RESULTS: There were no differences among the groups in mean length of follow-up (40.6, 36.9, 39.0 months, p = 0.27) or number of biopsies (20.5 +/- 0.16, 18.3 +/- 1.1, 18.0 +/- 1.1, p = 0.07). As the distance increased from the transplantation center, there was no greater incidence of adverse outcomes. Cellular rejection was the same among the groups (45%, 45%, 36%, p = 0.58). Likewise, emergency department visits and hospital admissions also did not vary: (9.7%, 5.8%, 8.3%, p = 0.61) and (22.2%, 13.0%, 16.7%, p = 0.23, respectively). There were no differences in the incidence of coronary vasculopathy (9.2%, 11.6%, 13.9%, p = 0.63). More importantly, the three groups did not differ in death/retransplantation rates (3-year survival, 84.5, 94.0 and 86.9, p = 0.14). Patients cared for by a local physician in addition to their transplant cardiologist had better survival rates than patients without a local physician (3-year survival rate, 90.7 vs 72.6, p = 0.0008). CONCLUSIONS: Long-distance management of heart transplant recipients is successful and is not associated with an increase in adverse outcomes. By itself, distance should not represent a contraindication to transplantation. Patients should be encouraged to maintain contact with a local physician, in addition to the regularly scheduled visits at the transplantation center.
Adolescent↗
The incremental risk of female sex in heart transplantation: a multiinstitutional study of peripartum cardiomyopathy and pregnancy. Cardiac Transplant Research Database Group.
BACKGROUND: Controversy remains regarding the reason females seem to be at increased risk for rejection after heart transplantation. Therefore this study was performed to define the effect of a pretransplantation diagnosis of peripartum cardiomyopathy and the effect of previous pregnancy on the outcome (incidence of rejection and death) of females after heart transplantation. METHODS: In this multiinstitutional study of 3244 adult (greater than 13 years of age) heart transplant recipients, (a) the outcome of 40 females who underwent transplantation for peripartum cardiomyopathy was compared with that of 200 females of childbearing age (13 to 45 years) who underwent transplantation for other indications and (b) the posttransplantation outcome of 543 females with a history of pregnancy was compared with that of 101 nulliparous adult females and 2562 adult males. RESULTS: The posttransplantation outcome of females with a history of peripartum cardiomyopathy was similar to that of females of childbearing age who underwent transplantation for other indications. However, parous females had a significantly shorter time to first rejection (p < 0.0001) and greater cumulative rejection than nulliparous females or males. By multivariable analysis, the risk factors for cumulative rejection at 1 year were a history of pregnancy (p < 0.0001), younger recipient age (p < 0.0001), induction therapy (p < 0.0001), and the number of human leukocyte antigen-DR mismatches (p = 0.007). CONCLUSION: Our data suggest that it is previous pregnancy, and not sex per se, that is associated with an increased frequency of rejection in females after heart transplantation.
Actuarial Analysis↗
Hemodynamic effects of a single intravenous injection of synthetic human brain natriuretic peptide in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.
Synthetic human brain natriuretic peptide (sBNP) is a polypeptide with the same amino acid sequence as the naturally occurring hormone. Preclinical studies have demonstrated that BNP has potent hemodynamic, diuretic, and natriuretic effects that might be beneficial in treating patients with heart failure. This study was a randomized, double-blind, placebo-controlled, ascending-dose trial of sBNP administered as a single intravenous bolus in 27 heart failure patients. Six groups of patients received sequentially increasing doses of sBNP (0.3, 1, 3, 10, 15, and 20 micrograms/kg, respectively) as a single intravenous injection, and hemodynamics were assessed by pulmonary artery monitoring catheter. The 10 and 15 micrograms/kg doses of sBNP resulted in significant reductions in pulmonary capillary wedge pressure (-73%, p < 0.001), mean pulmonary artery pressure (-41%, p < 0.001), mean arterial blood pressure (-28%, p = 0.001), and systemic vascular resistance (-53%, p = 0.004). Significant increases occurred in cardiac index (68%, p < 0.001) and stroke volume index (72%, p < 0.001). The magnitude and duration of hemodynamic changes were dose dependent. There were no adverse effects. sBNP injected as a single intravenous bolus in heart failure patients improves hemodynamics in a dose-related fashion. Further clinical investigations to determine the use of sBNP in decompensated heart failure are clearly warranted.
Cardiomyopathy, Dilated↗
Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging.
OBJECTIVE: The aim of this study was to evaluate the extent and distribution of coronary atherosclerosis after transplantation. BACKGROUND: Transplant coronary artery disease is an important cause of death after cardiac transplantation. Unlike coronary angiography, intravascular ultrasound is a sensitive tool for detection and quantitation of this disease. METHODS: We performed intravascular ultrasound imaging in 132 (106 men, 50 +/- 10 years) patients, 1 to 9 years after transplantation using a 30-MHz ultrasound catheter. RESULTS: All three coronary arteries were visualized in 49, two in 62 and one in 21 patients. Of the 1,188 coronary artery segments, 706 were imaged (74% proximal, 64% mid- and 40% distal). At least one site with atherosclerosis (intimal thickness > or = to 0.5 mm) was found in 83% of patients. Atherosclerosis was noted in 64% of proximal, 43% of mid- and 26% of distal segments. Disease was diffuse in 48% and focal in 52%, circumferential in 66% and noncircumferential in 34%. Focal atherosclerosis was more common in proximal (59%) than mid- (48%) and distal segments (27%) (p=0.001). Noncircumferential plaques were more common in the proximal (42%) than mid- (28%) and distal segments (12%) (p=0.001). This pattern of focal and noncircumferential disease proximally, diffuse and circumferential disease distally, was observed irrespective of the time from transplantation. CONCLUSION: Atherosclerosis was detected in more than 80% of patients, with proximal segments most frequently involved. Diffuse and circumferential atherosclerosis was more common in mid- and distal segments. However, focal and noncircumferential involvement was more frequent proximally, a similar pattern to native atherosclerosis. These findings suggest that transplant coronary artery disease has a dual etiology based on the dichotomous pattern of atherosclerosis seen by intravascular ultrasound.
Chi-Square Distribution↗
Implantable LVAD infections: implications for permanent use of the device.
BACKGROUND: Infection in implantable left ventricular assist device (LVAD) patients is common and has serious implications regarding permanent use of the LVAD. METHODS: Thirty-three patients had HeartMate LVAD insertion as a bridge to heart transplantation. The mean length of hospital stay was 8 days before LVAD insertion. Before insertion 6 patients (18%) had positive pulmonary cultures and 5 patients (15%) had bacteremia. RESULTS: During LVAD support 18 patients (55%) had bloodstream infection. Of 24 patients (73%) successfully bridged to transplantation, 12 (50%) had positive blood cultures including Staphylococcus species (n = 9), Candida (n = 3), Pseudomonas (n = 2), and Enterococcus (n = 2). Infectious complications encountered in this series included driveline infection requiring surgical revision, septic embolus, "cleared" device infection, "suppressed" device infection, and LVAD infection treated by device removal in 1 patient and device exchange in another. CONCLUSIONS: Infection in implantable LVAD patients is common, especially in patients in whom multiple organ failure develops, requiring prolonged stay in the intensive care unit. Strategies are needed to prevent these infections in recipients of the permanent LVADs because treatment of an established infection is difficult and expensive.
Adult↗
Bench repair of donor mitral valve before heart transplantation.
Bench repair of the donor mitral valve was performed before orthotopic heart transplantation in a 57-year-old status I recepient. Mitral regurgitation in the structurally normal mitral valve was due to annular dilatation at the attachment of the posterior leaflet and was corrected with posterior annuloplasty. The patient is clinically well 18 months after transplantation.
Heart Transplantation↗
Risk factors for early, cumulative, and fatal infections after heart transplantation: a multiinstitutional study.
BACKGROUND AND METHODS: By multivariable analysis, risk factors were identified for initial infection of any type, cumulative infections during the first 6 months and fatal infection among 2210 heart transplant recipients at 30 institutions. RESULTS AND CONCLUSIONS: Of the 1218 infections in 695 patients, bacterial infections were most frequent (47%), followed by viral (42%), fungal (8%), and protozoal (4%). Risk factors for earlier infection included older recipient age (p < 0.0001), ventilator support at time of transplant (p < 0.0001), ventricular assist device at time of transplant (p = 0.02), OKT3 induction therapy (p < 0.0001), donor black race (p = 0.0007), and positive donor cytomegalovirus serology (for cytomegalovirus infection) (p = 0.0007). Cumulative infections during the first 6 months were increased by older recipient age (p < 0.0001), ventilator support at transplant (p = 0.0004), ventricular assist at transplant (p = 0.009), Black donor (p = 0.03), female donor (p = 0.03), and OKT3 induction therapy (p = 0.005). The actuarial freedom from fatal infection was 96% at 1 year and 95% at 3 years. Risk factors for death from infection included very old (p = 0.002) and very young recipients (p = 0.004), ventilator support at time of transplant (p = 0.004), older donor (p < 0.0001), and longer donor ischemic time (p = 0.02). The risk of death from infection within the first 3 months exceeded 20% among older recipients (> 55 years) on ventilator support at time of transplantation who received an older (> 50 years) donor heart.
Actuarial Analysis↗
Effect of the implantable left ventricular assist device on neuroendocrine activation in heart failure.
BACKGROUND: The HeartMate left ventricular assist device has been successfully used as a bridge to cardiac transplantation. Because many patients exhibit marked clinical improvement in their heart failure after HeartMate implantation, we studied the physiological effect of this device on the neurohormonal axis. METHODS AND RESULTS: In 13 patients awaiting transplant (mean cardiac index, 1.7 +/- 0.3 L.min-1.m-2) who underwent HeartMate implantation, venous atrial natriuretic peptide, epinephrine, norepinephrine, plasma renin activity, angiotensin, and arginine vasopressin were measured immediately before insertion and at explant/transplantation. Mean time to explant was 86 +/- 40 days. All patients were taken off inotropic medications within 1 month. Mean cardiac index on support before explant was 3.1 +/- 0.9 L.min-1.m-2. Plasma renin activity decreased from 57 +/- 56 ng.mL-1.h-1 at baseline (before insertion) to 3 +/- 3 ng.mL-1.h-1 at explant (mean percent change, 92%; P < .001). Angiotensin II level decreased from 237 +/- 398 U/L at baseline to 14 +/- 14 U/L at explant (mean percent change, 73%; P < .001). Plasma epinephrine level fell from 6800 +/- 1323 pg/mL at baseline to 46 +/- 46 pg/mL at explant (mean percent change, 86%; P < .001). Norepinephrine level decreased from 2953 +/- 1457 pg/mL at baseline to 518 +/- 290 pg/mL at explant (mean percent change, 79%; P < .001). Atrial natriuretic peptide fell from baseline values of 227 +/- 196 to 168 +/- 40 pg/mL at explant (mean percent change, -49%; P = 519); and arginine vasopressin level decreased from 6 +/- 6 pg/mL at baseline to 0.8 +/- 0.5 pg/mL (mean percent change, 69%; P = .002). CONCLUSIONS: We provide data supporting that the neurohormonal axis markedly improves after HeartMate implantation, providing biochemical confirmation of the improvement in hemodynamic status.
Adult↗
The prevalence of coronary artery disease in liver transplant candidates over age 50.
The prevalence of angiographically proven coronary artery disease (CAD) in adults with end-stage liver disease who undergo evaluation for liver transplantation is unknown; also it is unclear if cholestatic liver disease represents an independent risk factor. Patients with end-stage liver disease over age 50 having liver transplantation were studied using coronary angiography. Arterial stenosis was graded as normal, mild (< 30%), moderate (30 to 70%), or severe (> 70%). Risk factors for CAD were also assessed (male sex, smoking, hypertension, diabetes, family history of premature heart disease). Complications related to the angiography and decision making based on the findings were recorded. Thirty seven patients (23 females) with a median age of 61 years (range 50 to 71) underwent angiography. Thirteen patients (35.1%) had cholestatic liver disease. Thirty patients had no history of heart disease. The overall prevalence of severe coronary artery disease was 16.2% (95% confidence interval [CI] = 6.2% to 32.0%). No association was detected between CAD and cholestatic liver disease (P = 0.72). After eliminating seven patients with a prior history of angina (n = 1), myocardial infarction (n = 1), or coronary revascularization (n = 5), the frequency of moderate or severe CAD was 13.3% (95% CI = 3.8% to 30.7%). No association was detected between unsuspected CAD and cholestatic liver disease (P = 0.61). Diabetes was the most important risk factor for moderate or severe disease (P = 0.01). Patients without risk factors had significantly less CAD than the group as a whole regardless of the liver disease type (P = 0.02). Two patients experienced transient renal insufficiency after the angiography. Three patients with severe CAD were denied transplantation. We conclude that CAD represents a significant problem in patients over age 50 undergoing liver transplant evaluation. Cholestatic liver disease was not associated with a significantly higher prevalence of moderate or severe CAD in our population. Diabetes was the most predictive risk factor, and those without risk factors do not require extensive preoperative cardiac evaluation.
Age Factors↗
Occult and frequent transmission of atherosclerotic coronary disease with cardiac transplantation. Insights from intravascular ultrasound.
BACKGROUND: Transplant coronary artery disease is a major cause of morbidity and mortality after cardiac transplantation. However, limited data exist regarding the potential contribution of coronary atherosclerosis in the donor heart to cardiac-allograft vasculopathy. METHODS AND RESULTS: We performed quantitative coronary angiography and intravascular ultrasound imaging in 50 of 62 consecutive heart-transplant recipients (40 men, 10 women, mean age, 53 +/- 9 years) 4.6 +/- 2.6 weeks after transplantation. The donor population consisted of 30 men and 20 women (mean age, 32 +/- 12 years). Ultrasound imaging visualized all three coronary arteries in 22 patients, two coronary arteries in 23, and one coronary artery in 5. Ultrasound imaging detected coronary atherosclerosis (intimal thickness > or = 0.5 mm) in 28 patients (56%). However, the angiography was abnormal in only 13 patients (26%). The sensitivity and specificity of coronary angiography were 43% and 95%, respectively. With ultrasound, the average atherosclerotic plaque thickness was 1.3 +/- 0.6 mm and the cross-sectional area narrowing was 34 +/- 16%. Atherosclerotic involvement frequently was focal (85%), eccentric (mean eccentricity index, 87 +/- 8), and near arterial bifurcations. Donors of the transplant recipients with coronary atherosclerosis were older than those without atherosclerosis (37 +/- 12 versus 25 +/- 10 years, P = .001). Maximal intimal thickness correlated with donor age (r = .54, P = .0001). Multivariate analysis demonstrated that donor age (P = .0001), male sex of donor (P = .0006), and recipient age (P = .03) were independent predictors of atherosclerosis. CONCLUSIONS: Coronary atherosclerosis is frequently but inadvertently transmitted by means of cardiac transplantation from the donor to the recipient. Long-term outcomes of donor-transmitted coronary artery disease will require further evaluation.
Adult↗
Hemodynamic and physiologic changes during support with an implantable left ventricular assist device.
To evaluate hemodynamic effectiveness and physiologic changes on the HeartMate 1000 IP left ventricular assist device (Thermo Cardiosystems, Inc., Woburn, Mass.), we studied 25 patients undergoing bridge to heart transplantation (35 to 63 years old, mean 50 years). All were receiving inotropic agents before left ventricular assist device implantation, 21 (84%) were supported with a balloon pump, and 7 (28%) were supported by extracorporeal membrane oxygenation. Six patients died, primarily of right ventricular dysfunction and multiple organ failure. Nineteen (76%) were rehabilitated, received a donor heart, and were discharged (100% survival after transplantation). Pretransplantation duration of support averaged 76 days (22 to 153 days). No thromboembolic events occurred in more than 1500 patient-days of support with only antiplatelet medications. Significant hemodynamic improvement was measured (before implantation to before explantation) in cardiac index (1.7 +/- 0.3 to 3.1 +/- 0.8 L/min per square meter; p < 0.001), left atrial pressure (23.7 +/- 7 to 9 +/- 7.5 mm Hg; p < 0.001), pulmonary artery pressure, pulmonary vascular resistance, and right ventricular volumes and ejection fraction. Both creatinine and blood urea nitrogen levels were significantly higher before implantation in patients who died while receiving support. Renal and liver function returned to normal before transplantation. We conclude that support with the HeartMate device improved hemodynamic and subsystem function before transplantation. Long-term support with the HeartMate device has a low risk of thromboemboli and makes a clinical trial of a portable HeartMate device a realistic alternative to medical therapy.
Adult↗
Flow cytometry crossmatching: a method for monitoring antidonor antibodies in heart transplant recipients.
Explore the source record for details and available documents.
B-Lymphocytes↗
Left ventricular diastolic dysfunction in lymphocytic myocarditis as assessed by Doppler echocardiography.
Pulsed-wave Doppler echocardiography of left ventricular (LV) inflows was performed in 30 consecutive patients with biopsy-proven lymphocytic myocarditis. There were 21 men and 9 women (mean age 50 +/- 15 years). LV ejection fraction was < or = 30% in 73% of the patients. Sixty-six percent were in New York Heart Association functional class III to IV. Peak early (E) velocity, late (A) velocity, deceleration time and filling pattern were assessed. These values were compared with a control population. E velocity in lymphocytic myocarditis was significantly higher than in control subjects (79 +/- 34 vs 67 +/- 14 cm/s, p = 0.0034). A velocity was lower in patients with myocarditis than in control subjects (38 +/- 20 vs 49 +/- 12 cm/s, p = 0.0001). Correspondingly, the E/A ratio was greater in the myocarditis group (2.5 +/- 1.3 vs 1.5 +/- 0.5, p < 0.0001). In particular, mean deceleration time in patients with myocarditis was significantly lower than that of control subjects (151 +/- 52 vs 194 +/- 30 ms, p < 0.0001). Diastolic filling patterns were abnormal in 29 of 30 patients (97%) with lymphocytic myocarditis, revealing a restrictive pattern in 25, abnormal relaxation in 4 and a normal pattern in 1. Lymphocytic myo-carditis is therefore associated with LV diastolic dysfunction of a predominantly restrictive pattern.
Adult↗
Congestive heart failure. Current and future strategies to decrease mortality.
The prevalence of and mortality from congestive heart failure increase with advancing age. The most important prognostic indicators are exercise tolerance and left ventricular function. Currently, drug treatment consists of digitalis, diuretics, and ACe inhibitors. Future management may include medications to modulate the extracardiac mechanisms of decompensation and newer surgical techniques to assist or replace the failing heart.
Age Factors↗
Pretransplant removal of anti-HLA antibodies by plasmapheresis and continued suppression on cyclosporine-based therapy after heart-kidney transplant.
Explore the source record for details and available documents.
Adult↗
Implantable left ventricular assist device. Approaching an alternative for end-stage heart failure. Implantable LVAD Study Group.
BACKGROUND: The implantable left ventricular assist device (LVAD) was designed to provide circulatory support as an alternative to heart transplantation or to continued medical therapy of end-stage heart failure. Initial experience with the implantable LVAD used as a bridge to heart transplantation provides a clinical opportunity to study the function of the device and adaptation by the patient. METHODS AND RESULTS: Nineteen heart transplant candidates (mean age, 50 years; 17 males) underwent insertion of the HeartMate LVAD as a bridge to heart transplantation from December 1991 to November 1993. All patients were in cardiogenic shock on inotropes, and 16 (84%) were on an intra-aortic balloon pump. Three patients died because of multiple organ failure; all had right ventricular (RV) dysfunction (2 required RV assist devices). Sixteen patients (84%) improved markedly and were rehabilitated to New York Heart Association functional class I-II. Three patients are still on support. Significant improvements in hemodynamic function (based on analysis of the percent change from pre-LVAD condition to pretransplantation) were observed: cardiac index rose from 1.6 +/- 0.2 to 3.2 +/- 0.9 L/min per m2 (P = .0002), left atrial pressure fell from 22.9 +/- 9.5 to 8.0 +/- 5.5 mm Hg (P = .003), RV ejection fraction increased from 19.8 +/- 11.3% to 40.8 +/- 8.9% (P = .0004), pulmonary vascular resistance decreased from 5.2 +/- 2.6 to 2.0 +/- 0.8 Wood units (P = .004). Thirteen patients had successful transplants after a mean duration of 66 days on the LVAD (range, 22 to 101 days). There were no thromboembolic events while the patients were on the LVAD. Only aspirin with dipyridamole was given for anticoagulation during a total of > 1100 patient days of support. CONCLUSIONS: Bridge to transplant implantable LVAD experience indicates that hemodynamic improvement should be significant after insertion of the devices and that the risk of thromboembolic events with the HeartMate LVAD should be extremely low. Rehabilitation and quality of life should be markedly improved. Limitations of extrapolating this clinical experience to the permanent implantable LVAD include that these patients were hospitalized (permanent implants will be outpatients); the "vented-electric" HeartMate LVAD was not tested (it is a portable, battery-powered device), and true "chronic" LVAD support (> 1 year) was not tested, so questions regarding long-term device reliability and the chronic risk of infection are unknown.
Equipment Design↗
Solitary ostial coronary artery stenosis.
Among 125,000 patients who underwent coronary arteriography at the Cleveland Clinic Foundation from 1960 to 1988, 128 (0.1%) were found to have 50-99% stenosis of one or both coronary ostia. All cases were associated with minimal or no obstruction in the distal coronary arteries. Thirty-six percent were males and 64% were females. Fifty percent had ostial narrowing of the left main trunk, 41% had ostial narrowing of the right coronary artery, and 9% had bilateral ostial stenosis. Based on angiographic appearance, the patients were categorized into three groups: 1) atherosclerotic (77%), 2) primary (unknown etiology) (13%), and 3) secondary to aortic valve disease (10%). Compared with the other groups, primary solitary coronary ostial stenosis was commonly found in middle-aged premenopausal or postsurgical menopausal females who had few coronary risk factors and were experiencing severe angina symptoms. At autopsy, most cases were atherosclerotic, however, fibromuscular dysplasia may be found in primary solitary ostial stenosis. This rate entity is difficult to diagnose, and is associated with increased risk during cardiac catheterization and bypass surgery. Solitary ostial stenosis should be included in the differential diagnosis of ischemic heart disease, especially in young or middle-aged female patients.
Adult↗