Influence of right ventricular function on the development of primary graft dysfunction after lung transplantation (original) (raw)
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Right ventricular echocardiographic parameters in patients with early cardiac graft dysfunction
PubMed, 2012
Background: There is limited information on the utility of certain echocardiographic measurements, such as right ventricular (RV) strain analysis, in predicting mortality in patients with acute pulmonary embolism (PE). Methods: A total of 211 patients with acute PE admitted to a medical intensive care unit (ICU) were retrospectively identified. Echocardiographic variables were prospectively measured in this cohort. The focus was on ICU, hospital, and long-term mortality. Results: The mean age was 61 6 15 years. Median Acute Physiology and Chronic Health Evaluation IV and simplified Pulmonary Embolism Severity Index scores were 60 (interquartile range, 40-71) and 2 (interquartile range, 1-2), respectively. Thirty-eight patients (18%) died during the sentinel hospitalization (13% died in the ICU). A total of 61 patients (28.9%) died during a median follow-up period of 15 months (interquartile range, 5-26 months). The echocardiographic variables associated with long-term mortality (from PE diagnosis) were ratio of RV to left ventricular end-diastolic diameter (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.2-4.8), tricuspid annular plane systolic excursion (HR, 0.53; 95% CI, 0.31-0.92), and RV-right atrial gradient (HR, 1.02; 95% CI, 1.01-1.4). ICU mortality was associated with ratio of RV to LV end-diastolic diameter (HR, 4.4; 95% CI, 1.3-15), RV systolic pressure (HR, 1.03; 95% CI, 1.01-1.05), tricuspid annular plane systolic excursion (HR, 0.4; 95% CI, 0.18-0.9), and inferior vena cava collapsibility < 50% (HR, 4.3; 95% CI, 1.7-11). These variables remain significantly associated with mortality after adjusting by Acute Physiology and Chronic Health Evaluation IV score, Pulmonary Embolism Severity Index score, or the use of thrombolytic agents. RV strain parameters were not correlated with hospital or long-term mortality. Conclusions: Four simple parameters that measure different aspects of the right ventricle (ratio of RV to left ventricular end-diastolic diameter, RV systolic pressure, tricuspid annular plane systolic excursion, and inferior vena cava collapsibility) were independently associated with mortality in patients presenting with acute PE who were admitted to the ICU.
European Respiratory Journal, 2016
Primary graft dysfunction is a significant cause of lung transplant morbidity and mortality, but its underlying mechanisms are not completely understood. The aims of the present study were: 1) to confirm that right ventricular function is a risk factor for severe primary graft dysfunction; and 2) to propose a clinical model for predicting the development of severe primary graft dysfunction.A prospective cohort study was performed over 14 months. The primary outcome was development of primary graft dysfunction grade 3. An echocardiogram was performed immediately before transplantation, measuring conventional and speckle-tracking parameters. Pulmonary artery catheter data were also measured. A classification and regression tree was made to identify prognostic models for the development of severe graft dysfunction.70 lung transplant recipients were included. Patients who developed severe primary graft dysfunction had better right ventricular function, as estimated by cardiac index (3.5...
European heart journal cardiovascular Imaging, 2014
Background: The risk stratification of chronic heart failure (CHF) patients can be performed using echocardiographic markers of left ventricle (LV) dysfunction, such as the ejection fraction (EF). LV global longitudinal strain (GLS) showed to be a sensitive measure of myocardium deformation. However, its role as prognostic marker in CHF patients with exclusively systolic dysfunction is still poorly addressed. Objectives: This study sought to evaluate the incremental prognostic role of twodimensional (2D) LV GLS in CHF outpatients. Methods: Fifty-five patients with CHF and LVEF ≤45% performed a 2D echocardiogram with assessment of conventional parameters and GLS by speckle tracking (STE) imaging averaged from apical 4-chamber, 3-chamber and 2-chamber views. A clinical follow-up of 12 months was performed to assess the occurrence of composite endpoint of overall mortality and nonfatal cardiovascular events. Results: We included 55 patients (mean age 55 + 12 years, 80% males, 30% with CHF of ischemic etiology, with mean LVEF of 27 + 9%, median BNP levels 162 [P25-75 56-542] pg/ml). The mean GLS was-10.35 + 3.14%. GLS was significantly correlated with NYHA functional class (R=0.41, p=0.002) and BNP levels (r=0.47, p=0.001) and showed a good correlation with LVEF (r=-0.687, p,0.001). The logistic regression analysis showed that GLS (OR 1.548 [95% CI 1.169-2.051]) and LVEF (OR 0.895 [95% CI 0.822-0.976]) were significantly associated with the composite end-point. Other variables that were significantly related with GLS included NYHA functional class (OR 7.333 [95% CI 2.084-25.809]) and BNP levels (OR 1.003 [95% CI 1.001-1.005]). Multivariated regression analysis, including GLS and LVEF, showed an independent association of GLS with adverse outcome (OR 1.460 [95% CI 1.036-2.058]). The area under the receiver operating characteristic (ROC) curve to predict the occurrence of the composite endpoint was 0.798 [0.678-0.919] with an optimal thresholds of-9.5 (80% sensitivity, 70% specificity, p=0.001), while EF had an area under the ROC curve of 0.276 [0.138-0.414]. Conclusions: GLS was strongly associated with severity disease status and predicted the occurrence of adverse outcomes. Quantifying LV GLS in CHF outpatients with systolic dysfunction provides greater accuracy for cardiovascular risk stratification than LVEF.
Report from a consensus conference on primary graft dysfunction after cardiac transplantation
The Journal of Heart and Lung Transplantation, 2014
Although primary graft dysfunction (PGD) is fairly common early after cardiac transplant, standardized schemes for diagnosis and treatment remain contentious. Most major cardiac transplant centers use different definitions and parameters of cardiac function. Thus, there is difficulty comparing published reports and no agreed protocol for management. A consensus conference was organized to better define, diagnose, and manage PGD. There were 71 participants (transplant cardiologists, surgeons, immunologists and pathologists), with vast clinical and published experience in PGD, representing 42 heart transplant centers worldwide. State-of-the-art PGD presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues. Graft dysfunction will be classified into primary graft dysfunction (PGD) or secondary graft dysfunction where there is a discernible cause such as hyperacute rejection, pulmonary hypertension, or surgical complications. PGD must be diagnosed within 24 hours of completion of surgery. PGD is divided into PGD-left ventricle and PGD-right ventricle. PGD-left ventricle is categorized into mild, moderate, or severe grades depending on the level of cardiac function and the extent of inotrope and mechanical support required. Agreed risk factors for PGD include donor, recipient, and surgical procedural factors. Recommended management involves minimization of risk factors, gradual increase of inotropes, and use of mechanical circulatory support as needed. Retransplantation may be indicated if risk factors are minimal. With a standardized definition of PGD, there will be more consistent recognition of this phenomenon and treatment modalities will be more comparable. This should lead to better understanding of PGD and prevention/minimization of its adverse outcomes.
The Journal of Heart and Lung Transplantation, 2012
Currently, pulmonary vascular resistance index (PVRI) &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;6 WU × m(2) (indexed units) is generally considered a contraindication to isolated orthotopic heart transplantation (OHT). However, this has been questioned in the literature. A retrospective review was performed on all patients &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;18 years old who underwent primary OHT for cardiomyopathy. Data were collected with regard to demographics, pre-operative hemodynamics, need for pre-operative mechanical circulatory support, vasodilator reactivity and 30-day mortality (30dM). A receiver operating characteristic (ROC) curve was used to establish an optimal threshold. Uni- and multivariate logistic regressions were performed to assess the influence of PVRI on 30dM. Complete data were available for 158 cardiomyopathy patients &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;18 years of age, who underwent primary OHT between June 1984 and November 2010. The ROC curve yielded a threshold of 9.290 indexed units. Four of 19 patients (21.1%) with PVRI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;9 died in the first 30 days. In patients with PVRI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;9, there was only 1 death among 139 patients (0.7%). Odds of mortality increased incrementally with PVRI as a continuous variable, with an odds ratio (OR) of 1.35 per indexed unit (95% confidence interval 1.12 to 1.63). PVRI was dichomotomized (PVRId) using the previously established threshold and revealed an increasing risk of mortality, OR 36.80 (95% confidence interval 3.86 to 350.90), with a PVRI of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;9 indexed units. Using a PVRI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;6 as a contraindication to isolated OHT may be too restrictive. Patients with PVRI ≤9 do not appear to be at increased risk of early mortality. In patients with PVRI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;9, 30-day survival was 78.9% in this study. This represents a viable alternative to heart-lung transplantation.
Journal of Cardiac Failure, 2020
Introduction: The incidence of right heart failure (RHF) after left ventricular assist device (LVAD) placement ranges reportedly from 10-40%. We determined to analyze the short and long term mortality rates for those with RHF after LVAD placement. Methods: In a single academic center, we conducted a retrospective analysis of those implanted with a LVAD from 2013 to 2019, and the incidence of postoperative RHF during index admission. Charts with insufficient data were excluded. RHF was defined via the classifications designated by INTERMACS, and patients were categorized into INTERMACS mild, moderate or severe RHF. Cox proportional analysis were performed for Kaplan Meyer curves for 1 and 5-year survival rates. Results: A total of 136 LVAD implantations met criteria in which 22.1% were implanted as bridge to transplant and 77.9% as destination therapy. RHF was diagnosed in 44.1% of patients, in which 14.7%, 17.7%, and 11.8% were categorized as INTERMACS mild, moderate, and severe RHF respectively. Ninety-day mortality rates for patients with INTER-MACS mild, moderate, and severe RHF were 15%, 10.9%, and 37.5%. The combined 90-day mortality rate for all patients with RHF was 23%. One-year mortality rates (FIGURE 1) for INTERMACS mild, moderate, and severe RHF were 20%, 25%, and 43.8%. The combined 1-year mortality rate for all patients with RHF was 28.3%, which contrasted the 1-year mortality rate for patients without RHF of only 6.7%. Five-year mortality rates (FIGURE 2) for INTERMACS mild, moderate, and severe RHF were 40%, 42.7% and 43.8%. The combined 5-year mortality rate for all patients with RHF was 41.2%, which contrasted the 5-year mortality rate for patients without RHF of 19.7%. For those with RHF who received temporary right VAD (tRVAD) support postoperatively, the average INTERMACS RHF severity was moderate. Ninety-day mortality rates for those with early tRVAD (24 hours) and delayed tRVAD (>24 hours) were 25% and 75%. Of those who received tRVAD, the 1-year mortality rate was 25% for those with early tRVAD, while those with delayed tRVAD had a 1-year mortality of 100% and all died on index admission. The 5-year mortality rate for those with RHF and early tRVAD was 50%. Total 90-day mortality for all patients (with and without RHF) was 16.2%. Total 1-year mortality for all patients was 11.7%. Conclusions: In our study, 44.1% of patients had RHF after LVAD implantation with nearly 1/3 dying within 1 year. Implantation of early tRVAD seemingly improved 1 year survival as compared to INTERMACS severe RHF.
International Journal of Cardiovascular Imaging, 2015
Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is routinely performed following orthotopic heart transplantation (OHT). The purpose of this study was to determine whether echocardiographic indices of LV diastolic function correlate with pulmonary capillary wedge pressure (PCWP) in the transplanted heart. Patients who had OHT between June 2009 and November 2011 underwent transthoracic echocardiography and right heart catheterization (RHC) at approximately 1 year post transplantation. We retrospectively assessed 33 potential parameters of LV diastolic function using 2-dimensional, spectral Doppler and tissue Doppler echocardiography. We measured PCWP by RHC. We compared echocardiographic measures with PCWP using linear regression analysis. Ninetyfive patients (mean age 49 ± 13 years, 73 males, mean LV ejection fraction 62 ± 10 %) were included in the study. Overall, echocardiographic parameters of LV diastolic function demonstrated poor correlation with PCWP. By linear regression, the parameter that most strongly correlated with PCWP was left atrial (LA) minimum area in the apical 4-chamber view (p = 0.002, r 2 = 0.1). Comparing patients with PCWP B 12 mmHg and those with PCWP [ 12 mmHg, the parameter that demonstrated the most significant difference was LA minimum area in the apical 2-chamber view (p = 0.002), and comparing patients with PCWP B 15 mmHg and those with PCWP [ 15 mmHg, the most significant difference was peak early diastolic velocity of the mitral annulus (p = 0.02). In patients with cardiac allografts, clinical echocardiographic measures of LV diastolic function correlate poorly with PCWP.
The Journal of Heart and Lung Transplantation, 2007
Primary graft dysfunction (PGD) is responsible for significant morbidity and mortality after lung transplantation and The International Society for Heart and Lung Transplantation (ISHLT) Working Group on PGD has recently reported standardized consensus criteria, based on the recipient arterial blood-gas analysis and chest X-ray findings, to define PGD and determine its severity (grade range, 0 -3). The grading system has been shown to predict post-transplant outcomes; however, further evaluation and refinement of the validity of the grading system is an important next step to enhance its utility. In this review, we describe advantage and disadvantages of the current PGD grading system based on series of analyses we have conducted and possible options for its potential refinement. The suggested revisions are (1) additional assessment time points at 6 and 12 hours should be included, (2) only bilateral infiltrates on chest X-ray (not unilateral infiltrates) should be considered as an infiltrate in bilateral lung transplants, (3) information from the chest X-ray is useful within 6 hours of final lung reperfusion (T0) but is not necessary to classify grade 3 at 12 to 72 hours, (4) apply PGD grade to single and bilateral lung transplant separately, (5) all extubated patients should be considered as grade 0 to 1, (6) note if PGD grade is being defined by specific inclusion and exclusion criteria, including extubation, with clear chest X-ray, on nitric oxide or extracorporeal membrane oxygenation. Although, further evaluations of the PGD definition and grading system are needed, the suggested refinements in this review may further enhance the reliability and validity of the PGD grading system as an important new lung transplant study instrument.