Timing of cardiac transplantation in patients with heart failure receiving beta-adrenergic blockers.

BACKGROUND: Previous work shows that patients with heart failure patients who have peak oxygen consumption (VO2 peak) >14 ml/kg/min do not derive a survival benefit from cardiac transplantation. However, this was shown before beta-blocker therapy for patients with systolic heart failure became common, and beta-blockers improve survival in patients with heart failure without changing VO(2) peak. Our purpose was to re-evaluate the utility of VO(2) peak >14 ml/kg/min as an indicator of the need for cardiac transplantation in patients with heart failure who are taking beta-blockers. METHODS: Actuarial, hemodynamic, and exercise ventilatory data were collected from 540 patients with heart failure, 256 of whom were taking beta-blockers. We tracked death and cardiac transplantation. We stratified the percentage of patients event-free 1 and 3 years after VO(2) peak study by their VO(2) peak and beta-blocker status, and compared 1- and 3-year post-transplant survival (United Network of Organ Sharing [UNOS] data). We also compared total mortality for the patients with heart failure as stratified by beta-blocker stats and VO(2) peak (excluding the 42 who underwent transplantation) with UNOS post-transplant survival. RESULTS: Patients with heart failure who were receiving beta-blockers and whose VO(2) peak was > or =12 ml/kg/min had greater 1- and 3-year event-free survival rates (95% confidence intervals, 92.6%-96.6% and 85.8%-96.0%) than did post-transplant patients (83.9%-86.3% and 75.4%-76.6%). However, in patients with heart failure not taking beta-blockers, VO(2) peak <14 ml/kg/min was associated with worse 3-year survival (38.9 - 62.1%) than that for post-transplant patients. Excluding the 42 patients with heart failure in our study who underwent transplantation and then evaluating survival of the remaining patients with heart failure (not event-free survival) did not substantially change these results. CONCLUSIONS: Patients with heart failure who are receiving beta-blockers do not derive a survival advantage at 1 and 3 years after cardiac transplantation if VO(2) peak is > or =12 ml/kg/min. Patients not taking beta-blockers whose VO(2) peak is <14 ml/kg/min have superior survival with cardiac transplantation.     

Heart failure survival score continues to predict clinical outcomes in patients with heart failure receiving β-blockers

BACKGROUND: The Heart Failure Survival Score (HFSS) has been previously shown to effectively risk-stratify patients under evaluation for heart transplantation. However, this model was developed before broad use of beta blockade. We hypothesized that the prognostic tool would retain its ability to risk stratify patients treated with beta-blockers. METHODS: We collected clinical data on 524 consecutive patients referred for heart transplantation from 1994 to 2001. Kaplan-Meier survival analysis and multivariable Cox regression analysis were performed with events defined as death, left ventricular assist device placement, or United Network of Organ Sharing 1 heart transplantation. RESULTS: Kaplan-Meier analysis of the patient population revealed effective discrimination by the survival score both for beta-blocker treated and untreated patients (both p <0.0001). Two-year event-free survival was 94% +/- 2% and 84% +/- 4% for beta-blocker and no beta-blocker patients in the low-risk HFSS strata. Cox proportional hazard modeling showed that HFSS strata (medium risk: HR 2.65, 95% CI 1.75-4.02, p <0.001; high risk: HR 5.51, 95% CI 3.64-8.33, p <0.001) and beta-blocker treatment (HR 0.45, 95% CI 0.31-0.64, p <0.001) were significant predictors of event-free survival. Receiver operating curves (area under the curve) for HFSS strata used to predict 2-year events were similar for beta-blocker treated (0.78 +/- 0.04) and untreated (0.80 +/- 0.03) patients. CONCLUSIONS: The HFSS provides effective risk stratification with or without beta-blocker therapy. Consideration of beta-blocker therapy with survival score strata improves outcome prediction in patients evaluated for heart transplantation.     

Impact of beta-blocker therapy on functional capacity criteria for heart transplant listing.

BACKGROUND: Peak exercise oxygen consumption is a widely used parameter to determine the need for transplant listing in patients with severe heart failure. Currently, beta-blocker therapy is known to benefit patients with severe heart failure, although it has minimal or no effects on peak exercise oxygen consumption. This raises the hypothesis that peak exercise oxygen consumption transplant-listing criteria are not valid for patients with heart failure who receive beta-blocker therapy. METHODS: We compared outcomes in patients with chronic heart failure who underwent heart transplant evaluation with peak exercise oxygen consumption 相似文献   

Decreased recipient survival following orthotopic heart transplantation with use of hearts from donors with projectile brain injury.

BACKGROUND: Fatal gunshot injury to the brain can cause significant alterations in the neuroendocrine state and myocardial dysfunction. Therefore heart allografts from these donors may result in graft failure following orthotopic heart transplantation (OHTx). We evaluated whether receiving a heart from a donor who died from fatal gunshot wound to the brain independently affected the outcome of transplantation. METHODS: A retrospective review of 113 consecutive patients undergoing OHTx at a university hospital from 1996 to 2002 was performed. Group 1 received hearts from donors with fatal gun shot brain injury (n = 17), and Group 2 received hearts from donors who died from other causes (n = 96). RESULTS: Recipient age, gender, United Network for Organ Sharing (UNOS) status, indication for transplantation, and other co-morbid conditions were similar in both groups. Young male donors pre-dominated in Group 1, but other donor characteristics were not significantly different. The incidence of Grade 3A rejection was higher in Group 1 than Group 2 (35% vs 6.3%, p = 0.003), as was the incidence of post-operative infection (35% vs 7.2%, p = 0.004). Actuarial survival at 1 and 5 years was significantly lower in Group 1 than in Group 2 (81% and 74% vs 97% and 94%, respectively, p = 0.005). Multivariate logistic regression analysis also demonstrated that fatal gunshot brain injury, as cause of donor death, was a risk factor for recipient mortality (p = 0.01). CONCLUSION: Receiving a heart from a donor with fatal gunshot brain injury is a significant risk factor for recipient mortality following OHTx. Cautious use of heart allograft from these donors, especially in low-risk recipients, may lead to improved outcome following heart transplantation.     

Use of hearts transplanted from donors with atraumatic intracranial bleeds.

BACKGROUND: Donor atraumatic intracranial bleed (aICB) is associated with older age and may reflect a history of hypertension. Hearts from donors who died of aICB may be at increased risk for graft failure because of the associated catecholamine surge. We evaluated whether receiving a heart from a donor who had an aICB independently affected the outcome of transplantation. METHODS: We reviewed adult patients (>18 years) who underwent heart transplantation between July 1994 and December 1999. We excluded patients who received non-standard hearts (e.g., donor age >55 years). Group 1 received hearts from donors with aICB (n = 80), and Group 2 received hearts from donors who did not have aICB (n = 171). RESULTS: Recipient age, gender, United Network for Organ Sharing status, and indication for transplantation were similar for both groups. Donors in Group 1 were older (41 vs 26 years, p = 0.001), more commonly women (55% vs 20%, p = 0.001), and more often had history of hypertension (26% vs 2%, p = 0.001). Survival to discharge was 86% in Group 1 and 95% in Group 2. Actuarial 5-year survival was 72% for Group 1 and 81% for Group 2 (p = 0.52). Regression analysis showed that receiving a heart from a donor with aICB was a risk factor for early recipient mortality but not for long-term outcome (odds ratio = 3.25, p = 0.02, and hazard ratio = 1.16, p = 0.69, respectively). Donor aICB, female gender, and abnormal initial echocardiogram (global hypokinesia) were selected as clinically relevant independent risk factors for early mortality of the recipient, using a fitted multifactor logistic regression model (goodness-of-fit chi-square p value = 0.94). Donor age, accident-to-retrieval time interval, and borderline left ventricular hypertrophy did not significantly differ. Five-year freedom from transplant coronary artery disease in Group 1 was 74% (vs 80% in Group 2, p = 0.05). CONCLUSIONS: The trend observed in this series suggests that receiving a heart from a donor with aICB is a potential independent risk factor for early mortality after transplantation independent of age. Caution should be used when evaluating such donors, particularly when other risk factors such as female donor or depressed ejection fraction are present.     

The effect of beta-adrenergic blockers on the prognostic value of peak exercise oxygen uptake in patients with heart failure.

OBJECTIVES: Our aim was to determine the effect of beta-adrenergic blockade on the prognostic value of peak oxygen consumption testing in patients with heart failure. BACKGROUND: Peak oxygen consumption has been shown to be a useful prognostic tool in patients with heart failure. However, studies demonstrating the utility of peak oxygen consumption were conducted before beta-blocker therapy became widespread. Thus, our objective was to determine the effect of beta-blockers on the prognostic value of peak oxygen consumption in patients with heart failure. METHODS: Actuarial, anthropomorphic, hemodynamic and exercise ventilatory data were collected from 369 patients with heart failure. Death and orthotopic heart transplants were the events tracked. Patients were divided into those taking beta-blockers and those not taking them. Event-free survival days were calculated. RESULTS: One hundred ninety-nine patients on beta-blockers and 170 not on beta-blockers were studied. There were 40 orthotopic heart transplants and 82 deaths during follow-up. Peak oxygen consumption (milliliters per kilogram per minute) trended toward being an independent predictor of event-free survival (p = 0.055). In patients on and not on beta-blockers, a peak oxygen consumption of >14 ml/kg.min was associated with a 1-year event rate of approximately half of that associated with a peak oxygen consumption 相似文献   

Intraaortic balloon pumping in patients undergoing coronary artery bypass grafting

Beneficial effect of preoperative intraaortic balloon pumping (IABP) treatment in high-risk patients who had open heart surgery have been demonstrated. The purpose of this study is to determine the impact of preoperative IABP use on survival in high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: Two hundred seventy-seven consecutive patients having CABG at our institution were reviewed. Patients having an IABP were identified retrospectively and grouped into one of 3 groups as follows. Group A (n = 14): preoperative IABP for high-risk urgent or elective cases. Group B (n = 26): preoperative IABP for emergency cases. Group C (n = 6): unplanned intraoperative or postoperative IABP. RESULTS: Forty-six patients had an IABP (16.6% of total). Parsonnet score in group B was significantly higher (p < 0.05). Length of operation for group C was significantly longer (p < 0.05). Overall hospital mortality in the total group of 277 cases was 4.2%. Hospital mortality was 7.1% in group A, 7.7% in group B, and 50% in group C. Hospital mortality in group C was significantly higher (p < 0.01). CONCLUSIONS: The beneficial effect of preoperative treatment with IABP in high-risk patients undergoing CABG was confirmed. This approach resulted in a significantly lower hospital mortality.     

Beta-blocker treatment of dilated cardiomyopathy with congestive heart failure in children: a multi-institutional experience.

BACKGROUND: Dilated cardiomyopathy is the primary indication for heart transplantation in children beyond infancy. Although beta-blockers improve symptoms, ejection fraction, and survival in adults with congestive heart failure, little is known of their effects in children. METHODS: This study reviews our pediatric experience with the beta-blocker, metoprolol, at 3 institutions. We gave metoprolol to 15 children, age 8.6 +/- 1.3 years (range 2.5 to 15 years), with idiopathic dilated cardiomyopathy (n = 9), anthracycline cardiomyopathy (n = 3), and Duchenne muscular dystrophy cardiomyopathy, postmyocarditis cardiomyopathy, and post-surgical cardiomyopathy (n = 1 each). All had been treated with conventional medications (digoxin, diuretics, and ACE inhibitors) for 22.5 +/- 9 months before starting metoprolol. Metoprolol was started at 0.1 to 0.2 mg/kg/ dose given twice daily and slowly increased over a period of weeks to a dose of 1.1 +/- 0.1 mg/kg/day (range 0.5 to 2.3 mg/kg/day). RESULTS: Between the time point of stabilization on conventional medications and the initiation of metoprolol therapy, there was no significant change in fractional shortening (13.1 +/- 1.2% vs 15.0 +/- 1.2%) or ejection fraction (25.6 +/- 2.1% vs 27.0 +/- 3.4%). However, after metoprolol therapy for 23.2 +/- 7 months, there was a significant increase in fractional shortening(23.3 +/- 2.6%) and ejection fraction (41.1 +/- 4.3%) (p < 0.05). CONCLUSIONS: Metoprolol improves ventricular function in some children with dilated cardiomyopathy and congestive heart failure. Further study is warranted to better define which children may benefit most from beta-blocker therapy and which beta-blockers are most efficacious.     

Response of right ventricular function to prostaglandin E1 infusion predicts outcome for severe chronic heart failure patients awaiting urgent transplantation.

BACKGROUND: Selection of patients for urgent heart transplantation who have end-stage heart failure requires objective criteria to distinguish between subjects who may deteriorate clinically and those who can be stabilized. This population appears to differ in terms of right ventricular function, and right ventricular changes in loading may provide prognostic information. To investigate predictive parameters of patients admitted for urgent heart transplantation, we prospectively studied the mechanical performance of the right ventricle during acute afterload reduction. PATIENTS AND METHODS: We studied 68 heart failure patients hospitalized for bridge-to-transplant. The patients underwent right heart catherization at baseline and during prostaglandin E1 infusion. We stratified patients according to clinical outcome: Group A comprised patients who could be weaned from bridging therapy or who were electively transplanted after at least 90 days, and Group B comprised patients who died or who remained unstable and required transplant under urgent conditions. RESULTS: Right ventricular hemodynamics at baseline were comparable in both groups. However, during maximal vasodilatation, with prostaglandin E1 infusion, the right ventricular end-diastolic volume index (EDVI) was significantly reduced in Group A, (-23 ml/m(2) (p < 0.01) vs +12 ml/m(2) (p = n.s. DeltaEDVI in Group B. Reduction of EDVI by less than 10% during prostaglandin E1 infusion has a sensitivity of 89% and a specificity of 70% for clinical deterioration. CONCLUSIONS: The response of right ventricular volumes to prostaglandin E1 may predict the outcome of patients with severe congestive heart failure listed for urgent heart transplantation.     

Destiny of candidates for heart transplantation in the Eurotransplant heart allocation system

OBJECTIVE: We analyzed the prognosis of candidates for heart transplantation (HTx) after being listed with 'urgent status' for donor heart allocation or after ventricular assist device (VAD) implantation without application for urgent status. METHODS: Urgent status as used in this study refers to both the high urgency (HU) status awarded by Eurotransplant until August 31, 2005 and the urgent (U) status that replaced it from then on. Patients who underwent primary VAD implantation between January 2001 and December 2006 and who were listed as transplantable (T) (group VAD-prim, n=159), and patients listed primarily in urgent status before VAD implantation and/or HTx during the same period (group U-prim, n=168) were enrolled in the study. Group U-prim consists of subgroups: group U-HTx (n=123), who underwent primarily HTx in urgent status; group U-VAD (n=25), who underwent primarily VAD implantation in urgent status; patients who died in urgent status before HTx or VAD implantation (n=6); and patients in urgent status without HTx or VAD implantation (n=14). The survival rate in each group was studied. RESULTS: Survival rates after VAD implantation in group VAD-prim were comparable to those after urgent status listing in group U-prim (67.0% vs 68.5% for 1-year survival, 56.6% vs 65.8% for 2-year survival, respectively). Actuarial survival after listing for urgent status in group U-HTx was significantly better than that in group U-VAD (73.7% vs 46.0% for 1-year survival, p<0.05, log-rank test). Actuarial survival during mechanical circulatory support after the VAD implantation (censored at HTx or weaning from the device) in group VAD-prim was significantly better than that in group U-VAD (80.7% vs 56.2% for 3-month survival, p<0.001, log-rank test). CONCLUSIONS: In order to receive urgent HTx, HTx candidates may choose urgency listing without primary VAD implantation at the risk of failed donor heart allocation in urgent status. However, the prognosis of the patients in the latter situation is poor.     

Tumor necrosis factor gene polymorphism and cardiac allograft vasculopathy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) limits survival after cardiac transplantation. Tumor necrosis factor-alpha (TNF-alpha) may be a key factor in the development of CAV. Two bi-allelic polymorphisms associated with high TNF-alpha production have been identified in the TNF gene locus, TNFA1/2, at position -308 and TNFB1/2 at +252. We hypothesized that recipient TNFA2 and TNFB2 homozygosity is associated with the development of CAV after heart transplantation. METHODS: TNF gene polymorphisms were analyzed by multiplex fluorescent solid-phase mini-sequencing in 70 cardiac transplant recipients. Recipients homozygous for TNFA2 or TNFB2 (Group A, n = 29) were compared with recipients heterozygous or homozygous for TNFA1 and TNFB1 (Group B, n = 41). Coronary arteriography was performed annually or when indicated. Cumulative freedom from CAV and survival was calculated according to the Kaplan-Meier test. RESULTS: Mean follow-up was 3.8 +/- 0.3 years. In Group A, 11 of 29 recipients (38%) developed CAV compared with 9 of 41 (22%) in Group B (p = 0.12). Cumulative freedom from CAV at 3 years was 42% in Group A and 80% in Group B (p = 0.043). In Group A, 11 of 29 recipients (38%) died during follow-up compared with 4 of 41 (10%) in Group B (p = 0.006). Cumulative survival at 3 years was 72% in Group A and 93% in Group B (p = 0.003). CONCLUSIONS: The results suggest that TNFA2 and TNFB2 allele homozygosity is associated with cardiac allograft vasculopathy and mortality in heart transplant recipients.     

Beta-blockers in isolated blunt head injury

BACKGROUND: The purpose of this study was to evaluate the effect of beta-blockers on patients sustaining acute traumatic brain injury. Our hypothesis was that beta-blocker exposure is associated with improved survival. STUDY DESIGN: The trauma registry and the surgical ICU databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2005. Patients sustaining major associated injuries (Abbreviated Injury Score > or = 4 in any body region other than the head) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcomes measure evaluated was in-hospital mortality. RESULTS: During the 90-month study period, 1,156 patients with isolated head injury were admitted to the ICU. Of these, 203 (18%) received beta-blockers and 953 (82%) did not. Patients receiving beta-blockers were older (50 +/- 21 years versus 38 +/- 20 years, p < 0.001), had more frequent severe (Abbreviated Injury Score > or = 4) head injury (54% versus 43%, p < 0.01), Glasgow Coma Scale < or = 8 less often (37% versus 47%, p = 0.01), more skull fractures (20% versus 12%, p < 0.01), and underwent craniectomy more frequently (23% versus 4%, p < 0.001). Stepwise logistic regression identified beta-blocker use as an independent protective factor for mortality (adjusted odds ratio: 0.54; 95% CI, 0.33 to 0.91; p = 0.01). On subgroup analysis, elderly patients (55 years or older) with severe head injury (Abbreviated Injury Score > or = 4) had a mortality of 28% on beta-blockers as compared with 60% when they did not receive them (odds ratio: 0.3; 96% CI, 0.1 to 0.6; p = 0.001). CONCLUSIONS: Beta-blockade in patients with traumatic brain injury was independently associated with improved survival. Older patients with severe head injuries demonstrated the largest reduction in mortality with beta-blockade.     

Selected patients listed for cardiac transplantation may benefit from defibrillator implantation regardless of an established indication.

BACKGROUND: End-stage heart failure (HF) patients are at high risk of sudden cardiac death. This study evaluates the role of implantable cardiac defibrillators (ICDs) in HF patients awaiting cardiac transplantation. METHODS: We identified 194 consecutive patients (age 51 +/- 12 years) with New York Heart Association Class 3 or 4 HF (ejection fraction 22 +/- 9%) listed for cardiac transplantation, 35 of whom underwent ICD implantation. Of the implanted patients, 16 (Group A) had an established indication for ICD implantation (cardiac arrest, n = 10; sustained ventricular tachycardia [VT], n = 3; and positive electrophysiology study, n = 3). Nineteen patients (Group B) underwent ICD implantation for non-established indications (syncope with non-ischemic cardiomyopathy, n = 4; non-sustained VT, n = 15). There were no procedural complications from ICD implantation. RESULTS: During follow-up of 9.2 +/- 10.1 months, there were 3 deaths in the ICD groups (A and B), and 40 in the control group (8.6% vs 25.2%, p = 0.032). Five patients in Group A and 6 in Group B (31%) received appropriate ICD therapy. The number of therapies per patient and the time to the first shock were similar between Groups A and B. Four of 6 Group B patients on outpatient inotropic therapy (67%) received appropriate ICD therapy. CONCLUSIONS: Selected end-stage heart failure patients awaiting heart transplantation, including those without established ICD indications, are at high risk for malignant arrhythmias and may benefit from ICD implantation. Patients with ICD seem to have improved survival compared to those without ICD. Randomized prospective studies are needed to confirm these findings.     

Pediatric Heart Transplant Candidates With Failed Donor Heart Allocation After Eurotransplant Urgency Listing Profit From Pretransplant Mechanical Circulatory Support Bridging

Abstract:  Due to the Eurotransplant organ allocation policy, urgency listing for heart transplantation (HTx) remains in force until ventricular assist device (VAD) implantation in Germany. We studied the prognosis of HTx candidates after failed donor heart allocation in urgent status. We studied all adult and pediatric (<18 years) HTx candidates who underwent primary HTx after Eurotransplant urgency listing between January 2001 and December 2006 (Group A-uHTx [A-"u"rgent status "HTx"], n  = 99; Group P-uHTx [P-"u"rgent status "HTx"], n  = 24) and those to whom donor heart was not urgently allocated before VAD implantation or death in the same period (Group A-fHA [A-"f"ailed "H"eart "A"llocation], n  = 21, Group P-fHA [P-"f"ailed "H"eart "A"llocation], n  = 10). Mortality rate after urgency listing or primary VAD implantation was studied in each group. In adult patients, 1-year mortality rate after urgency listing in Group A-fHA was 56.8% and significantly higher than in Group A-uHTx (30.6%, P  < 0.001, log-rank test). After failed urgent heart allocation, 15 out of 21 patients in Group A-fHA had VAD implantation and two patients (9.5%) underwent HTx after VAD implantation. In pediatric patients, 1-year mortality rate in Group P-fHA was 40.0% and significantly higher than in Group P-uHTx (8.5%, P  < 0.05). In Group P-fHA, all 10 patients underwent VAD implantation after failed urgent heart allocation and six patients (60.0%, P  < 0.01 vs. Group A-fHA, Fisher's exact test) underwent HTx after VAD implantation. After failed urgent donor heart allocation, pediatric HTx candidates seem to profit more from mechanical circulatory support than adults.     

Extent and Severity of Coronary Disease and Mortality in Patients with End-Stage Renal Failure Evaluated for Renal Transplantation

The purpose of this study is to explore the relationship between coronary artery disease (CAD), transplantation status and subsequent mortality in end-stage renal disease (ESRD) patients undergoing evaluation for renal transplantation. Two hundred fifty-three ESRD patients at high risk for CAD underwent coronary angiography as part of a renal transplant evaluation. The cohort was divided into three groups: Group 1 (n = 127) had no vessels with ≥50% stenosis, Group 2 (n = 56) had one vessel with ≥50% stenosis and Group 3 (n = 70) had two or more vessels with ≥50% stenosis. Long-term survival was determined; median follow-up was 3.3 years. The baseline characteristics were similar except for older age and higher proportion of diabetes mellitus, dyslipidemia and peripheral vascular disease in Groups 2 and 3 patients as compared to Group 1. Survival was worse in Group 3 compared to Group 1 (p < 0.0001). Each of the three subgroups had better survival with renal transplantation than those who did not undergo transplantation (p < 0.0001). Although the degree of CAD is related to subsequent mortality, transplantation is associated with better survival regardless of the extent and severity of CAD. Thus, the presence of CAD should not exclude ESRD patients from consideration for this therapy.     

New index for assessing the chronotropic response in patients with end-stage liver disease who are undergoing dobutamine stress echocardiography

The inability to achieve 85% of the maximum predicted heart rate (MPHR) on dobutamine stress echocardiography (DSE) is defined as chronotropic incompetence and is a predictor of major cardiac events after orthotopic liver transplantation (OLT). The majority of patients with end-stage liver disease (ESLD) receive beta-blockers for the prevention of variceal bleeding. In these patients, it is impossible to determine whether chronotropic incompetence is secondary to cirrhosis-related autonomic dysfunction or is merely a beta-blocker effect. We evaluated the usefulness of the maximum achieved heart rate (MAHR) and the heart rate reserve (HRR) in the detection of chronotropic incompetence in ESLD patients on beta-blocker therapy before DSE. We also evaluated the usefulness of a new index, the modified heart rate reserve (MHRR), in diagnosing chronotropic incompetence and predicting major cardiovascular adverse events after OLT. The study population consisted of 284 ESLD patients. The mean values of MAHR (expressed as a percentage of 85% of MPHR) and HRR were significantly lower for patients on beta-blockers versus patients off beta-blockers [97.1% versus 101.6% (t = 5.01, P < 0.001) and 71.7% versus 77.3% (t = 4.03, P < 0.001), respectively], whereas the values of MHRR were similar in patients on beta-blockers and patients off beta-blockers [102.3% versus 102.1% (t = 0.04, P = 0.97)]. A regression analysis showed a significant association of MAHR (P < 0.001) and HRR (P < 0.001) with beta-blockers, whereas MHRR was not associated with beta-blocker treatment (P = 0.92). MAHR and HRR were found to have no value for diagnosing chronotropic incompetence in ESLD patients. MHRR was not affected by beta-blocker therapy. Patients who developed heart failure (HF) and myocardial infarction (MI) after OLT had significantly lower MHRR values according to pretransplant DSE. MHRR was significantly associated with the subsequent development of HF (P = 0.01) and MI (P = 0.01) after OLT. MHRR may be useful for the determination of the target heart rate for stress testing, the diagnosis of chronotropic incompetence, and the prediction of adverse cardiac events after OLT.     

Urgent heart transplantation in patients with previous sternotomies

Critically ill patient status and prior sternotomy have separately been associated with increased risk of mortality and morbidity after heart transplantation. Consequently, the justification of assigning urgent priority for transplantation to critically ill patients with prior sternotomy may be arguable. The authors therefore undertook a retrospective analysis to evaluate the outcome of urgent and elective heart transplantation in 64 patients who had undergone one to four previous sternotomies. Patients in group 1 (n = 23) were critically ill and underwent urgent heart transplantation. Group 2 (n = 41) consisted of more stable patients who received heart transplantation as an elective procedure. Intravenous inotropes or mechanical circulatory support were required by all patients in group 1 but by none in group 2. The mortality rate within 30 days post-transplant was higher in group 1 than in group 2 (22% versus 10%), though the difference was not statistically significant. The 1-year actuarial allograft survival was similar between the two groups (72% versus 74%). In addition, there was no significant difference between groups 1 and 2 in the incidence of postoperative coagulopathy (57% versus 42%). re-exploration (13% versus 15%), early infections (57% versus 49%), renal failure (17% versus 10%) or rejection episodes in the first 3 months (65% versus 78%). The authors' findings suggest that despite higher operative mortality in critically ill patients with previous sternotomies, the intermediate-term outcome of heart transplantation in these patients is similar to that in more stable patients. Critically ill patients with prior sternotomies should therefore continue to be considered for urgent heart transplantation.     

Coronary atherosclerosis in cardiac transplant patients treated with total lymphoid irradiation.

BACKGROUND: Multiple episodes of rejection following cardiac transplantation have been associated with an increased incidence of coronary atherosclerosis. Total lymphoid irradiation (TLI) has been shown to be a successful treatment for persistent allograft rejection, but its effect on coronary arterial disease has yet to be evaluated. METHODS: From 1987 to 1999, 40 patients required TLI for persistent or recurrent allograft rejection following heart transplantation. Each patient's (Group 1, n = 31) post-transplant coronary angiograms were examined and compared with those of a control group (Group 2, (n = 32) matched for time of transplantation. Degree of coronary stenosis was assessed on a 6-point scale. All patients received induction therapy (rabbit anti-thymocyte globulin or OKT3) and standard triple immunosuppressive therapy. TLI (80 cGy x 10 fractions) was used for the treatment of recurrent or persistent rejection on the basis of clinical indications. Actuarial survival, number and treatment of rejection episodes, and severity of coronary artery disease were compared in each group. RESULTS: Recipient gender, age, race and cytomegalovirus (CMV) status at time of transplant, along with donor gender, CMV status and graft ischemia time, were similar in both groups. Group 1 donor age was younger than that of Group 2 (22.2 +/- 11.2 vs 31.5 +/- 13.6 years, p = 0.004), and the indication for surgery in Group 1 patients was more likely to be ischemic heart disease (15 of 31 vs 6 of 32, p = 0.02). Mean follow-up was 5.7 +/- 3.5 years in Group 1 vs 6.9 +/- 3.8 in Group 2 (p = NS). Group 1 had more rejection episodes (4.4 +/- 2.2 vs 2.3 +/- 2.0, p = 0.0002) and more steroid treatments (9.78 +/- 4.0 g vs 5.14 +/- 4.7 g, p < 0.0001), but less coronary artery disease compared with Group 2 (p = 0.035). CONCLUSIONS: Despite multiple episodes of rejection, patients treated with TLI after cardiac transplant appear to develop less coronary atherosclerosis than appropriately matched controls.     

Greater travel time to a liver transplant center does not adversely affect clinical outcomes.

The effect of patient travel time to a transplant center on outcomes is unknown. We compared outcomes between patients living >3 hours (Group A) vs. 90 days to list, listing, survival while listed, transplantation, and posttransplantation survival. Covariates included Model for End-Stage Liver Disease (MELD) score, hepatocellular carcinoma (HCC), alcoholic liver disease, insurance type, and psychosocial score. There were 38 (23%) patients in Group A and 128 (77%) in Group B. Median MELD scores were 14.5 (range, 6-36) for Group A and 14.0 (range, 7-32) for Group B (p = 0.20). Groups were similar for age, gender, diagnosis, psychosocial score, insurance, and HCC variables. Group A was not independently associated with >90 days to list (odds ratio, 0.98; 95% confidence interval [CI], 0.4-2.4). Kaplan-Meier cumulative probabilities for listing, transplantation, and 1-yr posttransplantation survival were similar (A vs. B: 0.77 vs. 0.83, 0.70 vs. 0.69, and 0.85 vs. 0.86, respectively; all p values >0.05). Being in Group A remained insignificant in terms of probability of listing, transplantation, and posttransplantation survival by Cox proportional hazard modeling. Survival on the list was significantly better for Group A (A: 1.0, B: 0.55; p = 0.02). Fewer patients at high MELD score in Group A and referral biases may explain this difference. In conclusion, after entering evaluation, patients living >3 hours away from a transplant center have comparable outcomes to those living closer.     

A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery.

OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.