Chhaya Aggarwal

Cardiac Transplantation in the New Era.

The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.

Does the relation between red blood cell transfusion and mortality vary according to transfusion indication? A case-control study among patients with acute coronary syndromes.

ObjectivesRed blood cell (RBC) transfusions are common among patients with acute coronary syndromes (ACS). We sought to determine their impact on mortality according to indication. MethodsWe conducted a case–control analysis of ACS patients admitted to a single coronary care unit. Transfused patients were matched to nontransfused patients for age, estimated glomerular filtration rate, and nadir hematocrit. Conditional logistic regression analysis was used to determine the independent relationship between RBC transfusion and inhospital mortality. Results were stratified according to the indication for transfusion. ResultsOf the 3190 patients admitted with ACS, 206 (6.4%) received at least one RBC transfusion. Of these, 103 patients were matched to 185 nontransfused patients. The most common indications for transfusion were nonspecific anemia (48%) and overt blood loss (42%). Transfused patients had a significantly lower ejection fraction and were more likely to present in Killip class IV, undergo pulmonary artery catheterization, and require an intra-aortic balloon pump. On univariate analysis, RBC transfusion was associated with a doubling of the risk of inhospital mortality [odds ratio: 2.0; 95% confidence interval: 1.0–3.9; P=0.046]. However, after adjustment for confounders, transfusion was no longer significantly associated with higher inhospital mortality (odds ratio: 1.8; 95% confidence interval: 0.6–5.1; P=0.3). On stratified analysis, RBC transfusion was not significantly associated with inhospital mortality among patients transfused for either nonspecific anemia or overt blood loss. ConclusionsAmong coronary care unit patients with ACS, RBC transfusion does not seem to have a significant impact on inhospital mortality irrespective of the indication for transfusion.

ARRHYTHMIAS IN HOSPITALIZED HEART TRANSPLANTED PATIENTS: A UNITED STATES NATIONAL STUDY

Background: Abnormal anatomy, sympathetic denervation, rejection, and infection may increase the risk for arrhythmias in heart transplant (HT) recipients. Data are limited regarding arrhythmias in hospitalized HT patients. Methods: Using the U. S. Nationwide Inpatient Sample databases 2003 through