Chris Anthony

A 25 year Review of Combined Cardiac and Renal Transplant Outcomes in Patients with End Stage Cardiac Failure on Renal Replacement Therapy. A Single Center Experience.

Background: Combined heart and kidney transplantation has been shown to be a viable option for patients who have concurrent end stage cardiac and renal failure. However there is limited long term survival data that compares the outcomes of patients undergoing combined heart-kidney transplantation to patients undergoing solitary cardiac transplantation. There is also limited data on patients with end stage cardiac failure who are on concurrent renal replacement therapy prior to organ transplantation and their outcomes. This study reviews the short and long term outcomes of combined heart kidney transplantation over a 25 year period in comparison to solitary cardiac transplantation in a majority of patients undergoing renal replacement therapy at time of transplant listing. Methods and Results: In total there were 16 patients who underwent combined heart and kidney transplantation in the period between October 1990 and June 2014 (including heart and kidney re-transplantation) with 14 patients (87.5%) on renal replacement therapy at time of combined procedure. They were listed for combined heart and kidney transplantation as they fulfilled our institution’s criteria for irreversible end-stage heart and kidney failure. Retrospective review of patient data from the transplant database, patient case notes and post-mortem reports were carried out. Statistical analysis was then performed on key patient demographics alongside actuarial survival analysis, which were then graphically annotated. IRB approval was obtained and informed consent from patients was also obtained. The mean (SD) recipient age was 42 (13) years and there were 3 females. Dilated cardiomyopathy was the most common primary cardiac pathology (50%) whilst ischemic nephrosclerosis (25%) and glomerulonephritis (25%) were the most common primary renal pathologies. Most patients experienced NYHA class IV symptoms (62.5%). The average wait time to transplantation at our institution was 12 months. There was no operative mortality. The cumulative 1 year survival in the combined transplant group was 0.75 with 4 out of 16 mortalities within the first year (25%). In comparison the cumulative 1 year survival of the heart only transplant group was 0.86 with 116 mortalities within the first year over a 25 year period. Cumulative survival at 5, 10, 15 and 25 years for the combined transplant group was 0.69, 0.55, 0.437 and 0.437 respectively. In comparison cumulative survival of the heart only transplant group at the 5, 10, 15 and 25 year mark was 0.76, 0.59, 0.45 and 0.23 respectively. The incidence of cardiac rejection episodes in the study time was 9 out of 16 (56%) versus 3/16 (19%) who had renal rejection. In the study period there was 1 death out of 7 deaths due to dual graft failure. Conclusions: Combined sequential cardiac and renal transplantation has good shortand long-term outcomes for patients with coexisting end stage cardiac and renal failure. At the ten year mark actuarial survival for combined heart and kidney transplantation is equivalent to cardiac transplantation alone. Received Date: February 08, 2016; Accepted Date: July 12, 2016; Published Date: July 15, 2016 Citation: Anthony, C., et al. A 25 Year Review of Combined Cardiac and Renal Transplant Outcomes in Patients with End Stage Cardiac Failure on Renal Replacement Therapy. A Single Center Experience. (2016) J Heart Cardiol 2(2): 59-67.

Transcatheter Aortic Valve Replacement for Native Aortic Valve Regurgitation

Transcatheter aortic valve replacement with either the balloon-expandable Edwards SAPIEN XT valve, or the self-expandable CoreValve prosthesis has become the established therapeutic modality for severe aortic valve stenosis in patients who are not deemed suitable for surgical intervention due to excessively high operative risk. Native aortic valve regurgitation, defined as primary aortic incompetence not associated with aortic stenosis or failed valve replacement, on the other hand, is still considered a relative contraindication for transcatheter aortic valve therapies, because of the absence of annular or leaflet calcification required for secure anchoring of the transcatheter heart valve. In addition, severe aortic regurgitation often coexists with aortic root or ascending aorta dilatation, the treatment of which mandates operative intervention. For these reasons, transcatheter aortic valve replacement has been only sporadically used to treat pure aortic incompetence, typically on a compassionate basis and in surgically inoperable patients. More recently, however, transcatheter aortic valve replacement for native aortic valve regurgitation has been trialled with newer-generation heart valves, with encouraging results, and new ancillary devices have emerged that are designed to stabilize the annulus-root complex. In this paper we review the clinical context, technical characteristics and outcomes associated with transcatheter treatment of native aortic valve regurgitation.

Ex Vivo Coronary Angiographic Evaluation of a Beating Donor Heart

Coronary artery disease in the cardiac transplant population has been identified as a cause of worse long-term outcomes and accelerated graft vasculopathy. Pre-existing double or triple vessel in the donor heart is associated with a 61.5% post-transplant 30-day mortality.1 Significant angiographic donor heart coronary artery disease is generally considered a contraindication to transplantation. As a result, pretransplant screening for coronary artery disease in the donor population is recommended in male donors >45 years of age and female donors >50 years of age with no cardiovascular risk factors. In the presence of risk factors, the screening age should be reduced by 5 to 10 years.2 In such marginal donors, invasive coronary angiography is the mainstay of investigation for coronary artery disease, although stress echocardiography has also been used successfully before organ harvesting.3–5 Failure to perform pretransplant coronary angiographic screening of marginal donor populations may be associated with significant financial ramifications related to retrieval cost if the allograft is subsequently found to be unsuitable for transplant. However, preharvest coronary angiography may not always be feasible because …

The Anesthetic Management of a Pre-Term Parturient Undergoing Urgent Cesarean Delivery for Fetal Complications within 30 Days of Drug-Eluting Stent Placement: A Case Report and Literature Review

Received date: February 20, 2018 Accepted date: March 23, 2018 Published date: March 30, 2018 1Department of Anesthesiology and Perioperative Medicine, Obstetric Anesthesiology and Acute Pain Management, Rutgers New Jersey Medical School, Newark, NJ, USA 2Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA Journal of Anesthesia and Surgery

Life-Saving Combined Heart–Kidney Transplantation in a Previous Sequential Heart and Kidney Transplant Recipient

Purpose Solid organ re-transplantation in the context of allograft failure is a challenging clinical and ethical problem. Ideally, solid organ re-transplantation after initial allograft failure should be performed in all recipients, but this is often not clinically or logistically feasible. Methods This report details what we believe is the first combined heart–kidney transplant in a recipient of a previous sequential heart and kidney transplant. Results Eight years after a combined heart and kidney transplant after initially receiving a sequential heart and kidney transplant, a 31-year-old man is doing extremely well, with no rejection episodes or significant complications after transplantation. Summary This case confirms that combined heart and kidney transplantation is a viable option for tackling the complex issue of graft failure in recipients of previous cardiac and renal grafts. LEARNING POINTS Good short- and long-term outcomes following combined heart–kidney transplantation can be achieved in patients with multi-system end-organ dysfunction. Advances in immunosuppressant therapy have enabled multiple transplantation procedures from different donors in a single recipient. We describe the first recipient in the world of combined heart–kidney transplantation on a background of previous sequential heart–kidney transplantation.

Isolated myocardial relapse of Philadelphia-positive acute lymphoblastic leukaemia causing myocarditis: a case report

Abstract Background Relapse of acute lymphoblastic leukaemia (ALL) causes significant morbidity. Extramedullary relapse is seldom isolated to one site and almost always coexists with extensive marrow disease. Leukaemic infiltration of the myocardium is a well described entity, evident in up to 44% of patients at post-mortem examination; however, ante-mortem diagnosis remains difficult and rare. As a result, myocardial involvement in the absence of any other foci of relapse has only seldom been reported. Case summary Here, we present an unusual case of isolated gross intracardiac relapse of ALL in a patient presenting with chest pain and fevers. Both cardiac magnetic resonance imaging and endomyocardial biopsy were utilized in the diagnosis and identified leukaemic infiltrate in the absence of peripheral lymphoblasts. Discussion Despite evidence supporting a positive correlation between peripheral lymphocyte count and myocardial infiltration, our case highlights the rare and hypothesis-driving occurrence of myocardial infiltration with a complete absence of a peripheral lymphoblastosis. The report highlights the utility of modern histopathological and imaging modalities in the diagnosis of isolated myocardial relapse of ALL and provides insight into the aetiologies driving this process.

Tenckhoff Catheter Implantation In Refractory Ascites Due To Right Heart Failure

Tenckhoff catheter implantation and modified peritoneal dialysis as a novel therapeutic approach in diuretic resistant congestive heart failure: a single-centre case-series. Background: Progressive renal insufficiency and diuretic resistance represent significant challenges in the management of advanced heart failure, particularly in the context of intractable ascites due to Right Heart Failure (RHF). There is growing interest in the potential use of intermittent paracentesis and peritoneal dialytic ultra-filtration in this setting but clinical experience is limited. Methods: We undertook retrospective analysis of changes in the following clinical parameters in six patients (66% males, average age 53 years) who underwent Tenckhoff catheter implantation (TCI) for the management of RHF-related intractable ascites i) body weight; ii) number of heart failure related admissions and time spent in hospital; and iii) diuretic requirements. Student t-test was performed to analyse statistical significance. Results: Follow-up ranged from 4 to 16 weeks post TCI. Compared to immediately prior to TCI: i) 83% (5/6) of patients experienced an improvement in renal function; ii) average weight fell from 72.2 + 4.7 to 67.7 + 3.9 kg (mean + SEM, p = 0.054); iii) none of the patients have required heart failure related admission compared to an average number of 40 days in hospital over 6.7 admissions in the twelve months preceding TCI and iv) frusemide dose decreased from 263 + 49 to 140 + 50 mg/day, p = 0.051). All patients report a subjective improvement in overall wellbeing and quality of life. One patient developed peritonitis which was controlled with antibiotic treatment without needing catheter removal. Conclusion: Our experience supports the use of TCI as a therapeutic modality in patients with RHF and intractable ascites resistant to medical management. Received Date: February 08, 2016 Accepted Date: March 22, 2016 Published Date: March 29, 2016 Citation: Anthony, C., et al. Tenckhoff Catheter Implantation in Refractory Ascites Due to Right Heart Failure. (2016) J Heart Cardiol 2(2): 1-5. DOI: 10.15436/2378-6914.16.020

Percutaneous Intervention to Large Left Anterior Descending Artery Fistula Post–Right Ventricular Biopsy in a Transplant Recipient

Endomyocardial biopsy through the right internal jugular vein is the gold standard to screen for rejection in orthotopic heart transplant recipients [(1)][1]. Complications associated with the procedure are mainly related to vascular access; however, coronary artery fistulae to the right ventricle

Dose-Adjusted Beta-Lactam Antibiotic-Induced Encephalopathy in a Patient with End-Stage Renal Impairment: A Case Report

Introduction: Despite adherence to current guidelines regarding dose adjustment and drug-level monitoring, beta-lactam-induced encephalopathy can still occur in the setting of chronic renal impairment. Case Report: We report what we believe is the first case of piperacillin- and tazobactam-induced encephalopathy in a patient with pre-existing cefepime-induced encephalopathy in the context of end-stage kidney disease despite adequate dose adjustment for renal impairment.

Disseminated Cerebral and Intradural Extramedullary Spinal Nocardiosis in an Immunocompetent Patient

Disseminated nocardiosis of the central nervous system (CNS) has been rarely reported, especially in the immunocompetent patient. We report a case of cerebral and cervical intradural extramedullary nocardiosis likely to have been the result of disseminated spread from a pulmonary infective focus. Attempts at tissue biopsy and culture of the initial cerebral and pulmonary lesions both failed to yield the diagnosis. Interval development of a symptomatic intradural extramedullary cervical lesion resulted in open biopsy and an eventual diagnosis of nocardiosis was made. We highlight the diagnostic dilemma and rarity of spinal nocardial dissemination in an immunocompetent individual.