Irena Milaniak

The influence of sense of coherence on emotional response in heart transplant recipients - a preliminary report.

Introduction The success of heart transplantation in prolonging life and well-being must be considered in reference to its psycho-social outcomes, which intrinsically affect the long-term post-transplant morbidity. Sense of coherence and emotional response to organ reception are important factors in this group of patients. The aim of this study The aim of this study was to assess the contribution of sense of coherence to emotional response to transplantation in heart transplant recipients. Material and methods The study was conducted on a group of 46 heart transplant recipients. The following research tools were applied in the assessment of personal resources (sense of coherence) and emotional response to heart transplant surgery: the Sense of Coherence Questionnaire developed by Antonovsky (SOC-29) and the Transplant Effects Questionnaire (TxEQ). The data were analyzed statistically. Results Heart transplant recipients do not experience guilt toward the donors and have no difficulties in disclosing their identities as heart transplant recipients. The study reports good adherence to immunosuppressive treatment recommendations and both a moderate concern about and a sense of responsibility for the transplanted organs among the patients. Global SOC was associated with guilt toward the donor, concern about the transplanted heart, and disclosure of the recipients identity. Conclusions The strength of the patients’ global sense of coherence is related to the level of their emotional response to the heart transplant surgery.

Impact of Postoperative Bleeding on Short-Term Outcome in Patients After Orthotopic Heart Transplantation: A Retrospective Cohort Study

BACKGROUND Orthotopic heart transplantation (HTX) remains the ultimate treatment option in patients with end-stage heart failure, endorsed by the European Society of Cardiology guidelines. The aim of the study is a complex evaluation of the postoperative bleeding after HTX and its influence on short-term outcome. MATERIAL AND METHODS A retrospective cohort study consisted of 53 patients (4 females and 49 males, median age 52.5 years, IQR 17 years) who underwent HTX in the Department of Cardiovascular Surgery and Transplantology of John Paul II Hospital in Krakow between 2007 and 2014. RESULTS The median chest tube output within first 24 hours after the surgery was 695 (550-870) mL. Bleeding decreased throughout the observation (p=0.000). The first postoperative hemoglobin level was a significant predictor of excessive blood loss (p=0.017). The volume of chest tube output increased the duration of mechanical ventilation (p=0.046) and the incidence of re-exploration after first 24 hours of observation (p=0.049). In patients with higher chest tube output, more packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelet (PLT) transfusions were required (p=0.000, p=0.019, and p=0.000, respectively). Early rethoracotomy (within the first 24 hours post-surgery) increased the in-hospital mortality (p=0.021; OR 7.43 [1.36-40.64]). CONCLUSIONS The study demonstrates the importance of postoperative bleeding and bleeding complications for short-term outcome in our post-HTX cohort. Throughout the analysis, the first postoperative hemoglobin level was detected to be a significant predictor of postoperative blood loss.

The effect of clinical variables on distress and depressive symptoms among heart transplant recipients

Background: Heart transplantation (HTx) is the standard treatment for end‐stage cardiomyopathy and coronary artery disease. Although major improvements have been made in the prevention and treatment of acute graft rejection, comorbidities still limit the long‐term survival of heart transplant recipients. The risk of poor outcome, such us major health status aggravation and death, can stimulate the occurrence of depression and stress in this population. The aim of this study was to determine the impact of comorbidities on depressive symptoms and distress among heart transplant recipients. Material/methods: The sample included 131 HTx recipients from one site. Data were collected during a follow‐up in‐hospital appointment, using the questionnaires assessing depression (Beck Depression Inventory Short Form) and stress (Perceived Stress Scale‐10). Statistical analyses included descriptive statistics, Pearson correlations, t‐tests, and generalized linear models. Results: Study patients were 75.6% (n = 97) male, 100% (n = 131) Caucasian, 74% (n = 89) married, with the mean age of 54 years at time of heart transplantation. Nearly half of the participants (40.5%) presented depression symptoms at the time of evaluation. Severe stress was observed in 30% of individuals. Depression symptoms and severe distress were more commonly observed in patients with many comorbidities, requiring multiple drug therapy, and high NYHA score. Moreover, in a multivariate logistic regression, depression and high distress level occurrence were predicted by the following independent factors: cardiac allograft vasculopathy, cancer, diabetes, higher NYHA score, and comorbidities. Conclusions: The prevalence of depression and severe distress is common among heart transplant recipients. Patients with many comorbidities are at higher risk of psychological indisposition.

How to predict the risk of postoperative complications after coronary artery bypass grafting in patients under 50 and over 80 years old. A retrospective cross-sectional study

BACKGROUND Coronary artery disease (CAD) remains the leading cause of death in developed countries, and there is an increasing number of both young and elderly patients requiring surgical treatment. Despite improvement of conventional risk stratification scores (EuroSCORE II, STS risk score), all of the calculations are estimated based on the typical population and the studies emphasise that the scales may need further investigation and modernisation because demographic changes of the population suffering from CAD are unavoidable. AIM To characterise two increasing and challenging cohorts of patients undergoing coronary artery bypass grafting (CABG) and to identify preoperative risk factors for postoperative complications. METHODS In the retrospective cross-sectional study, we analysed 388 patients ≥ 80 years old and 190 patients ≤ 50 years old, who underwent CABG consecutively at our Institution. Data were obtained from medical records. RESULTS The vast majority of studied patients had commonly described risk factors for cardiovascular diseases, regardless of the age group. Diabetes was present in almost twice as many individuals in the older cohort, when compared to the EuroSCORE population. A similar observation was made for hypertension, which was more frequent in both age groups. Summarising all of the postoperative complications, at least one occurred significantly more frequently among the older group (10% vs. 20.9%, p = 0.001). The vast majority of major adverse cardiac and cerebrovascular events (MACCE) in the older group led to death (79.4%). Among patients ≥ 80 years old, higher New York Heart Association (NYHA) class (p = 0.001, OR 2.05 [1.34-3.12] for every next class) and renal failure (p = 0.02, OR 2.47 [1.16-5.25]) increased the MACCE rate, whereas higher left ven-tricular ejection fraction (LVEF) (p = 0.002, OR 0.81 [0.7-0.93] for every 5%) decreased the risk. Emergent admission was the only factor increasing the occurrence of any postoperative complications among patients ≤ 50 years old (p = 0.007, OR 3.63, 95% CI 1.37-9.62). On the other hand, among patients ≥ 80 years old, emergent admission was not associated with any postoperative complications. CONCLUSIONS Young and old patients requiring CABG differ from the standard EuroSCORE population. Postoperative complications are more common among older patients, and MACCE is usually fatal in this age group. Individuals with risk factors for MACCE (higher NYHA class, renal failure, lower LVEF) should be carefully evaluated and qualified, and closely monitored post-surgery.

Risk factors for in-hospital mortality after coronary artery bypass grafting in patients 80 years old or older: a retrospective case-series study

Background Age remains a significant and unmodifiable risk factor for cardiovascular diseases, and an increasing number of patients older than 80 years of age undergo Coronary Artery Bypass Grafting (CABG). Old age is also an independent risk factor for postoperative complications. The aim of this study is to describe the population of patients 80 years of age or older who underwent CABG procedure and to assess the mortality rate and risk factors for in-hospital mortality. Methods A retrospective case-series study analyzing 388 consecutive patients aged 80 years of age or older who underwent isolated CABG procedure between 2010 and 2014 in the Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow. Results In-hospital mortality stood at 7%, compared to 3.4% for all isolated CABG procedures at our Institution. In an univariate logistic regression analysis, risk factors for in-hospital mortality were as follows: NYHA class (p = 0.005, OR 1.95, 95% CI [1.23–3.1]), prolonged mechanical ventilation (p < 0.001, OR 7.08, 95% CI [2.47–20.3]), rethoracotomy (p = 0.04, OR 3.31, 95% CI [1.04–10.6]), duration of the procedure and ECC (for every 10 min p = 0.01, OR 1.01, 95% CI [1.0–1.01]; p = 0.03, OR 1.01, 95% CI [1.0–1.02], respectively), PRBC, FFP, and PLT transfusion (for every unit transfused p = 0.004, OR 1.42, 95% CI [1.12–1.8]; p = 0.002, OR 1.55, 95% CI [1.18–2.04]; p = 0.009, OR 1.93, 95% CI [1.18–3.14], respectively). Higher LVEF (p = 0.02, OR 0.97, 95% CI [0.94–0.99]) and LIMA graft implantation (p = 0.04, OR 0.36, 95% CI [0.13–0.98) decreased the in-hospital mortality. Death before discharge was more often observed in patients with multiple risk factors for cardiovascular diseases (0–2 –5.7%; 3–7.4%, 4–26.6%; p = 0.03). Conclusions Older age is associated with higher in-hospital mortality after isolated CABG at our Institution. Risk stratification scores and individualized risk evaluation, centered on comorbidities, NYHA class and left ventricular function, should be assessed in all cases. Whenever suitable, LIMA grafts should be used. Prolonged procedure and ECC time worsen the short-term outcome. Elderly individuals should be closely monitored postoperatively and the care should be focused on excessive blood loss and respiratory failure.

Coronary Artery Disease in Young Adults: Who Needs Surgical Revascularization? A Retrospective Cohort Study.

BACKGROUND Coronary artery disease (CAD) is a major cause of death and disability in developed countries. Despite the fact that prevalence accrues with age, an increasing number of young patients suffering from CAD is being observed worldwide. The aim of this study is to describe the population of young adults suffering from CAD and requiring coronary artery bypass grafting (CABG), and to assess early outcomes after the procedure. METHODS A retrospective cohort study analyzed 190 consecutive patients aged ≤50 years old that underwent CABG between 2010 and 2014. Baseline characteristics and operative data were presented in the study. Postoperative complications, such as major adverse cardiac and cardiovascular events (MACCE), prolonged mechanical ventilation (>72 hours), bleeding requiring reexploration, sternal dehiscence, and others were assessed. RESULTS A population comprising mostly overweight or obese males with a mean age of 46 ± 4.1 years was analyzed. Patients suffered mostly from three-vessel disease (81%), hypertension (74.7%), and had previous history of myocardial infarction (MI) (60%). The majority of patients had normal left ventricle ejection fraction (LVEF) (83.1%). 22.6% of cases were emergent procedures. Perioperative mortality was low (1%) and overall MACCE rate stood at 2.6%. Emergent surgery was associated with a higher incidence of postoperative complications (P = .007). The number of diseased vessels, LVEF, and CCS/NYHA class-on-admission was not associated with a higher incidence of postoperative complications (P > .05 for all). CONCLUSION CAD in young patients remains an issue described insufficiently in the literature. Among our study cohort of younger patients undergoing CABG, the majority of the patients had multivessel disease and were slightly symptomatic with normal LVEF. Although the postoperative complication rate was low, the percentage of emergent surgeries was alarmingly high in this population. Consistent with the literature, we highlight the importance of CAD screening in the young population to detect subclinical disease, which might be treated therapeutically or operated electively.

Does the postoperative troponin I blood concentration measured in the perioperative period influence hemodynamic function of a transplanted heart

Introduction Plasma troponin I (TnI) concentration is a well-established and widely-used marker of myocardial damage. Aim To determine the correlation between TnI concentration measured within the first 4 days following heart transplantation (HTX) and clinical course, with consideration of hemodynamic performance. Material and methods The retrospective study included 54 patients (12-62 years) who underwent HTX. TnI levels were assessed over the first 4 post-operative days. Hemodynamic parameters were assessed daily at Swan-Ganz catheterization and echocardiography. The number of required inotropic drugs was also analyzed. Results There is a strong and positive correlation between the mean TnI levels and the mean number of required inotropic drugs (r = 0.51, p = 0.00), and also mean central venous pressure (CVP) (r = 0.33, p = 0.015). A weak trend towards a positive correlation between the mean values of pulmonary capillary wedge pressure (PCWP) and the mean plasma TnI levels was observed. There was no correlation between mean TnI levels and mean values of ejection fraction (EF) and cardiac output (CO). Detailed analysis showed a statistically significant correlation between TnI levels on days 3 and 4 after HTX and PCWP on the preceding days (r = 0.32, p = 0.04; r = 0.46, p = 0.006 respectively). Furthermore, a strong, inverse correlation between TnI levels on day 3 and CO on day 4 following HTX was observed (r = –0.44, p = 0.03). Conclusions Plasma TnI could be a useful marker for assessing the hemodynamic function after HTX.

Adherence to antihypertensive therapy among heart transplant recipients

Introduction Adherence to therapeutic recommendations, concerning in particular drug administration, diet and healthy life style, is essential to obtain optimal medical treatment effects. Elevated blood pressure is an extremely important risk factor for cardiovascular diseases such as coronary artery disease, chronic heart failure and stroke, as well as chronic kidney disease. Aim The aim of the study was to assess the level of adherence among heart transplant recipients and to explain the reasons for non-adherence phenomenon. Material and methods The study was performed on 55 heart allograft recipients: 11 women (20%) and 44 men (80%), all hypertensive. Participation in the study was voluntary and the three-part questionnaire was anonymous to obtain reliable answers. The second part was designed using the Modified Morisky Scale (MMS) consisting of questions assessing motivation and knowledge among patients. The third included questions concerning lifestyle, reasons for non-adherence and methods to improve it. Results In self-assessment of the adherence to medical recommendations on a scale of 0 to 10 the analyzed population estimated their level of adherence to be on average 8.49 ± 1.33, which is a considerably high result. It was discovered that both the level of motivation (2.20) and knowledge (2.83) are high among heart transplant recipients. Still, the level of knowledge was significantly higher than the motivation (p < 0.005). Correlation analysis revealed that the self-assessed adherence level correlated positively with the level of motivation (r = 0.357; p < 0.007). Conclusions Creation of an active attitude of the patient in the process of treatment is a crucial and at the same time often difficult task demanding cooperation of the patient, the patients close family and the whole therapeutic team.

The risk of cholelithiasis in patients after heart transplantation.

Introduction Extended immunosuppressive treatment in patients after heart transplantation modifies etiopathogenesis and occurrence of many diseases in this population. The aim of the present study was to evaluate the frequency and to define risk factors for cholelithiasis after heart transplantation (HTX). Material and methods The study population consisted of 176 subjects. Of them, 24 patients (group A) presented with symptomatic cholelithiasis. Another group of 24 patients without cholelithiasis (group B) served as controls. Both groups were similar with respect to age, gender and follow-up after the transplant. Clinical interview, surgical and hospitalization data were collected from medical records. Results The groups did not differ in demographic features. There were statistical differences (p < 0.05) between group A and B in rejection reaction, doses of immunosuppressive drugs, type 2 diabetes, serum lipid disorders and acute rejection episodes. These events were caused by modification of treatment, especially the immunosuppressive regimen. Group A consisted of 75% men and 25% women. The frequency of symptomatic cholelithiasis was 11.7% in men and 27.3% in women, on average 19.5%. Mean time to cholelithiasis following HTX was 37.9 ±4.9 (Me = 41.5) months, 27.7 ±8.2 (Me = 30.0) months in women and 41.3 ±5.9 (Me = 41.5) months in men. The female to male ratio was 2.3: 1. Conclusions Cholelithiasis following HTX was significantly more frequent as compared with the non-transplant population. Patients with cholelithiasis required more aggressive immunosuppression because of more frequent episodes of acute transplant rejection. Patients with cholelithiasis significantly more frequently showed increased glycemia and blood lipids, which could be the side effect of intensive immunosuppressive therapy.