Paul A. Perry

Vasoplegia after heart transplantation: outcomes at 1 year

OBJECTIVES Vasoplegia syndrome is a potentially life-threatening condition that can occur following cardiopulmonary bypass. Heart transplantation is a recognized risk factor for developing this vasodilatory state. The objective of this study was to determine the effects of vasoplegia syndrome on 1-year heart transplant outcomes. METHODS A retrospective review of orthotopic heart transplants at a single institution between November 2010 and December 2014 was performed. Of the 347 consecutive adult patients, 107 patients (30.8%) met criteria for vasoplegia syndrome. Preoperative factors and intraoperative variables were collected and compared between vasoplegia and non-vasoplegia cohorts. The incidence of postoperative complications, transplant rejection and patient survival within 1 year were evaluated. RESULTS Demographics and preoperative medication profiles were similar in both groups, while mechanical circulatory support device use was associated with vasoplegia syndrome (30.8% vs 20.0%; P = 0.039). Perioperative characteristics such as longer cardiopulmonary bypass [165.0 (interquartile range [IQR] 74) min vs 140.0 (IQR 42.7) min; P < 0.001] and increased blood product usage (24.7 ± 17.2 units vs 17.7 ± 14.3 units; P < 0.001) were associated with vasoplegia. Non-vasoplegia patients were more likely to be extubated [42.9 (IQR 37.3) h vs 66.8 (IQR 50.2) h; P < 0.001] and discharged earlier [10.0 (IQR 6) days vs 14.0 (IQR 11.5) days; P < 0.001]. One-year patient survival (92.0% vs 88.6%; P = 0.338) and any-treated rejection rates (82.7% vs 84.3%; P = 0.569) were not significantly different between groups. CONCLUSIONS Although vasoplegia syndrome was associated with an increase in perioperative morbidity, including greater mechanical ventilation time and hospital length of stay, no significant differences in survival or allograft rejection at 1 year was demonstrated.

Postoperative Care of Adult Cardiac Transplant Patients

Cardiac transplantation remains the definitive therapy for end-stage heart failure. Meticulous postoperative management is essential for optimizing successful outcomes in this relatively complex patient cohort. While the critical care considerations of heart transplant recipients are largely similar to that of other cardiac surgery patients, there exist important transplant-specific factors which require attention.

Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation

BACKGROUND Vasoplegia is characterized as a severe vasodilatory shock after cardiac surgery, and can be associated with substantial morbidity. Increased systemic inflammation and endothelial dysfunction, often related to prolonged cardiopulmonary bypass times, anesthesia, or mechanical circulatory support have been shown to be associated with the development of vasoplegia. We sought to identify risk factors and the impact of various degrees of vasoplegia after heart transplantation. METHODS A retrospective review was conducted of 244 consecutive patients who underwent heart transplantation over a 3-year period. Patients were divided into three groups: no vasoplegia, mild vasoplegia (requiring one vasopressor), and moderate/severe vasoplegia (more than two vasopressors). One-year survival, freedom from rejection, and postoperative complication rates were assessed. Risk factors for vasoplegia subgroups were retrospectively identified. RESULTS Vasoplegia syndrome was observed in 34.3% of patients after heart transplantation (mild, 74.1%; moderate/severe, 25.9%). Cardiopulmonary bypass time was significantly longer and pretransplant creatinine was significantly higher in the moderate/severe vasoplegia group. There was a strong trend toward greater use of mechanical circulatory support among moderate/severe vasoplegia patients compared with mild and no vasoplegia patients. After heart transplantation, 1-year survival, freedom from rejection, and need for hemodialysis were not significantly different between groups. CONCLUSIONS Vasoplegia syndrome is common after heart transplantation. Risk factors for increased severity include longer cardiopulmonary bypass times and elevated preoperative creatinine. Although higher rates of mortality or graft rejection were not detected, vasoplegia was associated with prolonged intubation, greater blood product usage, and lengthened hospital stay. Further studies involving larger cohorts are warranted.

Donor Organ Preservation and Surgical Considerations in Heart Transplantation

Human heart transplantation represents one of the seminal accomplishments for the field of cardiac surgery. The first successful human heart implant was performed on December 3, 1967 by Dr. Christiaan Barnard in Cape Town, South Africa. Several weeks later, Dr. Norman E. Shumwayof Stanford University performed the first adult heart transplant in the United States. Since the era of these early pioneers, nearly all elements of the procedure have undergone significant modification and refinement. In this chapter we review donor selection, organ procurement and preservation, and techniques for implantation.

Use of Intraoperative Frozen Section during Mediastinoscopy

Introduction: Staging of mediastinal lymph nodes (MLN) by mediastinoscopy can be of critical importance in assessing candidacy for lung resection. Mediastinoscopy is often performed as a sole procedure, with permanent pathology results guiding subsequent intervention. Our practice has been to perform mediastinoscopy followed by immediate surgical resection, as indicated, based on intraoperative frozen section (FS) assessment. The goal of our review is to evaluate the reliability of FS when compared to permanent section (PS) and to investigate any discordant findings. Materials and methods: A retrospective review of patients with lung cancer that underwent mediastinoscopy from June 2006 to January 2011. All received clinical staging according to NCCN guidelines and were considered potential candidates for surgical resection. Results for FS and PS of MLN were assessed. Results: Staging mediastinoscopy was performed on 191 patients, with a total of 549 MLN undergoing FS and PS analysis. Concordance between FS and PS was found in 545 MLN (99.3%). Discordance was found in 4 MLN (0.7%), each in a different patient. All 4 discordant MLN were initially negative on FS and then found to be positive on PS. Overall accuracy of FS analysis for detecting all malignancy was 97.9%, with 94.3% sensitivity, 100% specificity, 96.7% negative predicted value, and 100% positive predicted value. Conclusion: Our data suggest that for lung cancer patients with potentially resectable tumors, immediate FS analysis of MLN followed by definitive surgery is a reliable and safe strategy. Discordance with final pathology was rare (0.7%) and resulted in improper staging in 1 (0.5%) patient. Advantages of this “fast-track” approach include less medical costs and hastening of time from diagnosis/staging to definitive treatment.