Robert H. Messier

Gastroesophageal reflux disease in lung transplant recipients

Abstract: Background: Chronic allograft dysfunction after lung transplantation contributes to poor long‐term survival. A link between gastric aspiration and post‐transplant lung dysfunction has been suggested, but little is known about the significance of gastroesophageal reflux disease (GERD) after lung transplantation.

Hemodynamic changes after protamine administration: Association with mortality after coronary artery bypass surgery

Background:Protamine sulfate is standard therapy to reverse heparin anticoagulation. Hemodynamic responses to protamine are common, ranging from minor perturbations to cardiovascular collapse. Although severe fatal reactions occur, the relation of less extreme responses with postoperative mortality is unknown. Therefore, the authors tested the hypothesis that hemodynamic “protamine reactions” (systemic hypotension and pulmonary hypertension) are associated with mortality after cardiac surgery. Methods:In a university hospital setting, the authors studied 6,921 coronary bypass patients using automated anesthesia record–keeping data and quality assurance databases. Degree/duration integrals of systemic hypotension (< 100 mmHg) and pulmonary hypertension (> 30 mmHg) for the 30-min after protamine administration were assessed for linear associations with mortality using multiple logistic regression models adjusting for risk factors. Results:Overall mortality was 2%; greater hemodynamic responses were associated with increased mortality by odds ratios of 1.28 (systemic hypotension: 95% confidence interval, 1.14–1.43; P < 0.001) and 1.27 (pulmonary hypertension: 95% confidence interval, 1.06–1.48; P < 0.001) per 150-mmHg · min increment. Proximity of the response to protamine administration strengthened the relation, which persisted after exclusion of major hemodynamic disturbances. Tests for linearity confirmed an association even at the lowest range of values for both pressure effects. Conclusions:Hemodynamic perturbations after protamine administration are independently related to in-hospital mortality after primary coronary artery bypass surgery; the relation is present even in the lowest observed range of values for both systemic hypotension and pulmonary hypertension. Although randomized trials are necessary to address causality, this evidence suggests that strategies that avoid or attenuate these reactions may improve patient care.

The Bispectral Index in the Diagnosis of Perioperative Stroke: A Case Report and Discussion

We discuss a case where the bispectral index (BIS; Aspect Medical, Natick, MA) was the earliest indicator of acute perioperative stroke during the removal of an Abiomed BVS 5000 ® (Penn State Cardiovascular Center, Hershey, PA) left ventricular assist device (LVAD). Up to 3% of cardiac surgical patients suffer serious, typically embolic, neurological complications, with an associated 20% mortality rate (1). The opportunity to make an earlier diagnosis may help improve outcome in this group as novel therapeutic options become available.

Risk-Adjusted Short- and Long-Term Outcomes for On-Pump Versus Off-Pump Coronary Artery Bypass Surgery

Background—Surgeons have adopted off-pump coronary artery bypass grafting (OPCAB) in an effort to reduce the morbidity of surgical revascularization. However, long-term outcome of OPCAB compared with conventional coronary artery bypass grafting (CABG) remains poorly defined. Methods and Results—Using logistic regression analysis and proportional hazards modeling, short-term and long-term outcomes (perioperative mortality and complications, risk-adjusted survival, and survival/freedom from revascularization) were investigated for patients who underwent OPCAB (641 patients) and CABG-cardiopulmonary bypass (5026 patients) from 1998 to 2003 at our institution. For these variables, follow-up was 98% complete. OPCAB patients were less likely to receive transfusion (odds ratio for OPCAB, 0.80; P=0.037), and there were trends toward improvement in other short-term outcomes compared with CABG-cardiopulmonary bypass. Long-term outcomes analysis demonstrated no difference in survival, but OPCAB patients were more likely to require repeat revascularization (OPCAB hazard ratio, 1.29; P=0.020). Conclusions—OPCAB patients were less likely to receive transfusion during their hospitalization for surgery but had higher risk for revascularization in follow-up. These results highlight the need for a large randomized, controlled trial to compare these 2 techniques.

Hepatitis B Core Antibody Positive Donors as a Safe and Effective Therapeutic Option to Increase Available Organs for Lung Transplantation

Background. The use of hepatitis B core antibody (HBcAb+) and hepatitis C antibody (HCV Ab+) positive donors represents one strategy to increase available donor organs, but this remains controversial because of concern for viral transmission to recipients. We hypothesized that isolated HBcAb+ donors represent minimal risk of viral transmission in vaccinated lung transplant (LTx) recipients. Methods. A retrospective study was performed of LTx recipients who received HBcAb+ or HCV Ab+ pulmonary allografts. We analyzed liver function studies, viral hepatitis screening tests, quantitative polymerase chain reaction for hepatitis B viral DNA (HBV DNA) and hepatitis C viral RNA (HCV RNA), freedom from bronchiolitis obliterans syndrome, acute rejection, and survival. Results. Between April 1992 and August 2003, 456 LTx operations were performed. Twenty-nine patients (HB group) received HBcAb+ allograft transplants with a median posttransplant follow-up of 24.5 months. Three critically ill patients (HC group) received HCV Ab+ allografts with a median follow-up of 21.5 months. One-year survival for the HB group is 83% versus 82% for all patients who received non-HB organs (P=0.36). No patient in the HB group developed clinical liver disease because of viral hepatitis, and all patients alive (n=21) at follow-up are, to date, HBV DNA and/or HBcAb negative. All patients in the HC group tested HCV RNA positive; one patient died of liver failure at 22 months. Conclusions. Risk of viral transmission with HCV Ab+ allografts seems high after LTx. However, the use of HBcAb+ pulmonary allografts in recipients with prior hepatitis B vaccination seems to be a safe and effective strategy to increase organ availability.

Sepsis, Multiple Organ Failure, and Death Due to Pandoraea pnomenusa Infection after Lung Transplantation

ABSTRACT A 30-year-old man died with Pandoraea pnomenusa sepsis after lung transplantation. Pandoraea species are gram-negative rods, closely related to, and commonly misidentified as, Burkholderia cepacia complex or Ralstonia species. Heretofore considered soil bacteria and colonizers that infect patients with chronic lung diseases, Pandoraea species can produce severe infections.

Clinical outcome after coronary artery revascularization and lung transplantation

BACKGROUND Presence of coronary artery disease (CAD) in otherwise eligible lung transplant candidates is considered a contraindication to lung transplantation. We reviewed the clinical outcome of our experience in lung transplant recipients with operable coronary artery disease and normal left ventricular function. METHODS Medical records of all transplant recipients with coronary artery disease were reviewed. Data analyzed include demographics, coronary angiograms, coronary artery revascularization procedure, and clinical outcome after lung transplantation. RESULTS Between April 1992 and August 2001, 354 lung transplant procedures were performed. Eighteen patients (5%) had significant CAD (greater than 50% stenoses). Six male patients (mean age 59 years) underwent percutaneous transluminal coronary angioplasty/stent and after lung transplantation all were discharged after a median hospital stay of 8.5 days. All recipients are alive at a median follow-up time of 14.5 months after their transplant. Twelve male patients (mean age 58 years) had combined coronary artery bypass grafting and lung transplantation. All recipients were discharged after a median hospital stay of 16 days. Nine recipients are alive at a median follow-up time of 7.5 months after transplant. One-year survival by the Kaplan-Meier method is 88% for the 18 patients with coronary artery disease who underwent revascularization and lung transplantation. CONCLUSIONS Despite the traditional criteria of excluding all eligible transplant candidates due to coronary artery disease, coronary revascularization in select candidates with favorable anatomy and normal left ventricular function can allow patients to undergo lung transplantation with acceptable outcomes.

Delay of CMV infection in high‐risk CMV mismatch lung transplant recipients due to prophylaxis with oral ganciclovir

Abstract:  Cytomegalovirus (CMV) is a common opportunistic infection in lung transplant recipients. Despite the use of early post‐operative intravenous ganciclovir, most high‐risk patients develop CMV infection. We conducted this retrospective study to determine the efficacy of extended CMV prophylaxis with oral ganciclovir in high‐risk, donor‐positive–recipient‐negative, lung recipients. All patients initially received 3 months of intravenous ganciclovir and CMV hyperimmune globulin. Clinical outcomes in all CMV mismatch patients undergoing lung transplant surviving at least 3 months were included (n = 42). Since 1998, 14 patients received no oral ganciclovir prophylaxis (group 1) and 28 patients received indefinite oral ganciclovir after completion of intravenous therapy (group 2). In those patients receiving oral ganciclovir, the prevalence of post‐transplant CMV infection was significantly reduced over the first 180 d post‐transplant (50% in group 1 vs. 4% in group 2; p < 0.001). Although some CMV events were observed with additional follow‐up in group 2, there remained a significantly greater freedom from CMV infection by Kaplan–Meier analysis in group 2 as compared with group 1, with over 30 months follow‐up time in each group (log‐rank, p = 0.02). A moderate rate of drug discontinuation was observed in group 2, and no severe drug‐related events occurred. In high‐risk lung transplant recipients, CMV prophylaxis with intravenous ganciclovir, followed by indefinite oral ganciclovir, significantly delays and reduces post‐transplant CMV infections. A larger prospective randomized study is needed to confirm the benefits of oral ganciclovir on CMV prevention.

The association of patent foramen ovale and atrial fibrillation after coronary artery bypass graft surgery

Atrial fibrillation (AF) is associated with considerable morbidity and increased resource utilization after coronary artery bypass graft surgery. In this study, we sought to determine whether patent foramen ovale (PFO) and atrial septal aneurysm are associated with an increased risk of postoperative AF in this patient population. We performed a database study on 1008 patients undergoing primary coronary artery bypass graft surgery. All patients were assessed for the development of postoperative AF from the day of surgery to hospital discharge. Atrial septal defects were identified during comprehensive intraoperative transesophageal echocardiographic examination. Postoperative AF was present in 124 (12.3%) patients. Patients with AF were significantly older and had a more frequent incidence of preoperative congestive heart failure, longer cross-clamp time, and prolonged hospital length of stay. PFO was present in 72 (7.1%) and atrial septal aneurysm in 23 (2.3%) patients. In these patients, postoperative AF was present in 14 (19.4%) patients with PFO and 8 (34.8%) patients with atrial septal aneurysm. Multivariate logistic regression analysis identified that PFO (odds ratio [OR], 1.95; 1.007–3.778; P = 0.047), age (OR, 1.03; 1.015–1.053; P = 0.0004), and history of congestive heart failure (OR, 2.55; 1.671–3.900; P < 0.0001) were predictive of postoperative AF.

Serum creatinine patterns in coronary bypass surgery patients with and without postoperative cognitive dysfunction

Renal dysfunction is common after coronary artery bypass graft (CABG) surgery. We have previously shown that CABG procedures complicated by stroke have a threefold greater peak serum creatinine level relative to uncomplicated surgery. However, postoperative creatinine patterns for procedures complicated by cognitive dysfunction are unknown. Therefore, we tested the hypothesis that postoperative cognitive dysfunction is associated with acute perioperative renal injury after CABG surgery. Data were prospectively gathered for 282 elective CABG surgery patients. Psychometric tests were performed at baseline and 6 wk after surgery. Cognitive dysfunction was defined both as a dichotomous variable (cognitive deficit [CD]) and as a continuous variable (cognitive index). Forty percent of patients had CD at 6 wk. However, the association between peak percentage change in postoperative creatinine and CD (parameter estimate = −0.41;P = 0.91) or cognitive index (parameter estimate = −1.29;P = 0.46) was not significant. These data indicate that postcardiac surgery cognitive dysfunction, unlike stroke, is not associated with major increases in postoperative renal dysfunction.