S. Saito

A case of everolimus-associated chylothorax in a cardiac transplant recipient.

We herein report a case of putative everolimus-associated chylothorax in a cardiac transplant recipient. A 17-year-old Japanese boy with dilated cardiomyopathy and severe cardiac failure requiring left ventricular assist support was determined to be a cardiac transplant candidate in 1992. He underwent overseas heart transplantation in Houston, Texas in October 1992. He was subsequently treated with immunosuppression therapy: Cyclosporine (CSA), azathioprine, and prednisolone (PRD). After several acute rejection episodes requiring steroid therapy, intravascular ultrasonography revealed a moderate degree of transplant coronary arterial vasculopathy (TCAV) with 50% stenosis in 2003. He underwent coronary stenting twice; the immunosuppressive regimen was converted to CSA, mycophenolate mofetil, everolimus (EVL), and PRD in 2006. TCAV has not progressed since then. In October 2008, chest x-ray showed bilateral pleural effusion. As we thought that the pleural effusion was caused by cardiac dysfunction due to moderate mitral regurgitation and TCAV as well as renal impairment, he was treated with diuretics and digoxin. However, the pleural effusion progressed gradually associated with exertional dyspnea and moderate edema of his lower legs. Chest computed tomography showed massive bilateral pleural effusions without evidence of malignancy in 2011. A pleural tap in 2011 revealed chylothorax. Although mammalian target of rapamycin inhibitors were major drugs for lymphoangioleimyomatosis, we believed that the chylothorax was associated with EVL. EVL was discontinued in March 2011: the chylothorax spontaneously resolved in Novemberxa02011.

Hemodynamic Response to Continuous-flow Left Ventricular Assist Device Ramp Test and Volume Loading Predicts Successful Weaning from the Device Support

Introduction: Myocardial recovery occurs in small cohort of patients receiving left ventricular assist device (LVAD) support, but identification of candidates for device removal remains challenging. Hypothesis: We hypothesized that hemodynamic evaluation during LVAD speed ramp and volume loading test can assess cardiac recovery to predict successful device removal. Methods: The LVAD pump speed was decreased in 4 stages from the patient’s optimal speed to the minimal setting of the device. Under the minimal LVAD support, saline loading (body weight x 10mL in 15 minutes) was done. Echocardiographic and right heart catheter data were obtained in each stage of the LVAD ramp test, and every 3 minutes during the saline loading test. A total of 31 patients (HeartMate II 12, DuraHeart 7, Jarvik2000 5, EVAHEART 5, HVAD 2) underwent the test at our institution. The patients were divided into 2 groups: those who underwent successful LVAD explantation (Group R, n = 6) and those who did not (Group N, n = 25). Echocard...

Midterm Clinical Outcomes of the St Jude Medical Epic Porcine Bioprosthesis in the Mitral Position

BACKGROUNDnThe aim of this single-center study was to report the midterm clinical outcomes and hemodynamic performance of the St Jude Medical Epic porcine bioprosthesis, a tricomposite glutaraldehyde-preserved porcine bioprosthesis, in mitral position. Methodsu2004andu2004Results: Between January 2011 and March 2017, 117 patients (62 men, 55 women; mean age, 66.7±12.8 years) who underwent mitral valve replacement (MVR) with the Epic valve were retrospectively analyzed for early and mid-term morbidity and mortality. The mean follow-up period was 2.6±1.7 years. Three operative deaths occurred, and the operative mortality rate was 2.6%. Sixteen patients died during the follow-up period. On Kaplan-Meier analysis, freedom from all-cause death and major adverse cardiovascular and cerebrovascular events at 5-year follow-up were 80.9% and 54.8%, respectively. There were 6 reoperations: 2 for structural valve deterioration (SVD), 2 for prosthetic valve endocarditis, and 2 for thrombosis. Freedom from valve-related reoperation and SVD at 5 years were 89.0% and 93.1%, respectively. On multivariate analysis, age ≥71 years (HR, 6.78; 95% CI: 2.12-25.2, P<0.01), and NYHA functional class ≥III (HR, 3.20; 95% CI: 1.03-10.4, P=0.04) were independent predictors for all-cause death. Mean mitral pressure gradient at 1 year and 2 years were 5.1±1.9 mmHg and 4.5±1.4 mmHg, respectively.nnnCONCLUSIONSnMid-term clinical results and durability of the Epic valve in the mitral position are satisfactory.