Abdominal Aortic Aneurysm in Heart Transplant Recipients: New Insights from a 30-year Experience at a Single Center.

BACKGROUND: The improvement in survival rates for heart transplant recipients (HTRs) has increased their risk of developing extracardiac diseases such as abdominal aortic aneurysms (AAAs). The purposes of this study were to evaluate the prevalence and to describe the clinical features and natural history of AAA in HTRs. METHODS: A retrospective review of all patients (375) who underwent heart transplantation (HT) at our center over a 32-year period (1983-2015) was carried out. RESULTS: We identified 20 patients (5.3%) with AAA. All but one patient were male (95%), and most of them (80%) had a history of ischemic heart disease (IHD) prior to transplantation. The mean age of the patients with AAA at transplant was 57.2 ± 7.3 years (range: 42-62 years). Seven of the 20 patients with AAA already had an AAA (30-55 mm) prior to transplantation. The average aneurysm size at the time of diagnosis was 40.9 ± 9.6 mm, and the average patient age at the time of diagnosis was 62.2 ± 8.3 years. The mean linear expansion rate was 10.6 ± 2.12 mm/y, and the exponential expansion rate was 0.220 ± 0.040 year-1, respectively. The median follow-up time was 5.4 years (range 0.1-27.4 years). The median survival was 143 months (95% confidence interval (CI) 65 to 180 months) for the 20 HTRs with AAA and 68.8 months (95% CI 46 to 88 months) for the other HTRs. CONCLUSIONS: The natural history of AAA in HTR is characterized by an increased expansion rate. Male HTR with end-stage IHD are particularly at risk and should be closely followed-up after HT.

Efficacy of the RemoweLL cardiotomy reservoir for fat and leucocyte removal from shed mediastinal blood: a randomized controlled trial.

INTRODUCTION: Re-transfusion of lipid particles and activated leucocytes with shed mediastinal blood (SMB) can aggravate cardiopulmonary bypass-associated inflammation and increase the embolic load. This study evaluated the fat and leucocyte removal capacity of the RemoweLL cardiotomy reservoir. METHODS: Forty-five patients undergoing elective on-pump cardiac surgery were randomly allocated to filtration of SMB using the RemoweLL or the Admiral cardiotomy reservoir. The primary outcome was a drop in leucocytes and lipid particles obtained with the two filters. The effect of the filters on other blood cells and inflammatory mediators, such as myeloperoxidase (MPO), was also assessed. RESULTS: The RemoweLL cardiotomy filter removed 16.5% of the leucocytes (p<0.001) while no significant removal of leucocytes was observed with the Admiral (p=0.48). The percentage reductions in lipid particles were similar in the two groups (26% vs 23%, p=0.2). Both filters similarly affected the level of MPO (p=0.71). CONCLUSION: The RemoweLL filter more effectively removed leucocytes from SMB than the Admiral. It offered no advantage in terms of lipid particle clearance.

Hydroxyethyl Starch 130/0.4 and the Risk of Acute Kidney Injury After Cardiopulmonary Bypass: A Single-Center Retrospective Study.

OBJECTIVES: To investigate whether using hydroxyethyl starch (HES) 130/0.4 as a pump prime and for intraoperative fluid therapy is associated with postoperative acute kidney injury (AKI) after adult cardiac surgery. DESIGN: Retrospective observational study. SETTING: University hospital, single center. PARTICIPANTS: Six hundred six adult patients who underwent on-pump cardiac surgery between April 2013 and June 2014 were included. INTERVENTIONS: Until July 2013, balanced HES 130/0.4 (Volulyte(®), Fresenius Kabi AG, Bad Homburg, Germany) was used both as a pump prime (1,500 mL) and for intraoperative fluid therapy (1,000 mL). From August 2013, HES was replaced entirely by a balanced crystalloid solution (Plasma-Lyte A, Baxter, Lessines, Belgium). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the incidence of postoperative AKI during the first 48 postoperative hours, determined using the Acute Kidney Injury Network classification. Secondary outcomes included kidney function at postoperative day 7, postoperative dialysis or hemofiltration, postoperative pulmonary complications, lengths of intensive care unit and hospital stays, postoperative fluid balance and urinary output, surgical revision for bleeding, and 30-day mortality. Multivariable logistic regression was used to adjust for confounders. AKI occurred in 9.5% of crystalloid patients and in 21.5% of HES patients. Patients who received HES were about twice as likely to develop postoperative AKI as those treated with crystalloids (adjusted OR 2.26; 95% CI, 1.40-3.80; p = 0.02). HES patients also had a significantly more positive fluid balance and a lower urinary output during the first 48 postoperative hours. The incidence of surgical revision for bleeding was greater in the HES group (4.6% v 1.4%, p = 0.02). CONCLUSION: This study suggested that using balanced HES 130/0.4 as a pump prime and for intraoperative fluid therapy in adult patients undergoing on-pump cardiac surgery was associated with a greater incidence of AKI during the early postoperative period.

Incidence and outcomes of acute kidney injury after cardiac surgery using either criteria of the RIFLE classification.

BACKGROUND: Adult cardiac surgery is significantly associated with the development of acute kidney injury (AKI). Still, the incidence and outcomes of AKI vary according to its definition. Our retrospective monocentric study comparatively investigates the yield of RIFLE definition, which is based on the elevation of serum creatinine levels (SCr) or the reduction of urine output (UO), taking into account only one or both criteria. Pre- and per-operative risk factors for post-operative AKI were evaluated. METHODS: All adult patients undergoing cardiac surgery, with or without cardiopulmonary bypass, from April 2008 to March 2009 were included. Clinical, biological and surgical features were recorded. Baseline serum creatinine was determined as its value on day 7 before surgery. Post-operative AKI was diagnosed and scored based upon the highest serum creatinine and/or the lowest urine output. RESULTS: 443 patients (Male/Female ratio, 2.3; median age, 69y) were included, with 221 (49.9%) developing postoperative AKI. Elevated serum creatinine (AKISCr) and oliguria (AKIUO) was observed in 9.7% and 40.2%, respectively. AKI patients had a significantly higher BMI and baseline SCr. In comparison to AKIUO, AKISCr mostly occurred in patients with co-morbidities, and was associated with an increased mortality at 1-year post surgery. CONCLUSIONS: The use of standard RIFLE definition of AKI in a cohort of 443 patients undergoing cardiac surgery resulted in an incidence reaching 50%. Still, significant discrepancies were found between AKISCr and AKIUO regarding the incidence and outcomes. In line with previous reports, our data questions the utility of urine output as a criterion for AKI diagnosis and management after cardiac surgery.

The effect of intraoperative 6% balanced hydroxyethyl starch (130/0.4) during cardiac surgery on transfusion requirements.

OBJECTIVES: To compare transfusion requirements in adult cardiac surgery patients when balanced hydroxyethyl starches (HES) (130/0.4) or balanced crystalloids is used for pump prime and intraoperative fluid therapy. DESIGN: Data were obtained retrospectively from medical records and perfusion charts. Matching based on propensity scores was used to adjust for potential confounders. SETTING: A university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery with the use of cardiopulmonary bypass. INTERVENTIONS: Allocation to one of the study groups according to whether balanced HES or balanced crystalloids was used for pump prime and intraoperative fluid therapy. MEASUREMENTS AND MAIN RESULTS: 240 propensity-matched patients were retained for final analyses. Forty-eight patients (40%) of the colloid group and 28 patients (23.3%) of the crystalloid group received blood products, with an odd ratio (95% CI) of 2.1(1.2-3.8 (P=0.009). After bypass HES patients had lower hemoglobin levels (8.4 [1.3] gr/dL vs 9.6 [2] gr/dL; P<0.001) and a higher cumulative chest drain output after 3 hours (180 [210] mL vs 140 [100] mL, P<0.001]. Heparinase thromboelastogram (TEG®) showed longer K times (2.5[1.1] vs 1.6[0.8], P<0.001) and lower maximal amplitudes (55.1[12.5] vs 63.4[9.8], P=0.008). CONCLUSIONS: HES patients required more transfusions, owing to greater hemodilution, HES-induced clotting disturbances, and bleeding.