Outcomes of Patients Who Undergo Cardiac Surgical Procedures After Liver Transplantation.

BACKGROUND: There is a paucity of information available regarding the impact of cardiac surgical procedures on patients who have undergone previous liver transplantation. The primary purpose of this study was to ascertain the survival rate and predictors of death in this specific patient population. METHODS: This retrospective cohort study consisted of a consecutive series of patients with a functioning liver allograft who subsequently underwent cardiac surgical procedures between January 1991 and December 2012. The optimal Model for End-Stage Liver Disease (MELD) score for predicting late death was identified using receiver operating characteristic curve analysis. Risk of postoperative death was determined by parametric hazard analysis. RESULTS: Between January 1991 and December 2012, 43 patients (median age, 60 years) underwent cardiac surgical procedures after liver transplantation. The median interval between liver transplant and cardiac operation was 63 months (range, 1.1 to 217 months). Three operative deaths and 24 late deaths occurred. Receiver operating characteristic curve analysis identified the optimal preoperative and postoperative MELD score cut points for predicting late death as greater than 13.8 (area under the curve = 0.674) and greater than 17 (area under the curve = 0.633), respectively. Patients with a preoperative MELD score of 13.8 or less had significantly greater survival rates than those with a MELD score greater than 13.8 (p = 0.028); patients with a postoperative MELD score of 17 of less had significantly greater survival rates than those with a MELD score greater than 17 (p < 0.001). Multivariate parametric hazard analysis identified postoperative peak creatinine level as a statistically significant predictor of death (relative risk, 1.8; p = 0.01). The 1-, 5-, and 10-year Kaplan-Meier survival rates were 90%, 51%, and 35%, respectively; postoperative mortality rates followed a constant phase model with a hazard of death of 10% per year. CONCLUSIONS: Cardiac surgical procedures can be performed with acceptable short-term and long-term outcomes in liver transplant recipients. Elevated preoperative and postoperative MELD scores and postoperative peak creatinine level may portend death in this cohort. There is a constant hazard of death of 10% per year.

Impact of Transcatheter Aortic Valve Replacement on Surgical Volumes and Outcomes in a Tertiary Academic Cardiac Surgical Practice.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) was FDA approved for the Sapien valve (Edwards Lifesciences) in the United States in November 2011. We sought to examine the impact of TAVR post-FDA approval on aortic valve surgery at our institution. STUDY DESIGN: Prospective data were collected on 573 consecutive patients that underwent surgical aortic valve replacement (SAVR) or TAVR with either the Sapien or Sapien XT from January 1, 2009 through December 31, 2014. RESULTS: Patients were divided into the following groups: SAVR before TAVR (n = 215), SAVR post TAVR (n = 163), and TAVR (n = 195). The 30-day mortality was not different among the 3 groups, but the mortality for the SAVR post TAVR group was better than the SAVR before TAVR group (p = 0.03). Postoperative hospital length of stay, ventilation hours, and atrial fibrillation were all decreased in the TAVR group. The number of isolated SAVRs increased after TAVR from 60 per year in group 1 to 67 per year in group 2. The total number of all isolated aortic valve procedures (SAVR + TAVR) increased from 60 per year to 177 per year. The TAVR group was divided into the following subgroups to examine the procedural learning curve: patients 1 to 50, patients 51 to 100, and patients 101 to 195. Mortality was higher in group 1 (8%) vs group 2 (0%) and group 3 (1%). CONCLUSIONS: Since initiation of the TAVR program at our institution, the total number of aortic valve procedures has increased. Transcatheter aortic valve replacement patients had more preoperative comorbidities, but no difference in postoperative morbidity or mortality and shorter length of stay. Transcatheter aortic valve replacement mortality has continued to improve since the inception of the program.

Enterocolitis associated with cocaine use.

PURPOSE: Cocaine use has been reported to cause gastrointestinal complications. This retrospective review describes the presentation and clinical course of cocaine-associated enterocolitis. METHODS: Charts with a diagnoses of colitis or abdominal pain, between 1991 to 2001, were reviewed for a positive urine drug screen or documented cocaine use. Data about the patients' symptoms and physical findings, results of clinical studies, and outcome were collected. RESULTS: There were 18 patients identified. The interval from last use to the onset of pain was fewer than one day for seven patients, one to three days for seven patients, and more than three days for four patients. Physical examination demonstrated diffuse peritonitis in 2 patients, tenderness localized to a single quadrant in 11 patients, and tenderness in two or more quadrants in 5 patients. Computed tomography was obtained in 11 patients with 10 demonstrating signs of inflammation or ischemia. The anatomic locations of disease were proximal colon (14 patients), small bowel/gastric (1 patient), and distal colon (3 patients). The initial management was nonoperative in 15 patients. One patient presented in shock and died. Another developed peritonitis and underwent laparotomy. Surgical intervention occurred in four patients (3 initially, 1 on Day 4) for peritonitis. Two died postoperatively, a 50-percent surgical mortality. CONCLUSIONS: Cocaine-associated enterocolitis usually presents within three days of cocaine use. Inflammatory or ischemic changes are most common in the proximal colon. The majority of patients will recover with nonoperative therapy; however, those who develop peritonitis and undergo laparotomy have a 50 percent mortality.