Preoperative dobutamine stress echocardiographic findings and subsequent short-term adverse cardiac events after orthotopic liver transplantation.

Cardiovascular (CV) complications are the leading cause of non-graft-related death in orthotopic liver transplant (OLT) patients. Pretransplant cardiac evaluation using dobutamine stress echocardiography (DSE) is commonly utilized for risk stratification of OLT candidates. To determine if clinical and echocardiographic variables identify patients with increased CV risk, we performed a retrospective chart review of all 284 patients that underwent OLT at our institution between June 1999 and August 2005. Of these patients, 157 had a DSE prior to their OLT. Serious adverse CV events occurring during surgery and up to 4 months post-transplantation were defined as cardiac-related death, myocardial infarction (MI), new heart failure, or asystole or unstable ventricular arrhythmia requiring acute treatment. Sixteen of 157 patients (10%) had an adverse CV event with 2 deaths. These included ventricular tachycardia (n = 8), asystole (n = 2), MI (n = 5), and new heart failure (n = 1). Nine of the 16 CV events occurred at the time of surgery (including both deaths), 5 occurred postoperatively, and 3 occurred after hospital discharge. Variables that correlated with increased CV events were inability during DSE to achieve >82% of the maximum predicted heart rate (22% versus 6%, P = 0.01), a peak rate pressure product during DSE of <16,333 (17% versus 5%, P = 0.02), and a Model for End-Stage Liver Disease (MELD) score of >24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result = 3.78 + 0.07 MELD - 0.05 MAHR) identified a 47% risk for a value > 0 versus a 6% risk for a value < 0 (P < 0.001). In conclusion, the maximum heart rate achieved during DSE together with the MELD score may be a predictor of adverse CV events up to 4 months post-OLT. A large prospective study is needed to more decisively support this conclusion.

Clinical and bone density outcomes of tumor-induced osteomalacia after treatment.

OBJECTIVE: To report the outcomes of tumor-induced osteomalacia after treatment, particularly related to recovery of bone mass. METHODS: We review the clinical course of a 61-year-old man extremely debilitated from multiple fractures and neuromuscular weakness due to tumor-induced osteomalacia and report the changes in biochemical markers and bone density after removal of the causative neoplasm. RESULTS: At the time of diagnosis, the patient's serum phosphorus and 1,25 dihydroxyvitamin D levels were depressed, and his fibroblast growth factor-23 level was markedly elevated. These values normalized 2 days after surgery and remained within their respective reference ranges 4 and 12 months after resection of a mesenchymal tumor. Lumbar bone density values (T-scores) were 0.445 g/cm2 (-5.9) preoperatively, 0.939 g/cm2 (-1.4) 4 months after surgery, and 1.152 g/cm2 (0.7) 12 months after surgery. Left femoral neck values at the same time points were 0.525 g/cm2 (-3.0), 1.035 g/cm2 (-0.8), and 1.184 g/cm2 (1.9). Ultra-distal radius values at the same time points were 0.128 g/cm2 (-7.0), 0.191 g/cm2 (-5.9), and 0.259 g/cm2 (-4.8). In addition, he recovered neuromuscular function and was able to leave his wheelchair. CONCLUSION: Tumor-induced osteomalacia can be an extremely debilitating disease. With successful localization, identification, and resection of the neoplasm, bone mass and physical function can recover.