Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to ...balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation.
Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply.
The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.
The 2018 United Network for Organ Sharing (UNOS) heart transplant policy change (PC) sought to improve waitlist risk stratification to decrease waitlist mortality and promote geographically broader ...sharing for high-acuity patients awaiting heart transplantation. Our analysis sought to determine the effect of the UNOS PC on outcomes in patients waiting for, or who have received, a heart-kidney transplantation.
We analyzed adult (≥18 years old), first-time, heart-only and heart-kidney transplant candidates and recipients from the UNOS Registry. Patients were divided into pre-PC (PRE: October 18, 2016-May 30, 2018) and post-PC (POST: October 18, 2018-May 30, 2020) groups for comparison. Competing risks analysis (subdistribution and cause-specific hazards analyses) was performed to assess for differences in waitlist death/deterioration or heart transplantation. One-year post-transplant survival was assessed with Kaplan-Meier and Cox analyses. We included an interaction term (policy era × heart ± kidney) in our analyses to evaluate the effect of PC on outcomes in heart-kidney patients.
One-year post-transplant survival was similar (p = 0.83) for PRE heart-kidney and heart-only recipients, but worse (p < 0.001) for POST heart-kidney vs heart-only recipients. There was a policy-era interaction between heart-kidney and heart-only recipients (HR 1.921.04,3.55, p = 0.038) indicating a detrimental effect of policy on 1-year survival in POST vs PRE heart-kidney recipients. No added beneficial effect of PC on waitlist outcomes in heart-kidney vs heart-only candidates was observed.
There was no added policy-era benefit on waitlist outcomes for heart-kidney candidates when compared to heart-only candidates. POST heart-kidney recipients experienced worse 1-year survival compared to PRE heart-kidney recipients with no policy effect on heart-only recipients.
A 36 year old woman with history of heart failure and left ventricular assist device (LVAD) implantation, with subsequent explantation after myocardial recovery, presented for management of ...preconception counseling and subsequent pregnancy. To our knowledge, this case represents the first documented successful pregnancy after LVAD explantation. Management details are provided, and relevant literature is reviewed.
To develop a Radiation Therapy Oncology Group (RTOG) atlas delineating gross tumor volume (GTV) and clinical target volume (CTV) to be used for preoperative radiotherapy of primary extremity soft ...tissue sarcoma (STS).
A consensus meeting was held during the RTOG meeting in January 2010 to reach agreement about GTV and CTV delineation on computed tomography (CT) images for preoperative radiotherapy of high-grade large extremity STS. Data were presented to address the local extension of STS. Extensive discussion ensued to develop optimal criteria for GTV and CTV delineation on CT images.
A consensus was reached on appropriate CT-based GTV and CTV. The GTV is gross tumor defined by T1 contrast-enhanced magnetic resonance images. Fusion of magnetic resonance and images is recommended to delineate the GTV. The CTV for high-grade large STS typically includes the GTV plus 3-cm margins in the longitudinal directions. If this causes the field to extend beyond the compartment, the field can be shortened to include the end of a compartment. The radial margin from the lesion should be 1.5 cm, including any portion of the tumor not confined by an intact fascial barrier, bone, or skin surface.
The consensus on GTV and CTV for preoperative radiotherapy of high-grade large extremity STS is available as web-based images and in a descriptive format through the RTOG. This is expected to improve target volume consistency and allow for rigorous evaluation of the benefits and risks of such treatment.
Full text
Available for:
GEOZS, IJS, NUK, OILJ, UL, UM, UPUK
Abstract Purpose After initial surgery, there has been no established consensus regarding adjunctive therapy for patients with uterine carcinosarcoma (CS). This study was designed to compare patient ...outcome following treatment with adjuvant whole abdominal irradiation (WAI) versus (vs.) chemotherapy for patients with this rare group of female pelvic malignancies. Patients and methods Eligible, consenting women with stage I–IV uterine CS, no more than 1 cm postsurgical residuum and/or no extra-abdominal spread had their treatments randomly assigned as either WAI or three cycles of cisplatin (C), ifosfamide (I), and mesna (M). Results 232 patients were enrolled, of whom 206 (WAI = 105; CIM = 101) were deemed eligible. Patient demographics and characteristics were similar between arms. FIGO stage (both arms) was: I = 64 (31%); II = 26 (13%); III = 92 (45%); IV = 24 (12%). The estimated crude probability of recurring within 5 years was 58% (WAI) and 52% (CIM). Adjusting for stage and age, the recurrence rate was 21% lower for CIM patients than for WAI patients (relative hazard RH = 0.789, 95% confidence interval CI: (0.530–1.176), p = 0.245, 2-tail test). The estimated death rate was 29% lower among the CIM group (RH = 0.712, 95% CI: 0.484–1.048, p = 0.085, two-tail test). Conclusion We did not find a statistically significant advantage in recurrence rate or survival for adjuvant CIM over WAI in patients with uterine CS. However, the observed differences favor the use of combination chemotherapy in future trials.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The Federal Drug Agency approved CardioMEMS™ HF device has been shown in a prospective, randomized clinical trial, a long-term observational study, 2 large commercial use cohort studies, and a ...single-center retrospective series to reduce pulmonary artery (PA) pressures and future HF hospitalization rates (Table).3-7 The ability to assess PA pressures via a rapid, accurate and noninvasive method allows health care providers to adjust medications to achieve established PA pressure goals defined from prior clinical trials.8,9 However, in clinical practice, a proportion of patients are unable to reach these desired pressure goals. (2017) NYHA Class III Heart Failure Single-center, retrospective study 66 Improvement in NYHA functional class, 6-minute walk distance and reduction in heart failure hospitalization rates Prior hospitalization for heart failure within prior 12 months 1 A.T. Sandhu, P.A. Heidenreich, Heart failure management with ambulatory pulmonary artery pressure monitoring, Trends Cardiovasc Med, 2017, in press 2 W.T. Abraham, Remote heart failure monitoring, Curr Treat Options Cardiovasc Med., Vol. 15, 2013, 556-564 3 W.T. Abraham, P.B. Adamson, R.C. Bourge, M.F. Aaron, M.R. Costanzo, L.W. Stevenson, Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial, Lancet, Vol. 377, 2011, 658-666 4 W.T. Abraham, L.W. Stevenson, R.C. Bourge, J.A. Lindenfeld, J.G. Bauman, P.B. Adamson, Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial, Lancet, Vol. 387, 2016, 453-461 5 J.T. Heywood, R. Jermyn, D. Shavelle, W.T. Abraham, A. Bhimaraj, K. Bhatt, Impact of practice-based management of pulmonary artery pressures in 2000 patients implanted with the CardioMEMS sensor, Circulation, Vol. 135, 2017, 1509-1517 6 A.S. Desai, A. Bhimaraj, R. Bharmi, R. Jermyn, K. Bhatt, D. Shavelle, Ambulatory hemodynamic monitoring reduces heart failure hospitalizations in “real-world” clinical practice, J Am Coll Cardiol, Vol. 69, 2017, 2357-2365 7 R. Jermyn, A. Alam, J. Kvasic, O. Saeed, U. Jorde, Hemodynamic-guided heart-failure management using a wireless implantable sensor: Infrastructure, methods, and results in a community heart failure disease-management program, Clin Cardiol, Vol. 40, 2017, 170-176 8 M.S. Maurer, P.B. Adamson, M.R. Costanzo, N. Eigler, J. Gilbert, M.R. Gold, Rationale and design of the left atrial pressure monitoring to optimize heart failure therapy study (LAPTOP-HF), J Card Fail, Vol. 21, 2015, 479-488 9 J. Ritzema, R. Troughton, I. Melton, I. Crozier, R. Doughty, H. Krum, Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure, Circulation, Vol. 121, 2010, 1086-1095 10 S.I. Chaudhry, J.A. Mattera, J.P. Curtis, J.A. Spertus, J. Herrin, Z. Lin, Telemonitoring in patients with heart failure, N Engl J Med, Vol. 363, 2010, 2301-2309 11 M. Del Trigo, S. Bergeron, M. Bernier, I.J. Amat-Santos, R. Puri, F. Campelo-Parada, Unidirectional left-to-right interatrial shunting for treatment of patients with heart failure with reduced ejection fraction: a safety and proof-of-principle cohort study, Lancet, Vol. 387, 2016, 1290-1297
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
Intra‐aortic balloon pumps (IABP) are used to bridge select end‐stage heart disease patients to heart transplant (HT). IABP use and exception requests both increased dramatically after the ...UNOS policy change (PC). The purpose of this study was to evaluate the effect of PC and exception status requests on waitlist and post‐transplant outcomes in patients bridged to HT with IABP support.
Methods
We analyzed adult, first‐time, single‐organ HT recipients from the UNOS Registry either on IABP at the time of registration for HT or at the time of HT. We compared waitlist and post‐HT outcomes between patients from the PRE (October 18, 2016 to May 30, 2018) and POST (October 18, 2018 to May 30, 2020) eras using Kaplan‐Meier curves and time‐to‐event analyses.
Results
A total of 1267 patients underwent HT from IABP (261 pre‐policy/1006 post‐policy). On multivariate analysis, PC was associated with an increase in HT (sub‐distribution hazard ratio (sdHR): 2.15, p < .001) and decrease in death/deterioration (sdHR: 0.55, p = .011) on the waitlist with no effect on 1‐year post‐HT survival (p = .8). The exception status of patients undergoing HT was predominantly seen in the POST era (29%, 293/1006); only four patients in the PRE era. Exception requests in the POST era did not alter patient outcomes.
Conclusions
In patients bridged to heart transplant with an IABP, policy change is associated with decreased rates of death/deterioration and increased rates of heart transplantation on the waitlist without affecting 1‐year post‐transplant survival. While exception status use has markedly increased post‐PC, it is not associated with patient outcomes.
Cumulative incidence curves (waitlist outcomes) are shown in the two left columns and Kaplan‐Meier Curves (post‐transplant survival) are in the right two columns. The top row compares outcomes based on policy change era and the bottom row compares outcomes based on exception status; p‐values are shown on the figure.
Full text
Available for:
DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow.
Retrospective chart review.
Level 1 trauma center.
Two hundred and twenty-nine ...patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included.
All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery.
The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint.
Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified.
Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
PDF
