Liver health in adults with Fontan circulation: A multicenter cross-sectional study Wu, Fred M., MD; Kogon, Brian, MD; Earing, Michael G., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
03/2017, Letnik:
153, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Abstract Objectives Liver disease is an important contributor to morbidity and mortality in patients after Fontan surgery. There has been no large-scale survey of liver health in this population. We ...sought to explore the prevalence and predictors of liver disease in a multicenter cohort of adults with Fontan physiology. Methods Subjects were recruited from 6 adult congenital heart centers. Demographics; clinical history; and laboratory, imaging, and histopathology data were obtained. Results Of 241 subjects (median age 25.8 years 11.8-59.4, median time since Fontan 20.3 years 5.4-34.5), more than 94% of those who underwent testing (208 of 221) had at least 1 abnormal liver-related finding. All hepatic imaging (n = 54) and liver histology (n = 68) was abnormal. Subjects with abnormal laboratory values had higher sinusoidal fibrosis stage (2 vs 1, P = .007) and higher portal fibrosis stage (3 vs 1, P = .003) compared with those with all normal values. Low albumin correlated with lower sinusoidal fibrosis stage (1 vs 2; P = .02) and portal fibrosis stage (0 vs 3, P = .002); no other liver studies correlated with fibrosis. Regenerative nodules were seen on 33% of histology specimens. Conclusions Regardless of modality, findings of liver disease are common among adults with Fontan circulation, even those appearing clinically well. Cirrhosis is present in up to one-third of subjects. Correlations between hepatic fibrosis stage and clinical history or findings on noninvasive testing are few. Further research is needed to identify patients at risk for more severe liver disease and to determine the best methods for assessing liver health in this population.
Objective We have analyzed short- and long-term variations of pulmonary function in locally advanced non–small cell lung cancer after induction chemoradiotherapy. Methods Twenty-seven patients with ...stage IIIA (N2) non–small cell lung cancer underwent resection with radical intent after induction chemoradiotherapy in the period 2003 to 2006. Pulmonary function has been evaluated by spirometry, diffusing capacity of the lung for carbon monoxide, and blood gas analysis before induction chemoradiotherapy (T0), 4 weeks after induction chemoradiotherapy and before surgery (T1), and 1 (T2), 3 (T3), 6 (T4), and 12 months (T5) after surgery. Results A 22.80% decrease of diffusing capacity of the lung for carbon monoxide ( P < .001) was observed at T1. At T2 significant decreases in the following were present: vital capacity, −20.50% ( P < .001); forced vital capacity, −22.50% ( P < .001); forced expiratory volume in 1 second, −23.00% ( P < .001); peak expiratory flow, −29.0 ( P < .001); forced expiratory flow 25% to 75%, −13.7% ( P = .005); and diffusing capacity of the lung for carbon monoxide, 43.6% ( P < .001). However, in the interval between T2 and T5, a progressive improvement of lung function in most parameters was observed, but only diffusing capacity of the lung for carbon monoxide presented a significant increase ( P < .001). Within the same time gap (T2 to T5), subjects 65 years of age or younger showed an increasing trend for vital capacity, forced expiratory volume in 1 second, total lung capacity, and residual volume significantly different from that of elderly patients, in whom a decrease in these parameters is reported. Conclusions An impairment of respiratory function is evident in the immediate postoperative setting in patients with non–small cell lung cancer receiving induction chemoradiotherapy. In the long-term period, a general recovery in diffusing capacity of the lung for carbon monoxide was found, whereas an improvement of forced expiratory volume in 1 second, vital capacity, total lung capacity, and residual volume was detected in the younger population only.
Abstract Congenital heart disease (CHD) is the most common birth defect, affecting about 0.8% of live births. Advances in recent decades have allowed >85% of children with CHD to survive to ...adulthood, creating a growing population of adults with CHD. Little information exists regarding survival, demographics, late outcomes, and comorbidities in this emerging group, and multiple barriers impede research in adult CHD. The National Heart, Lung, and Blood Institute and the Adult Congenital Heart Association convened a multidisciplinary working group to identify high-impact research questions in adult CHD. This report summarizes the meeting discussions in the broad areas of CHD-related heart failure, vascular disease, and multisystem complications. High-priority subtopics identified included heart failure in tetralogy of Fallot, mechanical circulatory support/transplantation, sudden cardiac death, vascular outcomes in coarctation of the aorta, late outcomes in single-ventricle disease, cognitive and psychiatric issues, and pregnancy.
Left ventricular (LV) systolic dysfunction has been observed in patients with repaired tetralogy of Fallot (TOF), although its clinical associations are unknown. Adults with repaired TOF were ...identified from 11 adult congenital heart disease centers. Clinical history was reviewed. Patients with pulmonary atresia were excluded. Echocardiograms were reanalyzed to estimate LV ejection fraction. LV function was defined as normal (LV ejection fraction ≥55%) or mildly (45% to 54%), moderately (35% to 44%), or severely (<35%) decreased. Right ventricular (RV) and LV dimensions and Doppler parameters were remeasured. Function of all valves was qualitatively scored. Of 511 patients studied, LV systolic dysfunction was present in 107 (20.9%, 95% confidence interval 17.4 to 24.5). Specifically, 74 (14.4%) had mildly decreased and 33 (6.3%) had moderately to severely decreased systolic function. Presence of moderate to severe LV dysfunction was associated with male gender, LV enlargement, duration of shunt before repair, history of arrhythmia, QRS duration, implanted cardioverter–defibrillator, and moderate to severe RV dysfunction. Severity or duration of pulmonary regurgitation was not different. In conclusion, LV systolic dysfunction was found in 21% of adult patients with TOF and was associated with shunt duration, RV dysfunction, and arrhythmia.
Abstract Background and Objectives The present study aimed to evaluate the prognostic impact of predialysis dysnatremia in patients with acute kidney injury requiring renal replacement therapy (RRT). ...Design, Setting, Participants, and Measurements A secondary analysis of a prospective multicenter cohort study was performed. Serum sodium (Na) concentrations were categorized immediately before the first RRT as normonatremia (135 ≤ Na ≤ 145 mEq/L), hyponatremia (mild 130 ≤ Na ≤ 134 mEq/L or severe Na ≤ 129 mEq/L), and hypernatremia (mild 146 ≤ Na ≤ 155 mEq/L or severe Na ≥ 156 mEq/L). Multivariable logistic regression was used to estimate the impact of sodium levels categories on hospital mortality. Results Dysnatremia occurred in 47.3% of 772 included patients. Hypernatremia was more frequent than hyponatremia (33.7% vs 13.6%, P = .001). Intensive care unit (ICU) and hospital mortality rates were 64.6% and 69%, respectively. Hospital mortality was higher in severe hypernatremia (89.1% 95% confidence interval {CI}, 78.7%-95.8% vs 64.6% CI, 59.8%-69.2%, P < .001, in normonatremia). Older patients, clinical admission, number of comorbidities, length of ICU stay before the beginning of RRT, and the number of organ dysfunctions were associated with higher hospital mortality. In multivariate analysis, severe hypernatremia (odds ratio, 2.87; 95% CI, 1.2-6.9), poor chronic heath status, severity of illness, sepsis, and lactate were independently associated with outcome. Conclusion Almost 50% of patients with acute kidney injury in need of RRT in the ICU had mild or severe dysnatremia before dialysis initiation. Hypernatremia was the main sodium disturbance and independently associated with poor outcome in the study population.
Abstract Background Our purpose was to assess the prevalence and clinical implications of left ventricular (LV) and right ventricular (RV) diastolic dysfunction (DD) in patients with repaired ...tetralogy of Fallot (TOF). Methods Adults with repaired TOF at 11 North American congenital heart disease centres were included. Of 556 patients analyzed, 325 had sufficient Doppler data to evaluate for LV DD, defined as mitral lateral e′ < 10 cm/s and E/e′ ratio > 9. Abnormal RV diastolic function was defined as tricuspid E/A ratio of 0.8 to 2.1 with E/e′ ratio > 6 or a tricuspid ratio E/A > 2.1 with a deceleration time < 120 milliseconds, and 105 patients were found to have sufficient Doppler data. Results Abnormal LV diastolic Doppler indices were prevalent in 13.8% and associated with hypertension, dyslipidemia, 3 or more cardiac operations, and a history of ventricular tachycardia. Abnormal RV indices were prevalent in 52.4% and associated with hypertension, dyslipidemia, diabetes mellitus, and 3 or more cardiac operations. Ventricular tachycardia was more common in those with abnormal RV diastolic function. Conclusion Further prospective studies are needed to evaluate these associations with DD and the impact of treatment risk factors on diastolic function and arrhythmia burden.
Objective To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. Study design This was a ...retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. Results A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = −3.23; 95% confidence interval CI = −4.48 to −1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the “other” category (difference = −3.34, 95% CI = −5.40 to −1.27 and −3.12, 95% CI = −5.25 to −0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = −2.75; 95% CI = −5.40 to −0.05). Older children received better care. Conclusions The quality of care provided to children is associated with age, hospital setting, and physician training.
Deficits of physical function are associated with poor quality of life and adverse health outcomes, but data informing the association of these assessments among Black and Hispanic outpatients with ...heart failure (HF) are limited.
The multicentre, prospective Screening for Cardiac Amyloidosis With Nuclear Imaging for Minority Populations (SCAN-MP) study identified Black and Hispanic subjects with stable HF, collected baseline characteristics, and took measures using the short physical performance battery. Subjects completed a Kansas City Cardiomyopathy Questionnaire (KCCQ), and the clinical outcomes of HF hospitalization and death were ascertained by telephone and review of the electronic health record.
Of 320 participants, 227 (70.9%) had physical deficits, defined by a battery score of ≤ 9. Patients with severe physical deficits reported overall lower KCCQ scores compared to those with no deficits (KCCQ score of 57.0 vs 72.4, P < 0.001). Physical limitation was significantly associated with risk of HF hospitalization, after adjustments for age, sex, and New York Heart Association class (severe physical deficit hazard ratio, 3.61; 95% confidence interval CI, 1.19-10.93; P = 0.024; mild physical deficit hazard ratio, 2.59; 95% CI, 0.86-7.75; P = 0.090).
Reduced physical performance is highly prevalent among Black and Hispanic outpatients with HF, and it is associated with overall KCCQ score, as well as an increased risk for HF hospitalization.
La limitation physique est associée à une détérioration de la qualité de vie et à une aggravation de l’état de santé, mais il y a peu de données sur la corrélation entre ces paramètres chez les patients externes noirs et hispaniques atteints d’insuffisance cardiaque.
Dans l’étude multicentrique et prospective de dépistage de l’amylose cardiaque chez les populations minoritaires (SCAN-MP), on a ciblé des sujets noirs et hispaniques atteints d’insuffisance cardiaque stable, recueilli les caractéristiques initiales et mesuré les capacités au moyen du court test d’évaluation de la performance physique (short physical performance battery SPPB). Les sujets ont répondu au questionnaire de cardiomyopathie de Kansas City (KCCQ), et les critères cliniques des hospitalisations et des décès liés à l’insuffisance cardiaque ont été évalués par téléphone et par examen des dossiers de santé électroniques.
Des 320 participants, 227 (70,9 %) avaient des déficits physiques, définis par un score au SPPB de 9 ou moins. Les patients ayant des déficits physiques graves ont obtenu des scores globaux au KCCQ inférieurs aux patients sans déficit (score KCCQ de 57,0 contre 72,4; p < 0,001). La limitation physique est fortement associée au risque d’hospitalisation liée à l’insuffisance cardiaque, après ajustement pour tenir compte de l’âge, du sexe et de la classe d’insuffisance cardiaque de la New York Heart Association (rapport des risques instantanés RRI du déficit physique grave : 3,61; intervalle de confiance IC à 95 % de 1,19 à 10,93; p = 0,024; RRI du déficit physique léger : 2,59; IC à 95 % de 0,86 à 7,75; p = 0,090).
La diminution de la performance physique est très fréquente chez les patients externes noirs et hispaniques atteints d’insuffisance cardiaque, et elle est corrélée au score global au KCCQ ainsi qu’à une augmentation du risque d’hospitalisation liée à l’insuffisance cardiaque.
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Summary In acute rejection after renal transplant, glomerulitis is characterized by mononuclear cells in glomerular capillaries and endothelial cell enlargement. In association with C4d deposition in ...peritubular capillaries, glomerulitis is a feature of acute antibody-mediated rejection. Prognosis in C4d+ rejection is poorer than in C4d− rejection. We measured the glomerular endothelial cell area in C4d+ and C4d− acute rejections by morphometry. In 90 acute rejection biopsies, glomerulitis was present in 36 cases (group G) and absent in 54 (group G0). In biopsies without rejections and in C4d− biopsies of group G0, glomerular endothelial cell area was not significantly different. In C4d− and C4d+ biopsies of group G, the area in inflamed glomeruli was greater than that in C4d− biopsies of group G0 ( P < .02 and P < .006, respectively). In C4d+ biopsies of group G0, it was, unexpectedly, greater than in C4d− biopsies of group G ( P < .01). Circulating posttransplant anti–human leukocyte antigen class I and class II antibodies correlated with increased endothelial cell area ( P < .02). Glomerulitis was associated with diffuse C4d deposition (odds ratio OR, 4.27; P < .004); C4d deposition was associated with steroid resistance (OR, 4.97; P < .002). Only in C4d+ rejections did the presence of glomerulitis increase this association (OR, 9.17; P < .02). In conclusion, we quantified an increase of endothelial cell area in glomerulitis of C4d+ and C4d− acute rejections (group G). An increase of this area in C4d+ biopsies without glomerulitis (group G0) suggests complement-mediated damage in the absence of mononuclear cell margination.
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