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Donna Mancini - One of the best experts on this subject based on the ideXlab platform.
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mechanical circulatory support as a bridge to cardiac Retransplantation a single center experience
Journal of Heart and Lung Transplantation, 2015Co-Authors: K J Clerkin, Sunu S Thomas, Jennifer Haythe, Christian P Schulze, Maryjane Farr, Hiroo Takayama, Ulrich P Jorde, S Restaino, Yoshifumi Naka, Donna ManciniAbstract:Background Cardiac Retransplantation is increasing in frequency. Recent data have shown that Retransplantation outcomes are now comparable with primary transplantation. The use of mechanical circulatory support (MCS) as a bridge to Retransplantation has similar post-retransplant outcomes to those without MCS, but the success of bridging patients to retransplant with MCS has not been well studied. Methods From January 2000 to February 2014 at Columbia University Medical Center, 84 patients were listed for Retransplantation. Of this cohort, 48 patients underwent Retransplantation, 15 were bridged with MCS, 24 died, and 6 clinically improved. A retrospective analysis was performed examining waiting list time, survival to Retransplantation, and survival after retransplant. The effect of the United Network of Organ Sharing (UNOS) allocation policy change in 2006 on waiting list time and MCS use was also investigated. Results Of 48 patients who underwent Retransplantation, 11 were bridged with MCS. Overall 1-year survival to Retransplantation was 81.3%. There was no significant difference in waiting list survival ( p = 0.71) in those with and without MCS. Death from cardiac arrest or multiorgan failure with infection was more frequent in the medically managed group ( p = 0.002). After the UNOS 2006 allocation policy change, waiting list time (599 ± 936 days in Era 1 vs 526 ± 498 days in Era 2, p = 0.65) and waiting list survival ( p = 0.22) between eras were comparable, but there was a trend toward greater use of MCS ( p = 0.13). Survival after retransplant was acceptable. Conclusion The use of MCS as a bridge to cardiac Retransplantation is a reasonable strategy.
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heart Retransplantation
American Journal of Transplantation, 2007Co-Authors: Maryl R Johnson, Branislav Radovancevic, Keith D Aaronson, Charles E Canter, J K Kirklin, Donna Mancini, Mandeep R Mehra, David O Taylor, S A WebberAbstract:Retransplants comprise only a small minority (3–4%) of heart transplants, however outcome following Retransplantation is compromised. Risk factors for a poor outcome following Retransplantation include Retransplantation early (<6 months) after primary transplant, Retransplantation for acute rejection or early allograft failure, and Retransplantation in an earlier era. The incidence of rejection and infection is similar following primary transplant and Retransplantation. The compromised outcomes and risk factors for a poor outcome are similar in adult and pediatric heart Retransplantation. However, due to the short half-life of the transplanted heart, it is an expectation that patients transplanted in childhood may require Retransplantation. Based on the data available and the opinion of the working group, indications for heart Retransplantation are (i) chronic severe cardiac allograft vasculopathy with symptoms of ischemia or heart failure (should be considered) or asymptomatic moderate or severe left ventricular dysfunction (may be considered) or (ii) chronic graft dysfunction with symptoms of progressive heart failure in the absence of active rejection. Patients with graft failure due to acute rejection with hemodynamic compromise, especially <6 months post-transplant, are inappropriate candidates for Retransplantation. In addition, guidelines established for primary transplant candidacy should be strictly followed.
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long term survival after cardiac Retransplantation a twenty year single center experience
The Journal of Thoracic and Cardiovascular Surgery, 1999Co-Authors: Ranjit John, Jonathan M. Chen, Craig R. Smith, Eric A. Rose, Donna Mancini, Alan D Weinberg, Silviu Itescu, Mark Galantowicz, Niloo M EdwardsAbstract:Objective: To identify risk factors for survival after cardiac Retransplantation and compare the survival after Retransplantation with that after primary cardiac transplantation. Methods: A retrospective analysis of 952 patients undergoing cardiac transplantation for the treatment of end-stage heart disease at a single center between 1977 and October 1997. Of these, 43 patients (4.5%) underwent cardiac Retransplantation for cardiac failure resulting from transplant-related coronary artery disease, rejection, and early graft failure. Results: No significant difference in actuarial patient survival was found by Kaplan-Meier analysis at 1, 2, and 5 years between patients undergoing primary transplantation and those undergoing Retransplantation—76%, 71%, and 60% versus 66%, 66%, and 51%, respectively (P = .2). Multivariable analysis identified a shorter interval between transplants and an initial diagnosis of ischemic cardiomyopathy as significant risk factors for death after Retransplantation (P = .04 and .03, respectively). Since 1993, when our criteria for patient selection for Retransplantation were revised on the basis of earlier experience to exclude patients with allograft dysfunction as a result of primary graft failure and those with intractable acute rejection occurring less than 6 months after transplantation, the survival has been significantly better (<1993 = 45%, 45%, and 33% versus ≥1993 = 94%, 94%, and 94% at 1, 2, and 4 years, respectively, P = .003). Conclusion: The long-term outcome of cardiac Retransplantation is comparable with that of primary transplantation, especially in patients with transplant-related coronary artery disease. Patient characteristics and other preoperative variables should assist in the rational application of Retransplantation to ensure optimal use of donor organs. (J Thorac Cardiovasc Surg 1999;117:543-55)
Andrew J. Muir - One of the best experts on this subject based on the ideXlab platform.
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outcomes of liver Retransplantation in patients with primary sclerosing cholangitis
Liver Transplantation, 2017Co-Authors: Jacqueline B. Henson, Yuval A. Patel, Lindsay Y. King, Jiayin Zheng, Shein-chung Chow, Andrew J. MuirAbstract:Liver Retransplantation in patients with primary sclerosing cholangitis (PSC) has not been well studied. The aims of this study were to characterize patients with PSC listed for and undergoing Retransplantation and to describe the outcomes in these patients. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database was used to identify all primary liver transplantations and subsequent relistings and first Retransplantations in adults with PSC between 1987 and 2015. A total of 5,080 adults underwent primary transplantation for PSC during this period, and of the 1,803 who experienced graft failure, 762 were relisted, and 636 underwent Retransplantation. Younger patients and patients with graft failure due to vascular thrombosis or biliary complications were more likely to be relisted, while those with Medicaid insurance or graft failure due to infection were less likely. Both five-year graft and patient survival after Retransplantation were inferior to primary transplantation (p=0.001). Five-year survival after Retransplantation for disease recurrence, however, was similar to primary transplantation (graft survival, p=0.45; patient survival, p=0.09) and superior to other indications for Retransplantation (graft and patient survival, p<0.001). On multivariate analysis, mechanical ventilation, creatinine, bilirubin, albumin, advanced donor age, and a living donor were associated with poorer outcomes after Retransplantation. Conclusion: While survival after liver Retransplantation in patients with PSC was overall inferior to primary transplantation, outcomes after Retransplantation for PSC recurrence were similar to primary transplantation at five years. Retransplantation may therefore represent a treatment option with the potential for excellent outcomes in patients with recurrence of PSC in the appropriate clinical circumstances. This article is protected by copyright. All rights reserved.
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Outcomes of liver Retransplantation in patients with primary sclerosing cholangitis
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation S, 2017Co-Authors: Jacqueline B. Henson, Yuval A. Patel, Lindsay Y. King, Jiayin Zheng, Shein-chung Chow, Andrew J. MuirAbstract:Liver Retransplantation in patients with primary sclerosing cholangitis (PSC) has not been well studied. The aims of this study were to characterize patients with PSC listed for and undergoing Retransplantation and to describe the outcomes in these patients. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database was used to identify all primary liver transplantations and subsequent relistings and first Retransplantations in adults with PSC between 1987 and 2015. A total of 5,080 adults underwent primary transplantation for PSC during this period, and of the 1,803 who experienced graft failure, 762 were relisted, and 636 underwent Retransplantation. Younger patients and patients with graft failure due to vascular thrombosis or biliary complications were more likely to be relisted, while those with Medicaid insurance or graft failure due to infection were less likely. Both five-year graft and patient survival after Retransplantation were inferior to primary transplantation (p=0.001). Five-year survival after Retransplantation for disease recurrence, however, was similar to primary transplantation (graft survival, p=0.45; patient survival, p=0.09) and superior to other indications for Retransplantation (graft and patient survival, p
Thomas E. Starzl - One of the best experts on this subject based on the ideXlab platform.
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Hepatic Retransplantation in Cholestatic Liver Disease: Impact of the Interval to Retransplantation on Survival and Resource Utilization
Hepatology (Baltimore Md.), 1999Co-Authors: W. Ray Kim, Goran B. Klintmalm, Russell H. Wiesner, John J. Poterucha, Terry M. Therneau, Michael Malinchoc, Joanne T. Benson, Jeffrey S. Crippin, Jorge Rakela, Thomas E. StarzlAbstract:The aim of our study was to quantitatively assess the impact of hepatic Retransplantation on patient and graft survival and resource utilization. We studied patients undergoing hepatic Retransplantation among 447 transplant recipients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) at 3 transplantation centers. Cox proportional hazards regression analysis was used for survival analysis. Measures of resource utilization included the duration of hospitalization, length of stay in the intensive care unit, and the duration of transplantation surgery. Forty-six (10.3%) patients received 2 or more grafts during the follow-up period (median, 2.8 years). Patients who underwent Retransplantation had a 3.8-fold increase in the risk of death compared with those without Retransplantation (P < .01). Retransplantation after an interval of greater than 30 days from the primary graft was associated with a 6.7-fold increase in the risk of death (P < .01). The survival following Retransplantations performed 30 days or earlier was similar to primary transplantations. Resource utilization was higher in patients who underwent multiple consecutive transplantations, even after adjustment for the number of grafts during the hospitalization. Among cholestatic liver disease patients, poor survival following hepatic Retransplantation is attributed to late Retransplantations, namely those performed more than 30 days after the initial transplantation. While efforts must be made to improve the outcome following Retransplantation, a more critical evaluation may be warranted for late Retransplantation candidates.
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hepatic Retransplantation an analysis of risk factors associated with outcome
Transplantation, 1996Co-Authors: Howard R Doyle, Thomas E. Starzl, Franca Morelli, John Mcmichael, Cataldo Doria, Luca Aldrighetti, Ignazio R MarinoAbstract:Hepatic Retransplantation is controversial because the results are inferior to primary transplants and organs are so scarce. To determine the factors that are associated with poor outcome within the first year following Retransplantation, we performed a multivariate analysis, using stepwise logistic regression, of 418 hepatic Retransplantations performed at a single institution from November 1987 to December 1993. The minimum follow-up was 1 year. Seven variables were found to be independently associated with subsequent graft failure (defined as either patient death or Retransplantation): donor age (odds ratio 2.2 for each 10-year increase over age 45, 95% CI 1.3 to 3.7), female donor sex (odds ratio 1.7, 95% CI 1.05 to 2.7), recipient age (odds ratio 1.6 for each 10-year increase over age 45, 95% CI 1.2 to 2.3), need for preoperative mechanical ventilation (odds ratio 1.8, 95% CI 1.1 to 2.9), pretransplant serum creatinine (odds ratio 1.24 for each increase of 1 mg/dl, 95% CI 1.1 to 1.4), pretransplant total serum bilirubin (odds ratio 1.4 for each 10-mg/dl increase over 15 mg/dl, 95% CI 1.1 to 1.8), and the primary immunosuppressant, using tacrolimus as the reference category (odds ratio for cyclosporine-based immunosuppression 3.9, 95% CI 2.3 to 6.8). Although not part of the logistic regression model, the timing of Retransplantation was also found to be important, with the overall probability of failure increasing from 0.58 on day 0 to a peak of 0.8 on day 38 and decreasing slowly after that. The implications of these results regarding the appropriateness of Retransplantation are discussed.
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early death or Retransplantation in adults after orthotopic liver transplantation can outcome be predicted
Transplantation, 1994Co-Authors: Howard R Doyle, John Mcmichael, Ignazio R Marino, John J Fung, Nicholas Jabbour, Giorgio Zetti, Sandi Mitchell, Thomas E. StarzlAbstract:Early, reliable outcome prediction after a liver transplant would help improve organ use by minimizing unnecessary Retransplantations. At the same time, early intervention in those cases destined to fail may ameliorate the high morbidity and mortality associated with Retransplantation. The purpose of this study was to analyze several parameters that have been identified in the past as being associated with patient and graft outcome, and to try to develop a model that would allow us to make predictions based on data available in the early postoperative period. A total of 148 patients were followed in a prospective, observational study. Graft failure was defined as patient death or Retransplantation within 3 months of surgery. Preoperative variables studied included patient demographics, need for life support, presence of ascites, serum bilirubin, serum albumin, prothrombin time, serum creatinine, and the results of the cytotoxic crossmatch. During the first 5 postoperative days, standard measurements included serum transaminases, serum bilirubin, ketone body ratio, prothrombin time, factor V, and serum lactate. Oxygen consumption was measured shortly after surgery, once the patients had rewarmed to 36 degrees C. There were 131 successful transplants (88.5%) and 17 failures (11.5%). Most of the variables studied were found to be associated with outcome (by univariate analysis) at different points in the early postoperative period. However, receiver operating characteristic curve analysis showed that the predictive ability of even the best parameter was not adequate to make decisions on individual patients. Multivariate analysis, using stepwise logistic regression, yielded a model with an overall accuracy of 92.7%. Again, receiver operating characteristic curve analysis suggested that this model did not achieve the discriminating power needed for routine clinical use. We are still not able to accurately predict outcome in the early posttransplant period. We must be very careful when evaluating parameters, or scoring systems, that are said to accomplish this. It is especially important in this era of cost containment, with its renewed pressures to guide therapy based on our perceived understanding of a patient's future clinical course.
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orthotopic liver transplantation for patients with hepatitis b virus related liver disease
Hepatology, 1991Co-Authors: Satoru Todo, Anthony J Demetris, David H Van Thiel, Lewis Teperman, John J Fung, Thomas E. StarzlAbstract:Fifty-nine patients with prior hepatitis B virus infection underwent orthotopic liver transplantation. During the first 2 mo, mortality was not significantly different in the hepatitis B virus–infected group (25.5%) vs. a hepatitis B virus–immune control group (21 %). Beyond 2 mo, the mortality, rate of graft loss, need for Retransplantation and incidence of abnormal liver function were significantly higher in the hepatitis B virus–infected group. Treatment of the hepatitis B virus infection was attempted with passive immunization, combined active and passive immunization, α-interferon or nothing. The clinical outcome was not significantly influenced by any of these therapies. However, of the patients who lived more than 60 days, 6 of 22 treated with active plus passive immunization were cleared of HBsAg, something achieved once in 16 patients treated with α-interferon, never in 3 patients with passive immunization only and once in 4 patients with no therapy. In patients with recurrent hepatitis B virus infection, the pace of hepatitis development in the graft appeared to be accelerated, and this was particularly striking in patients who underwent multiple Retransplantations at progressively shorter intervals. None of the patients who became HBsAg-negative had HBeAg preoperatively.
Eric A. Rose - One of the best experts on this subject based on the ideXlab platform.
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long term survival after cardiac Retransplantation a twenty year single center experience
The Journal of Thoracic and Cardiovascular Surgery, 1999Co-Authors: Ranjit John, Jonathan M. Chen, Craig R. Smith, Eric A. Rose, Donna Mancini, Alan D Weinberg, Silviu Itescu, Mark Galantowicz, Niloo M EdwardsAbstract:Objective: To identify risk factors for survival after cardiac Retransplantation and compare the survival after Retransplantation with that after primary cardiac transplantation. Methods: A retrospective analysis of 952 patients undergoing cardiac transplantation for the treatment of end-stage heart disease at a single center between 1977 and October 1997. Of these, 43 patients (4.5%) underwent cardiac Retransplantation for cardiac failure resulting from transplant-related coronary artery disease, rejection, and early graft failure. Results: No significant difference in actuarial patient survival was found by Kaplan-Meier analysis at 1, 2, and 5 years between patients undergoing primary transplantation and those undergoing Retransplantation—76%, 71%, and 60% versus 66%, 66%, and 51%, respectively (P = .2). Multivariable analysis identified a shorter interval between transplants and an initial diagnosis of ischemic cardiomyopathy as significant risk factors for death after Retransplantation (P = .04 and .03, respectively). Since 1993, when our criteria for patient selection for Retransplantation were revised on the basis of earlier experience to exclude patients with allograft dysfunction as a result of primary graft failure and those with intractable acute rejection occurring less than 6 months after transplantation, the survival has been significantly better (<1993 = 45%, 45%, and 33% versus ≥1993 = 94%, 94%, and 94% at 1, 2, and 4 years, respectively, P = .003). Conclusion: The long-term outcome of cardiac Retransplantation is comparable with that of primary transplantation, especially in patients with transplant-related coronary artery disease. Patient characteristics and other preoperative variables should assist in the rational application of Retransplantation to ensure optimal use of donor organs. (J Thorac Cardiovasc Surg 1999;117:543-55)
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Clinical experience with cardiac Retransplantation.
The Journal of thoracic and cardiovascular surgery, 1993Co-Authors: Robert E. Michler, Jonathan M. Chen, Michael J. Mclaughlin, Richard Geimen, Felicia A. Schenkel, Craig R. Smith, Mark L. Barr, Eric A. RoseAbstract:Although more than 560 patients worldwide have undergone cardiac Retransplantation, few studies of this population have been reported. To evaluate the risk of cardiac Retransplantation and to better establish selection criteria, we reviewed the records of all patients who underwent Retransplantation at the Columbia-Presbyterian Medical Center. Of 431 patients who underwent transplantation between February 1977 and March 1991, 408 underwent the procedure in the era of cyclosporine-based immunosuppression. Thirteen of these 408 patients underwent Retransplantation (including one patient who received a third graft). Indications for the 14 Retransplantations included transplant coronary artery disease (n = 8), rejection (n = 5), and intraoperative graft failure (n = 1). Immunosuppression and follow-up protocols used in this cohort were similar to those in the primary transplantation population. No significant differences were found in either actuarial survival between primary transplant recipients (75.1% +/- 2.2% at 1 year and 71.3% +/- 2.4% at 2 years) and patients who underwent Retransplantation (71.4% +/- 12.1% at 1 year and 59.5% +/- 14.8% at 2 years) or in linearized rates of rejection and actuarial freedom from rejection between the two groups. No differences between these groups were found with regard to age, sex, race, origin of end-stage heart disease, or early (< 30 day) mortality. The origin of primary graft failure did not correlate with survival outcome in the Retransplantation cohort. Follow-up time for patients having primary transplantation ranged from 0 to 8 years (mean 24 months) with a cumulative patient follow-up of 830 patient-years; follow-up time for patients who underwent Retransplantation ranged from 0 to 3 years (mean 8.1 months) with a cumulative patient follow-up of 9.5 patient-years. Approximately 50% of patients in both groups had at least one rejection episode by 3 months. Within the limited time period studied after Retransplantation, only one patient had transplant coronary artery disease, approximately 27 months after her first Retransplantation procedure for acute rejection. These results indicate that the prognosis for patients undergoing cardiac Retransplantation is good for patients for whom the indication for Retransplantation is identified more than 30 days after initial transplantation.
Iradj Gandjbakhch - One of the best experts on this subject based on the ideXlab platform.
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Heart Retransplantation: a 23-year single-center clinical experience.
The Annals of thoracic surgery, 1998Co-Authors: Bruno Schnetzler, Alain Pavie, Richard Dorent, Anne-claude Camproux, Philippe Léger, Annick Delcourt, Iradj GandjbakhchAbstract:Abstract Background . The main causes of allograft failure after cardiac transplantation are primary graft dysfunction, intractable acute rejection, and coronary graft disease. Despite the important progress in the last several years in graft preservation, surgical techniques, immunosuppression, and treatment of coronary graft disease, Retransplantation in selected cases is the only way to achieve long-term recipient survival. Methods . We compare here in a case-control study 24 Retransplantations with 47 first transplants in patients matched for date of transplantation. Results . Between 1973 and 1996, 1,063 patients underwent cardiac transplantation in our institution. In this cohort, 22 patients had a total of 24 Retransplantations (2 second-time Retransplantations). The causes of Retransplantations were primary graft failure (n = 4), acute rejection (n = 7), coronary graft disease (n = 11), and miscellaneous (n = 2). Survival at 1 and 5 years of patients with Retransplantations is 45.5% and 31.2%, and survival of control patients is 59.4% and 38.8% ( p = 0.07). An interval between first transplantation and Retransplantation shorter (n = 11) or longer (n = 13) than 1 year is associated with a 1-year survival of 27.3% and 61.5% and a 4-year survival of 27.3% and 46%, respectively (not significant). Intervals shorter than 1 year between first transplantation and Retransplantation were exclusively secondary to primary graft failure or intractable acute rejection. Conclusions . In the face of lack of donor grafts, these and other data indicate that Retransplantation should be considered cautiously, especially when the interval between the first transplantation and Retransplantation is short.