Excellent Medium-term Outcomes Research Articles

Targeted cluster ablation of non-CTI-dependent atrial arrhythmias in congenital heart disease using ultrahigh-definition mapping.

Ablation of atrial arrhythmias in patients with congenital heart disease (CHD) has markedly improved with advanced mapping systems. However, recurrence rates remain high. The linear ablation strategy is not uncommonly practiced necessitating prolonged ablation times. We report the outcomes of adopting a strategy of minimal, cluster delivery of radiofrequency (RF) energy at critical substrates identified by ultrahigh-definition mapping for atrial arrhythmias in patients with CHD. Non-cavotricuspid isthmus (non-CTI) atrial tachycardias were ablated with a targeted ablation cluster technique (TACT) using an ultrahigh-density mapping system combined with multielectrode monitoring and endpoint determination in preference to linear ablation. The arrhythmia substrates, RF times, and acute- and medium-term success rates were studied. Fifty-eight tachycardias were mapped and ablated in 42 procedures: 34 non-CTIs and 24 CTIs. A targeted ablation cluster was performed for non-CTI tachycardias, with a median ablation time of 3.1 min. In 53% of non-CTI tachycardias, arrhythmia termination was achieved with ≤2 RF applications. After a mean follow-up of 23.6 months, 27 (80%) patients were free of recurrent atrial arrhythmias. One of 34 targeted non-CTI tachycardia recurred, with a final success rate of 91%. Linear ablation was performed for CTI flutters with a median ablation time of 6.8 min (vs. non-CTIs, p = .006). Three of 21 tachycardias recurred due to reconnection of the ablation line but the final success rate was 100%. The TACT approach for non-CTI atrial arrhythmias in congenital patients as guided by theultrahigh-density mapping is an effective method with short ablation times and excellent medium-term outcomes.

Abstract 11577: Clinical Presentation and Medium-Term Outcomes in Anomalous Aortic Origin of a Coronary Artery with High Take-Off

Introduction: Anomalous aortic origin of a coronary artery (AAOCA) confers risk of sudden death in the young. Paucity of data exists in AAOCA with high take-off (ht-AAOCA) from the aorta. Hypothesis: Patients with ht-AAOCA may be at risk of inducible myocardial ischemia and surgery might be indicated in a small subset with good medium-term outcomes. Methods: Patients with ht-AAOCA, defined as origin at the sinotubular junction and above by CTA, <25 years old were prospectively enrolled. Myocardial functional studies were obtained under provocative stress: exercise stress test, stress nuclear perfusion imaging, dobutamine stress cardiac MRI, or cardiac catherization (in select patients). These studies were repeated 3 months post-operatively (post-op) in surgical patients. Results: A total of 71 patients (45 male, 63%) with ht-AAOCA were enrolled, median age 15 [IQR 12; 19] years. ht-AAOCA of the right (ht-AAORCA) was seen in 66/71 patients (93%): 15 (23%) had exertional symptoms, 13 (20%) had nonexertional symptoms, 14 (21%) had both, 24 (37%) were asymptomatic. Ht-AAOCA of the left (ht-AAOLCA) was seen in 5/71 patients (7%), only 1 (20%) had exertional symptoms. In ht-AAORCA patients, 50/66 (76%) had abnormal ostia and 6/66 (9%) juxtacommissural origin, as compared to 3/5 (60%) and 2/5 (40%), respectively, in ht-AAOLCA patients. Average intramural course in ht-AAORCA was 4.46 mm and 2.36 mm in ht-AAOLCA. Abnormal functional testing corresponding to the affected territory was seen in 11/71 (15%) ht-AAOCA patients. Surgery was recommended for 18/71 (25%) patients due to concerning symptoms, coronary anatomy, or abnormal functional testing. Of these, 13/18 (72%) underwent coronary artery unroofing (in 12) or reimplantation (in 1), 3 declined surgery, 2 pending decision. All surgical patients have returned to unrestricted exercise after reassuring post-op studies, but 1/18 (6%) awaits completion. At median follow up of 1.8 years (range 0.1-8.9), all patients are alive and well, 93% are exercising with no restrictions. Conclusion: Although ht-AAOCA appears benign in most patients, 15% shows inducible myocardial ischemia. Surgery may be indicated in a subset of patients, with overall excellent medium-term outcomes and freedom from exercise restrictions.

Liver transplantation for alcoholic hepatitis in the United States: Excellent outcomes with profound temporal and geographic variation in frequency.

Medical-refractory severe alcoholic hepatitis (AH) has a high mortality. The national frequency, longer term outcomes and regional practices of AH liver transplantation (LT) in the United States are not well described, despite the increasing mortality from alcohol-associated liver disease. We analyzed the trends in frequency and outcomes of UNOS data on 39455 adult patients who underwent LT from 2014 to 2019, including AH LT recipients. LTs for AH increased 5-fold, from 28 in 2014 to 138 in 2019, varying 8-fold between UNOS regions. Three transplant centers accounted for 50%-90% of AH LTs within each region. The number of transplant centers performing AH LTs increased from 14 in 2014 to 47 in 2019. AH patients were younger (mean=39.4years), had higher MELD scores (mean=36.8), and were more often on dialysis (46.0%) and in ICU (38.4%), compared to other indications (all P<.05). One- and 5-year graft survivals for AH LT recipients were 91.7% and 81.9%, respectively. The frequency of AH LT is increasing rapidly, with excellent medium-term outcomes. An impact of AH recurrence on patient or graft survival is not apparent in this national analysis. There are marked geographic variations in practices, highlighting the lack of selection criteria standardization.

DCD donations and outcomes of heart transplantation: the Australian experience.

There is increasing clinical utilization of hearts from the donation after circulatory death (DCD) pathway with the aim of expanding the donor pool and mitigating the ever-present discrepancy between the inadequate availability of good quality donor hearts and the rising number of patients with end-stage heart failure. This article reviews the rationale, practice, logistical factors, and 5-year experience of DCD heart transplantation at St Vincent's Hospital, Sydney. Between July 2014 and July 2019, 69 DCD donor retrievals were undertaken resulting in 49 hearts being instrumented on an ex situ normothermic cardiac perfusion device. Seventeen (35%) of these hearts were declined and the remaining 32 (65%) were used for orthotopic DCD heart transplantation. At 5years of follow-up, the 1-, 3-, and 5-year survival was 96%, 94%, and 94% for DCD hearts compared with 89%, 83%, and 82% respectively for donation after brain death (DBD) hearts (n.s). The immediate post-implant requirement for temporary extra-corporeal membrane oxygenation (ECMO) support for delayed graft function was 31% with no difference in rejection rates when compared with the contemporaneous cohort of patients transplanted with standard criteria DBD hearts. DCD heart transplantation has become routine and incorporated into standard clinical practice by a handful of pioneering clinical transplant centres. The Australian experience demonstrates that excellent medium-term outcomes are achievable from the use of DCD hearts. These outcomes are consistent across the other centres and consequently favour a more rapid and wider uptake of heart transplantation using DCD donor hearts, which would otherwise be discarded.

671 Myocardial Infarction Due to Left Main Coronary Artery Compression in Eisenmenger’s Syndrome

Compression of the left main coronary artery (LMCA) is increasingly recognised as a cause of angina, myocardial infarction and sudden death in patients with pulmonary hypertension [[1]Gailé N. Saia F. Pallazini M. et al.Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension and Angina.JACC. 2017; 69: 2808-28017Crossref Scopus (70) Google Scholar,[2]Demerouti E.A. Manginas A.N. Athanassoupoulos G.D. et al.Complications leading to sudden cardiac death in pulmonary artery hypertension.Resp Care. 2013; 58: 1246-1254Crossref PubMed Scopus (50) Google Scholar]. Here we report a case of myocardial infarction with severe left ventricular dysfunction due to LMCA compression in a patient with Eisenmenger’s Syndrome. A 63-year-old female with Eisenmenger’s Syndrome due to a ventricular septal defect (VSD) and patent ductus arteriosus (PDA) presented with increasing dyspnoea over several weeks. Echocardiography illustrated severe global left ventricular systolic dysfunction (EF 17%), an unrestricted 12mm VSD, dilated and hypertrophied right ventricle with moderate tricuspid and pulmonary regurgitation. Estimated RV systolic pressure was 112mmHg. An ECG was revealed ST-elevation in aVR with widespread ST depression, with an elevated serum troponin of 6.7ug/L (<0.04). The patient had normal coronary angiography 2 years prior. Repeat coronary angiography revealed severe ostial LMCA stenosis due to extrinsic pulmonary artery compression, with the remaining vessels disease free. Percutaneous intervention to the LMCA was performed with a zotarolimus drug eluting stent with excellent angiographic result. Anti-platelets and up-titration of heart failure therapy was initiated. 2 years after discharge, she remains stable with a LVEF of 40% and NHYA Class II symptoms at home with her husband. In patients with pulmonary hypertension, progressive symptoms are often attributed to worsening pulmonary resistance or right heart dysfunction/ischaemia [[1]Gailé N. Saia F. Pallazini M. et al.Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension and Angina.JACC. 2017; 69: 2808-28017Crossref Scopus (70) Google Scholar,[3]Gómez A. Bialostozky D. Zajarias A. et al.Right ventricular ischaemia in patients with primary pulmonary hypertension.JACC. 2001; 38: 1137-1142Crossref Scopus (179) Google Scholar]. LMCA compression represents an important and treatable cause of myocardial infarction and LV dysfunction with excellent medium-term outcomes.

Immediate Postextraction Screw-Retained Partial and Full-Arch Rehabilitation: A 3-Year Follow-up Retrospective Clinical Study.

The aim of this study was to document the performance of a novel technique (OnlyOne), involving immediate restoration of postextraction implants supporting a partial or full-arch restoration. A retrospective analysis of patients with at least 3 years of follow-up was performed. Implants were tilted mesiodistally and vestibulopalatally according to the available bone. Prosthetically guided definitive abutments were connected at surgery and never disconnected. Anorganic bovine bone grafting was done to preserve the buccal bone and the ridge contour. Patients received a screw-retained provisional prosthesis within 24 hours of surgery and a final screw-retained prosthesis within 1 year. Prostheses emerged from natural soft tissue. Clinical and radiographic evaluation was routinely performed. A total of 70 patients received 153 implants in fresh extraction sockets. The mean follow-up was 38.0 ± 3.0 months (range 36 to 51 months). One implant failed at the 3-year follow-up. Implant survival was 99.3%. Marginal bone level change averaged -0.68 ± 1.2 mm at the last radiographic control. Immediate placement and restoration of implants designed for high primary stability with a definitive abutment placed at surgery and final screw-retained prosthesis with no artificial gingiva is a viable procedure with excellent medium-term outcomes.

Early radiological intervention and haematology screening is associated with excellent outcomes in Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder, resulting from thrombosis of the hepatic veins. Various treatments, including pharmacological, radiological and surgical interventions, have been used. To describe retrospectively our institution's experience with management of patients with BCS. A retrospective study of all cases of primary Budd-Chiari syndrome presenting to our institution between January 2000 and August 2012 was performed. Patients with secondary Budd-Chiari syndrome due to malignancy or local mass compression were excluded. Between 2000 and 2012, 27 patients with primary BCS presented with a median Rotterdam score of 1.16 (range: 0.07-2.11). A total of 24 patients (89%) had at least one risk factor, with the commonest being myeloproliferative neoplasm (MPN), detected in 17 of 24 (71%) of the tested patients, including four patients with normal blood counts at diagnosis. All patients were anticoagulated with warfarin or low-molecular-weight heparin (LMWH). A total of 25 (92.6%) patients also had primary radiological interventions, consisting of transjugular intrahepatic portosystemic shunt (TIPS) in 18 (67%) patients and/or angioplasty/stenting in 11 (40%). A total of 14 patients developed TIPS stenoses, requiring a median of 1.5 (range: 1-14) revisions. No patient developed TIPS failure requiring alternative therapy. Two patients were lost to follow-up. At a median follow up of 59 months (range: 2-248 months), the overall survival was 96% at 1 year and 81% at 5 years, much greater than predicted by the Rotterdam score. No patients required liver transplantation. There is a high incidence of MPN in patients with primary BCS, including patients with normal peripheral blood counts at the time of diagnosis. Our approach of anticoagulation, aggressive and early radiological intervention aimed at rapid decompression of the congested liver resulted in excellent medium-term outcomes.

Dual kidney transplants from adult marginal donors successfully expand the limited deceased donor organ pool.

The need to expand the organ donor pool remains a formidable challenge in kidney transplantation (KT). The use of expanded criteria donors (ECDs) represents one approach, but kidney discard rates are high because of concerns regarding overall quality. Dual KT (DKT) may reduce organ discard and optimize the use of kidneys from marginal donors. We conducted a single-center retrospective review of outcomes in adult recipients of DKTs from adult marginal deceased donors (DD) defined by limited renal functional capacity. If the calculated creatinine clearance in an adult DD was <65 mL/min, then the kidneys were transplanted as a DKT. Over 11.5 yr, 72 DKTS were performed including 45 from ECDs, 17 from donation after cardiac death (DCD) donors, and 10 from standard criteria donors (SCD). Mean adult DD and recipient ages were both 60 yr, including 29 DDs and 26 recipients ≥65 yr of age. Mean pre-DKT waiting and dialysis vintage times were 12 months and 25 months, respectively. Actual patient and graft survival rates were 84.7% and 70.8%, respectively, with a mean follow-up of 58 months. One yr and death-censored graft survival rates were 90% and 80%, respectively. Outcomes did not differ by DD category, recipient age, or presence of delayed graft function (DGF). Eleven patients died at a mean of 32 months post-DKT (eight with functioning grafts) and 13 other patients experienced graft losses at a mean of 33 months. The incidence of DGF was 25%; there were two cases (2.8%) of primary non-function. Mean length of initial hospital stay was 7.2 d. Mean serum creatinine and glomerular filtration rate levels at 12 and 24 months were 1.5 and 53 and 1.5 mg/dL and 51 mL/min/1.73 m(2) , respectively. DKT graft survival and function were superior to concurrent single ECD and similar to concurrent SCD KTs. Two patients underwent successful kidney retransplantation, so the dialysis-free rate in surviving patients was 87%. The proportion of total renal function transplanted from adult DD to DKT recipients was 77% compared to 56% for patients receiving single KTs. Dual kidney transplantation using kidneys from adult marginal DDs that otherwise might be discarded offer a viable option to counteract the growing shortage of acceptable single kidneys. Excellent medium-term outcomes can be achieved and waiting times can be reduced in a predominantly older recipient population.

Single vs dual (en bloc) kidney transplants from donors ≤ 5 years of age: A single center experience.

To compare outcomes between single and dual en bloc (EB) kidney transplants (KT) from small pediatric donors. Monocentric nonprospective review of KTs from pediatric donors ≤ 5 years of age. Dual EB KT was defined as keeping both donor kidneys attached to the inferior vena cava and aorta, which were then used as venous and arterial conduits for the subsequent transplant into a single recipient. Donor age was less useful than either donor weight or kidney size in decision-making for kidney utilization as kidneys from donors < 8 kg or kidneys < 6 cm in length were not transplanted. Post-transplant management strategies were standardized in all patients. From 2002-2015, 59 KTs were performed including 34 dual EB and 25 single KTs. Mean age of donors (17 mo vs 38 mo, P < 0.001), mean weight (11.0 kg vs 17.4 kg, P = 0.046) and male donors (50% vs 84%, P = 0.01) were lower in the dual EB compared to the single KT group, respectively. Mean cold ischemia time (21 h), kidney donor profile index (KDPI; 73% vs 62%) and levels of serum creatinine (SCr, 0.37 mg/dL vs 0.49 mg/dL, all P = NS) were comparable in the dual EB and single KT groups, respectively. Actuarial graft and patient survival rates at 5-years follow-up were comparable. There was one case of thrombosis resulting in graft loss in each group. Delayed graft function incidence (12% dual EB vs 20% single KT, P = NS) was slightly lower in dual EB KT recipients. Initial duration of hospital stay (mean 5.4 d vs 5.6 d) and the one-year incidences of acute rejection (6% vs 16%), operative complications (3% vs 4%), and major infection were comparable in the dual EB and single KT groups, respectively (all P = NS). Mean 12 mo SCr and abbreviated MDRD levels were 1.17 mg/dL vs 1.35 mg/dL and 72.5 mL/min per 1.73 m(2) vs 60.5 mL/min per 1.73 m(2) (both P = NS) in the dual EB and single KT groups, respectively. By transplanting kidneys from young pediatric donors into adult recipients, one can effectively expand the limited donor pool and achieve excellent medium-term outcomes.

Pectus excavatum: computed tomography and medium-term surgical outcome in a prospective cohort of 10 kittens.

The objective of this study was to report the use of computed tomography (CT) in conjunction with clinical signs to assess the severity of pectus excavatum (PE) in kittens and to guide surgical decision-making; also to report medium-term outcome in a prospective cohort of kittens undergoing surgical correction. This was a prospective study of 10-15-week-old kittens (n = 10) diagnosed with moderate/severe PE. CT provides additional information that is useful for selecting patients for surgical correction and for planning the surgery. Traditional radiographic indices (vertebral, frontosagittal) provide reasonable approximations of the CT-determined dimensions but these seem to correlate poorly with the severity of clinical signs. Kittens commonly have lateralised deformities, which are associated with less severe clinical signs, while those with midline deformities are associated with more severe clinical signs. Six of seven kittens with severe PE that had a ventral splint applied for 4 weeks had excellent medium-term outcomes. Restriction of diastolic filling by midline sternal deviation may be an important cause of exercise intolerance in cats with PE. CT can be used to assess affected kittens and to plan surgery when indicated.

Evolving Experience Using Kidneys from Deceased Donors with Terminal Acute Kidney Injury

Kidney transplantation from deceased donors with terminal acute kidney injury (AKI) is not widely accepted. Acute kidney injury donor kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level and a terminal SCr level >2.0 mg/dL before organ recovery. Over 5.5 years, we transplanted 84 AKI donor kidneys, including 64 kidneys from standard criteria donors (SCD), 11 from expanded criteria donors (ECD), and 9 from donation after cardiac death (DCD) donors. Mean donor age was 36 years (range 15 to 68 years); mean admission and terminal donor SCr levels were 1.25 mg/dL and 3.2 mg/dL, respectively (mean terminal estimated glomerular filtration rate 25.5 mL/minute). With a mean follow-up of 35 months (range 6 to 70 months), actual patient and graft survival rates are 98% and 89%, respectively, which are numerically, but not statistically, higher than concurrent kidney transplants from brain-dead (non-AKI) SCDs at our center. Delayed graft function (DGF) occurred in 34 patients (40%). Mean 1-, 12-, and 24-month SCr levels were 1.8, 1.6, and 1.7 mg/dL, respectively. Delayed graft function was associated with lower 3-year graft survival for non-AKI SCD transplants (68% vs 90%, with and without DGF), but there was no impact of DGF on graft survival for AKI donor kidneys (89% vs 91%). Although AKI donor kidneys more commonly have DGF, the higher rate of DGF does not worsen graft outcomes. Kidneys from deceased donors with terminal AKI transplanted into appropriately selected patients have excellent medium-term outcomes and represent a method to safely expand the donor pool.

Active surveillance in prostate cancer

The long-term safety and effectiveness of active surveillance depends on our ability to select appropriate patients and trigger delayed treatment in those who need it, whereas avoiding intervention in those who do not. In this review, we will consider how recent advances have influenced patient selection for active surveillance and review the range of different intervention triggers that have been proposed. Several large surveillance cohort studies have been reported recently showing excellent medium-term outcomes in well selected patients, with approximately a third of patients going on to have deferred treatment. Debate continues on the most appropriate eligibility criteria for active surveillance and what triggers for intervention should be used. There is growing interest in the role of transperineal template biopsies and multiparametric MRI, both for patient selection and in identifying triggers for intervention. Active surveillance is a well tolerated treatment option in well selected groups of patients. There is no 'one size fits all' set of criteria for patient selection or triggers for intervention but decisions can be guided by information from histology, prostate-specific antigen kinetics and imaging.

Foldoplasty: A New and Simplified Technique for Mitral Valve Repair That Produces Excellent Medium-Term Outcomes

Quadrangular resection with sliding valvuloplasty is the most common technique used to repair the posterior leaflet of the prolapsed mitral valve. Folding valvuloplasty is a simplified repair that does not involve resection and reduces the effective height of the posterior leaflet. We describe medium-term outcomes of patients who underwent folding valvuloplasty at our institution. From 2002 to 2010, 161 patients underwent folding valvuloplasty at our institution. The primary endpoints in our study of these patients' medium-term outcomes included survival, freedom from reoperation, and echocardiographic evidence of recurrent mitral regurgitation (MR). The patients' median age was 61 ± 14 years, 68 of the patients (42%) were male, and 146 of the patients (90%) had more than moderate to severe MR. Cardiopulmonary bypass and cross-clamp times were 117 ± 40 minutes and 83 ± 29 minutes, respectively. In addition to folding valvuloplasty, mitral rings with a median size of 38 mm (interquartile range, 34 mm to 38 mm) were used in 155 (96%) of the patients. One patient died during surgery. Medium-term follow-up data were available for all of the patients at a mean of 3.0 ± 1.9 years after folding valvuloplasty. The patients' mean New York Heart Association class decreased significantly, from 2.0 ± 0.9 to 1.1 ± 0.4 (p < 0.0001), from the time of valvuloplasty to their mean medium-term follow-up evaluation. Two patients required reoperative mitral valve repair in the follow-up period. Postoperative echocardiograms were obtained for 142 (88%) patients at a mean of 1.6 ± 1.2 years after valvuloplasty. The patients' mean grade of MR decreased significantly from the time of valvuloplasty to the time of mean medium-term follow up, from 3.8 ± 0.5 (severe) to 0.8 ± 0.8 (trace-mild) (p < 0.0001), with only five patients (3%) having moderate MR at follow-up. Folding valvuloplasty is durable and provides excellent structural and symptomatic results in patients with mitral prolapse. Given the ease and reproducibility of this technique, it should be offered as a suitable alternative to quadrangular resection for repair of the posterior leaflet in mitral prolapse.

Lessons Learned from a Single Center's Experience with 134 Donation after Cardiac Death Donor Kidney Transplants

Reports of kidney transplantation from donation after cardiac death (DCD) donors describe high rates of delayed graft function (DGF). From April 1, 2003 to October 17, 2010, we performed 134 kidney transplants from DCD donors including 120 (90%) from standard-criteria donors (SCDs) and 14 (10%) from expanded-criteria donors (ECDs). Nineteen kidneys were recovered from donors managed with extracorporeal interval support for organ retrieval (EISOR) after cardiac arrest to minimize ischemic injury. Comparison of donor and recipient characteristics found no differences for cases managed with or without EISOR. Overall actuarial patient survival rates were 93%, 91%, and 89% at 1, 3, and 5 years, respectively, with a mean follow-up of 31 months. Overall actuarial kidney graft survival rates were 89%, 76%, and 76% at 1, 3, and 5 years, respectively. Actuarial graft survival rates of DCD ECD kidneys were 58% and 48% at 1 and 3 years, compared with 90% and 79% at 1 and 3 years for non-ECD grafts (p = 0.013). DGF occurred in 73 patients (54%) overall and was reduced from 55% to 21% (p = 0.016) with the use of EISOR in locally recovered kidneys. The mean resistance value on machine perfusion and the mean estimated glomerular filtration rate 1 month after transplantation were both improved (p < 0.05) in kidneys from donors managed with EISOR. Mean initial hospital stay was reduced from 8.0 to 5.0 days in patients receiving kidneys recovered with EISOR (p = 0.04). EISOR is associated with a lower rate of DGF, lower graft resistance on machine perfusion, and shorter initial hospitalization. Kidneys from DCD SCDs have excellent medium-term outcomes and represent an important means of expanding the donor pool. Kidneys from DCD ECDs have inferior outcomes.