No abstract

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 ϭ 8), asystole (n ϭ 2), MI (n ϭ 5), and new heart failure (n ϭ 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 Ͼ82% of the maximum predicted heart rate (22% versus 6%, P ϭ 0.01), a peak rate pressure product during DSE of Ͻ16,333 (17% versus 5%, P ϭ 0.02), and a Model for End-Stage Liver Disease (MELD) score of Ͼ24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result ϭ 3.78 ϩ 0.07 MELD Ϫ 0.05 MAHR) identified a 47% risk for a value Ͼ 0 versus a 6% risk for a value Ͻ 0 (P Ͻ 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.

Background: The benefit of emergent coronary angiography after resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain for patients without ST-segment elevation (STE). The aim of this randomized trial was to evaluate the efficacy and safety of early coronary angiography and to determine the prevalence of acute coronary occlusion in resuscitated OHCA patients without STE. Methods: Adult (>18 years) comatose survivors without STE after resuscitation from OHCA were prospectively randomized in a 1:1 fashion under exception to informed consent regulations to early coronary angiography versus no early coronary angiography in this multi-center study. Early angiography was defined as ≤ 120 minutes from arrival at the percutaneous coronary intervention capable facility. The primary endpoint was a composite of efficacy and safety measures, including efficacy parameters of survival to discharge, favorable neurological status at discharge (Cerebral Performance Category ≤ 2), echocardiographic measures of left ventricular ejection fraction >50% and a normal regional wall motion score of 16 within 24 hours of admission. Adverse events included re-arrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension (systolic arterial pressure ≤90 mmHg), and pneumonia. Secondary endpoints included the incidence of culprit vessels with acute occlusion. Results: The study was prematurely terminated before enrolling the target number of patients. A total of 99 patients were enrolled from 2015-2018, including 75 with initially shockable rhythms. Forty-nine patients were randomized to early coronary angiography. The primary endpoint of efficacy and safety was not different between the two groups (55.1% vs 46.0%; p=0.64). Early coronary angiography was not associated with any significant increase in survival (55.1% vs 48.0%; p=0.55 or adverse events (26.5% vs 26.0%; p=1.00). Early coronary angiography revealed a culprit vessel in 47%, with a total of 14% of patients undergoing early coronary angiography having an acutely occluded culprit coronary artery. Conclusions: This underpowered study, when considered together with previous clinical trials, does not support early coronary angiography for comatose survivors of cardiac arrest without ST elevation. Whether early detection of occluded potential culprit arteries leads to interventions that improve outcomes requires additional study. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02387398