The significance of pre‐operative coronary interventions on outcome after pancreas transplantation

Abstract

Pancreas transplant candidates are at very high risk of coronary vascular disease. We hypothesized that the requirement for pre-operative coronary intervention (PCI) may be associated with an adverse impact on short- and long-term outcomes. Retrospective analysis of 366 consecutive primary pancreas transplants was undertaken. Outcomes were compared between recipients who had undergone PCI (n = 48) and those who had not (n = 318). In 48% (23/48) of instances, the PCI was initiated by the transplant cardiology evaluation. The recipients undergoing PCI were older than those not undergoing PCI (47.6 yr vs. 41.9 yr, respectively, p < 0.0001). Although not statistically significant, there was a higher rate of post-operative major cardiovascular events (MCVE) in the PCI group (10.4%) compared with those not undergoing PCI (4.7%) (RR [95% CI]: 2.0 [0.90-4.5]; p = 0.17). In the long term, there were no differences in the rate of death with graft function (p = 0.77) or rejection (p = 0.17). There were no statistically significant differences between the groups with respect to patient (p = 0.54), kidney (p = 0.76), or pancreas (p = 0.63) graft survival. PCI is not a risk factor for short-term perioperative events, and long-term transplant outcomes are equivalent to patients not requiring PCI. PCI, by itself, should not be considered a contraindication for pancreas transplantation, but should raise awareness of perioperative risk.

Modern indications for referral for kidney and pancreas transplantation

“…Probably, the single most important aspect of recipient selection is the overall assessment of cardiovascular risk, burden and reserve because untreatable cardiac disease is an absolute contraindication to transplant [47][48][49][50][51][52][53][54][55][56][57]. The cardiac status of each candidate must be assessed carefully because significant (and silent) coronary artery disease is not uncommon in this population.…”

“…However, treatment of cardiac disease including coronary stenting or bypass for coronary artery disease, replacement or endovascular intervention for valve pathology, or ablation for conduction abnormalities may render the candidate subsequently suitable [54]. A history of previous myocardial infarction, angioplasty, stenting, or coronary artery bypass grafting is not considered an absolute contraindication because excellent outcomes have been reported in patients with previous cardiac interventions or events [50,51,54,56,57]. However, sudden cardiac death, in the absence of significant structural heart disease, continues to be a primary cause of cardiac mortality following PTx [49][50][51][52][53][54][55][57][58][59][60].…”

“…A history of previous myocardial infarction, angioplasty, stenting, or coronary artery bypass grafting is not considered an absolute contraindication because excellent outcomes have been reported in patients with previous cardiac interventions or events [50,51,54,56,57]. However, sudden cardiac death, in the absence of significant structural heart disease, continues to be a primary cause of cardiac mortality following PTx [49][50][51][52][53][54][55][57][58][59][60]. In addition to cardiac testing, the presence and severity of peripheral vascular (particularly iliac arterial) disease should be assessed carefully by a noncontrast abdominal and pelvic computerized tomographic scan in combination with duplex ultrasonography of the iliac vessels.…”

Pancreas Transplantation in Minorities including Patients with a Type 2 Diabetes Phenotype

“…In addition to dysmetabolism and progressive diabetic complications, significant psycho-emotional or physical difficulties with insulin therapy are another indication for PTx. However, the most important part of recipient selection is the overall evaluation of cardiovascular disease burden, risk, and functional reserve [44,71,[83][84][85][86][87][88][89][90][91].…”

“…Cardiac catheterization may be required at some centers in all potential SPKT candidates whereas others may reserve it for selected indications [84][85][86][87][88][89][90]. Prior cardiac interventions or history of cardiac events are not necessarily contraindications for PTx because excellent outcomes can still be achieved in these patients [83,[88][89][90][91]. However, in the absence of discernible structural heart disease, sudden cardiac death continues to be a cause of mortality in PTx recipients [84][85][86][87][88][89][90][91][92][93][94].…”