101: Are Recipients from Heart Donors Listed as Homeless at Increased Risk for Poor Outcome after Heart Transplantation?

Mammalian target of rapamycin (mTOR) inhibitors have been shown to reduce proliferation of lymphoid cells; thus, their use for immunosuppression after heart transplantation (HT) may reduce post-transplant lymphoproliferative disorder (PTLD) risk. This study sought to investigate whether the sirolimus (SRL)-based immunosuppression regimen is associated with a decreased risk of PTLD compared with the calcineurin inhibitor (CNI)-based regimen in HT recipients. We retrospectively analyzed 590 patients who received HTs at two large institutions between 1 June 1988 and 31 December 2014. Cox proportional-hazard modeling was used to examine the association between type of primary immunosuppression and PTLD after adjustment for potential confounders, including Epstein–Barr virus (EBV) status, type of induction therapy, and rejection. Conversion from CNI to SRL as primary immunosuppression occurred in 249 patients (42.2%). During a median follow-up of 6.3 years, 30 patients developed PTLD (5.1%). In a univariate analysis, EBV mismatch was strongly associated with increased risk of PTLD (HR 10.0, 95% CI: 3.8–26.6; p < 0.001), and conversion to SRL was found to be protective against development of PTLD (HR 0.19, 95% CI: 0.04–0.80; p = 0.02). In a multivariable model and after adjusting for EBV mismatch, conversion to SRL remained protective against risk of PTLD compared with continued CNI use (HR 0.12, 95% CI: 0.03–0.55; p = 0.006). In conclusion, SRL-based immunosuppression is associated with lower incidence of PTLD after HT. These findings provide evidence of a benefit from conversion to SRL as maintenance therapy for mitigating the risk of PTLD, particularly among patients at high PTLD risk.

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Impact of Obesity on Heart Transplantation Outcomes

Journal of the American Heart Association ◽

10.1161/jaha.121.021346 ◽

2021 ◽

Vol 10 (23) ◽

Author(s):

Fouad Chouairi ◽

Aidan Milner ◽

Sounok Sen ◽

Avirup Guha ◽

James Stewart ◽

...

Keyword(s):

Heart Transplantation ◽

Organ Procurement ◽

Left Ventricular ◽

Ventricular Assist Devices ◽

Left Ventricular Assist Devices ◽

Ventricular Assist ◽

Allocation System ◽

Increased Risk ◽

The Impact ◽

Transplantation Outcomes

Background Patients with obesity and advanced heart failure face unique challenges on the path to heart transplantation. There are limited data on waitlist and transplantation outcomes in this population. We aimed to evaluate the impact of obesity on heart transplantation outcomes, and to investigate the effects of the new organ procurement and transplantation network allocation system in this population. Methods and Results This cohort study of adult patients listed for heart transplant used the United Network for Organ Sharing database from January 2006 to June 2020. Patients were stratified by body mass index (BMI) (18.5–24.9, 25–29.9, 30–34.9, 35–39.9, and 40–55 kg/m 2 ). Recipient characteristics and donor characteristics were analyzed. Outcomes analyzed included transplantation, waitlist death, and posttransplant death. BMI 18.5 to 24.9 kg/m 2 was used as the reference compared with progressive BMI categories. There were 46 645 patients listed for transplantation. Patients in higher BMI categories were less likely to be transplanted. The lowest likelihood of transplantation was in the highest BMI category, 40 to 55 kg/m 2 (hazard ratio [HR], 0.19 [0.05–0.76]; P =0.02). Patients within the 2 highest BMI categories had higher risk of posttransplantation death (HR, 1.29; P <0.001 and HR, 1.65; P <0.001, respectively). Left ventricular assist devices among patients in obese BMI categories decreased after the allocation system change ( P <0.001, all). After the change, patients with obesity were more likely to undergo transplantation (BMI 30–35 kg/m 2 : HR, 1.31 [1.18–1.46], P <0.001; BMI 35–55 kg/m 2 : HR, 1.29 [1.06–1.58]; P =0.01). Conclusions There was an inverse relationship between BMI and likelihood of heart transplantation. Higher BMI was associated with increased risk of posttransplant mortality. Patients with obesity were more likely to undergo transplantation under the revised allocation system.

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Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?

Journal of Neurosurgery ◽

10.3171/jns.1996.85.3.0410 ◽

1996 ◽

Vol 85 (3) ◽

pp. 410-418 ◽

Cited By ~ 242

Author(s):

Giuseppe Lanzino ◽

Neal F. Kassell ◽

Teresa P. Germanson ◽

Gail L. Kongable ◽

Laura L. Truskowski ◽

...

Keyword(s):

Prognostic Factors ◽

Subarachnoid Hemorrhage ◽

Age Groups ◽

Age Group ◽

Content Type ◽

Poor Outcome ◽

Symptomatic Vasospasm ◽

Age Related ◽

Increased Risk ◽

Fine Print

✓ Advanced age is a recognized prognostic indicator of poor outcome after subarachnoid hemorrhage (SAH). The relationship of age to other prognostic factors and outcome was evaluated using data from the multicenter randomized trial of nicardipine in SAH conducted in 21 neurosurgical centers in North America. Among the 906 patients who were studied, five different age groups were considered: 40 years or less, 41 to 50, 51 to 60, 61 to 70, and more than 71 years. Twenty-three percent of the individuals enrolled were older than 60 years of age. Women outnumbered men in all age groups. Level of consciousness (p = 0.0002) and World Federation of Neurological Surgeons grade (p = 0.0001) at admission worsened with advancing age. Age was also related to the presence of a thick subarachnoid clot (p = 0.0001), intraventricular hemorrhage (p = 0.0003), and hydrocephalus (p = 0.0001) on an admission computerized tomography scan. The rebleeding rate increased from 4.5% in the youngest age group to 16.4% in patients more than 70 years of age (p = 0.002). As expected, preexisting medical conditions, such as diabetes (p = 0.028), hypertension (p = 0.0001), and pulmonary (p = 0.0084), myocardial (p = 0.0001), and cerebrovascular diseases (p = 0.0001), were positively associated with age. There were no age-related differences in the day of admission following SAH, timing of the surgery and/or location, and size (small vs. large) of the ruptured aneurysm. During the treatment period, the incidence of severe complications (that is, those complications considered life threatening by the reporting investigator) increased with advancing age, occurring in 28%, 33%, 36%, 40%, and 46% of the patients in each advancing age group, respectively (p = 0.0002). No differences were observed in the reported frequency of surgical complications. No age-related differences were found in the overall incidence of angiographic vasospasm; however, symptomatic vasospasm was more frequently reported in the older age groups (p = 0.01). Overall outcome, assessed using the Glasgow Outcome Scale at 3 months post-SAH, was poorer with advancing age (p < 0.001). Multivariate analysis of overall outcome, adjusting for the different prognostic factors, did not remove the age effect, which suggests that the aging brain has a less optimal response to the initial bleeding. Age as a risk factor is a continuum; however, there seems to be a significant increased risk of poor outcome after the age of 60 years.

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468: Microvascular Dysfunction and Suboptimal Glycemic Control Predicts Poor Outcome Following Heart Transplantation

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2008.11.475 ◽

2009 ◽

Vol 28 (2) ◽

pp. S228

Author(s):

P. Khazanie ◽

F. Haddad ◽

A.M. Simos ◽

D.M. Weisshaar ◽

S.V. Desai ◽

...

Keyword(s):

Glycemic Control ◽

Heart Transplantation ◽

Microvascular Dysfunction ◽

Poor Outcome

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Abstract TP25: Increased Risk for Unfavorable Outcome in Patients with Pre-existing Disability Undergoing Endovascular Therapy

Stroke ◽

10.1161/str.48.suppl_1.tp25 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Ronen R Leker ◽

Pavel Gavriliuc ◽

Nour Eddine Yagmur ◽

John M Gomori ◽

Jose E Cohen

Keyword(s):

Endovascular Therapy ◽

Real Life ◽

Unfavorable Outcome ◽

Stroke Severity ◽

Imaging Data ◽

Anterior Circulation ◽

Poor Outcome ◽

Increased Risk ◽

Degree Of Disability ◽

Pre Treatment

Background and Objectives: Most studies evaluating endovascular therapy (EVT) for stroke only included patients without pre-existing disability. However, in real life many patients have pre-existing disability and whether they can benefit from EVT remains unknown. Methods: Patients with large vessel anterior circulation stroke were prospectively enrolled. Patients with no or mild disability (modified Rankin Scale [mRS] 0-2) were compared with patients presenting with pre-existing moderate disability (mRS≥3). Baseline demographics and risk factors, stroke severity (studied with the National Institutes of Health Stroke Scale [NIHSS]), imaging data including pre-treatment ASPECTS and ASPECTS collateral scores, as well as procedure related variables were accrued. Unfavorable outcome was defined as mRS≥4 at day 90. Results: Out of 100 enrolled patients, 85 had baseline mRS≤2 and 15 had pre-stroke mRS≥3. Patients with pre-existing mRS≥3 were significantly older (79.0±6 vs. 66.6±14, p=0.001) and more often had previous strokes (47% vs. 19%, p=0.04) and ASPECTS≤7 (33% vs. 12%, p=0.03). Patients with mRS≥3 at presentation were more likely to have poor outcome or death (OR 4.4 95%CI 1.3-15.0). Four of the patients with pre-existing moderate disability (27%) maintained their previous degree of disability. On multivariate analysis age (OR 1.1 95%CI 1.1-1.2), admission NIHSS (OR 1.2 95%CI 1-1.3) and complete recanalization (OR 0.2 95%CI 0.04-0.68) remained significant modifiers of poor outcome. Conclusions: Patients with pre-existing moderate disability have higher chances for sustaining unfavorable outcomes despite EVT. Nevertheless, some patients maintain the same level of moderate disability and therefore patients with pre-existing moderate disability should not be excluded from EVT.

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An evaluation of the SAFIRE grading scale as a predictor of long-term outcomes for patients in the Barrow Ruptured Aneurysm Trial

Journal of Neurosurgery ◽

10.3171/2020.7.jns193431 ◽

2021 ◽

pp. 1-5

Author(s):

Joshua S. Catapano ◽

Mohamed A. Labib ◽

Fabio A. Frisoli ◽

Megan S. Cadigan ◽

Jacob F. Baranoski ◽

...

Keyword(s):

Univariate Analysis ◽

Ruptured Aneurysm ◽

Poor Outcome ◽

Increased Risk ◽

Grade Ii ◽

Grading Scale ◽

Poor Outcomes ◽

Grade Iii

OBJECTIVEThe SAFIRE grading scale is a novel, computable scale that predicts the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients in acute follow-up. However, this scale also may have prognostic significance in long-term follow-up and help guide further management.METHODSThe records of all patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were retrospectively reviewed, and the patients were assigned SAFIRE grades. Outcomes at 1 year and 6 years post-aSAH were analyzed for each SAFIRE grade level, with a poor outcome defined as a modified Rankin Scale score > 2. Univariate analysis was performed for patients with a high SAFIRE grade (IV or V) for odds of poor outcome at the 1- and 6-year follow-ups.RESULTSA total of 405 patients with confirmed aSAH enrolled in the BRAT were analyzed; 357 patients had 1-year follow-up, and 333 patients had 6-year follow-up data available. Generally, as the SAFIRE grade increased, so did the proportion of patients with poor outcomes. At the 1-year follow-up, 18% (17/93) of grade I patients, 22% (20/92) of grade II patients, 32% (26/80) of grade III patients, 43% (38/88) of grade IV patients, and 75% (3/4) of grade V patients were found to have poor outcomes. At the 6-year follow-up, 29% (23/79) of grade I patients, 24% (21/89) of grade II patients, 38% (29/77) of grade III patients, 60% (50/84) of grade IV patients, and 100% (4/4) of grade V patients were found to have poor outcomes. Univariate analysis showed that a SAFIRE grade of IV or V was associated with a significantly increased risk of a poor outcome at both the 1-year (OR 2.5, 95% CI 1.5–4.2; p < 0.001) and 6-year (OR 3.7, 95% CI 2.2–6.2; p < 0.001) follow-ups.CONCLUSIONSHigh SAFIRE grades are associated with an increased risk of a poor recovery at late follow-up.

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Abstract TP326: Lymphopenia, Infectious Complications and Outcome in Spontaneous Intracerebral Hemorrhage

Stroke ◽

10.1161/str.48.suppl_1.tp326 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Andrea Morotti ◽

Sandro Marini ◽

Michael J Jessel ◽

Kristin Schwab ◽

Alison M Ayres ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Lymphocyte Count ◽

Cox Regression ◽

Case Fatality ◽

Retrospective Chart Review ◽

Infectious Complications ◽

Multiple Infections ◽

Spontaneous Intracerebral Hemorrhage ◽

Poor Outcome ◽

Increased Risk

Background and Purpose: lymphopenia is increasingly recognized as a consequence of acute illness and may predispose to infections. We investigated whether admission lymphopenia (AL) is associated with increased risk of infectious complications and poor outcome in patients with spontaneous intracerebral hemorrhage (ICH). Methods: we analyzed a prospectively collected cohort of ICH patients ascertained between 1994 and 2015. Subjects were included if they had a lymphocyte count obtained within 24 h from onset and AL was defined as lymphocyte count<1000/uL. Infectious complications were assessed through retrospective chart review and the association between AL, infectious complications and mortality was investigated with a multivariable Cox regression and logistic regression respectively. Results: 2014 patients met the inclusion criteria (median age 75, males 54.0%) of whom 548 (27.2%) had AL and 605 (30.0%) experienced an infectious complication. Overall case fatality at 90 days was 36.9%. Patients with AL were more severely affected, as highlighted by larger hematoma volume, higher frequency of intraventricular hemorrhage and lower Glasgow Coma Scale score (all p<0.001). AL was independently associated with increased risk of pneumonia (Hazard Ratio [HR] 1.65, 95% confidence interval [CI] 1.32-2.05, p<0.001) and multiple infections (HR 1.75, 95% CI 1.22-2.51, p=0.002). The association with urinary tract infection, sepsis or other infections was not significant. AL was also an independent predictor of 90-day mortality (odds ratio 1.55, 95% CI 1.18-2.04, p=0.002) after adjusting for confounders. Conclusions: AL is common in ICH and associated with increased risk of infectious complications and poor outcome. Further studies will be needed to determine whether prophylactic antibiotics in ICH patients with AL can improve outcome.

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