Factors associated with long-term survival following cardiac transplantation/Kalp nakli sonrasi uzun donem sagkalimi etkileyen faktorler.
Objective: By improving short and long-term survivals, cardiac transplantation would be a more realistic curative treatment modality. The aim of this study was to evaluate factors associated with the long-term survival following cardiac transplantations in our center.
Methods: Forty-four patients were operated on cardiac transplantation between 1989 and November 2006. The study was designed in a retrospective manner and all data were collected from hospital records. Our study population consisted of 16 patients (Group A) who survived >1 month, but died <2 years after cardiac transplantation and 17 patients (Group B) who survived more than 2 years. All patients had triple immunosuppressive therapy (cyclosporine, azathioprine, corticosteroid). Statistical analyses were performed using Fischer's exact and Mann Whitney U tests, and multivariate regression analysis. Survival was analyzed using Cox proportional hazard regression analysis.
Results: Group B patients had lower pre-transplant creatinine levels (0.93 [+ or -] 0.28 mg/dl vs. 1.16 [+ or -] 0.21 mg/dl, p=0.033) younger donor age (24.5 [+ or -] 6.3 years vs. 30.1 [+ or -] 8.1 years, p=0.017) and more male donors (82.3% vs. 50%, p=0.05) as compared with Group A patients. The perioperative and follow-up analysis showed that patients with long-term survival had shorter ischemic time (141.5 [+ or -] 33.2 min vs.182.5 [+ or -] 49.2 min, p=0.007), aortic cross clamp time (65.9 [+ or -] 10.2 min vs. 83.6 [+ or -] 7.9 min, p<0.001), less amount of blood transfusion (3.4 [+ or -] 1.6 units vs. 5.0 [+ or -] 1.5 units, p=0.01), better NYHA status after operation (1 [+ or -] 0 vs. 1.63 [+ or -] 0.72, p=0.014) and less frequent acute rejection episodes (11.8% vs. 68.8%, p<0.001) than those with short-term survival after operation. Cox proportional hazard regression analysis showed higher preoperative creatinine level (HR=42.6, 95% CI 4.67-388.21, p=0.001), acute rejection (HR=4.45, 95% 1.44-13.77, p=0.01), early postoperative functional status (HR=4.84, 95% CI 1.9-12.27, p=0.001) and unsatisfactory rejection surveillance protocol in the first 6 months after transplantation (HR=0.2, 95% CI 0.07-0.67, p=0.008) were prominent factors associated with the long-term survival.
Conclusion: The availability of the donor hearts from younger male donors with the shortest ischemic times is identified as the most significant factor improving long-term survival. The main strategy in cardiac transplantation should be shortening ischemic times and applying strict postoperative follow-up. (Anadolu Kardiyol Derg 2008,& 360-6)
Key words: Cardiac transplantation, rejection, ischemic time, survival analysis
Amag: Gunumuzde kisa ve uzun donem sag kalimda elde edilen gelismeler sonrasinda kalp nakli daha tercih edilebilir kuratif bir tedavi yontemi olmustur. Bu calismanin amaci, klinigimizin gerceklestirdigi kalp nakli girisimlerinin uzun donem sonuclarini irdelemektir.
Yontemler: Kirk dort hasta 1989 ile Kasim 2006 arasinda kalp nakli ameliyatina alindi. Bu calisma retrospektif olarak dizayn edilmis olup, hastalara ait veriler hastane kayitlarindan to planmistir. Bu calismaya ameliyat tarihi uzerinden en az 2 yil gecen 33 hasta dahil edildi. Hastalar 2 gruba ayrildi: Grup A'da kalp naklinden sonra en az 1 ay yasamis, fakat 2 sene icinde kaybedilmis 16 hasta yer almaktayken, Grup B'de 2 seneden fazla yasayan 17 hasta yer almaktaydi. Tum hastalar uclu immunospressif (siklosporin, azatioprin, kortikosteroid) tedavi gordu. Istatistiksel analiz Fischer ve Mann Whitney U testleri, ve coklu regresyon analizleri ile yapildi. Sagkalim Cox oransal hazard regresyon analiz ile incelendi.
Bulgular: Grup B hastalari Grup A'ya gore daha dusuk pre-transplant kreatinin seviyesine (0.93 [+ or -] 0.28 mg/dl karsin 1.16 [+ or -] 0.21 mg/dl, p=0.033), daha genc yasta vericiye (24.5 [+ or -] 6.3 yil karsin 30.1 [+ or -] 8.1 yil, p=0.017) ve daha fazla erkek donore (%82.3 karsin %50, p=0.05) sahipti. Perioperatif ve takip analizlerine gore uzun sagkalima sahip hastalar daha kisa surede kaybedilen gruba nazaran daha kisa iskemik (141.5 [+ or -] 33.2 dak karsin 182.5 [+ or -] 49.2 dak, p=0.007) ve aortik kros klemp (65.9 [+ or -] 10.2 dak karsin 83.6 [+ or -] 7.9 dak, p<0.001) surelerine, daha az kan urunu kullanimina (3.4 [+ or -] 1.6 uniteye karsin 5.0 [+ or -] 1.5 unite, p=0.01), transplantasyondan sonra daha iyi fonksiyonel kapasiteye (NYHA 1 [+ or -] 0 karsin 1.63 [+ or -] 0.72, p=0.014) ve daha az akut rejesiyon ataklarina (%11.8 karsin %68.8, p<0.001) sahipti. Cox oransal hazard regresyon analizi yuksek preoperatif kreatinin seviyesini (HR=42.6, %95 GA 4.67-388.21, p=0.001), akut rejeksiyonu (HR=4.45, %95GA 1.44-13.77, p=0.01), erken postoperatif fonksiyonel kapasiteyi (HR=4.84, %95GA 1.912.27, p=0.001;) ve postoperatif ilk 6 aydaki yetersiz rejeksiyon takibini (HR=0.2, %95 GA 0.07-0.67, p=0.008) uzun donem sag kalimi olumsuz etkileyen faktorler olarak ortaya koydu.
Sonuc: Uzun donem sag kalimi etkileyen en onemli faktor, genc erkek donorlerden alinan kalbin ek kisa iskemik surede nakledilmesidir. Kalp nakli programlarinda uygulanmasi gereken en onemli strateji iskemik surenin en aza indirilmesi ve siki postoperatif takibin uygulanmasidir. (Anadolu Kardiyol Derg 2008; 8: 360-6)
Anahtar kelimeler: Kalp nakli, rejeksiyon, iskemik sure, sag kalim analizi
Cardiac transplantation is a proven treatment modality for end stage heart failure in experienced centers with comparable clinical outcomes (1). The success of cardiac transplantation is evaluated by the early-mid-long term surveillance results and quality of life. Improvements gained over 35 years of cardiac transplantation have decreased early mortality (three months) because of graft failure, infection or rejection dramatically. However, the success of cardiac transplantation is determined by long-term survival. In some detailed studies, it has been shown that long-term survival following cardiac transplantation is correlated with preoperative and postoperative factors in both the donor and recipient (2, 3). Recent trends show increasing time on waiting lists, more frequent emergency transplantations, more usage of donor hearts with longer ischemic times and those with increasing inotropic support (4-6). Although these risky procedures for cardiac transplantation are widely accepted, more detailed studies are needed to evaluate factors influencing early and late mortality following cardiac transplantation. Given these circumstances, we aimed to investigate factors affecting long-term survival in a single center experience.
Between 1989 and November 2006, forty-four patients underwent cardiac transplantation at our center. The study was designed in a retrospective manner and all data were collected from hospital records. Investigating risk factors associated with long-term survival, we grouped patients who survived more than 24 months or died earlier. The first reason was the first longest survivor-recipient in Turkey died at the end of his second year. The second, we used Shumway technique for orthotopic cardiac transplantation until 1989 (7), but after 2002 we have preferred the bicaval technique and the longest survivor with this method was in his third year during this study. The third, most recipients died in their second postoperative year. Our study population consisted of 16 patients (Group A) who survived >1 month, but died < two years after cardiac transplantation and 17 patients (Group B) who survived more than two years. Remaining 11 patients were excluded from the study since 8 of them are still alive but have not filled the 24 months period. Two patients died in their first month, possibly due to early graft failure and the last one underwent heterotopic cardiac transplantation.
All patients had triple immunosuppressive therapy (cyclosporine, azathioprine, corticosteroid). Endomyocardial biopsy (7), cytoimmunologic monitoring (8), echocardiography (9) and pace electrocardiography (10) are the techniques that we have used for follow-up and rejection surveillance. Endomyocardial biopsy and echocardiography were used to identify acute rejection, and we performed coronary angiography and, echocardiography when a recipient was hospitalized because of heart failure and chronic rejection. The standardized grading system for the pathologic diagnosis of rejection in cardiac biopsies and its revision were used to address a uniform description and grading scheme for acute cardiac rejection (11).
Pre-transplant clinical and demographic variables, peroperative and follow-up data including long-term complications are collected prospectively and recorded in our center's computer based data bank. We have investigated our study groups by evaluating this data bank retrospectively.
All data were analyzed by using SPSS for Windows version 13.0 software (Chicago, IL, USA). Data are shown as mean [+ or -] standard deviation (min-max) values. Univariate and multivariate analyses were used to assess risk factors as independent predictors of late mortality. Cox proportional hazard regression analysis was used to assess risk factors as independent predictors of patient survival. Categorical data between groups were compared with Fischer's exact test, while continuous and discrete data were analyzed with Mann Whitney U-test. All variables significant at the p<0.1 level in the univariate analysis were included into Cox proportional hazard regression test. Statistical significance was determined with p<0.05 values.
Demographic variables and follow-up periods for both groups are shown in Table 1. More patients in Group A needed more inotropic support. In Group B patients, younger age and male gender were more prominent. Preoperative creatinine levels were lower in Group B (p=0.033) Although patients in Group B had poorer NYHA preoperative status, they had better long-term survival. Comparison for preoperative risk factors and echocardiographic data are shown in Table 2. When groups were compared according to the echocardiographic data, no significant difference was determined except mitral insufficiency (p=0.041).
Per- and Postoperative Findings
Comparisons of peroperative and postoperative findings for both groups are shown in Table 3. When ischemic times between groups were compared, we observed significant differences. Cold ischemic and aortic cross clamp (ACC) times were longer in Group A than in Group B (p=0.007 and p<0.001, respectively). The need for inotropic support and prostaglandin 12 after operation were more prominent in Group A as compared with Group B (p=0.014 and p=0.031, respectively). We also observed more sinus node dysfunction in Group A (p=0.004). In the intensive care unit, less blood products were transfused to Group B patients (p=0.01).
Late Period Complications
One patient in Group A died because of the right ventricular rupture and acute tamponade following cardiac biopsy for rejection surveillance. Four patients died because of infections. Six patients in Group A died in their first year because of acute cellular rejection. Four patients in Group B died following rehospitalization with the diagnosis of chronic rejection, supported by echocardiographic evidence of segmental wall movement impairment and decreasing in ejection fraction. Mortality causes in groups are given in Table 4.
Eleven patients in Group A and two patients in Group B had severe rejection in their first year. Six patients in Group A died from acute rejection and 3 patients died from chronic rejection. In Group B, mortality was observed in 7 patients due to chronic rejection. Late mortality due to ventricular fibrillation was thought to be a cause for chronic rejection. In Group B, 12 patients had new onset segmental wall motion abnormality on echocardiography in the first year after the transplantation.
Ten patients in Group A and 3 patients in Group B had severe infection. Four patients in Group A died because of infection due to Enterobacter sepsis, gram-negative sepsis, Neisseria pneumonia and Klebsiella pneumonia. The remaining patients were cured following appropriate antibiotic treatment and were discharged.
Risk Factors Associated with Long-term Survival
Survival curves of all patients are shown in Figure 1. The longest follow-up time was 98 months and 66% of our patients (n=22) had survived more then one year, 33% (n=11) had completed their third years following the transplantation.
Univariate analysis showed that advanced donor age and female donor, higher preoperative creatinine level, prolonged ischemic and aortic cross-clamp time, postoperative blood products transfusion, early postoperative NYHA status, rejection episode type and frequency were found to be significant factors associated with long-term survival (Table 5). Cox proportional hazard regression analysis showed higher preoperative creatinine level, acute rejection, early postoperative functional status and unsatisfactory rejection surveillance protocol in the first 6 months after transplantation were prominent factors associated with the long-term survival (Table 6, Fig. 2).
[FIGURE 1 OMITTED]
Many investigators have described various risk factors affecting survival after cardiac transplantation. There are differences in risk factors between different studies. Defining risk factors help to anticipate problems in recipients after cardiac transplantation, and to provide appropriate and early treatment of complications. Defining risk factors also provide appropriate procurement and matching strategy of donor hearts. Matching donors with appropriate recipients serve to improve long-term survival, and decreases mortality and morbidity for high-risk recipient and donors. We found significant differences between two groups.
Donor age and allograft coronary artery disease
Multicenter data define advanced donor age as a prominent risk factor for poor survival (3, 12). In our study, mean donor age was found to be significantly lower in the long-term group (p = 0.017). Although antigenic sensitivity causes negative results in younger recipients, we have not observed a difference for age distribution in our study groups. Literature data suggest advanced age as a prominent risk factor for increased allograft coronary artery disease (13). In our study, we observed more allograft coronary artery disease in long-term survival group. Since 69% of patients in short-term survival group had died in their first year, it was not possible to compare two groups for allograft coronary artery disease.
Obesity becomes a significant risk factor for the general population when accompanied by hypertension, dyslipidemia, diabetes and coronary artery disease. This is also observed in most of transplant patients. Many investigators have declined that obesity and hyperlipidemia may be related to allograft coronary artery disease and possibly unsatisfactory immunosuppression (14, 15). Grady et al. (16) declined that pretransplant obesity increased mortality without increasing the risk of acute rejection and allograft coronary artery disease. In contrast to the literature, we observed that the recipients in the long-term group were more obese when compared to the recipients in the short-term group. We did not observe a difference in complications related to obesity between two groups. Most of the patients in our study were not morbidly obese and therefore possibly did not face significant complications from obesity. Only two patients in Group B and one patient in Group A had new onset diabetes that needed oral anti-diabetic treatment.
[FIGURE 2 OMITTED]
In some studies, male gender was associated with short-term survival, and this was thought to be due to ischemic cardiomyopathy (17, 18). Ischemic cardiomyopathy etiology can cause the development of allograft coronary artery disease. Young age and male gender can be prominent factors for long-term survival. In one study, male donor and female recipient combination was declared to be a cause for increased rejection in the first year and the reason for this was thought as an increased immune response in women or dimension discrepancy (19). Lietz et al. (20) pointed out higher acute rejection incidence in female recipients in the first 6 months and declared early mortality (< 6 months) caused by infection. Allograft coronary artery disease is more seldom in female patients during the first postoperative year (17). In our study, there were four females in Group B and one in Group A. Although we did not find a significant difference in gender between our recipients (p = 0.17), we found more female donor hearts in the short-term survival group (p = 0.05).
Time in Waiting List
Although we have not found waiting time as a risk factor for the long-term survival, there are relevant data for prolonged time in waiting lists which as a significant risk factor for early mortality (17,18) Improved therapies for heart failure increase the waiting time without causing secondary organ damage. In this study, we observed that the patients in the long-term survival group spent more time on waiting lists with longer symptom duration. Beyond these facts, there was no difference between groups before transplantation in terms of functional status criteria. Longer times in waiting lists did not cause significant organ dysfunction in Group B patients preoperatively. Patients in Group B had been involved to the waiting list earlier with elective criteria's for transplantation.
We observed at least one rejection episode in 10 patients in Group A and we lost 69% of patients in their first year because of acute cellular rejection and early graft failure. In Group B, only three patients had an acute rejection episode. When considering two years period as a cut-off point for the long-term survival, rejection itself is a terminal point other than a risk factor.
We observed more infectious events in Group A (p = 0.007). Three of the eight patients died because of infection in the early period. Incidence of more infectious events was found as a risk factor for increased mortality itself. Infection is a serious issue in these immunosuppressed patients although proper antibiotics are used. Infection control is very important for the long time survival.
Prolonged ischemic time, which can be a cause of graft failure itself, is thought to be a prominent risk factor for survival. Ischemic times can be shortened with the success of improving organizations in donor organ transportation. Donor cold ischemic and recipient operation ischemic times were statistically different between groups. In Group B, shorter overall ischemic times were observed. In Group A, donor cold ischemic time was longer because of the difficulties in transportation of donor hearts. Prolonged ischemic times in donor hearts by causing early graft failure manifest clinically with prolonged inotropic needs and sinus node dysfunction. Both of these negative consequences were observed more in short-term survival group (69%). Cold ischemic time on an average was 4 hours in Group A and 3 hours in Group B. Better results would be accomplished if total ischemic time could be reduced to less than 3 hours. Intraregional organ sharing would be the best option other than interregional transfers of donor hearts. Cardiac recipient transfer to that region should be considered as a second best option to avoid prolonged ischemic times.
Quality Standards of Life after Transplantation
The main reason for early death after transplantation was the lower standards of home-life of our patients. The end stage cardiac failure is observed mostly in patients with lower social and economical level. After transplantation they must be followed very closely and carefully in Turkey. They have to be informed about their post-transplant life, exercise capacity, sexual behavior, infection risk and work area. We observed if the recipients were careful with health, work and medication, than they had longer high-quality life with longer survival. If we worry that recipients can not continue their high-quality life, we hold them in the hospital and give them a special room and work.
The patient number was low, quite enough to compare both groups. May be, it would be better if we could perform angiographic evaluation in all patients including early deaths.
By improving short and long-term survivals, cardiac transplantation would be more beneficial treatment modality. Towards this goal, the availability of the donor hearts from younger male donors with the shortest ischemic time would be the best factor in improving long-term survival. The main strategy in cardiac transplantation should be shorten ischemic times and enforce strict postoperative surveillance and follow-up protocols
This paper was presented at the 25th Meeting of the Society of Cardiac Surgeons, Pamplona, Spain, 21-23 June 2007 and 19h Annual Meeting of Asian Society of Cardiovascular Surgery, Beijing, China, 17-20 May 2007
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Basar Sareyyupoglu, Kaan Kirali, Deniz Goksedef, Murat Bullent Rabus, Altug Tuncer, Vedat Erentug, Denyan Mansuroglu, Cevat Yakut
Cardiovascular Surgery Center, Kartal Kosuyolu Yuksek lhtisas Education and Research Hospital, Kosuyolu, Istanbul, Turkey
Yazisma Adresi/Address for Correspondence: Dog. Dr. Kaan Kirali, Cardiovascular Surgery Center, Kartal Kosuyolu Yuksek Ihtisas Education and Research Hospital, Kosuyolu, Istanbul, Turkey Tel: +90 216 467 70 30 Faks: +90 216 369 63 63 E-mail: firstname.lastname@example.org
Table 1. Comparison of groups for preoperative demographic data Parameters Group A (n =16) Congestive symptoms, months 15.0 [+ or -] 10.8 (1-36) Mean follow-up, months 9.1 [+ or -] 8.9 (1-24) Time in waiting list, months 7.3 [+ or -] 8.7 (1-36) Demographic variables Recipient gender, male, n (%) 15(93.8) Recipient age, years 31.6 [+ or -] 13.1 (16-58) Donor age, years 30.1 [+ or -] 8.1 (14-48) Recipient weight, kg 63.5 [+ or -] 7.9 (46-76) Male Donor, n (%) 8(50) Etiologic factors Ischemic cardiomyopathy, n (%) 12(75) Dilated cardiomyopathy, n (%) 4(25) Parameters Group B (n =17) * p Congestive symptoms, months 24.3 [+ or -] 12.6 (6-58) 0.028 Mean follow-up, months 49.6 [+ or -] 26.4 (25-98) <0.001 Time in waiting list, months 12.8 [+ or -] 14.8 (1-58) 0.23 Demographic variables Recipient gender, male, n (%) 13(76.5) 0.17 Recipient age, years 29.5 [+ or -] 10.9 (16-51) 0.85 Donor age, years 24.5 [+ or -] 6.3 (16-40) 0.017 Recipient weight, kg 66.3 [+ or -] 12.9 (45-98) 0.56 Male Donor, n (%) 14(82.3) 0.05 Etiologic factors Ischemic cardiomyopathy, n (%) 12(70.6) 0.95 Dilated cardiomyopathy, n (%) 5(29.4) 0.78 Data are represented as Mean [+ or -] SD (Min-Max) values and proprotion/percentage * Fischer's exact test for categorical data comparison and Mann Whitney U-test for comparison of continuous variables Table 2. Comparison of groups by means of preoperative risk factors Variables Group A (n =16) Preoperative NYHA class 3.75 [+ or -] 0.45 (3-4) Patients in inotropic support, n (%) 7(43.8) Family history, n (%) 1(6.3) Urea, mg/dl 54.8 [+ or -] 10.4 (38-78) Creatinine, mg/dl 1.16 [+ or -] 0.21 (0.8-1.6) Lung failure, n (%) 1(6.3) Liver failure, n (%) 2(12.5) Renal failure, n (%) 3(18.8) Cardiothoracic index, % 0.59 [+ or -] 0.04 (0.5-0.7) LVESD, cm 6.63 [+ or -] 0.52 (5.6-7.8) LVEDD, cm 6.99 [+ or -] 0.65 (5.4-8.2) Mitral regurgitation, degree 2.94 [+ or -] 0.57 (2-4) Tricuspid regurgitation, degree 0.19 [+ or -] 0.4 (0-1) Ejection fraction, % 21.7 [+ or -] 5.9 (10-35) Pulmonary artery pressure, mmHg 46.1 [+ or -] 6.2 (40-60) Variables Group B (n =17) * P Preoperative NYHA class 3.71 [+ or -] 0.47 (3-4) 0.85 Patients in inotropic support, n (%) 6(35.3) 0.63 Family history, n (%) 1(5.9) 0.96 Urea, mg/dl 51.2 [+ or -] 16.7 (27-94) 0.11 Creatinine, mg/dl 0.93 [+ or -] 0.28 (0.5-1.5) 0.033 Lung failure, n (%) 1(5.9) 0.96 Liver failure, n (%) 2(11.7) 0.95 Renal failure, n (%) 2(11.7) 0.59 Cardiothoracic index, % 0.59 [+ or -] 0.02 (0.6-0.7) 0.74 LVESD, cm 6.59 [+ or -] 0.89 (5.1-8.9) 0.85 LVEDD, cm 6.6 [+ or -] 0.78 (5.4-8.4) 0.13 Mitral regurgitation, degree 2.41 [+ or -] 0.71 (1-4) 0.041 Tricuspid regurgitation, degree 0.06 [+ or -] 0.2 (0-1) 0.53 Ejection fraction, % 24.2 [+ or -] 9.9 (10-45) 0.53 Pulmonary artery pressure, mmHg 47.7 [+ or -] 11.1 (30-70) 0.79 Data are represented as Mean [+ or -] SD (Min-Max) values and proprotion/percentage *--Fischer's exact test for comparison of categorical data and Mann Whitney U-test for comparison of continuous variables LVEDD--left ventricle end diastolic diameter, LVESD--left ventricle end systolic diameter, NYHA -functional capacity Table 3. Comparison of groups for peroperative data and postoperative follow-up Variables Group A (n =16) * Anastomoses technique, n (%) 13(81.3) Ischemic time, min 182.5 [+ or -] 49.2 (120-270) Cross-clamp time, min 83.6 [+ or -] 7.9 (65-98) ** Total ischemic time, min 265.6 [+ or -] 51.8 (200-345) Inotropic support, day 6.75 [+ or -] 2.9 (3-14) Prostavazine usage, n (%) 14(87.5) Sinus rhythm, n (%) 10(62.5) Permanent pacing need, n (%) 6(37.5) Post-operative PAP, mmHg 39.2 [+ or -] 7.6 (25-50) Intubations time, hour 27.5 [+ or -] 7.6 (15-48) *** Drainage , mLs 1759.4 [+ or -] 1740.2 (450-7000) Chest tube removal, day 8.1 [+ or -] 7.6 (2-28) Transfusion, blood units 5.0 [+ or -] 1.5 (1-8) Mobilization, day 4.75 [+ or -] 1.1 (2-7) Intensive care unit stay, day 30.5 [+ or -] 22.3 (12-100) Hospital stay, day 87.1 [+ or -] 57.9 (20-193) Renal function impairment, n (%) 6(37.5) Infection, n (%) 10(62.5) Rejection, n (%) 13(81.3) Endomyocardial biopsy, n (%) 3(18.8) Anti-rejection therapy, n (%) 12(75) Rejection monitorization, n (%) 9(56.3) Acute rejection, n (%) 11(68.8) Chronic rejection, n (%) 1(6.3) Early NYHA functional capacity 1.63 [+ or -] 0.72 (1-3) Hospital mortality, n (%) 9(56.3) Late mortality, n (%) 7(43.8) Variables Group B (n =17) P **** * Anastomoses technique, n (%) 15(88.2) 0.59 Ischemic time, min 141.5 [+ or -] 33.2 (110-200) 0.007 Cross-clamp time, min 65.9 [+ or -] 10.2 (48-92) <0.001 ** Total ischemic time, min 208.7 [+ or -] 33.4 (174-280) 0.001 Inotropic support, day 4.5 [+ or -] 2 (2-10) 0.011 Prostavazine usage, n (%) 9(52.9) 0.031 Sinus rhythm, n (%) 17(100) 0.004 Permanent pacing need, n (%) 5(29.4) 0.6 Post-operative PAP, mmHg 35.5 [+ or -] 12.4 (25-80) 0.31 Intubations time, hour 31.4 [+ or -] 27.2 (10-129) 0.12 *** Drainage , mLs 1003.5 [+ or -] 545.1 (110-2750) 0.13 Chest tube removal, day 3.1 [+ or -] 0.7 (2-5) 0.006 Transfusion, blood units 3.4 [+ or -] 1.6 (2-7) 0.01 Mobilization, day 5.1 [+ or -] 2.1 (2-12) 0.98 Intensive care unit stay, day 27.1 [+ or -] 16.2 (14-80) 0.76 Hospital stay, day 68.1 [+ or -] 35.6 (30-180) 0.68 Renal function impairment, n (%) 2(11.7) 0.09 Infection, n (%) 3(17.6) 0.007 Rejection, n (%) 5(29.4) 0.002 Endomyocardial biopsy, n (%) 5(29.4) 0.49 Anti-rejection therapy, n (%) 6(35.2) 0.064 Rejection monitorization, n (%) 14(82.3) 0.1 Acute rejection, n (%) 2(11.8) <0.001 Chronic rejection, n (%) 12(70.6) <0.001 Early NYHA functional capacity 1 [+ or -] 0 (1) 0.014 Hospital mortality, n (%) 0 <0.001 Late mortality, n (%) 7(41.2) 0.63 Data are represented as Mean [+ or -] SD (Min-Max) values and proprotion/percentage ****--Fischer's exacttest for comparison of categorical data and Mann Whitney U-testfor comparison of continuous variables NYHA--Newyork Heart Association, PAP--pulmonary artery pressure * Orthotopic, bicaval orthotopic ** Total time from cross-clamping the donor's aorta to releasing cross-clamp from recipient's aorta *** Total drainage including postoperative hemorrhage and serous fluid Table 4. Comparison of groups for mortality analysis Variables Group A (n=16) Group B (n=17) Mortality, n (%) 16(100) 7(41) Rejection, n 10 7 Acute 6 Ventricular fibrillation during hospitalization 2 3 Sudden death 1 Chronic 1 4 Infection, n 4 Pneumonia 2 Sepsis 2 Acute renal failure, n 1 latrogenic, n 1 Table 5. Risk factors for late death (univariate analysis) Risk Factor p Demographic variables Donor age 0.011 Male donor 0.024 Preoperative creatinine 0.009 Per operative variables Cold ischemic time 0.05 Cross-clamp time 0.002 Postoperative transfusion units 0.002 Inotropic support 0.03 Postoperative Follow-up Early functional capacity <0.001 Rejection monitorization 0.045 Number of rejection periods 0.004 Acute rejection 0.002 Chronic Rejection 0.002 Table 6. Cox proportional hazard analysis for risk factors for late death Factor Hazard ratio (95% CI) p Preoperative high creatinine level 42.6 (4.67-388.21) 0.001 Acute rejection 4.45 (1.44-13.77) 0.01 Early worse functional capacity 4.84 (1.9-12.27) 0.001 Rejection monitorization 0.2 (0.07-0.67) 0.008
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|Title Annotation:||Orijinal Arastirma/Original Investigation|
|Author:||Sareyyupoglu, Basar; Kirali, Kaan; Goksedef, Deniz; Rabus, Murat Bulent; Tuncer, Altug; Erentug, Ved|
|Publication:||The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)|
|Date:||Oct 1, 2008|
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