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.
of oral sildenafil therapy. Conclusions: Increased arterial inflow is the primary hemodynamic event in the development of penile erection. NO acts as a messenger molecule stimulating guanylate cyclase, and leading to the formation of cyclic guanosine monophosphate (cGMP). cGMP then acts through calcium-gated potassium channels to cause vascular smooth muscle relaxation. Phosphodiesterases (PDE) are an integral component of cyclic nucleotide signaling. PDE5 is found in high concentration within the smooth muscle of the pulmonary vasculature and corpus cavernosum. Therefore, PDE5 inhibitors such as sildenafil. known to improve erectile dysfunction. have also been used in the treatment of PPHN. We hypothesize that the NO administered in the first case and the oral sildenafil given in the second case resulted in a high flow state leading to prolonged penile erection. By the proposed mechanism, hypoxia and acidosis would not occur. The clinical course of PPE of the newborn differs greatly from that of priapism. In most instances, spontaneous detumescence occurs, and therefore observation rather than surgical therapy is advocated.
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