The long-term mortality benefit that was associated with a mechanical prosthesis, as compared with a biologic prosthesis, persisted until 70 years of age among patients undergoing mitral-valve replacement and until 55 years of age among those undergoing aortic-valve replacement. (Funded by the National Institutes of Health and the Agency for Healthcare Research and Quality.).
In patients with end-stage heart failure (ESHF) who are candidates for isolated heart transplant (HRT), dialysis dependence (DD) is considered an indication for combined heart-kidney transplantation (HKT). HKT remains controversial in ESHF transplant candidates with nondialysis-dependent renal insufficiency (NDDRI). Using United Network for Organ Sharing data, we examined the cumulative incidences of transplant and mortality in patients with DD and NDDRI waitlisted for HKT or HRT. In all groups, 3-month waitlist mortality was dismal: 31% and 21% for HRTand HKT-listed patients with DD and 12% and 7% for HRT-and HKT-listed patients with NDDRI. Five-year posttransplant survival was improved in HKT recipients compared with HRT recipients for both patients with DD (73% vs. 51%, p < 0.001) and NDDRI (80% vs. 69%, p < 0.001). Likewise, multivariable analysis associated HKT with better outcomes than HRT in HKT-listed patients, although both improved survival. These data argue strongly for HKT in ESHF transplant candidates with DD. However, in patients with NDDRI, HKT must be weighed against the possibility of renal recovery with isolated HRT. Whether HRT (followed by a staged kidney transplant in patients who do not recover renal function after HRT), as opposed to HKT, maximizes organ benefit for patients with NDDRI and ESHF requires assessment. Nevertheless, given their dismal waitlist outcomes and excellent posttransplant results, we suggest that patients with DD and NDDRI with ESHF be considered for early listing and transplant.
Background
Medical treatment of initially uncomplicated acute Stanford type-B aortic dissection is associated with a high rate of late adverse events. Identification of individuals who potentially benefit from preventive endografting is highly desirable.
Methods and Results
The association of CT imaging features with late adverse events was retrospectively assessed in 83 patients with acute uncomplicated Stanford type-B aortic dissection, followed over a median of 850 (IQR 247–1824) days. Adverse events were defined as fatal or non-fatal aortic rupture, rapid aortic growth (>10 mm/year), aneurysm formation (≥6 cm), organ or limb ischemia, or new uncontrollable hypertension or pain. Five significant predictors were identified using multivariable Cox regression analysis: connective tissue disease (HR 2.94, 95%CI: 1.29–6.72, p=0.01), circumferential extent of false lumen in angular degrees (HR 1.03 per degree, 95%CI: 1.01–1.04, p=0.003), maximum aortic diameter (HR 1.10 per mm, 95%CI: 1.02–1.18, p=0.015), false lumen outflow (HR 0.999 per mL, 95%CI: 0.998–1.000, p=0.055), and number of intercostal arteries (HR 0.89 per n, 95%CI: 0.80–0.98, p=0.024). A prediction model constructed to calculate patient specific risk at 1, 2 and 5 years and to stratify patients into high, intermediate, and low risk groups. The model was internally validated by bootstrapping and showed good discriminatory ability with an optimism-corrected c-statistic of 70.1%.
Conclusions
CT imaging-based morphologic features combined into a prediction model may be able to identify patients at high risk for late adverse events after an initially uncomplicated type B aortic dissection.
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