Background— Although newer immunosuppressive agents, such as mTOR (mammalian target of rapamycin) inhibitors, have lowered the occurrence of malignancies after transplantation, cancer is still a leading cause of death late after heart transplantation. Statins may have an impact on clinical outcomes beyond their lipid-lowering effects. The aim of the present study was to delineate whether statin therapy has an impact on cancer risk and total mortality after heart transplantation. Methods and Results— A total of 255 patients who underwent heart transplantation at the University Hospital Zurich between 1985 and 2007 and survived the first year were included in the present study. The primary outcome measure was the occurrence of any malignancy; the secondary end point was overall survival. During follow-up, a malignancy was diagnosed in 108 patients (42%). The cumulative incidence of tumors 8 years after transplantation was reduced in patients receiving a statin (34% versus 13%; 95% confidence interval, 0.25–0.43 versus 0.07–0.18; P <0.003). Statin use was associated with improved cancer-free and overall survival (both P <0.0001). A Cox regression model that analyzed the time to tumor formation with or without statin therapy, adjusted for age, male sex, type of cardiomyopathy, and immunosuppressive therapy (including switch to mTOR inhibitors or tacrolimus), demonstrated a superior survival in the statin group. Statins reduced the hazard of occurrence of any malignancy by 67% (hazard ratio, 0.33; 95% confidence interval, 0.21–0.51; P <0.0001). Conclusions— Although it is not possible to adjust for all potential confounders because of the very long follow-up period, this registry suggests that statin use is associated with improved cancer-free and overall survival after cardiac transplantation. These data will need to be confirmed in a prospective trial.
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SummaryWe describe a case of a so far unknown complication after failed extraction of defibrillator leads. Perforation of the LIMA bypass caused by Excimer laser created an arterio-venous fistula from the proximal bypass to the superior subclavian vein and occlusion of the distal LIMA bypass with consecutive anterior ST-elevation myocardial infarction.Key words: Excimer laser extraction; defibrillator leads; myocardial infarction; arterio-venous fistula; aortocoronary bypass Case reportA 60-year-old woman was admitted to our hospital for replacement of broken defibrillator leads. The patient was known to have ischemic heart disease since a medically treated inferior myocardial infarction in 1985. In early 1996, coronary bypass surgery was performed with implantation of a LIMA to LAD and RIMA to RCA graft. A single chamber defibrillator was implanted at the left pectoral region in late 1996 for non-sustained ventricular tachycardia and persistent low left ventricular ejection fraction. In 1998, an isolation defect of the defibrillator leads was diagnosed and new leads were implanted. The original lead could not be removed and was left in place. In 2007, a coronary angiogram documented open LIMA to LAD and RIMA to RCA grafts. Native LAD and RCA were both chronically proximally occluded.After repeated inadequate shock deliveries occurred in late 2010 because of electrical artefacts produced by the patient's arm movement, defibrillator lead malfunction was diagnosed and the patient was sent for lead replacement. The Excimer laser extraction technique was attempted on both right ventricular leads, but the cleaning guide wire could not be advanced more than 20 cm and both leads could not be removed. Finally, a third ventricular lead and a new single chamber ICD were implanted through the right subclavian vein. During the procedure, a short fall in blood pressure was noticed and successfully treated with a single bolus of 250 ml of pure saline. After extubation, the patient instantaneously complained about severe chest pain and ECG showed new ST segment elevation of the anterior wall. An immediately performed angiogram showed arteriovenous fistula between the proximal LIMA bypass and the superior subclavian vein and occlusion of the distal LIMA bypass ( fig. 1). Due to the anatomical proximity, the laser had probably perforated the vein, "cutted" the LIMA-graft and created a connection between LIMA and the left subclavian vein. Several attempts to reopen the distal LIMA bypass percutaneously were unsuccessful. Finally, the arterio-venous fistula was coiled with a 4×6 mm Amplatzer ® vascular plug to prevent persistent left to right shunt and consecutive volume overload ( fig. 2). An intra-aortic balloon pump was placed and used for 24 hours after the procedure. Thereafter the patient remained haemodynamically stable. Repetitive blood samples showed a relevant CK peak of 2993 U/l on day two after the LIMA occlusion and a decline of left ventricular ejection fraction measured in echocardiography from 38% pre-operatively t...
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