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Eculizumab suppresses the effector functions of the complement system and represents a therapeutic breakthrough for patients with paroxysmal nocturnal hemoglobinuria or atypical hemolytic uremic syndrome (aHUS). Safety monitoring is ongoing; so far, most notable is the expected increase in infection risk with encapsulated organisms. Despite potential applicability in multiple complement-mediated disorders, the off-label use of eculizumab has been limited, mainly by its prohibitive cost. The purpose of this review is to summarize the current data relevant to the use of eculizumab in kidney transplantation.In aHUS, prone to high rates of recurrence and allograft loss, eculizumab has made the most notable therapeutic impact. Further clarification of complement defects may help predict therapeutic responses and hopefully guide treatment duration. In C3 glomerulopathies, the clinical response to eculizumab appears more heterogeneous and less effective in processes mediated by upstream to C5 complement deregulation. A large clinical trial of eculizumab for prevention of delayed graft function is ongoing. In antibody-mediated rejection, the role of eculizumab is unclear as its use has been limited to very complex, mostly presensitized, patients in mixed combinations of therapeutic modalities.Overall, eculizumab has raised awareness of complement-mediated disorders as an exciting, new therapeutic option with multiple potential applications in kidney transplantation. Further research is needed to develop a better understanding of eculizumab applicability, efficacy, and treatment monitoring and beyond, to future therapeutic tools targeting the complement.

Objective: The Duke Activity Status Index (DASI) questionnaire has become an established measure of cardiac functional capacity and quality of life. However, the relationship between a low DASI score and presence of major adverse cardiac events has not yet been assessed. This study evaluates differences in patient function and occurrence of late cardiac events in patients undergoing coronary artery bypass (CAB). Methods: Patients undergoing CAB between 1994 and 2014 at the Valley Hospital were assessed and propensity matched for surgical approach. The resulting population of 1856 patients was followed for a mean time of 11.2 years ranging from 1 to 20 year. Survival, occurrence of MI, stroke, repeat revascularization and patient function using the DASI questionnaire were assessed. At the latest follow-up, 1363 patients were still alive, of which 776 had completed the DASI questionnaire. Patients who completed the questionnaire (Responders) were compared to those who did not complete the DASI (Non-Responders) on baseline demographic and clinical characteristics. Kaplan-Meier and Cox Proportional Hazards Regression were used to compare late non-fatal events that occurred in patients with a low (52, N=310) DASI score. Results: Responders had a higher rate of prior MI, increased hypertension, and were significantly older at baseline procedure compared to Non-Responders. Both groups had comparable surgical risk and left ventricle ejection fraction at baseline revascularization. Kaplan-Meier analysis of the Responders showed that patients with a low scoring DASI had significantly greater occurrence of all late events. Cox Regression analysis controlling for all baseline factors showed that patients with a low DASI score had a two-fold increase in late non-fatal events compared to medium and high DASI scoring patients (adjusted hazard ratio: 2.076, 95% C.I. 1.309-3.293, p=0.002) (Figure 1). Conclusions: This study demonstrates that in cardiac surgical patients, a low score on DASI is independently associated with a higher occurrence of late non-fatal cardiac events. This provides further evidence supporting the use of the DASI questionnaire in evaluating patient functioning after cardiac surgery.

Background: The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our technique of doubly ligating the LAA (LLAA) has recently demonstrated a 95% success rate of achieving complete LAA occlusion by follow-up transesophageal echocardiography. However, the outcomes of these patients have yet to be compared to a set of non-ligated patients. Methods: From 2005 to 2012, 814 patients received LLAA using our previously published technique of double ligation with both a PDS II endosnare and a running 4-0 Prolene pledgeted suture. Propensity scores were developed based on 22 observed baseline covariates in a logistic regression model with LLAA as the dependent variable. This produced two patient cohorts of 602 patients balanced for baseline factors. These patients were retrospectively analyzed regarding their incidence of 30-day outcomes. Results: Overall, the ligated group had a higher rate of comorbidities, shorter ICU and post-surgical length of stay, less post-operative bleeding, lower rate of permanent stroke, and an overall significantly lower in-hospital mortality (0.7% vs. 3.0% p Conclusions: Propensity matched analysis demonstrates that LLAA correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in intraoperative or postoperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared to LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi peri-operatively and in the long term.