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BACKGROUND Little is known about the incidence of acute kidney injury (AKI), as defined using the Kidney Disease Improving Global Outcome classification, after heart transplantation (HT). Our objective was to evaluate the impact of AKI in a cohort of HT recipients. (Setting: University Hospital.) METHODS: We studied 310 consecutive HT recipients from 1999 to 2017, with AKI being defined according to the Kidney Disease Improving Global Outcome criteria. Risk factors were analyzed by multivariable analyses, and survival by Kaplan-Meier curves and a risk-adjusted Cox proportional hazards regression model. RESULTS One hundred twenty-five (40.3%) patients developed AKI, with 73 (23.5%), 18 (5.8%), and 34 (11%) patients having AKI stages 1, 2, and 3, respectively. Cardiac tamponade (odds ratio [OR], 16.82; 95% confidence interval [CI], 1.06-138), acute right ventricular failure (OR, 3.54; 95% CI, 1.82-6.88), and major bleeding (OR, 2.46; 95% CI, 1.18-5.1) were the principal risk factors for AKI. Patients with AKI had a greater hospital mortality (3.8% vs 16%, P < 0.05), especially those requiring renal replacement therapy (46.9% vs 5.4%, P = 0.006). Acute kidney injury requiring renal replacement therapy was independently associated with hospital mortality (OR, 11.03; 95% CI, 4.08-29.8). With a median follow-up after hospital discharge of 6.7 years (interquartile range, 2.4-11.6), overall survival at 1, 5, and 10 years was 95.4%, 85.1%, and 75.4% versus 85.2%, 69.8% and 63.5% among patients without AKI and with AKI stages 2 to 3, respectively (P = 0.08). CONCLUSIONS The onset of AKI after HT is mainly associated with postoperative complications. Only severe AKI stage predicts worse short-term outcome, with this impact appearing to be lost at long-term follow-up.

Objective The evaluation of right ventricular systolic function is essential to the hemodynamic management of critically ill cardiac patients. Nevertheless, assessment of right ventricular function remains problematic. We sought to analyze the correlation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular ejection fraction (RVEF) in the assessment of global and regional right ventricular function, respectively. Methods This was a prospective study of 61 cardiac surgical patients. TAPSE was measured with transthoracic echocardiography and RVEF was obtained by a thermodilution pulmonary artery catheter. Both measurements were estimated simultaneously during the early postoperative period. Patients with previously identified severe tricuspid insufficiency were excluded from the study to avoid confounding results. Results The etiologies for cardiac surgery were surgical pulmonary thromboendarterectomy in 19 patients, valve replacement in 17 patients, heart transplant in 13 patients, and coronary artery bypass graft in 9 patients. Mean RVEF and TAPSE were 26.2% ± 9.7% and 11.4 ± 4 mm, respectively. RVEF and TAPSE showed a significant correlation (r = 0.73, P Conclusions TAPSE is a robust measure of right ventricular function that correlates with RVEF assessed by pulmonary artery catheter. A noninvasive method such as echocardiography can guide and support invasive monitoring of right ventricular function in cardiac surgical patients.

Right ventricular failure after cardiac surgery remains an important clinical problem, especially in certain surgical settings: congenital heart disease, mitral valve disease with pulmonary hypertension, high-risk coronary artery disease, heart transplantation, pulmonary thromboendarterectomy and left ventricular assist device placement. In recent years, a number of studies have demonstrated the prognostic value of right ventricular function in cardiac surgery and, therefore, the usefulness of accurate risk stratification. The survival rate for acute, refractory, right ventricular failure after cardiac surgery may be as low as 20-25%. Less severe disease is also associated with increased postoperative morbidity and mortality and has a marked effect on the length of hospitalization. This highlights the importance of understanding the underlying pathophysiology of the condition, its clinical spectrum, early diagnosis and preventive strategies, all of which are discussed in this review article.

La disfuncion ventricular del injerto en el postoperatorio inmediato del paciente trasplantado cardiaco es una complicacion grave, que cursa con un sindrome de bajo gasto cardiaco y necesidad de soporte circulatorio, y es una de las causas mas frecuentes de morbimortalidad inicial. Presentamos la experiencia clinica con 6 pacientes trasplantados en los que, tras un manejo hemodinamico habitual con aminas simpaticomimeticas, no se consiguio una adecuada situacion hemodinamica y se utilizo levosimendan intravenoso, un farmaco sensibilizador al calico con propiedades inodilatadoras. El uso de este farmaco fue bien tolerado y favorecio una mejoria hemodinamica que facilito la retirada del soporte inotropico con aminas y la recuperacion clinica (con alta de UCI de 5 de los 6 pacientes).

Introduction: The presence Pulmonary Hypertension (PH) in the pre-transplant evaluation period, had an increase in morbidity and mortality following heart transplant, secondary to right ventricular failure; however, in recent years it has been shown that the presence of PH while still reversible does not appear to be associated with this increase risk. The aim of this work is to study the efficacy and safety of sildenafil in order to evaluate the reversibility of PH associated with CHF in heart transplant candidates in relation to the clinical outcome after surgery. Methods and Results: Included were all heart transplant patients with PH who had previously undergone an acute vasodilator test and then chronic treatment with sildenafil, and the morbidity and mortality of these patients were compared to those of heart transplant patients without prior PH. Between September 2001 and April 2010, 165 orthotopic transplants were performed, 31 of these patients had out of proportion PH and 134 of them not. Patients with PH underwent an acute vasodilator test and then chronic treatment with sildenafil. There were no statistically significant differences observed in the subsequent evolution of the PH group vs. the non-PH group in terms of total mortality (22.6% vs. 24.6%), in-hospital mortality (6.5% vs. 8.2%), days in ICU (3-7 d vs. 4-7 d), need for vasoactive drugs (1-3 d vs. 1-4 d), need for counterpulsation balloon pump (53.4% vs. 46.4%) or need for hemodiafiltration (4.5% vs. 7%). Conclusion: In patients with out of proportion PH associated with CHF in pre-transplant evaluation, a positive response to the acute vasodilator test with sildenafil predicts mortality and morbidity similar to that of heart transplant patients with no prior PH.

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit.

We describe the appearance of long QT interval and polymorphous ventricular tachycardia in a patient treated with amiodarone who presented with hypokalemia secondary to chronic diuretic therapy. Ventricular pacing was initiated upon admission. The hypokalemia was corrected and amiodarone was discontinued. After three days the patient showed a normal QT interval and was free of ventricular tachyarrhythmias. Although hypokalemia could itself have been the arrhythmogenic factor in this particular patient, the additional toxic effect of amiodarone cannot be ruled out. It seems reasonable to consider the combination of both as dangerous when we take into account that the majority of patients cited as having amiodarone-induced torsade de pointes had also potassium depletion.