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Hemodynamic Rounds
The essential resource on cardiac hemodynamics—now in a new edition
Hemodynamic Rounds, Fourth Edition is intended to help cardiologists, cardiovascular fellowship trainees, residents and other members of the medical community enhance their understanding of cardiac physiology and its associated hemodynamic presentations in health and disease. This includes the basic principles of flow and pressure measurements, systemic as well as coronary hemodynamics in normal and diseased states, and changes in hemodynamics following interventional procedures ranging from TAVI and valvuloplasty to stent placement.
Like its popular predecessors, this new edition draws on case studies to illustrate characteristic cardiac hemodynamic findings and discusses the essential methods used in interpreting pressure waveforms as a diagnostic and monitoring tool.
The text is organized into chapters on specific areas of the heart, common cardiac pathophysiologic conditions, and hemodynamic situations resulting from different therapeutic procedures. It includes discussions of both normal and abnormal pressure waveforms. This new edition has been revised throughout to include brand new content on aortic and mitral valve stenosis and regurgitation as well as TAVI and mitral clip hemodynamics. Highlights include:
* Essential and easy to understand resource for those required to interpret cardiac blood flow and blood pressure tracings
* Covers hemodynamic assessment by cardiac disorder, plus the bedside applications of hemodynamics
* Revised throughout and includes brand new content on valve stenosis and regurgitation and TAVI and mitral clip hemodynamics
Hemodynamic Rounds: Interpretation of Cardiac Pathophysiology from Pressure Waveform Analysis, Fourth Edition is an indispensable tool for all physicians, nurses, and students responsible for measuring and interpreting cardiac waveforms in cardiac diagnosis and monitoring.
eBook
Single-centre study of 628 adult, primary kidney transplant recipients showing no unfavourable effect of new-onset diabetes after transplant
Aims/hypothesis
To better understand the implications of new-onset diabetes after transplant (NODAT), we used our prospectively followed cohort of 628 adult primary kidney transplant recipients to determine the prognostic impact of pretransplant diabetes and NODAT.
Methods
The study cohort consisted of all participants in four randomised immunosuppression trials performed at our centre since May 2000. For each cause-specific hazard analysed, Cox stepwise regression was used to determine a multivariable model of significant baseline predictors; the multivariable influence of having pretransplant diabetes and NODAT (t) (the latter defined as a zero-one, time-dependent covariate) was subsequently tested. Similar analyses of estimated glomerular filtration rate (eGFR) at 36 and 60 months post transplant were performed using stepwise linear regression. Finally, a repeated measures analysis of mean HbA
1c
as a function of diabetes category (pretransplant diabetes vs NODAT) and randomised trial (first to fourth) was performed.
Results
Median follow-up was 56 months post transplant. Patients with pretransplant diabetes comprised 23.4% (147/628), and 22.5% (108/481) of the remaining patients developed NODAT. Pretransplant diabetes had no prognostic influence on first biopsy-proven acute rejection and death-censored graft failure hazard rates, nor on eGFR, but was associated with significantly higher rates of death with a functioning graft (DWFG) (
p
= 0.003), DWFG due to a cardiovascular event (
p
= 0.005) and infection that required hospitalisation (
p
= 0.03). NODAT (t) had no unfavourable impact on any of these hazard rates nor on eGFR, with actuarial freedom from DWFG remaining at over 90% among patients in pre- and post-NODAT states at 72 months post transplant/NODAT. Mean HbA
1c
for patients in the first to fourth randomised trials, averaged across diabetes category, decreased by trial (7.28%, 6.92%, 6.87% and 6.64% [56.1, 52.1, 51.6 and 49.1 mmol/mol], respectively;
p
= 0.02).
Conclusions/interpretation
Less-than-expected post-NODAT risk for graft loss and death may exist in the current climate of tighter glucose monitoring post transplant.
Journal Article
Analysis of Failure in Living Donor Liver Transplantation: Differential Outcomes in Children and Adults
Over the past decade we have reported excellent outcomes in pediatric living‐donor liver transplantation (LDLT) with recipient survival exceeding 90%. Principles established in these patients were extended to LDLT in adults. To compare outcomes in donors and recipients between adult and pediatric LDLT in a single center, we reviewed patient records of 45 LDLT performed between 1/98 and 2/01: 23 adult LDLT (54 ± 6.5 yr) and 22 pediatric LDLT (33.7 ± 53.5 months). Preoperative liver function was worse in adults (International Normalized Ratio [INR] 1.5 ± 0.4 vs. INR 1.2 ± 0.5; p = 0.032). 4 adults (17%) met criteria for status 1 or 2A. Only 1 child was transplanted urgently. Analysis included descriptive statistics and Kaplan‐Meier estimation. Donor mortality was 0% with 1 re‐exploration, 2.4%. Median hospital stay (LOS) was 6.0 days (range, 4–12 days). Donor morbidity and LOS did not differ by sex, extent of hepatectomy, or adult and pediatric LDLT (p = 0.49). In contrast, recipient outcomes were worse for adults. Adult 1 year graft survival was 65% (3 retransplants [ReTx], 5 deaths) vs. 91% for children (1 ReTx, 1 death) p = 0.02. Graft losses in adults were due to sepsis (n = 3), small for size (n = 2), suicide, and hepatic artery thrombosis (HAT), whereas in children graft losses were due to portal thrombosis and total parenteral nutrition (TPN) liver failure. Biliary leaks occurred in 22% of adults and 9% of children. Hepatic vein obstruction occurred in 17% of adults and in none of the children. Median LOS was comparable (adult, 16.5 days (range, 7–149 days); child, 17 days (range, 10–56 days), p = 0.2). Graft function (total bilirubin (TBili) < 5mg/dl, INR < 1.2, aspartate aminotransferase (AST) < 100 U/l) normalizing by day 4 in children and by day 14 in adults. Adults fared worse, with an array of problems not seen in children, in particular, hepatic vein obstruction and small‐for‐size syndrome. Biliary leaks were diagnosed later in adults and were lethal in 3 cases; this was later avoided with biliary drainage in adult recipients. Finally, use of LDLT in decompensated adults led to death in 3 of 4 patients, and should be restricted to elective use.
Journal Article
Identifying Risk Factors in Renal Allografts before Transplant: Machine-Measured Renal Resistance and Posttransplant Allograft Survival
Enhancement of renal allograft function and survival in an era where expanded criteria donors are increasingly used requires validated selection criteria. The goal of this retrospective study was to evaluate the significance of pretransplant donor and allograft parameters to identify risk factors that can be used in a model to predict 1-year allograft outcomes. Donor demographic factors, donor type, and allograft parameters such as biopsy results and machine-measured renal resistance were correlated with 1-year graft outcome. The Kaplan-Meier method was used to estimate graft survival using the categorical predictors of donor type, donor age, and machine-measured renal resistance at 1.5, 3, and 5 hours. The log-rank test was used to test the difference in survival curves between cohorts. The Cox regression analysis was used to estimate hazard ratios for machine-measured renal resistance, donor age, donor terminal creatinine level, donor's estimated glomerular filtration rate, cold ischemia time, and percent glomerulosclerosis. The data show that machine-measured renal resistance at 3 and 5 hours has a statistically significant inverse relationship to 1-year graft survival. All other risk factors had no correlation with 1-year graft survival. The machine-measured renal resistance at 3 hours is the earliest significant predictor of 1-year allograft outcome.
Journal Article
Hemoglobin A1c testing is associated with improved pancreas utilization for transplant
Aging, higher prevalence of diabetes, worsening obesity, and hyperglycemia among potential donors increase the likelihood that pancreata will be declined by transplant centers. Hemoglobin A1c testing, also known as glycated hemoglobin testing, identifies a donor's average blood glucose concentration for the preceding 2 to 3 months and is the standard test for identifying prolonged periods of hyperglycemia.
To compare pancreas utilization rates before and after implementation of hemoglobin A1c testing.
A retrospective study of data from the New York Organ Donor Network was conducted. Potential donors were defined as standard criteria donors who had no history of diabetes and were not seropositive for hepatitis B or C. Criteria for \"ideal\" potential pancreas donors were based on age, body mass index, lipase level, and terminal creatinine level. Potential donors who did not meet the criteria for ideal donors were considered \"expanded\" potential pancreas donors. Pancreas utilization rate was defined as the number of pancreata transplanted divided by the number of potential pancreas donors.
Of 779 standard criteria donors, 691 (89%) were potential pancreas donors: 251 ideal (36%) and 440 expanded (64%) donors. In 2005 and 2006, before hemoglobin A1c testing, pancreas utilization rates were 21% and 18%, respectively. In 2008, 2009, and 2010, after hemoglobin A1c testing was incorporated, utilization rates were 27%, 28%, and 32%, respectively. Utilization of ideal donors increased from 33% to 51% (P= .003), and utilization of expanded donors increased from 11% to 17% (P= .05). Pancreas utilization increased 51.0%, and pancreas discards decreased 50.8% with the implementation of hemoglobin A1c testing.
Hemoglobin A1c testing may increase utilization of ideal and expanded criteria pancreata.
Journal Article
Multiple perspectives on family relationships: a latent variables model
Many scholars are skeptical of family member reports on their interpersonal relationships. Familial reports are assumed to be biased by social desirability as well as other factors. In this study, a latent variables modeling approach was employed to evaluate rater reliability and bias in mother, father, and child ratings of parent-child negativity. Results based on 78 clinical families demonstrate that family member ratings contain a significant \"true score\" component that correlates with observer ratings of parental behavior. The presence of systematic rater effects is also demonstrated. The latent variables approach, which provides statistical control for rater effects, is recommended for the analysis of this type of data.
Journal Article