Cardiothoracic Transplant Anesthesia Article of the Month

Godino C, Munafo A, Scotti A, Estevez-Loureiro R, Hernandez AP, et al. MitraClip in secondary mitral regurgitation as a bridge to heart transplantation: 1 year outcomes from the International MitraBridge Registry. J Heart Lung Transplant. 2020 Dec;39(12): 1353-1362.

Abstract:

BACKGROUND: Patients awaiting heart transplantation (HTx) often need bridging therapies to reduce worsening and progression of underlying disease. Limited data are available regarding the use of the MitraClip procedure in secondary mitral regurgitation for this clinical condition.

METHODS: We evaluated an international, multicenter (17 centers) registry including 119 patients (median age: 58 years) with moderate-to-severe or severe secondary mitral regurgitation and advanced heart failure (HF) (median left ventricular ejection fraction: 26%) treated with MitraClip as a bridge strategy according to 1 of the following criteria: (1) patients active on HTx list (in list group) (n = 31); (2) patients suitable for HTx but awaiting clinical decision (bridge to decision group) (n = 54); or (3) patients not yet suitable for HTx because of potentially reversible relative contraindications (bridge to candidacy group) (n = 34).

RESULTS: Procedural success was achieved in 87.5% of cases, and 30-day survival was 100%. At 1 year, Kaplan−Meier estimates of freedom from the composite primary end-point (death, urgent HTx or left ventricular assist device implantation, first rehospitalization for HF) was 64%. At the time of last available follow-up (median: 532 days), 15% of patients underwent elective transplant, 15.5% remained or could be included in the HTx waiting list, and 23.5% had no more indication to HTx because of clinical improvement.

CONCLUSIONS: MitraClip procedure as a bridge strategy to HTx in patients with advanced HF with significant mitral regurgitation was safe, and two thirds of patients remained free from adverse events at 1 year. These findings should be considered exploratory and hypothesis-generating to guide further study for percutaneous intervention in high-risk patients with advanced HF. “

Expert Summary by Barbara Wilkey, MD

References:

1. Feldman T, Foster E, Glower DD, Kar S, Rinaldi MJ, Fail PS, Smalling RW, Siegel R, Rose GA, Engeron E, Loghin C, Trento A, et al. for the EVEREST II Investigators. Percutaneous Repair or Surgery for Mitral Regurgitation. N Engl J Med 2011;364:1395-1406.
2. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim S, Mishell JM, Whisenant B, Grayburn PA, Rinaldi M, Kapadia SR, Rajagopal V, Sarembock IJ et al. for the COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med 2018; 379: 2307-2318.

Abdominal Organ Transplant Article of the Month

Abstract:

Background. Opioid use in liver transplantation is poorly understood and has potential associated morbidity.

Methods. Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peri-transplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use post-transplant.

Results. Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Post-transplant, 61% of patients filled an opioid prescription 0–2 months after discharge, and 21% filled an opioid between 10–12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use post-transplant. Among patients with pre-transplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pre-transplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased post-transplant opioid use.

Conclusions. Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use post-transplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

Expert summary by Cara Crouch, MD

References:

1. Cron D, Tincopa M, Lee J, Waljee A, Hammoud A, Brummet C, Waljee J, Englesbe M, Sonnenday C. Prevalence and Patterns of Opioid Use Before and After Liver Transplantation. Transplantation. 2021; 105(1):100-107
2. Braun H, Ascher N. Opioid Use and Liver Transplantation. Transplantation. 2021; 105(1):25-26