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Eur J Cardiothorac Surg 2002;21:1061-1072
© 2002 Elsevier Science NL

Short- and long-term results of open heart surgery in patients with abdominal solid organ transplant

Division of Cardiothoracic Surgery, The Ohio State University, Columbus, OH, USA

Received 21 September 2001; received in revised form 10 January 2002; accepted 16 January 2002.

* Corresponding author. Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Tel.: +81-3-3815-5411; fax: +81-3-5684-3989
e-mail: ono-tho{at}h.u-tokyo.ac.jp

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
Objectives: Cardiac disease is a common cause of mortality and morbidity in patients with abdominal solid organ transplant. Improvement of the results of abdominal organ transplantation has contributed to an increasing pool of patients who require open heart surgery. We investigated short- and long-term results of open heart surgery in patients with functioning abdominal solid organ transplants. Methods: We retrospectively examined 60 patients (52.5 years in average) undergoing coronary artery bypass grafting and/or valve surgery since July 1988 after abdominal organ transplantation. There were 22 females (37%). They consisted of 46 kidney, nine kidney-pancreas and five liver recipients. Cardiac surgery was performed 68.9 months after transplantation. Preoperative serum creatinine level was 2.1 mg/dl, and 11 patients (18%) had creatinine level more than 3.0 mg/dl. Eleven patients (18%) were operated upon on non-elective basis. Twelve patients (20%) were not given stress-dose steroids postoperatively. Results: Three patients died early after surgery (5.0%). Twenty-six major complications were seen in 17 patients (28%), including deterioration of renal function in seven (three patients required temporary hemodialysis), three major infections, two bleeding complications, and two strokes. No graft loss was encountered. No differences were seen in mortality and morbidity between patients with or without stress-dose steroids. Multivariate analysis identified cardiopulmonary bypass time (P<0.05) as a risk factor for operative death, preoperative creatinine level (P<0.05), cardiopulmonary bypass time (P<0.05) and the amount of fresh frozen plasma used (P<0.05) for major complication, non-elective surgery (P<0.01) for deterioration of renal function. Thirteen patients died and five kidney allografts failed late after surgery. Three- and 5-year patient and graft survivals were 70.8 and 66.8, 84.5 and 84.5%, respectively. Multivariate regression analysis identified female gender (P<0.05), body mass index (P<0.001) and non-elective surgery (P<0.001) as risk factors for late death, and preoperative creatinine level (P<0.05) for late graft loss. Conclusions: Open heart surgery can be performed with acceptable short- and long-term results in patients with functioning abdominal transplants. Stress-dose steroid may be unnecessary in selected patients. Aggressive use of open heart surgery in this patient population to avoid non-elective surgery may further improve early and late surgical outcomes.

Key Words: Open heart surgery • Coronary artery bypass grafting • Renal transplantation • Pancreas transplantation • Liver transplantation

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
Patient survival after abdominal solid organ transplantation (kidney [1], kidney-pancreas [2,3] and liver [4,5]) has been improving due to better recipient selection, refinements of surgical techniques and postoperative patient care, and advancement of immunosuppressive agents. Expansion of abdominal solid organ transplantation to patients with older age and/or coronary artery disease [1,3] has been further increasing the number of patients who require surgical intervention to ischemic heart disease and/or valvular heart disease.

Several groups reported excellent surgical results of open heart surgery (OHS) in patients with functioning abdominal organ transplant [4,6–8]. However, very few studies were reported regarding long-term results in these particular patients [6,7]. We retrospectively investigated early and late results of open heart surgery in 60 patients with functioning abdominal solid organ transplant.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
This is a retrospective review of the abdominal solid organ recipients with at least one functional graft (kidney, combined kidney-pancreas, or liver) who underwent coronary artery bypass surgery and/or valve surgery at this medical center (OSU) between July 1988 and May 2001 after transplantation. Sixty patients were identified by computerized search of the database of the division of cardiothoracic surgery. All patients except 4 kidney recipients had their transplantation performed at this medical center. All data were collected from the divisional computerized database and medical records.

2.1. Patient demographics
Patient demographics are shown in Table 1. The average age of the patients was 52.5±9.9 years (range, 28–80 years). There were 22 female patients (37%). Twenty-two patients (37%) were in New York Heart Association (NYHA) functional class 4. Twenty-three patients (38%) had history of at least one percutaneous coronary intervention (PCI) prior to OHS, but no patient had history of cardiac surgery. The patients consisted of 46 kidney, nine simultaneous kidney-pancreas and five liver recipients. The kidney-pancreas recipients were significantly younger at the time of both transplantation and OHS compared to kidney or liver transplant recipients (P<0.05). Other parameters were not statistically significant among three transplant groups. Two of nine kidney-pancreas recipients were on dialysis (hemodialysis: one, peritoneal dialysis: one) with functioning pancreas at the time of OHS. Preoperative creatinine level (excluding two dialysis-dependent patients with kidney-pancreas transplant) was 2.1±1.1 mg/dl (range, 0.8–7.5 mg/dl). Nine kidney and two kidney-pancreas recipients had preoperative renal dysfunction, which is defined as serum creatinine level more than 3.0 mg/dl without dialysis. Left ventricular ejection fraction (LVEF) was 52.6±13.4% (range 25–79%). Left ventricular function was impaired (LVEF=<35%) in six patients (10%). OHS was performed 68.9±57.2 months (range 1–313 months) after transplantation. Patient age at the time of transplantation was 46.6±9.8 years (range 23–70 years). Diabetes mellitus was the most common cause of organ failure in kidney recipients. Type 1 diabetes mellitus was the reason for transplantation in all kidney-pancreas recipients. Liver transplantation was performed for various reasons (Table 1).

2.3. Prophylactic use of antibiotics
Before operation all but five patients who had ongoing infection were prophylactically given intravenous broad-spectrum antibiotics (1 g of vancomycin and 1 g of cefazolin). Postoperatively 1 g of vancomycin was given once 12 h after the preoperative dose, and 1 g of cefazolin was given twice every 8 h. In five patients who had active infection (endocarditis, leg stump infection, scrotal abscess) other antibiotics that were effective for causative organisms were given pre- and postoperatively.

2.4. Open heart surgery
Routine cardiac anesthesia including narcotics and muscle relaxant was used in all patients. A median sternotomy was performed in all patients but one. Fifty-six patients underwent OHS using cardiopulmonary bypass (CPB). CPB flow was maintained more than 2.4 l/min per m², and perfusion pressure more than 60 mmHg. High urine output (more than 1.5–2 ml/kg per h) was maintained using diuretics if necessary. Three patients underwent off-pump CABG by median sternotomy, and one minimally invasive CABG through a small anterior left thoracotomy under videoscopic guidance. All of them were high-risk patients; an 80-year-old kidney recipient, a 52-year-old kidney-pancreas recipient with scrotal abscess infected by vancomycin-resistant enterococcus, and a 49-year-old kidney-pancreas recipient with acute myocardial infarction 2 days after transplantation. Activated clotting time was maintained more than 400 s in patients with on-pump procedure, and more than 250 s in patients with off-pump procedure. Fresh frozen plasma (FFP) and/or platelet were given as needed to ensure hemostasis. Forty-eight patients (80%) underwent coronary artery bypass grafting (CABG), ten valve surgery, and two combined CABG and valve surgery (Table 1). Three patients underwent OHS on an emergency basis. Double valve replacement using mechanical valves was performed in a 28-year-old female with cardiogenic shock and active infective endocarditis complicated by aortic ring abscess and significant insufficiency of aortic and mitral valves 23 months after kidney-pancreas transplantation. Forty-four-year-old male with history of PCI 3 years ago underwent CABG 39 months after kidney transplantation following acute myocardial infarction complicated by cardiac arrest. Fifty-seven-year-old male with history of PCI 7 years ago underwent CABG 74 months after kidney transplantation due to unstable angina pectoris and left main disease. Eight patients had OHS performed urgently due to unstable angina pectoris (seven patients) and progressive congestive heart failure (one patient). Left internal mammary artery was used in 37 patients (74%). A mechanical valve was used in eight patients (67%), bioprosthesis in two (17%), and autologous valve tissue in two (Ross procedure in one and mitral valvuloplasty in one). CPB time was 113±44 min (range 53–292 min), and aortic crossclamp time was 63±29 min (range 18–150 min). Packed red blood cell was used in 52 patients (87%), FFP in 39 patients (65%), and platelet in 43 patients (72%).

2.5. Postoperative care
Most patients were given renal dose of dopamine (2–5 µg/kg per min). Dobutamine and/or epinephrine were given when patients needed higher cardiac output. Efforts were made to keep systolic blood pressure more than 120 mmHg in all patients and more than 140 mmHg in patients whose renal function was impaired preoperatively or worsening after operation. Norepinephrine was used to obtain higher blood pressure immediately after operation as appropriately. Nitroglycerin or nitroprusside was used to control high blood pressure and obtain after load reduction. A close attention was paid to the use of diuretics in order to avoid dehydration. A gentle hydration was employed in patients whose renal function was marginal pre- or postoperatively. Transplant surgeon (and nephrologist, if necessary) was readily consulted on the management of immunosuppressive regimen and abdominal transplant protection. Blood cell count was checked for at least 3 days or daily until the normal values were obtained after operation. Serum creatinine and blood urea nitrogen (BUN) were measured for at least 4 days in patients with stable renal function, or daily until these data started to return to the preoperative level in those with impaired renal function. In liver recipients liver function was checked for 3 days after operation, and further if necessary. Serum amylase level was measured for 2 or 3 days in kidney-pancreas recipients. Serum level of cyclosporine or tacrolimus was checked daily in patients with pre- or postoperative renal dysfunction. It was not measured routinely in patients having normal renal function with uncomplicated postoperative course.

2.6. Analysis of early postoperative course
Durations of ventilator support, chest tube placement and intensive care unit stay were reviewed in medical records of patients who were operated upon after 1996 (n=36). Time course of serum creatinine, blood urea nitrogen, liver enzymes and amylase was examined. Major morbidities in this analysis consisted of bleeding requiring reexploration, stroke, major infection (mediastinitis requiring surgical intervention, pneumonia and sepsis), deterioration of renal function with or without hemodialysis, prolonged ventilator support (exceeding 2 days), low cardiac output requiring intra-aortic balloon pump support, malignant ventricular arrhythmia and multiple organ failure. Deterioration of renal function was defined as increase of serum creatinine level more than twice a preoperative level.

2.7. Late patient and graft survivals
Follow-up data on patients and grafts were complete through June 30, 2001. Graft loss was defined as transplant nephrectomy and/or induction of dialysis for kidney, and return to insulin dependence for pancreas. Late graft survival rate was calculated with or without patient death censored. Patient death with functioning graft was excluded for analysis of risk factors contributing to graft loss.

2.8. Statistical analysis
All continuous variables were expressed as a mean±standard deviation. Thirty-eight potential risk factors were examined (see Appendix). They included 16 patient-related, seven transplantation-related, ten surgery-related and five postoperative factors. Non-risk adjusted univariate analyses of risk factors contributing to early mortality, major complication, major infection, and renal complication were made using Mann–Whitney U-test, or chi square test (or Fisher's exact test when one of cells contained a patient number not more than 5). Multivariate stepwise logistic regression analyses were conducted using explanatory variables with P-value less than 0.05 by univariate analysis. Actuarial analyses of patient and graft survivals were made using Kaplan–Meier method. Non-risk adjusted univariate analyses of risk factors affecting late patient and graft survivals were accomplished using log-rank method. Stepwise Cox regression analyses were performed using explanatory variables with P-value less than 0.05 by univariate analysis. Statistical analyses were conducted using Stata Version 7 (Stata Co., TX, USA). A P-value less than 0.05 was considered statistically significant.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
All patients tolerated surgery. Twenty-seven patients (45%) required inotropic support other than dopamine. The duration of ventilator support was 15.7±14.7 h (range 6±80 h). Four patients (7%, four/60) needed prolonged ventilator support exceeding 2 days. The duration of chest tube placement was 2.2±0.5 days (range 2–4 days). Only four patients (11%, four/36) required prolonged chest tube placement exceeding 2 days. A mean length of stay in intensive care unit was 40.1±27.4 h (range 15–120 h). Surviving patients were discharged from the hospital 8.5±6.9 days (range 3–42 days) after OHS (Table 2). Twenty patients (33%) required prolonged hospitalization more than 7 days after surgery.

3.3. Transplanted organ function
3.3.1. Kidney
Time-course changes of serum creatinine and BUN levels are shown in Fig. 1 . Indices of serum creatinine and BUN are calculated as ratios of postoperative creatinine and BUN levels to preoperative ones. There were mild elevations in early postoperative days without significant difference. Postoperative kidney dysfunction occurred in seven patients, three of whom required temporary hemodialysis. No allograft loss was seen in early postoperative period. A mean preoperative creatinine level was 3.4 mg/dl (range 1.3–7.5 mg/dl) in seven patients with renal dysfunction, and it was higher than 3.0 mg/dl in five of them. By univariate analysis following factors were found to adversely affect postoperative renal function; pulmonary hypertension, preoperative creatinine level and non-elective surgery (Table 3). Multivariate analysis identified non-elective surgery as a risk factor for deterioration of renal function after OHS (P<0.01).

View larger version (10K): [in this window] [in a new window]   Fig. 1. Postoperative serum creatinine and blood urea nitrogen levels. Ratios are calculated by dividing postoperative levels by preoperative level.

View larger version (12K): [in this window] [in a new window]   Fig. 2. Postoperative changes of serum liver enzyme levels. AST: Aspartate aminotransferase; and ALT: Alanine aminotransferase

3.4. Stress-dose steroid
Twelve out of 21 patients undergoing OHS after January 1999 were not given stress-dose steroids postoperatively. Neither operative death nor major infection was encountered in this subgroup of patients. Two patients had major complications (low output syndrome, worsening of renal function). There was, however, no statistically significant difference between patients with or without stress-dose steroids in either mortality or morbidity.

3.5. Late patient survival
Fifty-seven operative survivors were followed-up for 38.7±35.0 months, ranging from 1 to 148 months (Table 4). Four patients were lost to follow-up (follow-up rate: 93%). There were 13 late deaths (23%). No late death was seen in liver transplant recipients. Cardiac-related causes (including sudden death) were the most common (five cases, 50%), followed by neurologic-related causes (four cases). Three- and 5-year actuarial survival rates including operative deaths were 70.8 and 66.8%, respectively (Fig. 3) . Survival curves and 3- and 5-year actuarial survival rates of each allograft recipients are shown in Fig. 4 and Table 5, respectively. Univariate analysis of potential risk factors for late death identified seven significant factors; female gender, NYHA class 4, presence of peripheral vascular disease, history of cerebrovascular accident, body mass index (BMI), non-elective surgery and presence of major complication. Multivariate analysis identified female gender (P=0.02), BMI (P<0.001) and non-elective surgery (P<0.001) as the incremental risk factors for late patient death (Table 6).

View larger version (22K): [in this window] [in a new window]   Fig. 3. Patient survival curve.

View larger version (20K): [in this window] [in a new window]   Fig. 4. Graft survival curve.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
Cardiovascular disease is a common cause of late mortality and morbidity after abdominal solid organ transplantation. It is reported that cardiovascular causes accounted for 29–52% of late deaths in patients with kidney transplants [1,9,10]. After pancreas or kidney-pancreas transplantation 45–49% of recipients died of cardiac diseases [2,11]. Sixty-five (13.3%) of 487 patients with liver transplant developed cardiac events after transplantation [12]. The use of increased steroids and local immune events are believed to accelerate atherosclerosis in coronary arteries in kidney transplant recipients [7]. Immunosuppressive drugs can also contribute indirectly to the development of cardiovascular diseases through hyperlipidemia, obesity, hypertension, and diabetes in organ transplant recipients [13]. Recently, several groups reported the surgical results of OHS in patients with functioning abdominal solid organ transplant [4,6,7,14,15]. In single center experiences, 2.0% of kidney recipients required CABG [14], and 1.3% of liver recipients underwent CABG and/or valve surgery after transplantation [4]. At the Ohio State University CABG and/or valve surgery was performed in 2.4% of kidney-pancreas recipient during follow-up. Early mortality rate after open heart surgery in patients with functioning abdominal transplant was reported 0–8.8% [6,7,15]. Three patients (5.0%) died early after operation in the present study. This is not statistically different from early mortality rate (3.4%) of total patient population undergoing CABG and/or valve surgery at our institute in the same time frame.

Prevention of infectious complications and maintenance of transplant function are the perioperative major concerns for patients who undergo OHS. Mitruka et al. [7] reported high incidence of major infections (19%) after cardiac surgery in patients with kidney or liver allograft. They considered bacterial colonization of the airways, gastrointestinal tract, and skin caused by long-term immunosuppressive therapy as an important etiology. In the present study three patients (5.0%) were complicated by major infection. We believe that standard perioperative antibiotic prophylaxis just as non-transplant patients is sufficient in this patient population except those with active infection at the time of operation. Prolonged use of broad-spectrum antibiotics may cause alteration of bacterial flora of the airways and gastrointestinal tract, which increases the chance of postoperative infection.

Stress-dose steroids were used by two groups on patients undergoing OHS [7,15]. Another group [4] did not use stress-dose steroids in 15 patients with liver transplant. There was neither early death nor liver graft rejection episode in this group. They concluded that stress-dose steroids are unnecessary and its avoidance may reduce the incidence of infectious complications while avoiding transplant rejection. We routinely administered stress-dose steroids to patients until recently. Based on the recommendation of transplant surgeons some of patients operated upon after 1999 were not given stress-dose steroids. There was no operative death, and only two major complications occurred in this subgroup of patients. No significant differences were seen in both early morbidity and mortality between patients with or without stress-dose steroids. Bromberg et al. [16] described that clinically significant adrenal suppression is uncommon in renal transplantation, and that exogenous supplementation with routine baseline doses of steroids for maintenance immunosuppression may also contribute to the stress response except those who are on long-term steroid therapy or who are receiving large dose of steroids.

Long-term steroid administration may increase a risk for perioperative bleeding. Prabhaker et al. [4] required no chest reexploration for bleeding in patients with liver allograft, whereas Mitruka et al. [7] experienced nine cases (15.8%) necessitating reoperations for bleeding in 57 kidney or liver recipients. Two kidney recipients (3.3%) underwent reexploration for bleeding in the present study. This is not statistically different from a reexploration rate (4.0%) for bleeding after CABG and/or valve surgery in the same time frame. The majority of patients in the present study were given FFP and platelet more aggressively than regular patients. Prophylactic use of these blood products may be effective in this patient population to prevent perioperative bleeding.

Dresler et al. (n=45) [6] and Ferguson et al. (n=32) [14] reported no perioperative renal allograft loss in patients with OHS. They observed a mild-to-moderate elevation of serum creatinine after surgery, which returned to preoperative levels in the majority of patients within a week. Mitruka et al. [7] described three perioperative losses (7.5%) of kidney transplants in 40 patients. Prabhaker et al. (n=15) [4] and Mitruka et al. (n=17) [7] did not experience any liver graft loss early after OHS. Liver function test showed mild transient deterioration without any complicating coagulopathies related to CPB use [15]. Our study demonstrated similar results to previous studies. There were no episodes of permanent loss of either graft early after OHS. Postoperative elevations of serum creatinine, BUN, transaminase and amylase were transient, and these levels returned to the preoperative values within a week in the majority of patients.

Off-pump CABG was demonstrated to reduce both early mortality and morbidity in high risk patients [17]. In the present study four patients with significant comorbidities underwent CABG without CPB. Neither operative death nor major complication was encountered. There were, however, no significant differences in early mortality and morbidity between patients undergoing CABG with or without CPB, probably because the number of patients with off-pump CABG was too small to have a sufficient statistical power. Avoidance of CPB has several advantages. Damage to host immune response is minimal. This is extremely beneficial to patients on immunosuppressive regimen. Reduction of consumption of platelet and coagulation factors by the CPB circuit may allow easier hemostasis. Retainment of platelet and coagulation factors is essential for patients on long-term steroid therapy, who tend to have fragile and easily bleeding tissue. Perfusion to an abdominal transplant may be better maintained on the beating heart than on CPB. This is particularly important for a kidney allograft with impaired function by chronic rejection and/or immunosuppressive regimen.

Theoretically, the best option to treat valve disease in patients on immunosuppressive regimen is to avoid prosthetic valves by performing valvuloplasty or using autologous pulmonary valve (Ross procedure). In the present study one patient who underwent mitral valvuloplasty developed rupture of resutured mitral posterior leaflet. This may have been caused by leaflet tissue fragility due to long-term steroid therapy (15 years). Another patient undergoing Ross procedure died of stroke. Control of bleeding was not so difficult. Tissue weakness due to steroids, however, may result in a serious problem in controlling bleeding. Homograft valves are the next best, because they are more resistant to infection than prosthetic valves, and because anticoagulation is unnecessary [18]. The use of bioprosthesis is not preferred in these patients because they are generally young and are likely to live long in view of improving long-term survival. Degeneration of leaflet tissue could be accelerated by renal failure [4]. Mechanical valve provides reliable durability. However, it requires lifelong anticoagulant therapy, which would be a concern at the time of transplant biopsy. Further study is necessary to decide the best treatment option for valve disease in this patient population.

Based on 252 experiences of major general surgery in patients with functioning liver transplant, Testa et al. [5] described that emergency procedures were plagued by a greater incidence of complication. Similar results were observed in the present study. Major complications, postoperative renal dysfunction and early operative death developed in two of three patients with emergency surgery. Eight out of 11 patients with non-elective surgery experienced major complications. Non-elective surgery is an incremental risk factor for postoperative renal dysfunction and late patient death by multivariate analysis. Considering acceptable early mortality and morbidity rates, aggressive surgical treatment of ischemic and/or valvular heart disease on an elective basis is proposed to decrease the incidence of emergency or urgent surgery. This would contribute to decrease the occurrence of late patient death as well as early postoperative morbidity.

Although early mortality and morbidity rates were generally acceptable, late patient and graft survival rates, and risk factors affecting long-term patient and graft survivals were not still well understood. Three- and 5-year survival rates in the present study were 70.8 and 66.8%, respectively. Ferguson et al. [14] reported a similar patient survival after CABG in 32 kidney recipients (3- and 5-year actuarial survival: 77 and 65%). Dresler et al. [6] reported an excellent 5-year cumulative survival (85%) in 45 kidney recipients. The most common cause for late death was cardiac (50%) in the present study as in the report by Ferguson et al. [14]. In the present study multivariate analysis identified three factors affecting long-term survival; female gender, lower BMI and non-elective surgery. Unstable angina was found to adversely affect long-term survival by Ferguson et al. Lower BMI increased a risk of late death, probably because lower BMI may have reflected poorer nutrition status. No graft loss was observed in both early- and late phase after OHS in pancreas-kidney or liver transplant recipients, although follow-up periods were not still sufficient. For late (kidney) graft loss preoperative creatinine level was the single risk factor. It was not still clear whether OHS accelerated graft loss, or whether graft survival followed the natural course after transplantation. Considering that the average time from transplantation to graft loss, and from OHS to graft loss were 120 and 20 months, respectively, OHS may not accelerate graft loss if a graft tolerates an acute phase. Further study is required to investigate influences of OHS on long-term results of abdominal organ transplants.

	5. Conclusions

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
Open heart surgery can be performed with acceptable short- and long-term results in patients with functioning abdominal solid organ transplants. Stress-dose steroid may not be necessary in selected patients except those on long-term steroid therapy or those taking large dose of steroid. Non-elective OHS in this patient population adversely affected late patient survival as well as early postoperative mortality and morbidity. Considering acceptable early postoperative results, aggressive surgical treatment of ischemic and/or valvular heart disease on an elective basis would be warranted in patients with functioning abdominal transplants.

	Acknowledgments

 
All statistical analyses were conducted by Dr Hajime Sato (MD, PhD, Department of Public Health, Graduate School of Medicine, University of Tokyo). We express our deepest gratitude for his assistance in this study.

	Footnotes

 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.

	Appendix A. Potential risk factors

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 

Patient factors.

Patient age at cardiac surgery.

Patient gender.

Patient race (Caucacian or others).

Patient body size (estimated by body mass index).

NYHA functional class (four or less).

History of myocardial infarction.

History of percutaneous coronary intervention.

History of cerobrovascular accident.

Presence of insulin dependent diabetes mellitus.

Presence of systemic hypertension.

Presence of pulmonary hypertension.

Presence of peripheral vascular disease.

Presence of obesity (body mass index 30).

Preoperative serum creatinine level.

Left ventricular ejection fraction.

Impaired left ventricular function (ejection fraction 35).

Transplantation-related factors.

Patient age at transplantation.

Year of transplantation.

Interval between transplantation and cardiac surgery.

Transplanted organ.

Use of cyclosporine or tacrolimus before cardiac surgery.

Use and kind of nucleic acid synthesis inhibitor.

Preoperative predonine dose.

Use of stress-dose steroid after surgery.

Surgery-related factors.

Cardiac procedure (coronary bypass surgery).

Cardiac procedure (valve surgery).

Timing of surgery (elective or not).

Year of cardiac surgery.

Use of left internal mammary artery in coronary bypass surgery.

Bypass time.

Aortic crossclamp time.

Off-pump or on-pump.

Amount of red blood cell transfused.

Amount of fresh frozen plasma transfused.

Postoperative factors.

Presence of major complication.

Presence of major infection.

Presence of deterioration of renal function.

Early death.

Length of postoperative hospital stay.

	Appendix B. Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 
Mr J. Pepper (London, UK): I would like to ask you about what precautions you took to avoid raising antibody levels in these patients with solid organ transplants. You used blood transfusions and you used blood components. Did you take any precautions to wash cells, because there must be a concern that the procedure should not accelerate late rejection?

Dr Ono: We usually give the patient a maintenance dose of immunosuppression regimen in the morning of the operation. Also we start a maintenance dose of immunosuppression regimen, if possible, in the next morning to reduce the incidence of graft rejection. We didn't use any hemofiltration or something like that to avoid an adverse reaction.

Mr Pepper: Could I ask you why you didn't use the internal mammary or internal thoracic artery more often?

Dr Ono: Until 1994, many patients have the saphenous vein graft for bypass grafting, but after that, we decided to use the left mammary artery routinely on these patients, because this patient population has a younger age. Also, based on the improved survival of the patients with functioning abdominal solid organ transplant, we considered that a better graft with longer longevity is better for the patients. So we selected the left mammary artery routinely on these patients.

Mr Pepper: And particularly when you have got a population who must have a much higher incidence of venous graft occlusion than a normal population.

Dr Ono: Yes, that's right. We need to follow-up these patients very closely to find out the ischemic symptoms.

Mr Pepper: Has this retrospective analysis caused you to change the way that you are going to tackle these problems in the future? For example, given that 80% of the patients were undergoing coronary artery surgery, are you tempted to use off-pump techniques or minimally invasive techniques in the future?

Dr Ono: Yes. So far we did four off-pump cases. These four patients were very high risk patients, but we think of the aggressive treatment of this type of patient on an elective basis. We may need to do the off-pump surgery to avoid some adverse effect or before the coronary artery disease progresses very severely. So I think we can use it in much more cases.

Mr Pepper: So you think this might be an indication for off-pump surgery?

Dr Ono: I agree.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A. Potential risk... Appendix B. Conference... References

 

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