Abdominal Aortic Aneurysms Following Orthotopic Heart Transplantation

Abstract

The purpose of these authors' study was to analyze their center's experience with orthotopic heart transplantation (OHT) and abdominal aortic aneurysms (AAA) with particular attention to corticosteroid dosing, hemodynamic parameters, and aneurysm growth rate. A retrospective review of all patients (453) who underwent OHT at their university-affiliated medical center over an 18-year period (1981–1999) was undertaken. Nine (2%) patients who developed AAAs were identified and aneurysm growth was correlated with corticosteroid immunosuppression and hemodynamic parameters. The mean age of OHT patients was 44.5 ±15 years and the majority were males (371 males, 82%). Median follow-up was 5.7 years. Ischemic cardiomyopathy (IC) was the most common indication for transplantation (45.5% of patients). All AAA patients were male (p= 0.157), with a mean age of 58.4 ±4.8 years (p= 0.001), and had undergone OHT for IC (p= 0.001). Mean arterial blood pressure and ejection fraction in the AAA patients had increased from pretransplant values of 107 mm Hg and 14.3 ±5.7% to 142 mm Hg (p=0.017) and 54.1 ±14.1% (p<0.001), respectively, before aneurysm repair. Mean aneurysm diameter at the time of repair was 6.0 ±0.8 cm, and the average growth rate was 1.2 ±0.4 cm/year in the 4 patients in whom it could be measured. Aneurysm repair was performed urgently in 2 patients and electively in 7 patients with 1 early postoperative death (11%). The extent of corticosteroid immunosuppression, corticosteroid pulses, and total corticosteroid dosing did not correlate with the rate of aneurysm growth. Improved hemodynamics and progressive posttransplant hypertension may contribute to aneurysm formation and growth in this group of patients.

Get full access to this article

View all access options for this article.

References

Diciolla F , Sassi C , Neri E , et al: Abdominal aortic aneurysms in heart transplanted patients. J Mal Vasc 23:358-360, 1998.

Ammori BJ , Madan M , Bodenham AR , et al: A review of the management of abdominal aortic aneurysms in patients following cardiac transplantation. Eur J Vasc Endovasc Surg 14:185-190, 1997.

Defraigne JO , Sakalihasan N , Demoulin JC , et al: Successful abdominal aortic aneurysm resection in long-term survivors of cardiac transplantation. Cardiovasc Surg 3:321-324, 1995.

Muluk SC , Steed DL , Makaroun MS , et al: Aortic aneurysm in heart transplant recipients. J Vasc Surg 22:689-694, 1995.

Chandrasekar R , Nott DM , Enabi L , et al: Successful repair of a ruptured abdominal aortic aneurysm in a cardiac transplant patient. Eur J Vasc Surg 8:750-751, 1994.

Bull DA , Neumayer LA , Venerus BJ , et al: The effects of improved hemodynamics on aortic dimensions in patients undergoing heart transplantation. J Vasc Surg 20:539-544, 1994.

Shenaq SA , Schultz S , Noon GP , et al: Case 3 — 1993. Combined abdominal aortic aneurysm resection and cholecystectomy following prior heart transplantation. J Cardiothorac Vasc Anesth 7:610-614, 1993.

MacIntyre A , Garnett L : Abdominal aortic aneurysm repair in a patient with a cardiac transplant. Can J Anaesth 38:926-930, 1991.

Piotrowski JJ , McIntyre KE , Hunter GC , et al: Abdominal aortic aneurysm in the patient undergoing cardiac transplantation. J Vasc Surg 14:460-465, 1991.

10.

Reichman W , Dyke C , Lee HM , et al: Symptomatic abdominal aortic aneurysms in long-term survivors of cardiac transplantation. J Vasc Surg 11:476-479, 1990.

11.

Nevitt MP , Ballard DJ , Hallett JW Jr : Prognosis of abdominal aortic aneurysms. A population-based study. N Engl J Med 321:1009-1014, 1989.

12.

Collin J , Araujo L , Walton J : How fast do very small abdominal aortic aneurysms grow? Eur J Vasc Surg 3:15-17, 1989.

13.

Cronenwett JL , Murphy TF , Zelenock GB , et al: Actuarial analysis of variables associated with rupture of small abdominal aortic aneurysms. Surgery 98:472-483, 1985.

14.

Sterpetti AV , Schultz RD , Feldhaus RJ , et al: Abdominal aortic aneurysm in elderly patients. Selective management based on clinical status and aneurysmal expansion rate. Am J Surg 150:772-776, 1985.

15.

Bernstein EF , Chan EL : Abdominal aortic aneurysm in high-risk patients. Outcome of selective management based on size and expansion rate. Ann Surg 200:255-263, 1984.

16.

Kremer H , Weigold B , Dobrinski W , et al: [Sonographic observation of the course of aneurysms of the abdominal aorta]. Klin Wochenschr 62:1120-1125, 1984.

17.

Lederle FA , Johnson GR , Wilson SE , et al: Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 126:441-449, 1997.

18.

Lederle FA , Johnson GR , Wilson SE , et al: The aneurysm detection and management study screening program: Validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 160:1425-1430, 2000.

19.

Vazquez C , Sakalihasan N , D'Harcour JB , et al: Routine ultrasound screening for abdominal aortic aneurysm among 65 and 75-year-old men in a city of 200,000 inhabitants. Ann Vasc Surg 12:544-549, 1998.

20.

Thurmond AS , Semler HJ : Abdominal aortic aneurysm: Incidence in a population at risk. J Cardiovasc Surg (Torino) 27:457-460, 1986.

21.

Allardice JT , Allwright GJ , Wafula JM , et al: High prevalence of abdominal aortic aneurysm in men with peripheral vascular disease: Screening by ultrasonography. Br J Surg 75:240-242, 1988.

22.

Shapira OM , Pasik S , Wassermann JP , et al: Ultrasound screening for abdominal aortic aneurysms in patients with atherosclerotic peripheral vascular disease. J Cardiovasc Surg (Torino) 31:170-172, 1990.

23.

Erdoes LS , Hunter GC , Venerus BJ , et al: Prospective evaluation of peripheral vascular disease in heart transplant recipients. J Vasc Surg 22:434-440, 1995.

24.

Englesbe MJ , Wu AH , Clowes AW , et al: The prevalence and natural history of aortic aneurysms in heart and abdominal organ transplant patients. J Vasc Surg 37:27-31, 2003.

25.

Reilly JM , Savage EB , Brophy CM , et al: Hydrocortisone rapidly induces aortic rupture in a genetically susceptible mouse. Arch Surg 125:707-709, 1990.

26.

Dobrin PB , Baumgartner N , Anidjar S , et al: Inflammatory aspects of experimental aneurysms. Effect of methylprednisolone and cyclosporine. Ann NY Acad Sci 800:74-88, 1996.

27.

Sato O , Takagi A , Miyata T , et al: Aortic aneurysms in patients with autoimmune disorders treated with corticosteroids. Eur J Vasc Endovasc Surg 10:366-369, 1995.

28.

Lokanathan R , Taylor DC : Abdominal aortic aneurysm after pulmonary transplantation: A case report. J Vasc Surg 31:585-588, 2000.

29.

Ierardi RP , Coll DP , Kumar A , et al: Abdominal aortic aneurysectomy after kidney transplantation: Case report and review of the literature. Am Surg 62:961-966, 1996.

30.

Palm SJ , Russwurm GP , Chang D , et al: Acute enlargement and subsequent rupture of an abdominal aortic aneurysm in a patient receiving chemotherapy for pancreatic carcinoma. J Vasc Surg 32:197-200, 2000.