Asian Cardiovasc Thorac Ann 2006;14:e83-e85
© 2006 Asia Publishing EXchange Ltd
Multivalvular Heart Failure Improvement after Successful Kidney Transplantation
Majid A Asgari, MD,
Farid Dadkhah, MD,
Ahmad Tara, MD,
Hamid Noshad, MD,
Hamed Akhavizadegan, MD1,
Gity Birashk, MD
Shahid Modarres Hospital, Shahid Beheshty University of Medical Sciences
1 Shahid Dr. Labbafinegad Hospital, Shahid Beheshty University of Medical Sciences, Tehran, Iran
For reprint information contact: Hamed Akhavizadegan, MD Tel: 98 21 2254 9010 Fax: 98 21 2254 9088, Email:hamed_akhavizadegan{at}yahoo.com, Shahid Dr. Labbafinegad Hospital, 9th Boostan Street, Pasdaran Avenue, Tehran, Iran.
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ABSTRACT
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Chronic renal disease is responsible for various cardiac complications. After renal transplantation many of these complications improve. However the extent to which cardiac failure is reversible post transplant is not known. We report two cases of end stage renal disease (ESRD) and severe heart failure characterized by left ventricular ejection fraction (LVEF) less than 20%. Three months after kidney transplantation, the LVEF rose to more than 50%. Successful renal transplantation can significantly improve cardiac function compromised as a result of ESRD.
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INTRODUCTION
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It is well documented that patients with renal failure suffer from some degree of cardiovascular illness.1 In chronic uremia, cardiovascular disease manifests as concentric left ventricular hypertrophy, left ventricular dilatation, systolic dysfunction, or diastolic dysfunction.2 These conditions create a predisposition for the development of heart failure, arrhythmias, and sudden death3 which can be prevented with renal transplantation.4,5 We report two patients with ESRD and severe systolic dysfunction with multi-valvular dysfunction whose cardiac indexes improved considerably after kidney transplantation.
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CASE REPORT
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Two girls (a 20-year-old and a 15-year-old) with ESRD, the first of unknown etiology and the other due to attempted suicide, presented with severe dyspnea, high blood pressure, and anemia. Both patients had been on hemodialysis for about 2 years. The first patient presented with massive pericardial effusion on admission, so she underwent pericardiotomy. Both patients were candidates for heart transplantation due to severe refractory congestive heart failure (CHF). Echocardiographic findings in both patients included left ventricular ejection fractions about 15%–20%, mitral regurgitation (MR), aortic insufficiency (AI), tricuspid regurgitation (TR), and severe cardiomegaly.
After medical management of the CHF for one month, the best-achieved LVEFs were 20%–25%. Intraoperatively, after decreasing the afterload and minimizing the effects of AI, intra-aortic balloon pumping was performed because of the critical condition of the first patient. Three months after successful kidney transplantation the patients were asymptomatic and echocardiographic findings were suggestive of considerable improvement in left ventricular ejection fraction, mitral regurgitation, aortic insufficiency, tricuspid regurgitation, and moderate cardiomegaly. The laboratory and echocardiographic data before and after transplantation are shown in Table 1
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At the one year follow-up both patients were in good general condition with LVEFs about 65% and considerable improvement in the valvular disorders. Other than maintenance triple therapy (corticosteroid, cyclosporine, and azathioprine), no other medication was required. Chest X-Rays of the first patient before and after surgery are presented in Figure 1.
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Figure 1. Case 1– Chest X-Ray before transplantation (left), and 1 month after transplantation (right).
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DISCUSSION
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Renal transplantation has a beneficial impact on the uremic patient’s cardiomyopathy, whether it manifests as left ventricular hypertrophy (LVH), left ventricular dilatation or systolic dysfunction.2 There is a significant reduction in left ventricular dilatation after transplantation.2,4 There are four types of valvular dysfunction in chronic renal failure (CRF), classified according to the postulated etiology. They include: dystrophic calcification, effects of CRF (autosomal polycystic kidney disease), dilated cardiomyopathy, and hemostatic (anemia, overload, hyperadrenergism, and arteriovenous fistula). Only the first two groups need valve replacement.6 Case reports detailing cardiovascular outcome in CHF after kidney transplantation are published in the international medical literature.4,5
While many have studied the effects of renal transplantation on heart pathology due to ESRD, none of the cases involved a LVEF below 50%.2,4,5 Although there are case reports with lower ejection fraction (EF),7,8 none had significant multi-valvular dysfunction. It is known that some degree of LVH and probably heart failure improves after successful renal transplantation.2 Both of our patients were severely afflicted by CHF, with marked multi-valvular dysfunction refractory to medical treatment. Some groups have used angiography to rule out coronary artery disease or the need for cardiac biopsy. We did not use angiography as there was no evidence of any heart-related risk factors other than uremic related factors. Both of our patients were candidates for cardiac transplantation because of severe heart failure.
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CONCLUSION
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Patients with ESRD with heart failure and multivalvular dysfunction, even in severe cases, should not be advised to present for early cardiac transplantation. Both overt heart failure and multivalvular dysfunction are reversible with renal transplantation. The presence of multivalvular dysfunction does not contribute to a poorer prognosis for cardiac outcome post renal transplantation. Young patients with these conditions and without any primary cardiogenic dysfunction or coronary artery disease risk factors are especially good candidates even without invasive cardiac work-up.
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REFERENCES
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- Levin A, Foley RN. Cardiovascular disease in chronic renal insufficiency. Am J Kidney Dis 2000;36(6 Suppl 3):S24–30.[Medline]
- Ferreira SR, Moises VA, Tavares A, Pacheco-Silva A. Cardiovascular effects of successful renal transplantation: a 1-year sequential study of left ventricular morphology and function, and 24-hour blood pressure profile. Transplantation 2002;74:1580–7.[Medline]
- Levey AS. Controlling the epidemic of cardiovascular disease in chronic renal disease: where do we start? Am J Kidney Dis 1998;32(5 Suppl 3):S5–13.[Medline]
- Kobori G, Moroi S, Yoshida H, Yamamoto S, Kamoto T, Okuno H, et al. Marked improvement of cardiac function following renal transplantation: a case report. Hinyokika Kiyo 2003;49:17–9.[Medline]
- Rigatto C, Foley RN, Kent GM, Guttmann R, Parfrey PS. Long-term changes in left ventricular hypertrophy after renal transplantation. Transplantation 2000;70:570–5.[Medline]
- Straumann E, Meyer B, Misteli M, Blumberg A, Jenzer HR. Aortic and mitral valve disease in patients with end stage renal failure on long-term haemodialysis. Br Heart J 1992;67:236–9.[Abstract/Free Full Text]
- Harnett JD, Foley RN, Kent GM, Barre PE, Murray D, Parfrey PS. Congestive heart failure in dialysis patients: prevalence, incidence, prognosis and risk factors. Kidney Int 1995;47:884–90.[Medline]
- Fleming SJ, Caplin JL, Banim SO, Baker LR. Improved cardiac function after renal transplantation. Postgrad Med J 1985;61:525–8.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
