Rising Lactate After Orthotopic Heart Transplant: The Predictive Value of Lactate Levels in the Immediate Post-Operative Period
University of California San Francisco
San Francisco, CA
United States - Contact Me
Phoebe Miller M.D. M.S. is a general surgery resident at UCSF. She completed her B.A. at Haverford College where she majored in English Literature. Following her graduation she worked at the African Leadership Academy and volunteered at Tambo Memorial Hospital in Johannesburg, South Africa. Dr. Miller completed a Masters in Science at the University of California Berkeley and attended medical school at the University of California San Francisco as part of the UC Berkeley-UCSF Joint Medical Program. During this time she conducted research with the East Africa Preterm Birth Initiative focusing on prenatal care in Rwanda. Since Dr Miller has completed a wide array of research work with a focus on both clinical outcomes using large databases to ask essential questions about patient-centered outcomes and more translational immunology based work. Dr Miller is now completing two years of dedicated research time between her third and fourth years of general surgery residency at UCSF. She is passionate about cardiothoracic transplantation and advanced heart failure as well as aortic disease and immunology.
Description
Methods: We conducted a single-institution retrospective analysis. Patients included had undergone OHT between January 2022 and May 2023. The EMR was used to interrogate individual patient charts. Data was collected on patient demographics, indications for transplant, donor type, post-operative echo, and both pressor and mechanical-assist device requirements.
Results: Our sample included 33% (16/49) women with a mean age of 47 (17-70) years. The majority underwent OHT alone (83%, 41/49), 7 underwent combined heart/kidney transplant, and 1 heart/lung transplant. Of the donors, 92% were brain dead donors (45/49). POLA was separated into a high and low groups based on the median distribution (>6 mmol/L). An elevated POLA was correlated with being male (48%, 16/33 vs 25%, 4/16 p =0.1) and pre-operative LVAD placement (88%, 7/8 vs 32%, 13/41 p=0.03). There was a trend towards higher POLA after brain dead donation (DBD) as compared to cardiac death donation (DCD) (41%, 19/46 vs 0%, 0/3 p=0.17). In the immediate post-operative period depressed cardiac function on TEE (57%, 8/14 vs 30%, 10/33 p=0.03), at least three pressor requirement (82%, 9/11 vs 48%, 11/23 p=0.01), PGD, defined as the requirement of a cardiac mechanical support device for more than 24 hours (16%, 5/30 vs 1%, 1/29 p=0.02) and all-cause mortality (2%, 4/20 vs 0%, 0/29 p=0.01) were associated with POLA. In the adjusted outcomes, these factors remained associated with an elevated POLA.
Conclusion: Our study significantly expands upon existing literature. We demonstrate an association between a spike in lactate levels and, pre-operatively, those with LVADs and, post-operatively, those who develop PGD, require an increase in ionotropic support, and with all-cause mortality. There were trends towards both donor and recipient factors including male sex and DBD status that may increase the risk of POLA. Further exploration of both donor and recipient factors may elucidate the drivers behind lactic acidosis in the immediate post-operative period.
Authors
Phoebe Miller (1), Andrew Akcelik (1), Alison Baskin (1), Mohammad Arammash (1), Alexander Merriman (1), Jason Smith (1), Amy Fiedler (1)
Institutions
(1) University of California San Francisco, San Francisco, CA