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Venous thromboembolism in heart transplantation: Should we consider genetic predisposition?
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CASE ANECDOTES, COMMENTS AND OPINIONS Ironman triathlon performance pre- and post-heart transplant Mark J. Haykowsky, PhD,a Kenneth J. Riess, PhD,b and Christian A. Schneider, MDc From the aDepartment of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada; b School of Health Sciences, Northern Alberta Institute of Technology, Edmonton, Alberta, Canada; and the cDepartment of Cardiology, PAN Klinik, Faculty of Medicine, University of Cologne, Cologne, Germany
The Ironman Triathlon (3.8-km swim, 180.2-km bike, 42.2km run) World Championship, held yearly in Kailua-Kona Hawaii, is one of the most challenging single-day ultra-endurance events.1 Herein we report on a 42-year-old male heart transplant recipient (28 months post-surgery) who, on October 11, 2014, became the first heart transplant recipient to finish the Ironman World Championship (race time 12 hours and 30 minutes, 1,490th place out of 1,985 official finishers). Fourteen weeks before competing in this triathlon, he also finished the Ironman European Championship event in 11 hours and 39 minutes (1,282th place out of 2,396 official finishers). To our knowledge, these are the fastest Ironman finish times ever reported for a heart transplant recipient and the first report of a heart transplant recipient completing 2 Ironman races within 14 weeks. During the 6-year period before being diagnosed with heart failure, he also completed 6 Ironman distance races
Venous thromboembolism in heart transplantation: Should we consider genetic predisposition? Ahmet Dolapoglu, MD,a and Ilimbek Beketaev, MDb From the aCardiovascular Surgery Department; and the bCenter for Stem Cell Engineering, Texas Heart Institute, Houston, Texas
We read the recent article in The Journal of Heart and Lung Transplantation (October 2014), ‘‘Venous Thromboembolism In Heart Transplant Recipients: Incidence, Recurrence and Predisposing Factors’’ by Alvarez-Alvarez et al1 with great interest. The authors prepared a high-quality
(mean race time: 10 hours and 44 minutes). Notably, his mean Ironman finish time post-surgery is only 80 minutes slower than the average time taken to complete similar distance races with his native heart. Except for 1 episode of mild cardiac allograft rejection 2 months after surgery, his post-transplant recovery has been unremarkable. Indeed, before the Ironman World Championship his resting ejection fraction was 79% and his maximal oxygen uptake was 53 ml/kg/min (92% of age-predicted value for an endurance-trained individual).2 In conclusion, the finding that this individual placed in the top 54% and 75% of all triathletes who officially finished the 2014 Ironman European and World Championship races, respectively, demonstrates that a heart transplant recipient can compete in premier ultra-endurance races that occur within a relatively short-time period, with a performance time similar to that achieved as a competitive triathlete before being diagnosed with heart failure.
Disclosure statement The authors have no conflicts of interest to disclose.
References 1. Haykowsky MJ, Riess K, Burton I, et al. Heart transplant recipient completes Ironman triathlon 22 years after surgery. J Heart Lung Transplant 2009;28:415. 2. Wilson TM, Tanaka H. Meta-analysis of the age-associated decline in maximal aerobic capacity in men: relation to training status. Am J Physiol Heart Circ Physiol 2000;278:H829-34.
research on the topic of venous thromboembolism in heart transplantation; however, we would like to make a few suggestions regarding thromboembolism. It is essential to keep in mind that in the general population, 2 single nucleotide polymorphisms (SNPs), factor V Leiden and prothrombin G20210A (PT G20210A), have been associated with an increased in the risk of thrombosis and may be related to genetic predisposition.2 The authors did not report any information about the SNPs in their report. Did they evaluate SNPs in their venous thromboembolism patient group? Furthermore, thrombosis related to lead extraction is also very important risk factor, because it is becoming more common indication for pacing and |implantable cardioverter defibrillator (ICD) implantation.3 Therefore, it is recommended routinely to anticoagulate after
1053-2498/$ - see front matter r 2015 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2014.12.015
Case Anecdotes, Comments and Opinions the extraction procedure and suggest that adding a patient group with pacemaker and or ICD would make it more reasonable. We would like to conclude by congratulating Alvarez-Alvarez et al1 on their outstanding study.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
Author’s response to “Venous thromboembolism in heart transplantation. Should we consider genetic predisposition?” Rolando J. Alvarez-Alvarez, MD,a,b Eduardo Barge-Caballero, MD, PhD,a,c and María G. Crespo Leiro, MD, PhDa,c From the aServicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain; bFundación BBVA-Carolina, Madrid, Spain; and the cInstituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
We thank Dr. Beketaev and Dr. Dolapoglu for their interest1 in our research.2 We agree with them that the determination of single nucleotide polymorphisms factor V Leiden and prothrombin G20210A might provide interesting information about the mechanisms of venous thromboembolism among heart transplant recipients. However, our clinical protocol does not include routine genetic testing in these cases. Our study was retrospective and based on an historical cohort; data on single
Figure 1 Kaplan-Meier cumulative estimates of venous thromboembolic episodes (deep venous thrombosis and pulmonary embolism) during the first year after heart transplantation in patients with an intracardiac device before surgery and in patients who did not have an intracardiac device.
757
References 1. Alvarez-Alvarez RJ, Barge-Caballero E, Chavez-Leal SA, et al. Venous thromboembolism in heart transplant recipients: incidence, recurrence and predisposing factors. J Heart Lung Transplant 2015; 34:167-74. 2. Miriuka SG, Langman LJ, Evrovski J, et al. Thromboembolism in heart transplantation: role of prothrombin G20210A and factor V Leiden. Transplantation 2005;80:590-4. 3. Hanninen M, Cassagneau R, Manlucu J, Yee R. Extensive thrombosis following lead extraction: further justification for routine post-operative anticoagulation. Indian Pacing Electrophysiol 2014;14:150-1.
nucleotide polymorphisms were not shown simply because they were unavailable. At our institution, lead extraction is routinely performed during the surgical procedure for heart transplantation in patients with intracardiac devices. Although lead extraction might be a risk factor for venous thromboembolic complications, we do not consider early post-operative anticoagulation as a routine strategy because of concerns about serious thoracic bleeding. Among 635 heart transplant patients included in our study,2 127 (20%) had an intracardiac device at the time of surgery (38 pacemakers, 67 implantable defibrillators, and 22 cardiac resynchronization devices). Kaplan-Meier cumulative estimates of venous thromboembolic episodes—deep venous thrombosis or pulmonary embolism—during the first post-transplant year among patients with an intracardiac device compared with patients without an intracardiac device before surgery did not differ in a statistically significant manner (log-rank, p ¼ 0.361) (Figure 1). To control the effect of potential confounders, the variable pre-operative intracardiac device was entered to the multivariable Cox regression model designed to predict venous thromboembolism during the first post-transplant year, which included age, obesity, renal dysfunction, and emergency transplantation.2 After multivariable adjustment, the association between preoperative intracardiac devices and early (o1 year) posttransplant venous thromboembolism was not statistically significant (hazard ratio ¼ 1.42, 95% confidence interval ¼ 0.55 to 3.68, p ¼ 0.476). In conclusion, our exploratory analysis showed a slight increase in the incidence of early (o1 year) venous thromboembolic episodes in heart transplant patients who had an intracardiac device before surgery, but this association did not reach statistical significance either in univariable or multivariable analyses. These data do not support lead extraction as a relevant risk factor for early venous thromboembolism after heart transplantation. However, these results might be affected by type II statistical error, given the relatively small number of patients who had an intracardiac device at the time of transplantation in our cohort. Further studies with specific design and proper sample size are warranted to clarify this question.
Disclosure statement The authors have no conflicts of interest to disclose.
CASE ANECDOTES, COMMENTS AND OPINIONS Ironman triathlon performance pre- and post-heart transplant Mark J. Haykowsky, PhD,a Kenneth J. Riess, PhD,b and Christian A. Schneider, MDc From the aDepartment of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada; b School of Health Sciences, Northern Alberta Institute of Technology, Edmonton, Alberta, Canada; and the cDepartment of Cardiology, PAN Klinik, Faculty of Medicine, University of Cologne, Cologne, Germany
The Ironman Triathlon (3.8-km swim, 180.2-km bike, 42.2km run) World Championship, held yearly in Kailua-Kona Hawaii, is one of the most challenging single-day ultra-endurance events.1 Herein we report on a 42-year-old male heart transplant recipient (28 months post-surgery) who, on October 11, 2014, became the first heart transplant recipient to finish the Ironman World Championship (race time 12 hours and 30 minutes, 1,490th place out of 1,985 official finishers). Fourteen weeks before competing in this triathlon, he also finished the Ironman European Championship event in 11 hours and 39 minutes (1,282th place out of 2,396 official finishers). To our knowledge, these are the fastest Ironman finish times ever reported for a heart transplant recipient and the first report of a heart transplant recipient completing 2 Ironman races within 14 weeks. During the 6-year period before being diagnosed with heart failure, he also completed 6 Ironman distance races
Venous thromboembolism in heart transplantation: Should we consider genetic predisposition? Ahmet Dolapoglu, MD,a and Ilimbek Beketaev, MDb From the aCardiovascular Surgery Department; and the bCenter for Stem Cell Engineering, Texas Heart Institute, Houston, Texas
We read the recent article in The Journal of Heart and Lung Transplantation (October 2014), ‘‘Venous Thromboembolism In Heart Transplant Recipients: Incidence, Recurrence and Predisposing Factors’’ by Alvarez-Alvarez et al1 with great interest. The authors prepared a high-quality
(mean race time: 10 hours and 44 minutes). Notably, his mean Ironman finish time post-surgery is only 80 minutes slower than the average time taken to complete similar distance races with his native heart. Except for 1 episode of mild cardiac allograft rejection 2 months after surgery, his post-transplant recovery has been unremarkable. Indeed, before the Ironman World Championship his resting ejection fraction was 79% and his maximal oxygen uptake was 53 ml/kg/min (92% of age-predicted value for an endurance-trained individual).2 In conclusion, the finding that this individual placed in the top 54% and 75% of all triathletes who officially finished the 2014 Ironman European and World Championship races, respectively, demonstrates that a heart transplant recipient can compete in premier ultra-endurance races that occur within a relatively short-time period, with a performance time similar to that achieved as a competitive triathlete before being diagnosed with heart failure.
Disclosure statement The authors have no conflicts of interest to disclose.
References 1. Haykowsky MJ, Riess K, Burton I, et al. Heart transplant recipient completes Ironman triathlon 22 years after surgery. J Heart Lung Transplant 2009;28:415. 2. Wilson TM, Tanaka H. Meta-analysis of the age-associated decline in maximal aerobic capacity in men: relation to training status. Am J Physiol Heart Circ Physiol 2000;278:H829-34.
research on the topic of venous thromboembolism in heart transplantation; however, we would like to make a few suggestions regarding thromboembolism. It is essential to keep in mind that in the general population, 2 single nucleotide polymorphisms (SNPs), factor V Leiden and prothrombin G20210A (PT G20210A), have been associated with an increased in the risk of thrombosis and may be related to genetic predisposition.2 The authors did not report any information about the SNPs in their report. Did they evaluate SNPs in their venous thromboembolism patient group? Furthermore, thrombosis related to lead extraction is also very important risk factor, because it is becoming more common indication for pacing and |implantable cardioverter defibrillator (ICD) implantation.3 Therefore, it is recommended routinely to anticoagulate after
1053-2498/$ - see front matter r 2015 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2014.12.015
Case Anecdotes, Comments and Opinions the extraction procedure and suggest that adding a patient group with pacemaker and or ICD would make it more reasonable. We would like to conclude by congratulating Alvarez-Alvarez et al1 on their outstanding study.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
Author’s response to “Venous thromboembolism in heart transplantation. Should we consider genetic predisposition?” Rolando J. Alvarez-Alvarez, MD,a,b Eduardo Barge-Caballero, MD, PhD,a,c and María G. Crespo Leiro, MD, PhDa,c From the aServicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain; bFundación BBVA-Carolina, Madrid, Spain; and the cInstituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
We thank Dr. Beketaev and Dr. Dolapoglu for their interest1 in our research.2 We agree with them that the determination of single nucleotide polymorphisms factor V Leiden and prothrombin G20210A might provide interesting information about the mechanisms of venous thromboembolism among heart transplant recipients. However, our clinical protocol does not include routine genetic testing in these cases. Our study was retrospective and based on an historical cohort; data on single
Figure 1 Kaplan-Meier cumulative estimates of venous thromboembolic episodes (deep venous thrombosis and pulmonary embolism) during the first year after heart transplantation in patients with an intracardiac device before surgery and in patients who did not have an intracardiac device.
757
References 1. Alvarez-Alvarez RJ, Barge-Caballero E, Chavez-Leal SA, et al. Venous thromboembolism in heart transplant recipients: incidence, recurrence and predisposing factors. J Heart Lung Transplant 2015; 34:167-74. 2. Miriuka SG, Langman LJ, Evrovski J, et al. Thromboembolism in heart transplantation: role of prothrombin G20210A and factor V Leiden. Transplantation 2005;80:590-4. 3. Hanninen M, Cassagneau R, Manlucu J, Yee R. Extensive thrombosis following lead extraction: further justification for routine post-operative anticoagulation. Indian Pacing Electrophysiol 2014;14:150-1.
nucleotide polymorphisms were not shown simply because they were unavailable. At our institution, lead extraction is routinely performed during the surgical procedure for heart transplantation in patients with intracardiac devices. Although lead extraction might be a risk factor for venous thromboembolic complications, we do not consider early post-operative anticoagulation as a routine strategy because of concerns about serious thoracic bleeding. Among 635 heart transplant patients included in our study,2 127 (20%) had an intracardiac device at the time of surgery (38 pacemakers, 67 implantable defibrillators, and 22 cardiac resynchronization devices). Kaplan-Meier cumulative estimates of venous thromboembolic episodes—deep venous thrombosis or pulmonary embolism—during the first post-transplant year among patients with an intracardiac device compared with patients without an intracardiac device before surgery did not differ in a statistically significant manner (log-rank, p ¼ 0.361) (Figure 1). To control the effect of potential confounders, the variable pre-operative intracardiac device was entered to the multivariable Cox regression model designed to predict venous thromboembolism during the first post-transplant year, which included age, obesity, renal dysfunction, and emergency transplantation.2 After multivariable adjustment, the association between preoperative intracardiac devices and early (o1 year) posttransplant venous thromboembolism was not statistically significant (hazard ratio ¼ 1.42, 95% confidence interval ¼ 0.55 to 3.68, p ¼ 0.476). In conclusion, our exploratory analysis showed a slight increase in the incidence of early (o1 year) venous thromboembolic episodes in heart transplant patients who had an intracardiac device before surgery, but this association did not reach statistical significance either in univariable or multivariable analyses. These data do not support lead extraction as a relevant risk factor for early venous thromboembolism after heart transplantation. However, these results might be affected by type II statistical error, given the relatively small number of patients who had an intracardiac device at the time of transplantation in our cohort. Further studies with specific design and proper sample size are warranted to clarify this question.
Disclosure statement The authors have no conflicts of interest to disclose.