Curs de Chirurgie Cardiaca Pt Studenti

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<ul><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 1/86</p><p>Surgery for</p><p>Acquired Heart Disease</p><p>Sef de lucrari dr. Adrian MolnarCardiovascular Surgery Clinic</p><p>HEART INSTITUTE</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 2/86</p><p>Cardiac Surgery the bad</p><p> Medical School</p><p> 5 years General Surgery</p><p> 2 years clinical/basic scienceresearch</p><p> 2 years CT Fellowship</p><p> 1 year advanced Fellowship Job opportunities</p><p> Stress/Work hours</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 3/86</p><p>Cardiac Surgery the good</p><p> You operate on the heart</p><p> Huge impact on patients lives!</p><p> Potential to fix the sickest patients in thehospital.</p><p> Technically and intellectually challanging.</p><p> Worse ways to make a living</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 4/86</p><p>Introduction</p><p> Cardiopulmonary Bypass</p><p> Coronary Artery Disease</p><p> Valvular Heart Disease</p><p> Transplant</p><p> Mechanical Assist Devices</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 5/86</p><p>The Father of Bypass</p><p>(John H. Gibbon (1903-1973)</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 6/86</p><p>CPB: Basic Principles</p><p> Full anticoagulation Heparin</p><p> Venous drainage</p><p> Right atrium SVC/IVC</p><p> Oxygenator</p><p> Pump</p><p> Arterial Inflow Aorta</p><p> Femoral artery</p><p> Axillary artery</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 7/86</p><p>CPB: Cardiac Arrest</p><p> Cardiopledgia</p><p> K+ (hyperkalemic arrest)</p><p> Energy substrates</p><p> Free radical scavangers</p><p> Antegrade aortic root</p><p> Retrograde coronarysinus</p><p> Deep HypothermicCirculatory Arrest</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 8/86</p><p>CPB: Myocardial Oxyge</p><p>nDema</p><p>ndUnloading the heart</p><p>Allen BS, Rosenkranz ER, Buckberg GD, et al: Studies of controlled reperfusion afterischemia, VII: high oxygen requirements of dyskinetic cardiac muscle. J Thorac</p><p>Cardiovasc Surg 1986; 92:543.)</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 9/86</p><p>CPB: Myocardial Oxyge</p><p>nC</p><p>onsumptio</p><p>n</p><p>Influence of temperature</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 10/86</p><p>CPB: Factor Activation</p><p>Bleeding</p><p>CoagulopathyFactor activation</p><p> doesnt help that we</p><p>have to heparinize!</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 11/86</p><p>CPB: Inflammatory Activation</p><p>Reactive Oxygen Species Ischemia/Reperfusion</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 12/86</p><p>CPB - Pros andCons</p><p> Hemolysis</p><p> Consumption</p><p>platelets</p><p>clottingfactors</p><p> Cytokineactivation</p><p> Embolism</p><p> Rest myocardium</p><p> Operate on still</p><p>heart Bloodless field</p><p> Allows opening ofchambers</p><p> Keeps patientstable</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 13/86</p><p>nevertheless a cornerstone</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 14/86</p><p>Coronary Artery Disease</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 15/86</p><p>Anatomy: RightCoronary Artery</p><p> RCA</p><p> anterior on aorta</p><p> R A-V groove</p><p> nodal arteries</p><p> acute marginal</p><p>postero lateral posterior</p><p>descending</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 16/86</p><p>Anatomy: Left Anterior Descending</p><p> LAD</p><p> branch of Left</p><p>main septal</p><p> diagonal</p><p> apex</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 17/86</p><p>Anatomy: LeftCircumflex Artery</p><p> Left A-V groove</p><p> obtuse marginals</p><p> posteriordescending</p><p> postero lateral</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 18/86</p><p>CAD: What is it?</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 19/86</p><p>CAD: Why is it a problem?</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 20/86</p><p>0 No angina</p><p>1 Angina only with strenuous or prolonged exertion</p><p>2 Angina with walking at a rapid pace on the level, on a grade,or up stairs (slight limitation ofnormal activities)</p><p>3 Angi</p><p>na with walki</p><p>ng at a</p><p>normal pace less tha</p><p>n2</p><p>blocks orone flight of stairs (marked limitation)</p><p>4 Angina with even mild activity</p><p>Can</p><p>adian</p><p>C</p><p>ardiovascular SocietyAngina Classification</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 21/86</p><p>CAD: Goals ofTherapy</p><p>IMPROVE BLOOD FLOW</p><p> Relief of symptoms</p><p> Prevention of complicationsMortality</p><p>MI</p><p>CHFArrhythmias</p><p> Prolong quality and quality of life</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 22/86</p><p>CAD: Outcomes /Prognosis</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 23/86</p><p>Coronary Artery Disease - Treatment</p><p> Medical Beta blockers, ASA, Nitrates</p><p> Risk factor modification Smoking, Lipid control, diet, activity</p><p> Interventional PTCA</p><p> Stents</p><p> Surgery CABG Coronary Artery Bypass Grafting</p><p> TMR Transmyocardial Revasc.</p><p> Transplant</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 24/86</p><p>AHA/ACCGuidelines forCABG:</p><p>Asymptomatic/mild/stable Angina</p><p>Asymptomatic/mild Angina Class I</p><p> left main stenosis</p><p> left main equivalent (proximal LAD and proximal circumflex)</p><p>triple-vessel disease</p><p> Class IIa</p><p> proximal LAD stenosis and one or two vessel disease</p><p> Class IIb</p><p> one or two vessel disease not involving proximal LAD</p><p>Stable angina Class I</p><p> left main stenosis</p><p> left main equivalent (proximal LAD and proximal circumflex) triple vessel disease</p><p> two vessel disease with proximal LAD stenosis and EF </p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 25/86</p><p>AHA/ACCGuidelines forCABG:</p><p>Unstable Angina / Acute MI</p><p>Unstable Angina Class I</p><p> proximal LAD stenosis with one vessel disease</p><p> one or two vessel disease without proximal LAD stenosis, but with a moderateterritory at risk and demonstrable ischemia</p><p> ongoing ischemia despite medical therapy</p><p> Class IIa</p><p> proximal LAD stenosis and one or two vessel disease</p><p> Class IIb</p><p> one or two vessel disease not involving the LAD</p><p>ST segment elevation (Q-wave) MI Class I None</p><p> Class IIa Ongoing ischemia despite medical therapy</p><p> Class IIb</p><p> progressive heart failure with remote territory at risk</p><p> primary reperfusion within 612 hours</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 26/86</p><p>CAD Treatment MovingTarget</p><p> Safer surgery</p><p> Myocardialprotection</p><p> Anesthesia</p><p> Better peri-operative care</p><p> Better</p><p>medications Statins</p><p> Beta-blockers</p><p> Sicker patients</p><p> Higherexpectations</p><p> Lifestylemodification</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 27/86</p><p>Surgery CABG</p><p> CPB arrested heart</p><p> Off-pump (20%)</p><p> Conduits</p><p> IMA (L/R)</p><p> Aorto-Coronary</p><p> Vein (Saphenous)</p><p> Radial Artery</p><p> Other / Exotic NOT:</p><p> Prostetic</p><p> Non-autologous</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 28/86</p><p>CABG: OnPump</p><p>Benefits Comfortable for the surgeon Bloodless field</p><p> Motionless field Myocardial protection Exposure to all vessels for total</p><p>revascularization</p><p>Risks</p><p> Aortic cannulation Cerebral Emboli Dissection</p><p> Negative effects of cardiopulmonary bypass</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 29/86</p><p>CABG OffPump</p><p> OPCAB</p><p> Beating heart</p><p> No CPB</p><p> Lower heparin</p><p> Lower risk</p><p> Technically difficult</p><p> ?outcome?</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 30/86</p><p>CABG Durability: ConduitPatency</p><p>1967 1989(even better with modern meds!)</p><p>P</p><p>ercentPate</p><p>nt</p><p>P</p><p>ercentPate</p><p>nt</p><p>100100</p><p>8080</p><p>606011 22 33 44 55 66 77 88 99 1010 1111 1212</p><p>YearsYears</p><p>N= 5657N= 5657</p><p>N=24145N=24145</p><p>ITAITA</p><p>SVGSVG</p><p>1389138910541054</p><p>456456 402402 415415</p><p>343343338338 291291 222222</p><p>175175 167167405405</p><p>5796579647804780</p><p>17561756</p><p>13661366</p><p>15351535</p><p>15891589</p><p>1553155313451345</p><p>1183118310291029</p><p>738738 14751475</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 31/86</p><p>CAD: CASS Registry Survival</p><p>Caracciolo, E., et Al., Circulation 1995; 91: 2325-2334.</p><p>100100</p><p>8080</p><p>6060</p><p>4040</p><p>2020</p><p>00</p><p>00 55 1010 1515</p><p>MedicalMedical</p><p>SurgicalSurgical</p><p>27%27%</p><p>37%37%</p><p>%%</p><p>YearsYears </p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 32/86</p><p>CAD Treatment</p><p> What about people who you cant doa CABG on?</p><p>Previous CABG Growing number of redo-CABGs</p><p>Poor targets</p><p>No conduitToo sick</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 33/86</p><p>Transmyocardial Laser Revascularization</p><p> Create Reptilian Circulation</p><p> Patients deemed non</p><p>revascularizable Documented ischemia</p><p> Carbon dioxide / HolmiumYAG laser</p><p> 30-40 holes drilled</p><p> Thoracotomy</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 34/86</p><p>Transmyocardial Laser Revascularization</p><p> Outcomes</p><p>improved angina</p><p>increased exercise tolerance</p><p>increased quality of life scores</p><p>decreased medical regimen</p><p>higher rate of survival free of cardiacevents</p><p>NEJM vol. Sept 1999341:14</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 35/86</p><p>Valve Disease</p><p> Tricuspid</p><p> Pulmonic</p><p> Mitral</p><p>Aortic</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 36/86</p><p>Valve Surgery: Repair vs Replacement</p><p>No CoumadinLess durability</p><p>Re-operations</p><p>CoumadinMore durability</p><p>Bleeding</p><p>Emboliccomplications</p><p>Patient factors and preference the most important considerations</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 37/86</p><p>Tissue Valves</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 38/86</p><p>MechanicalValves</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 39/86</p><p>Aortic Valve Disease</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 40/86</p><p>Anatomy: Aortic Valve</p><p>The noncoronary leafletstraddles the central fibrous bodyoverlying the anterior leaflet ofthe mitral valve.</p><p>The conduction tissue traversesthe membranous septum betweenthe right coronary andnoncoronary leaflets.</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 41/86</p><p>Aortic Valve Pathology</p><p> Stenosis</p><p> bileaflet</p><p> calcifications</p><p> Insufficiency</p><p> annulus</p><p> leaflet prolapse</p><p> Both</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 42/86</p><p>Aortic Stenosis: Calcification</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 43/86</p><p>Aortic Stenosis: The Problem</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 44/86</p><p>AV R: Grading Aortic Stenosis</p><p> Mild aortic stenosis: area &gt;1.5 cm2</p><p> Moderate aortic stenosis: area 1 to1.5 cm2</p><p>Severe aortic stenosis: area </p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 45/86</p><p>Aortic Stenosis: Disease Progression</p><p> not to mention the effects of CAD</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 46/86</p><p>Aortic Regurgitation</p><p> Improper or inadequate coaptation of the valve leafletsduring diastole.</p><p> Allows previously ejected blood to flow retrograde into theleft ventricle.</p><p> Effective stroke volume is reduced. Unlike aortic stenosis, both volume and pressure overload</p><p>of the left ventricular chamber occurs. Volume overload secondary to regurgitant flow</p><p> Pressure overload is due to the increased wall stress Law of Laplace.</p><p> Acute overload leads to immediate decompensation andsigns of left-sided failure as left ventricular end-diastolicvolume is exceeded.</p><p> Chronic volume/pressure overload allows forcompensatory changes in left ventricular volume, leadingto eccentric hypertrophy of the chamber.</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 47/86</p><p>AVR: Surgery</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 48/86</p><p>AVR: Cribier Edwards Perc. ValveThe Future?</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 49/86</p><p>AVR: Tissue Valve Durability</p><p>Current Thoughts:</p><p>Young PatientsMechanical ValvesPregnancyRisk of re-opLifestyle</p><p>Middle AgeMechanicalRisk of re-opPatient preference</p><p>ElderlyTissue valvesRisk of coumadin</p><p>Influence of other comorbidities</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 50/86</p><p>AVR: LongTerm Survival</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 51/86</p><p>MitralValve Disease</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 52/86</p><p>MitralValve: Anatomy</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 53/86</p><p>MitralValve: Anatomy</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 54/86</p><p>MitralValve: Anatomy</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 55/86</p><p>Mitral Stenosis</p><p> Generally the result of rheumatic heart disease.</p><p> Very rare in the U.S. (and modern countries)</p><p> Nonrheumatic causes</p><p>Severe mitral annular and/or leaflet calcification Congenital mitral valve deformities</p><p> Malignant carcinoid syndrome</p><p> Neoplasm</p><p> Left atrial thrombus</p><p> Endocarditic vegetations</p><p> A definite history of rheumatic fever can be obtained inonly about 50% to 60% of patients; women are affectedmore often than men by a 2:1 to 3:1 ratio. Nearly alwaysacquired before age 20, rheumatic valvular diseasebecomes clinically evident one to three decades later.</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 56/86</p><p>Mitral Regurgitation: EtiologyMuch larger problem</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 57/86</p><p>Etiology: Mitral Regurgitation</p><p>Carpentier's functional classification</p><p> Type I: Leaflet motion is normal.</p><p> Type II: Due to leaflet prolapse or excessive motion.</p><p> Type III: (restricted leaflet motion) is subdivided intorestriction during diastole ("a") or systole ("b"). Type IIIb is</p><p>typically seen in patients with ischemic MR.</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 58/86</p><p>Functional Mitral Regurgitation</p><p>Bolling: Sem. Thor. Card. Surg. 2002</p><p>CHFNormal</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 59/86</p><p>MitralValve Surgery: Indications</p><p> Complications</p><p>Left atrialenlargement</p><p>PulmonaryHypertension</p><p>Atrial fib.</p><p>LV DysfxnSymptoms</p><p>Endocarditis</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 60/86</p><p>Mitral Repair: Annuloplasty</p><p> Reduce annulardilatation</p><p> Reduce volumeoverload</p><p> Reduceventricular stressresponse</p><p> Reverseremodeling</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 61/86</p><p>Mitral Repair: Leaflet Resection</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 62/86</p><p>MitralValve Replacement</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 63/86</p><p>Outcomes: Degenerative Mitral Disease</p><p>Mitral Valve Repair</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 64/86</p><p>Outcome: Repair vs Replacement</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 65/86</p><p>Survival After MVR</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 66/86</p><p>Survival: Repair is Better!</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 67/86</p><p>Mitral Repair: Sounds Great</p><p> But:</p><p> 60% of Functional MR never gets addressed</p><p>&gt;50% of all valve surgery is replacement most are mechanical</p><p> Why?</p><p> Technically difficult</p><p> Surgeon preference/bias Outcomes</p><p> ?Not sure</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 68/86</p><p>When Fixing the Heart Doesnt Work</p><p>REPLACE IT</p><p> Transplant</p><p> Mechanical Support</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 69/86</p><p>Norman Shumway</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 70/86</p><p>Cardiac Transplantation</p><p> &gt; 5,000 patients listed for cardiactransplantation in the U.S.*</p><p>20-30% per year die waiting</p><p> &lt; 2500 cardiac transplantsperformed per year in theU.S.*</p><p>unchanged since 1989 despite moremarginal donors utilized</p><p>* ISHLT database</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 71/86</p><p>Cardiac Transplantation</p><p>2004ISHLT</p><p>189 318669</p><p>1185</p><p>2165</p><p>2720</p><p>31563380</p><p>40244186 4219</p><p>4382 4438 4356 4206 40873769</p><p>3436 3314 3219 3107</p><p>0</p><p>500</p><p>1000</p><p>1500</p><p>2000</p><p>2500</p><p>3000</p><p>3500</p><p>4000</p><p>4500</p><p>1982</p><p>1983</p><p>1984</p><p>1985</p><p>1986</p><p>1987</p><p>1988</p><p>1989</p><p>1990</p><p>1991</p><p>1992</p><p>1993</p><p>1994</p><p>1995</p><p>1996</p><p>1997</p><p>1998</p><p>1999</p><p>2000</p><p>2001</p><p>2002</p><p>NumberofTran</p><p>splants</p><p>J Heart Lung Transplant 2004;23:796-803</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 72/86</p><p>Long-Term Functional Status</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 73/86</p><p>Transplant: Underlying Diagnosis</p><p> CAD 45%</p><p> Dilated CM 45%</p><p> Valvular 4%</p><p> Congenital 2%</p><p> Retransplant 2%</p><p> Misc. 2%</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 74/86</p><p>Transplant: Donor selection</p><p> Age </p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 75/86</p><p>Transplant: Donor cardiectomy.</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 76/86</p><p>Transplantation: Implant</p></li><li><p>8/3/2019 Curs de Chirurgie Cardiaca Pt Studenti</p><p> 77/86</p><p>Transplant Rejection: A Worse Disease?</p><p>Symptoms:</p><p>AsymptomaticUnexplained arrhythmiasCongestive Heart Failure</p><p>Cardiogenic shock</p><p>vs</p><p>Infection/Sepsis</p><p>About 30% have some...</p></li></ul>