Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Feb 27, 2022; 14(2): 400-410
Published online Feb 27, 2022. doi: 10.4254/wjh.v14.i2.400
Takotsubo cardiomyopathy in orthotopic liver transplant recipients: A cohort study using multi-center pooled electronic health record data
Mohammad Zmaili, Jafar Alzubi, Motasem Alkhayyat, Joshua Cohen, Saqer Alkharabsheh, Mariam Rana, Paulino A Alvarez, Emad Mansoor, Bo Xu
Mohammad Zmaili, Joshua Cohen, Saqer Alkharabsheh, Paulino A Alvarez, Bo Xu, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Jafar Alzubi, Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA 19141, United States
Motasem Alkhayyat, Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Mariam Rana, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
Emad Mansoor, Department of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
Author contributions: Zmaili M designed the research study and formulated the idea of the research topic, collected the data, wrote the manuscript, contributed to the statistical analysis and figure formatting; Alzubi J contributed to manuscript writing; Alkhayyat M contributed to manuscript writing, data collection, data analysis, and figure formatting; Cohen J contributed to manuscript writing and revision; Alkharabsheh S contributed to manuscript writing and revision, and data analysis; Rana M contributed to manuscript writing; Alvarez PA contributed to manuscript writing and revision; Mansoor E contributed to manuscript writing and revision; Xu B contributed to manuscript writing and revision, finalizing the research work.
Institutional review board statement: This study is based on a multicenter analytics and research platform developed by IBM Watson Health (Explorys Inc, Cleveland, OH, USA). At present, Explorys database is rich, integrated, and growing living clinical data set that is HIPAA-enabled, including more than 70 million unique patients across all 50 states in the United States, and thus provides a broad regional and climatic distribution of source population. Ethical review and informed consent were waived, since there are no identifiers associated with any of the patient data. The Explorys rounds cell counts to the nearest 10 and treats all cell counts between zero and 10 as equivalent in order to further protect the identities of patients. In other words, the identities of subjects is completely anonymous and there is no risk involved in the study. Additionally, the research presents no risk of harm to subjects and involves no procedures for which written consent is normally required outside the research context.
Conflict-of-interest statement: This statement is to certify that all Authors have seen and approved the manuscript being submitted. We warrant that the article is the Authors' original work. We certify that there is no actual or potential conflict of interest in relation to this article to declare.
Data sharing statement: This study is based on a multicenter analytics and research platform developed by IBM Watson Health (Explorys Inc, Cleveland, OH, USA). At present, Explorys database is rich, integrated, and growing living clinical data set that is HIPAA-enabled, including more than 70 million unique patients across all 50 states in the United States, and thus provides a broad regional and climatic distribution of source population. Ethical review and informed consent were waived, since there are no identifiers associated with any of the patient data. The Explorys rounds cell counts to the nearest 10 and treats all cell counts between zero and 10 as equivalent in order to further protect the identities of patients. In other words, the identities of subjects is completely anonymous and there is no risk involved in the study. Additionally, the research presents no risk of harm to subjects and involves no procedures for which written consent is normally required outside the research context.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Bo Xu, MD, FACC, FRACP, FASE, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, United States. xub@ccf.org
Received: June 29, 2021
Peer-review started: June 29, 2021
First decision: July 27, 2021
Revised: August 8, 2021
Accepted: February 10, 2022
Article in press: February 10, 2022
Published online: February 27, 2022
Processing time: 238 Days and 7.6 Hours
Abstract
BACKGROUND

Takotsubo cardiomyopathy (TCM), or stress-induced cardiomyopathy, is associated with adverse prognosis. Limited data suggest that TCM occurring in orthotopic liver transplant (OLT) recipients is associated with elevated peri-operative risk.

AIM

To characterize the predictors of TCM in OLT recipients, using a large, multi-center pooled electronic health database.

METHODS

A multi-institutional database (Explorys Inc, Cleveland, OH, USA), an aggregate of de-identified electronic health record data from 26 United States healthcare systems was surveyed. A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms of “liver transplant” between 09/2015 and 09/2020 was identified. Subsequently, individuals who developed a new diagnosis of TCM following OLT were identified. Furthermore, the risk associations with TCM among this patient population were characterized using linear regression.

RESULTS

Between 09/2015 and 09/2020, of 37718540 patients in the database, 38740 (0.10%) had a history of OLT (60.6% had an age between 18-65 years, 58.1% female). A new diagnosis of TCM was identified in 0.3% of OLT recipients (45.5% had an age between 18-65 years, 72.7% female), compared to 0.04% in non-OLT patients [odds ratio (OR): 7.98, 95% confidence intervals: 6.62-9.63, (P < 0.0001)]. OLT recipients who developed TCM, compared to those who did not, were more likely to be greater than 65 years of age, Caucasian, and female (P < 0.05). There was also a significant association with cardiac arrhythmias, especially ventricular arrhythmias (P < 0.0001).

CONCLUSION

TCM was significantly more likely to occur in LT recipients vs non-recipients. Older age, Caucasian ethnicity, female gender, and presence of arrhythmias were significantly associated with TCM in LT recipients.

Keywords: Takotsubo cardiomyopathy; Orthotopic liver transplant; Stress-induced cardiomyopathy; Clinical outcomes

Core Tip: In a large cohort study using de-identified pooled electronic health record data, liver transplant recipients were more likely to develop Takotsubo cardiomyopathy compared to non-recipients. Older age, Caucasian ethnicity, female gender, and presence of arrhythmias were significantly associated with Takotsubo cardiomyopathy in liver transplant recipients.