Outcome of children with end-stage congenital heart disease waiting for cardiac transplantation.

BACKGROUND: End-stage congenital heart disease (CHD) is a major indication for pediatric cardiac transplantation. The objective of the study was to evaluate pre-transplant outcome of children with CHD. METHODS: The clinical profile and outcome of patients with CHD <20 years of age listed for transplantation (1993 to 1999) were reviewed and patients who died waiting (Group I) were compared with survivors to transplant (Group II). RESULTS: Mean age of the patients (n = 46) was 8.3 +/- 8 years. Primary indications for transplant were ventricular dysfunction in 36 (78%), failed Fontan in 8 (18%) and severe hypoxemia in 2 (4%) patients. Thirty-two patients were Status 1 (70%), 14 were Status 2 and 5 patients were de-listed. Twenty-nine of the 41 patients that remained listed survived to transplant, 12 (29%) died waiting. Causes of death were sepsis in 2 and severe heart failure (HF) in 10 patients. Eight patients died with multi-system organ failure, including 3 on mechanical circulatory support. Mean time to death was 29 +/- 28 days and time to transplant was 94 +/- 176 days. Mean age at listing was younger in Group I (2.6 +/- 4 years) compared with Group II (9.1 +/- 7 years, p < 0.05). Mean HF duration was shorter in Group I (3.6 +/- 3.9 months) compared with Group II (25 +/- 33 months, p < 0.05). Fifty-day actuarial survival on the waiting list was lower in infants (38%) compared with older children (91%, p < 0.05). In contrast to the high mortality (71%) in infants with CHD, all infants with cardiomyopathy survived to transplant. CONCLUSIONS: Seventy-one percent of patients listed with CHD survived to transplant. Younger age at listing and rapid onset of HF were significant risk factors for pre-transplant mortality.     

Long-term survival after cardiac retransplantation: a twenty-year single-center experience

OBJECTIVE: To identify risk factors for survival after cardiac retransplantation and compare the survival after retransplantation with that after primary cardiac transplantation. METHODS: A retrospective analysis of 952 patients undergoing cardiac transplantation for the treatment of end-stage heart disease at a single center between 1977 and October 1997. Of these, 43 patients (4.5%) underwent cardiac retransplantation for cardiac failure resulting from transplant-related coronary artery disease, rejection, and early graft failure. RESULTS: No significant difference in actuarial patient survival was found by Kaplan-Meier analysis at 1, 2, and 5 years between patients undergoing primary transplantation and those undergoing retransplantation 76%, 71%, and 60% versus 66%, 66%, and 51%, respectively (P =.2). Multivariable analysis identified a shorter interval between transplants and an initial diagnosis of ischemic cardiomyopathy as significant risk factors for death after retransplantation (P =.04 and.03, respectively). Since 1993, when our criteria for patient selection for retransplantation were revised on the basis of earlier experience to exclude patients with allograft dysfunction as a result of primary graft failure and those with intractable acute rejection occurring less than 6 months after transplantation, the survival has been significantly better (<1993 = 45%, 45%, and 33% versus >/=1993 = 94%, 94%, and 94% at 1, 2, and 4 years, respectively, P =.003). CONCLUSION: The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation, especially in patients with transplant-related coronary artery disease. Patient characteristics and other preoperative variables should assist in the rational application of retransplantation to ensure optimal use of donor organs.     

Outcome of infants listed for lung or heart/lung transplantation

BACKGROUND: Little is known about outcome, characteristics, or organ availability for infants listed for lung or heart/lung transplantation. METHODS: Within a 45-month period at one institution, all pediatric patients who were listed for primary lung or heart/lung transplantation and who reached the end point of either transplant or death prior to transplant were identified. Outcomes for those patients listed as younger than and older than 1 year of age were compared. RESULTS: Among 48 pediatric patients, 19 were infants less than one year of age. The median age among infants at listing was 3.7 months (range 0.5 to 8.9 months). Death before transplant occurred in 10 of 19 infants (53%) compared with 14 of 29 (48%) children. When comparing those infants who died prior to transplant with those who received organs, there were no significant differences with respect to size, blood type, age at listing, presence of pulmonary hypertension, or type of transplant for which the patient was listed. There was a trend toward poorer pre-transplant survival for infants when compared with children. Waiting times were significantly shorter for infants vs children (p = 0.02). The incidence of acute cellular rejection and serious infection was similar in the 2 groups. Infants had significantly longer hospitalization post-transplant and a trend toward poorer hospital survival, although survival at 1 year was comparable between the 2 groups. CONCLUSION: The outcome for infants listed for lung or heart/lung transplantation is similar to that of children; thus, very young age should not be considered a contraindication to lung or heart/lung transplantation. Earlier diagnosis and listing may decrease pre-transplant mortality.     

Mid-term follow up results of Japanese heart transplant patients operated in UCLA Medical Center.

Japanese candidates have been accepted for heart transplantation by the UCLA Medical Center in the US since 1993 due to the lack of donors available from brain-dead patients. OBJECTIVES AND METHODS: We monitored to patients who underwent such heart transplantation and have been seen at the out-patient clinic at Tokyo Women's Medical University following transplantation. Pre-operative diagnosis was dilated cardiomyopathy in all patients. One patient underwent Novacor implantation as a bridge to heart transplant. All patients underwent cardiac echocardiography and cardiac catheterization including intraluminal echography. RESULTS: All patients survived with an actuarial survival curve of 100% at 1 year, 100% at 3 years and 87% at 5 years in 4.15 years of average follow-up. Two patients died due to liver dysfunction and cerebral emboli. The postoperative functional status of patients was New York Heart Association classification I in 8 (100%). Immunosuppressive therapies included triple drug therapy using either cyclosporin or tacrolimus. The incidence of acute rejection (/pt) exceeding grade 3 was 4% within three months, 3.5% in 3-6 months, and no significant rejection episode more than 6 months after transplantation. Posttransplantation coronary artery disease was seen in 2 patients, but no progression was seen after diltiazem therapy. CONCLUSION: Our postoperative follow-up after cardiac transplantation appears to be satisfactory.     

Utility of extracorporeal membrane oxygenation for early graft failure following heart transplantation in infancy.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is widely used for postcardiotomy cardiogenic shock in children. However, the efficacy of ECMO for early post-heart transplant graft failure in infants has not been reported. Our aims were to determine: (1) the utility of ECMO in infants with severe donor-heart dysfunction, (2) predictors for requiring ECMO, and (3) the long-term outcome of surviving ECMO patients. METHODS: All infants (age < 6 months at listing) undergoing heart transplantation were reviewed. Diagnostic categories were hypoplastic left heart syndrome (HLHS) and non-HLHS (complex congenital heart disease and cardiomyopathies). Continuous and categorical comparisons were by Wilcoxon's rank sum test and Fisher's exact test respectively. RESULTS: 14 (12 HLHS, 2 non-HLHS) of 63 (46 HLHS, 17 non-HLHS) infants were placed on ECMO. Ten patients (71%) were successfully weaned from ECMO and 8 (57%) were discharged alive. All ECMO hospital survivors remain alive (mean follow-up 36.2 +/- 21.4 months, range 13.1-77.6 months). Mean duration of ECMO support was 68 hours in weaned patients vs 144 hours (p = 0.19) in nonweaned patients, and 64 hours in survivors vs 123 hours (p = 0.35) in nonsurvivors. ECMO deaths were due to sepsis (n = 3), intractable pulmonary hypertension (n = 2), and intracranial bleed (n = 1). Neurologic deficits occurred in 2 survivors. Median ICU and hospital stays for ECMO survivors were 29 and 33 days vs 7 (p = 0.0003) and 9 (p = 0.0004) days for non-ECMO patients. Age listed, age transplanted, wait time, body weight, donor/recipient weight ratio, total ischemia time, and diagnosis did not predict the need for ECMO. CONCLUSIONS: (1) ECMO is useful for post-heart transplant circulatory support in infants with early graft failure. (2) All survivors were weaned in fewer than 4 days. (3) Three-year survival of ECMO hospital survivors has been high, but neurologic complications are prevalent.     

Should stable UNOS Status 2 patients be transplanted?

BACKGROUND: Improved outcomes with contemporary medical therapy in patients with advanced heart failure brings into question the survival advantage of transplantation for patients in stable United Network for Organ Sharing (UNOS) Status 2. METHODS: Between January 1999 and June 2001, a total of 7,539 adult patients were listed for heart transplantation. Of those, 4,255 (56.4%) patients were listed as UNOS Status 2. Using a competing risk method, we computed probabilities of events while on the waiting list. Additionally, we used a time-dependent proportional hazards model to determine predictors of death before and after transplantation. RESULTS: Demographics included age >60 (72%), female sex (23%), ischemic causes for transplantation (49%), white race (85%), and median time on the waiting list (544 days). Laboratory and hemodynamic values included mean serum albumin of 3.9 g/dl, serum creatinine of 1.4 mg/dl, mean pulmonary artery pressure of 28 mm Hg, mean pulmonary capillary wedge pressure of 19 mm Hg, and mean cardiac output of 4.5 liter/min. Final outcomes on the waiting list for patients initially listed as UNOS Status 2 were transplantation (48%), removal from the list (11.5%), death (11.4%), and continued listing (29%). At 30 months after transplantation, survival was 81% for patients undergoing transplantation as Status 1A, 77% as Status 1B, and 83% as Status 2, and showed no difference among groups. At 365 days, survival analysis showed no difference for patients listed and undergoing transplantation as UNOS Status 2 compared with those still waiting as Status 2. CONCLUSION: In the current era of advances in medical and surgical therapies for heart failure, we found no survival benefit of cardiac transplantation at 1 year for patients initially listed as UNOS Status 2.     

Mechanical limitation of pulmonary blood flow facilitates heart transplantation in older infants with hypoplastic left heart syndrome.

OBJECTIVES: Progression of pulmonary vascular disease limits heart transplantation for hypoplastic left heart syndrome (HLHS) to early infancy. Our objective was to assess the impact of bilateral pulmonary artery banding (PAB) on the operative courses of HLHS infants transplanted at ages older than 4 months. METHODS: Courses of all HLHS patients in our center who remained listed to age >or=120 days before heart transplantation were assessed. Patients undergoing transplantation after standard management (control group) were compared to patients having a prior pulmonary blood flow limiting procedure (PAB group). RESULTS: Of 16 identified patients, one crossed over to stage I Norwood on day 185 and died post-operatively. Fifteen patients were transplanted at age >or=120 days (control group n=9, PAB group n=6). Four PAB patients had open PA band placement. Two PAB patients underwent experimental percutaneous bilateral internal pulmonary artery flow limiting device insertion. The PAB group mean age at banding was 141+/-54 days, and mean interval from PAB to transplant was 35+/-31 days (range 1.5-68 days). No differences in age at transplant, weight at transplant, warm graft ischemia time or total graft ischemia time were detected between groups. Mean times of mechanical ventilation (control 143+/-69h vs. PAB 44+/-13h), inhaled nitric oxide (control 126+/-70h vs. PAB 37+/-9h), inotropic support (control 171+/-64h vs. PAB 87+/-17h), intensive care unit (ICU) stay (control 8.3+/-2.7 days vs. PAB 4.5+/-1.4 days), and hospital stay (control 10.4+/-3.9 days vs. PAB 7.0+/-1.1 days) were all lower in the PAB group (P<0.05 all comparisons). Two control patients died, three required extracorporeal membrane oxygenation (ECMO), and six did not tolerate primary chest closure. No PAB patient died or required ECMO. All PAB patients tolerated primary chest closure. All PAB patients had widely patent branch pulmonary arteries with no re-interventions to date. All hospital survivors remain alive (mean follow-up, control 50.2 months, PAB 11.5 months). CONCLUSIONS: Pre-transplant mechanical limitation of pulmonary blood flow simplified management and reduced morbidity for HLHS patients undergoing heart transplantation at ages >or=4 months. This strategy extends the permissible transplant waiting time in older infants with HLHS.     

Listing for lung transplantation: life expectancy and transplant effect, stratified by type of end-stage lung disease, the Eurotransplant experience.

BACKGROUND: Increased referral for lung transplantation, persistent shortage of donor lungs, and moderate transplant outcome call not only for adequate listing criteria, but also for an optimal allocation scheme. We used global cohort survival after listing and survival benefit from transplantation to study the effect of a lung allocation scheme, primarily driven by waiting time, on the different types of end-stage lung disease. METHODS: We followed all adult patients consecutively listed for first, lung-only transplantation between 1990 and 1996 (n = 1,208) for at least 2 years, with an additional 2-year follow-up after transplantation (n = 744). We used the competing risk method, the Kaplan-Meier method, and a time-dependent non-proportional hazards model to analyze waiting-list outcome and global mortality after listing, post-transplant survival, and transplant effect, respectively. Each analysis was stratified for type of end-stage lung disease. RESULTS: At 2 years, 57% of the total cohort had received lung transplants, whereas 25% had died on the waiting list. The 2-year survival post-transplant was 55%. The global mortality of the cohort, since listing, amounted to 46% at 2 years. Compared with continued waiting, patients experienced benefit from transplantation by Day 100, which lasted until the end of the 2-year analysis period. We noticed the highest global mortality rates for patients with pulmonary fibrosis and pulmonary hypertension (54% and 52%); emphysema patients had the lowest (38%). Patients with pulmonary fibrosis and cystic fibrosis had much earlier benefit from transplantation, 55 and 90 days, respectively. Transplantation also benefited emphysema patients by Day 260. CONCLUSIONS: Lung transplantation conferred transplant benefit in a Western European cohort of adults, in particular for patients with pulmonary fibrosis and cystic fibrosis, but also for patients with emphysema. The global survival rate, reflecting the real life expectancy for a newly listed transplant candidate, is poor for patients with pulmonary fibrosis and pulmonary hypertension. Allocation algorithms that lessen the impact of waiting time and take into account the type of end-stage lung disease should be developed.     

Smoking After Cardiac Transplantation

Although smoking cessation is a prerequisite prior to listing for cardiac transplantation, some patients return to smoking after recovery. We have covertly assessed the smoking habits of our cardiac transplant recipients (with ethical approval) since 1993 by measuring urinary cotinine: a level of >500 ng/mL signifying continued tobacco use. We retrospectively analyzed survival, causes of death and the development of graft coronary artery disease (GCAD) with respect to the number of positive and negative cotinine levels. One hundred four of 380 (27.4%) patients tested positive for active smoking at some point posttransplant, and 57 (15.0%) tested positive repeatedly. Smokers suffered significantly more deaths due to GCAD (21.2% vs. 12.3%, p < 0.05), and due to malignancy (16.3% vs. 5.8%, p < 0.001). In univariate analysis, smoking after heart transplantation shortened median survival from 16.28 years to 11.89 years. After correcting for the effects of pretransplant smoking in time-dependent multivariate analysis, posttransplant smoking remained the most significant determinant of overall mortality (p < 0.00001). We conclude that tobacco smoking after cardiac transplantation significantly impacts survival by accelerating the development of graft vasculopathy and malignancy. We hope that this information will deter cardiac transplant recipients from relapsing, and intensify efforts in improving cessation rates.     

Value of the MELD score for the assessment of pre- and post-liver transplantation survival

The MELD score has now been implemented in the United States for liver allocation, but it has not been validated in Europe. Its association with posttransplant outcome is unclear. Optimal cutoff values of MELD and Child-Pugh scores to predict death on the liver waiting list were defined in a series of 137 cirrhotic patients listed for liver transplantation. Six-month actuarial survival while on the waiting list was 90% with a Child-Pugh <11 and MELD <17, whereas it decreased progressively to 40% at 6 months after listing for those having a Child-Pugh and MELD score >10 and >16. Analysis of a series of 112 patients (85 chronic liver disease and 27 hepatocellular carcinoma) revealed no change in MELD value at the time of transplantation compared to the score at the time of listing (mean +/- SD: 15.5 +/- 7.7 vs 15 +/- 5.8) with a mean waiting time of 118 days. Using either the optimal cutoff for MELD score (<17 or >16) or seven different strata (3 to 7, 8 to 10, 11 to 13, 14 to 16, 17 to 19, 20 to 22, 23 to 39), whether measured at listing or just before liver transplantation, there was no significant difference (chi(2) 4.97, P = .58) in survival: 82.7% and 63% at 6 and 60 months, overall. Our data confirm that the MELD score with only three parameters is as good as the Child-Pugh score to predict mortality on the Eurotransplant waiting list. The optimal cutoff to assess higher priority for the bad category is >16. There was no negative impact on short- or long-term prognosis of the bad categories of MELD.     

Emergency use of wearable left ventricular assist devices in patients not eligible for heart transplantation

BACKGROUND: We reviewed our experience concerning the clinical outcomes of emergency implantation of left ventricular assist devices (LVAD) in patients not eligible for heart transplantation (HTX). PATIENTS AND METHODS: Between January 1998 and September 2006, 62 patients were referred for emergency HTX including 35 (55%) who received cardiac allografts; 9 (14%) died on the waiting list. The other 18 subjects (31%) did not meet listing criteria due to pulmonary hypertension with massive transpulmonary gradients (TPG), severe diabetes, or another factor; 7 patients had wearable LVAD implants and the remaining 11 who had contraindications both to HTX and to LVAD implantation remained on medical therapy. RESULTS: Twelve month actuarial survivals were 47% in LVAD G1 vs 1% in medical therapy G2 (P< .005). Four G1 patients died either due to cerebrovascular vascular episodes or to thromboembolic events. The beneficial use of LVAD in 3 patients led to consistent improvement in hemodynamic performance allowing listing for HTX. Two of them have been successfully transplanted; 1 is still waiting. Due to refractory heart failure, 90% of G2 died within the first months after evaluation. CONCLUSION: Our limited experience indicated that emergency use of LVAD ensued a satisfactory outcome allowing better actuarial survival.     

How great is the survival advantage of transplantation over dialysis in elderly patients?

BACKGROUND: Patients >60 years old represent 66% of all new patients starting renal replacement therapy in Scotland. The aim of this study was to investigate whether or not transplantation provides any survival benefit in this group of patients. METHODS: 325 patients >60 years old listed for transplantation in Scotland between 1 January 1989 and 31 December 1999 were followed up until 31 December 2000. Sociodemographic, comorbidity, listing and transplant data were obtained from the national renal and transplant databases and case-notes review. Survival was compared between those who received a transplant and those who were listed but did not receive a transplant by the end of the follow-up period. Mann-Whitney, chi(2), Fisher's exact and log-rank tests were used where appropriate. RESULTS: Of the 325 patients listed, 128 (39.4%) received a first transplant within the study period and the remaining 197 (60.6%) continued to undergo dialysis. The transplant recipients were younger at listing (P<0.0001), lived closer to the transplant centre (P = 0.043) and spent less time on the active waiting list (P<0.0001) than patients who remained on dialysis. They had less ischaemic heart disease (P = 0.024), cerebrovascular disease (P = 0.03) and arrhythmias (P = 0.016). The overall mortality rate was 0.16 per patient-year for dialysis and 0.10 for transplantation. There was a significantly lower risk of death (RR = 0.35, 95% CI 0.22--0.54; P<0.0001, log-rank) and a longer life expectancy after listing with a transplant (8.17 vs 4.32 years). CONCLUSIONS: Renal transplantation offers a significant survival advantage over dialysis in elderly patients with end-stage renal failure who are considered suitable for transplantation.     

Liver transplantation for neuroendocrine tumors

Liver transplantation for the treatment of metastatic neuroendocrine tumors (NETs) is radical. Although cure is not impossible, it is improbable. The reported experience with transplantation for NETs is limited to less than 150 cases with widely varying results and few 5-year disease-free survivors. We reviewed our experience with transplantation for patients with NETs. Fourteen symptomatic patients with unresectable NET liver metastases who had failed medical management were listed for transplantation. Two patients listed for transplantation underwent prior right lobectomies. Three patients were listed but did not undergo transplantation: one was lost to follow-up, one died 14 months after listing, and one remains waiting over 4 years. Eleven patients underwent liver transplantation, three with living donor grafts. There were four men (36.4%) and seven women (63.6%) who had a mean age of 51.2 ± 6.3 years. Three patients had distal pancreatectomies and one patient had a Whipple procedure at the time of transplantation. There were six nonfunctioning tumors (54.6%), three carcinoid tumors (27.3%), and two (18.2%) Vipomas. In one patient, with fulminant hepatic failure, the NET was an incidental finding in the explant. The 1- and 5-year survival among transplanted patients is 73% and 36%, respectively, with a mean follow-up of 34 ± 40 months (range 0 to 119 months). Of the three patients surviving more than 5 years, only one was disease free. In carefully selected patients with metastatic NETs, liver transplantation may be an appropriate option. Presented in part at the Fourth Americas Congress of the American Hepato-Pancreatico-Biliary Association, Miami, Florida, February 28, 2003.     

Staged Surgical Palliation in Hypoplastic Left Heart Syndrome and Its Variants

Abstract   Background: Surgical options for infants with hypoplastic left heart syndrome (HLHS) and/or its variants are cardiac transplantation or the heart-preserving staged palliation with Norwood operation, followed by a two-staged Fontan procedure. We describe our 17-year experience with staged palliation of HLHS and/or its variants. Methods: Between December 1989 and December 2006, 64 patients with HLHS and/or its variants underwent a Norwood procedure (mean age/weight, 11.8 ± 2.5 days/3.4 kg). Forty-four patients had classical HLHS. Twenty-eight percent had associated congenital cardiac, structural, and genetic anomalies. Subsequently, 25 patients underwent a bidirectional Glenn procedure (stage II) and 11 patients a modified Fontan procedure (stage III). Others await stage II and/or stage III. The follow-up was 143.2 patient-years. Results: Including the learning curve, overall early mortality from 1989 to 1999 after the Norwood procedure was 39.06%. This decreased tremendously for the last seven years, and reduced to 12.8% in 2000 to 2003 until 0% in 2004 to 2006 (p < 0.005). The causes of mortality were sepsis, capillary leak, or heart failure. Three patients died between stages II and III. One patient underwent heart transplantation after the second stage because of heart failure. Among 34 Norwood survivors, four are slightly tachypneic from a mild pulmonary hyperperfusion; one presents symptoms of minimal brain disease. Conclusion: This report identified an outcome improvement after staged paliation of HLHS, attributed to an increase in experience and expertise gained over time. Lower operative weight, ascending aortic size, prolonged duration of cardiopulmonary bypass, and hypothermic circulatory arrest were identified to significantly influence early mortality after the Norwood procedure.     

Outcome of bilateral lung volume reduction in patients with emphysema potentially eligible for lung transplantation.

OBJECTIVE: Between January 1993 and May 1998, we performed 200 consecutive bilateral lung volume reduction operations. After initial assessment, 99 of these patients were eligible for lung volume reduction and potentially eligible for immediate or eventual lung transplantation on the basis of age and absence of contraindications. All chose to proceed with lung volume reduction surgery. The outcomes of these 99 patients are reviewed to assess the consequences of proceeding with lung volume reduction surgery on patients potentially eligible for lung transplantation. METHODS: A retrospective study was performed with the use of a prospectively assembled computer database. RESULTS: The 61 men and 38 women were 55 +/- 7 years old at evaluation for lung volume reduction. Mean values for first second expired volume, total lung capacity, and residual volume were 24% +/- 8%, 141% +/- 19%, and 294% +/- 54% predicted. There were 4 operative deaths and 17 late deaths. Two-year and 5-year survival after evaluation for lung volume reduction are 92% and 75%. The 32 patients who have been listed for transplantation after lung volume reduction include 15 who have undergone transplantation, 14 who remain on the list, and 3 who have been removed from the list. All 15 transplant recipients survived transplantation and 3 have subsequently died of rejection or late infection. The 12 living recipients have a median post-transplantation follow-up of 1.7 years. The age at transplantation was 58 +/- 5 years with transplantation occurring 3.8 +/- 1.1 years after lung volume reduction. Sixteen of 99 patients underwent lower lobe volume reduction with an increased rate of listing (63%, P =.008) and transplantation (38%, P =.003) compared with patients undergoing upper lobe volume reduction. Patients listed for transplantation were younger, more impaired, and experienced less benefit from lung volume reduction than patients not yet listed for transplantation. CONCLUSIONS: The preliminary use of lung volume reduction in patients potentially suitable for transplantation does not appear to jeopardize the chances for subsequent successful transplantation.     

Long-term follow-up of Thoratec ventricular assist device bridge-to-recovery patients successfully removed from support after recovery of ventricular function.

BACKGROUND: In certain forms of severe heart failure there is sufficient improvement in cardiac function during ventricular assist device (VAD) support to allow removal of the device. However, it is critical to know whether there is sustained recovery of the heart and long-term patient survival if VAD bridging to recovery is to be considered over the option of transplantation. METHODS: To determine long-term outcome of survivors of VAD bridge-to-recovery procedures, we retrospectively evaluated 22 patients with non-ischemic heart failure successfully weaned from the Thoratec left ventricular assist device (LVAD) or biventricular assist device (BVAD) after recovery of ventricular function at 14 medical centers. All patients were in imminent risk of dying and were selected for VAD support using standard bridge-to-transplant requirements. There were 12 females and 10 males with an average age of 32 (range, 12-49). The etiologies were 12 with myocarditis, 7 with cardiomyopathies (4 post-partum [PPCM], 1 viral [VCM], and 2 idiopathic [IDCM]), and 3 with a combination of myocarditis and cardiomyopathy. BVADs were used in 13 patients and isolated LVADs in 9 patients, for an average duration of 57 days (range, 11-190 days), before return of ventricular function and successful weaning from the device. Post-VAD survival was compared with 43 VAD bridge-to-transplant patients with the same etiologies who underwent cardiac transplantation instead of device weaning. RESULTS: Nineteen of the 22 patients are currently alive. Three patients required heart transplantation, 1 within 1 day, 2 at 12 and 13 months post-weaning, and 2 died at 2.5 and 6 months. The remaining 17 patients are alive with their native hearts after an average of 3.2 years (range, 1.2-10 years). The actuarial survival of native hearts (transplant-free survival) post-VAD support is 86% at 1 year and 77% at 5 years, which was not significantly different (p = 0.94) from that of post-VAD transplanted patients, also at 86% and 77%, respectively. CONCLUSIONS: Long-term survival for bridge-to-recovery with VADs for acute cardiomyopathies and myocarditis is equivalent to that for cardiac transplantation. Recovery of the native heart, which can take weeks to months of VAD support, is the most desirable clinical outcome and should be actively sought, with transplantation used only after recovery of ventricular function has been ruled out.     

The management of second primary lung cancers. A single centre experience in 15 years.

OBJECTIVE: In patients treated for an initial lung cancer, the cumulative risk of developing a second primary lung cancer is a recognised occurrence. This study reviews our experience in the clinical assessment and surgical management of second primary lung cancer (SPLC). METHODS: Between 1985-1999 a series of 892 patients with primary carcinoma of lung underwent surgical resection with curative intent in our institution. Using criteria set out by Martini and Melamed (J Thorac Cardiovasc Surg 70 (1975) 606) we were able to identify 51 patients who had developed a SPLC identified as the first site of re-occurrence. RESULTS: Forty-one patients developed a metachronous SPLC within a mean of 46+/-14 months of the first operation while ten patients had synchronous double lung cancer (six unilateral, four bilateral). The cumulative probability of cancer free interval for metachronous cancers was 39% at 3 years, 15% at 5 years and 2% at 10 years. There were three postoperative deaths among the metachronous cancers (7.5%) and there were no operative deaths among patients with synchronous cancers. The overall actuarial 5-year survival for all patients with SPLC was 38% with a median survival of 40 months (range 1-142 months). The actuarial 5-year survival for metachronous SPLC was 44%, median survival of 49 months (range 1-142 months), while the actuarial 5-years survival for synchronous SLPC was 10% with a median survival of 31 months (range 4-78 months). CONCLUSION: Aggressive assessment and surgical intervention is safe, effective and warranted in patients with a second lung primary cancer if they satisfy the usual criteria of operability after full assessment. This is true for patients with metachronous cancers, while patients with synchronous cancers tend to have worse prognosis. A long term follow-up policy after the initial resection of the primary lung cancer is recommended at intervals of 6 months for at least 3-5 years and then annually to enable the early detection of the second cancer.     

Reduced Mortality with Right-Lobe Living Donor Compared to Deceased-Donor Liver Transplantation When Analyzed from the Time of Listing

Right lobe living donor liver transplantation (RLDLT) is not yet a fully accepted therapy for patients with end-stage liver failure in the Western hemisphere because of concerns about donor safety and inferior recipient outcomes. An outcome analysis from the time of listing for all adult patients who were listed for liver transplantation (LT) at our center was performed. From 2000 to 2006, 1091 patients were listed for LT. One hundred fifty-four patients (LRD; 14%) had suitable live donors and 153 (99%) underwent RLDLT. Of the remaining patients (DD/Waiting List; n = 937), 350 underwent deceased donor liver transplant (DDLT); 312 died or dropped off the waiting list; and 275 were still waiting at the time of this analysis. The LRD group had shorter mean waiting times (6.0 months vs. 9.8 months; p < 0.001). Although medical model for end-stage liver disease (MELD) scores were similar at the time of listing, MELD scores at LT were significantly higher in the DD/Waiting List group (15.4 vs. 19.5; p = 0.002). Patients in Group 1 had a survival advantage with RLDLT from the time of listing (1-year survival 90% vs. 80%; p < 0.001). To our knowledge, this is the first report to document a survival advantage at time of listing for RLDLT over DDLT.     

Cardiac transplantation in survivors of lymphoma: a multi-institutional survey

BACKGROUND: Cardiac transplantation has been successfully performed in patients with a history of presumably cured Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Though the risk of recurrence is a major concern, the long-term influence of prior cancer and cancer therapy on posttransplant outcome has not been previously investigated. METHODS: Questionnaires were sent to 130 cardiac transplant centers in the United States registered with the United Network for Organ Sharing. Data collected included patient demographics; type, stage, and timing of HD/NHL; treatment for HD/NHL; posttransplant immunosuppressive regimen, rejection history, and outcomes; and Epstein-Barr virus status. RESULTS: Thirty-four cardiac transplant recipients with a previous history of HD (n=16) or NHL (n=18) were identified. HD patients averaged 41+/-15 years of age, with a mean disease-free interval of 15+/-9 years at the time of transplantation. NHL patients averaged 42+/-17 years of age with a mean disease-free interval of 10+/-9 years at the time of transplantation. The mean follow-up for the entire group was 50 months (range, 2 days to 136 months), and mean follow-up for the survivors was 67 months (range, 23-136 months). The 1-, 3-, 5-, 7-, and 10-year actuarial survival estimates for the entire group are 77%, 64%, 64%, 64%, and 50%, respectively. Actuarial survival was lower in HD patients (P=0.04) and in patients who had previously undergone splenectomy (P=0.008). Cox regression analysis identified only prior splenectomy (P=0.02) as an independent risk factor for mortality after cardiac transplantation with an adjusted relative risk of 6.2 (1.7-21.9, 95% confidence intervals). CONCLUSIONS: Although the numbers are small, these data strongly suggest that there is an increased mortality risk for cardiac transplant recipients with prior HD who have undergone splenectomy.     

Destiny of candidates for heart transplantation in the Eurotransplant heart allocation system

OBJECTIVE: We analyzed the prognosis of candidates for heart transplantation (HTx) after being listed with 'urgent status' for donor heart allocation or after ventricular assist device (VAD) implantation without application for urgent status. METHODS: Urgent status as used in this study refers to both the high urgency (HU) status awarded by Eurotransplant until August 31, 2005 and the urgent (U) status that replaced it from then on. Patients who underwent primary VAD implantation between January 2001 and December 2006 and who were listed as transplantable (T) (group VAD-prim, n=159), and patients listed primarily in urgent status before VAD implantation and/or HTx during the same period (group U-prim, n=168) were enrolled in the study. Group U-prim consists of subgroups: group U-HTx (n=123), who underwent primarily HTx in urgent status; group U-VAD (n=25), who underwent primarily VAD implantation in urgent status; patients who died in urgent status before HTx or VAD implantation (n=6); and patients in urgent status without HTx or VAD implantation (n=14). The survival rate in each group was studied. RESULTS: Survival rates after VAD implantation in group VAD-prim were comparable to those after urgent status listing in group U-prim (67.0% vs 68.5% for 1-year survival, 56.6% vs 65.8% for 2-year survival, respectively). Actuarial survival after listing for urgent status in group U-HTx was significantly better than that in group U-VAD (73.7% vs 46.0% for 1-year survival, p<0.05, log-rank test). Actuarial survival during mechanical circulatory support after the VAD implantation (censored at HTx or weaning from the device) in group VAD-prim was significantly better than that in group U-VAD (80.7% vs 56.2% for 3-month survival, p<0.001, log-rank test). CONCLUSIONS: In order to receive urgent HTx, HTx candidates may choose urgency listing without primary VAD implantation at the risk of failed donor heart allocation in urgent status. However, the prognosis of the patients in the latter situation is poor.