Incidence and prognostic value of electrocardiographic abnormalities after heart transplantation

Background: The improvement of surgical techniques and the use of immunosuppressive drugs within the past 15 years has made heart transplantation an increasingly performed procedure and an accepted treatment for end-stage cardiac failure. Hypothesis: The aim of this study was to describe the changes of the 12-lead electrocardiogram (ECG) after heart transplantation and to determine their prognostic value on complications such as rejection or graft coronary artery disease during follow-up. Methods: The ECGs of 62 consecutive patients were analyzed for 5 years at follow-up periods of 1,2,3,6 months and yearly after transplantation. Results: The most prevalent abnormality was the presence of complete or incomplete right bundle-branch block (RBBB). New RBBB appeared in 69% (43/62) of the patients, mainly during the first month (21/43). There was no left bundle-branch block. We detected nine episodes of supraventricular arrhythmias: one atrial fibrillation, six atrial flutter, one junctional tachycardia, one orthodromic tachycardia on a Wolff-Parkinson-White syndrome; all appearing during the first 3 months. Three of the six episodes of atrial flutter occurred during an episode of acute rejection. There was no relation between RBBB and the gender and age of recipients and donors, nor with the graft ischemic time and the pre-transplantation hemodynamic values. Right bundle-branch block was not associated with acute rejection nor with graft coronary artery disease. Conclusion: The ECG abnormalities after heart transplantation have no predictive value on the long-term evolution. Right bundle-branch block is very frequent and is not associated with adverse prognosis.     

Long-term prognostic value of elevated heart rate one year after heart transplantation

Background

Elevated heart rate (HR) is associated with adverse cardiovascular outcome in the general population and in patients with cardiovascular disease. Elevated HR due to graft denervation is often found in heart transplantation (HTx) patients; the effect on graft survival and vasculopathy is unclear. Thus, the aim of this study was to evaluate the role of elevated HR at 12 months post-HTx and its power to predict HTx long-term outcome.

Methods

We evaluated retrospectively a prospective database of 312 patients undergoing HTx at two centers. HR was registered at 12 months post-HTx. The median HR was used as a cutoff point. Cox regression analysis was performed with variables known to be clinically relevant to mortality and those selected from the univariate analysis.

Results

During a mean follow-up of 5.5 ± 2.8 years there were 58 deaths (19%). Patients with a HR ≥ 90 bpm (median HR) at 12 months had an increased risk for all-cause mortality (Hazard Ratio = 2.4, 95% CI 1.2 to 4.5, p = 0.009) and mortality related to coronary allograft vasculopathy (CAV) (Hazard Ratio = 3.0, 95% CI 1.25–7.14, p = 0.01). Multivariate analysis showed that a HR ≥ 90 bpm independently predicted mortality (HR 3.2, 95% CI 1.4–7.1, p = 0.004).

Conclusions

Elevated HR measured at 12 months after HTx is an independent predictor of all-cause mortality in HTx recipients. A HR ≥ 90 bpm identifies a group of patients at high risk of death and CAV-related mortality at mid- to long-term.     

心脏移植术后急性排异反应三例报告

心脏移植是治疗终末期心脏病患者的有效手段,但排异反应仍然是移植失败最常见的原因。治疗排异反应最重要的问题之一是明确诊断。心内膜心肌活检是心脏移植术后判断急性排异反应的金标准。但其为有创性检查,且价格昂贵,诊断周期长,限制了临床应用。故临床特点的总结、无创监测项目的筛选,对及早发现急性排斥反应尤为重要。现将3例患者的诊治体会报道如下。     

Metabolic profile of patients after heart transplantation

Orthotopic heart transplantation improves life expectancy and quality of life in patients with severe heart failure. After transplantation, metabolic complications are frequent. They are caused particularly by immunosuppressive therapy. In our cohort of 315 patients, 52% of patients had diabetes mellitus together with hyperlipoproteinemia, 41% of patients had hyperlipoproteinemia without diabetes, 3% of patients had diabetes mellitus without hyperlipoproteinemia and only 4% of patients had none of these disorders. Therapeutic options with respect to interactions with immunosuppressive therapy are discussed in this article.     

不同术式心脏移植患者心电图的观察分析

目的：探讨应用不同手术方式的同种异体原位心脏移植术后患者的心电图改变特点,方法：对6例心脏移植的患术前、术后分别进行15个月-9年体表12导联心电图跟踪观察。主要观察PR间期、QT间期、Ⅰ、Ⅱ、Ⅲ、Ⅴ6导联QRS波电压总和（∑QRS）的变化。结果发现应用标准式心脏移植术后患者出现双窦性心律;应用全心脏移植术式和双腔静脉原位心脏移植术后患者则出现单一窦性心律。结论：不同的手术方式实施心脏移植对患者术后心脏功能恢复、血液动力学的改善及预防后起着关键性的作用。心电图可作为心脏移植术后疗效和急性排斥反应判定的客观指标之一。     

Malignant lymphoma in the donor heart after heart transplantation

A case of post-transplant lymphoproliferative disease (PTLD)with donor heart involvement is reported. The 49-year-old patientpresented with heart failure initially ascribed to acute graftrejection. The treatment with high doses of immunosuppressiveagents was unsuccessful and the outcome rapidly fatal. Thiscase suggests that cardiac failure occurring after high dosesof immunosuppressive therapy could be a sign of early PTLD inheart transplant recipients.     

Electrocardiographic changes after heart transplantation

Electrocardiographic (ECG) changes are described after heart transplantation in almost 75% patients. During the early postoperative period the usual finding are conduction disorders which in 3-5% call for implantation of a pacemaker. The most frequent persisting disorder is bundle branch block which is of clinical importance only when it has a progressive character. The incidence of postoperative atrial fibrillation or flutter is lower as compared with other cardiosurgical operations and their sudden development may be associated with acute rejection. Ventricular arrhythmias develop as a rule as a complication of advanced coronary disease of the graft and are frequently the cause of sudden death. Before the introduction of cyclosporin A a relatively reliable sign of acute rejection was a reduction of the QRS complex voltage. During contemporary treatment ECG changes develop only in severe forms of rejection, incipient changes can be recorded only by an intracardial electrogram.     

Reduced high-frequency QRS components in electrocardiogram leads facing an area of the heart with intraventricular conduction delay due to bundle branch block

Background

The mechanisms underlying high-frequency QRS components (HF-QRS) are incompletely understood. One theory is that HF-QRS are related to the conduction velocity of the heart. The purpose was to test this hypothesis by comparing HF-QRS in patients with left or right bundle branch block (LBBB and RBBB, respectively) to those in healthy subjects and in patients with ischemic heart disease (IHD).

Methods

Twenty-two patients with LBBB, 19 patients with RBBB, 63 normal subjects, and 64 patients with IHD were included. Twelve-lead electrocardiograms were analyzed in the frequency interval 150 to 250 Hz.

Results

The study showed reduced HF-QRS in patients with LBBB compared with healthy subjects and patients with IHD. The difference, however, was small in lead V₁ and V₂. In patients with RBBB, no differences in HF-QRS could be detected except in few leads; among those is lead V₁.

Conclusion

The results support the theory that HF-QRS are related to the conduction velocity of the heart.     

原位心脏移植的围术期处理

目的总结3例原位心脏移植成功患者的围术期处理经验。方法2001年8月至2003年12月为3例终末期心脏病患者施行原位心脏移植术,术式均采用双腔静脉吻合法,术后采用环孢素A、泼尼松及吗替麦考酚酯联合免疫抑制治疗。结果3例患者均顺利出院,心功能恢复至Ⅰ-Ⅱ级(NYHA),围术期无感染或严重排异反应发生。结论正确的围术期处理是心脏移植术后早期顺利康复的关键。     

体外膜肺氧合在心脏移植术后移植物衰竭支持治疗中的应用

目的:总结心脏移植术后早期移植物衰竭体外膜肺氧合(extracorporeal membrane oxygena-tion,ECMO)支持治疗的临床经验。方法:自2008年1月至2011年12月,阜外医院共进行心脏移植181例,其中16例患者在心脏移植术后使用ECMO进行循环支持治疗。记录ECMO运行期间相关参数、机械辅助时间、并发症等指标。观察ECMO建立时、辅助24 h和撤机时患者血浆乳酸值,ECMO辅助前和ECMO辅助24 h多巴胺及肾上腺素的用量。结果:16例心脏移植围手术期接受ECMO支持治疗的患者中脱机14例(87.5%),存活出院13例(81.3%)。其中2例因心脏功能无改善不能脱机放弃治疗,1例脱机后发生慢性排斥反应,出现多器官功能衰竭(MOF)死亡。所有患者均采用动脉—静脉(A-V)ECMO辅助方式,患者ECMO前、ECMO运行24 h和停止ECMO时血浆乳酸值分别为:(8.36±3.41)、(2.42±1.53)、(2.25±2.17)mmol/L。运行24 h及停止ECMO时,血浆乳酸值较安装前明显下降(P<0.05)。ECMO前和运行24 h多巴胺用量分别为:(7.38±3.42)和(5.29±1.93)μg.min-1.kg-1,两者之间比较,差异无统计学意义(P>0.05)。ECMO前和运行24 h肾上腺素用量分别为:(0.17±0.11)和(0.02±0.03)μg.min-1.kg-1,运行24 h较ECMO前肾上腺素用量明显减小(P<0.05)。结论:ECMO是一种有效的循环呼吸衰竭辅助支持疗法,能明显降低终末期心脏病患者心脏移植术后早期病死率。     

Relationship of echocardiographic left ventricular dyssynchrony with QRS width on surface electrocardiogram in patients with systolic heart failure: An observational study

This study aimed to evaluate left ventricular dyssynchrony with QRS width on ECG in patients with systolic heart failure. 100 study patients were classified into two groups. Narrow QRS group-N- QRS (80-119 msec) and Wide QRS group-W- QRS (120-160 msec). Out of each 50 patients in W- QRS group, 38(76%) had LV dyssynchrony and 18 (36%) in N- QRS group had ventricular dyssynchrony. Dyssynchrony in narrow QRS patients with heart failure also needs attention as a therapeutic target in future studies.     

High-dose dipyridamole echocardiography test in coronary artery disease after heart transplantation

In order to evaluate the usefulness of high-dose dipyridamoleechocardiography test (DET) for the detection of coronary arterydisease (CAD) after heart transplant and for the assessmentof prognosis, 80 heart transplant patients underwent this testwithin 48 h of tile scheduled yearly coronary angiography. Coronary angiography showed normal coronary arteries in 55 patientsand CAD in 25, eight of whom had >50% luminal narrowing.Segmental hypokinesis on baseline echocardiography was presentin 27 patients, 19 of whom had CAD (sensitivity = 76%; specificity= 85%). DET was negative in all the patients with normal coronaryarteries (specificity 100%). Out of 25 patients with CAD, eighthad a positive DET and 17 a negative DET (sensitivity 32%),but DET was positive in seven of the eight patients with coronaryartery stenosis >50% (sensitivity 87%). During follow-up(9.8±4.5 months) seven cardiac events occurred in sevenpatients, all with CAD and wall motion hypokinesis (six on baselineechocardiogram and four after dipyridamole infusion). In our experience, DET does not seem adequate for the screeningof post-transplant CAD, but useful in identifying patients withsevere lesions (>50%). Wall motion abnormalities on baselineechocardiogram or after dipyridamole infusion might identifypatients who require closer surveillance. A longer experienceis needed to confirm these results.     

Electrocardiographic patterns of left bundle-branch block caused by intraventricular conduction impairment in working myocardium: a model study

By definition, the electrocardiographic (ECG) patterns of left bundle-branch block (LBBB) represent distinctive changes in duration and shape of the QRS complex caused by intraventricular conduction delay in the left ventricle (LV) due to structural abnormalities in the His-Purkinje conduction system and/or ventricular myocardium. However, impaired conduction in the working myocardium is not taken into consideration in the practical ECG diagnosis.Because the degree of LV myocardium impairment could be of importance for clinical evaluation of patients, we studied the effects of blocked and of delayed onsets of activation in the LV to simulate complete and incomplete LBBBs and slowed conduction in the LV myocardium by applying an analytical computer model.We demonstrated that typical LBBB patterns were caused both by block or delay in the onset of the LV activation, as well as by impaired conduction in the myocardium itself while maintaining the location and onset of the LV activation. The most important difference was the absence of initial anteriorly oriented electrical forces in cases of the simulated complete LBBB and of incomplete LBBB if the onset of LV activation was delayed (≥6 milliseconds). Under the conditions defined in this model that did not consider myocardial infarction, the presence of initial anteriorly oriented electrical forces was indicative of preserved conduction in the left bundle and of impaired conduction in LV working myocardium.

Conclusion

The elucidation of the participation of working myocardium impairment in the intraventricular conduction delay in the LV could be of vital significance for the clinical management of patients with LBBB patterns, for example, indicated for resynchronization therapy.     

体外膜肺氧合支持治疗在心脏移植围术期的应用

目的 回顾性总结分析体外膜肺氧合(ECMO)支持治疗在心脏移植围术期应用的临床结果 和经验.方法 2004年6月至2008年12月共实施原位心脏移植131例,14例心脏移植围术期患者均使用Medtronic ECMO系统行静脉-动脉ECMO辅助循环支持治疗,活化凝血时间维持160～200 s,辅助期间平均流量在1.8～3.3 L/min.结果 12例患者纽约心功能Ⅰ级出院,2例因多脏器功能哀竭、严重感染及中枢神经系统并发症死亡.ECMO辅助时间29～824 h,平均149 h,12例存活患者ECMO辅助后减少了血管活性药物使用,床旁超声心动图评价心功能得到恢复,循环稳定,辅助时间约100 h可顺利撤除ECMO.5例患者出现7次出血并发症,插管远端动脉栓塞1例,所有ECMO患者均存在不同程度的低蛋白血症,高胆红素血症,血肌酐增高11例,5例患者行连续性肾替代治疗,1例患者顽固性高胆红素血症行血浆置换及人工肝治疗.切口延期愈合7例,气管切开6例.结论 ECMO可作为终未期心力衰竭的心脏移植桥梁,扩大边缘性供休的使用范围,掌握ECMO应用适应证及时机,避免重要脏器的不可逆损伤,防止并发症,降低危重症患者心脏移植围术期死亡率.     

原位心脏移植8例报告

目的探讨影响心脏移植手术效果的主要因素。方法2003年3月至2004年12月8例患者施行了原位心脏移植术,其中扩张型心肌病7例,肥厚型心肌病1例。采用标准原位心脏移植手术1例,双腔静脉吻合法原位心脏移植手术7例。4例术前存在中度肺动脉高压,NO吸入等措施降肺动脉压力。抗排异治疗采用环孢素A(CsA)+皮质激素(Pred)+骁悉(MMF)三联方案。结果手术均获成功,1例术后第9天出现急性排异反应,给予大剂量泼尼松龙冲击治疗3d缓解;1例术后第3天出现肾功能衰竭,给予血液透析治疗;1例于术后35天死于肾功能衰竭及抗排异药物神经毒性反应,其余病例心功能恢复至Ⅰ￣Ⅱ级。术后5例已恢复正常工作和生活。结论严格掌握受体适应证、供体的心脏保护、合适的手术方法及围术期患者管理,是心脏移植手术成功的关键。     

Factors associated with nutritional status in liver transplant patients who survived the first year after transplantation

Background and Aims: Most studies published focus on the evaluation of the impact of nutritional status on the morbidity and mortality during the immediate postoperative period or on the short‐term evolution of liver transplant patients. The aim of the study was to evaluate long‐term trends in nutritional status. Methods: Seventy patients consecutively submitted to liver transplantation were studied. Nutritional assessment was performed the day before transplantation and the 45, 90, 180 and 365 days after transplantation, consisting of determination of dietary intake, anthropometric and biochemical analysis. Results: Sixty‐nine percent of the patients presented with malnutrition on the day before liver transplantation, decreasing to 44% at end of the first year. The prevalence of protein–calorie malnutrition (PCM) was 63% at 90 days post‐transplant. A significant difference of PCM was observed between patients with cirrhosis and non‐cirrhotic disease (53.6% × 100%) at 90 days post‐transplant. The pre‐transplant nutritional diagnosis and 90‐day calorie intake were identified as variables independently associated with nutritional status at 90 days post‐transplant. The variables independently associated with nutritional status in the 1‐year assessment were pre‐transplant PCM and 365‐day calorie requirements. Conclusion: No influence on nutritional status was observed for peri‐ or postoperative factors after 3 or 12 months of follow up. As expected, dietary factors, especially adequate calorie intake, were always associated with nutritional status during all periods analyzed.