Heterotopic Cardiac Transplantation: Current Status

Heterotopic cardiac transplantation first introduced by Bernard in 1974 currently is rarely used as the procedure of choice when orthotopic cardiac transplantation can be considered. Specific indications for heterotopic cardiac transplantation include elevation of pulmonary vascular resistance and availability of a small or poorly functioning donor organ for a mortally ill recipient. Most cardiac transplant centers have abandoned its routine use because the recipient's diseased and poorly functioning heart remains as a potential source for embolism, infection, and continued angina, because the operative procedure is more complicated. Pulmonary complications are common due to compressive atelectasis of the right lung. Experience indicates that the heterotopic procedure is useful for those selected individuals in whom the orthotopic procedure is not appropriate and that rates of survival are nearly equal.     

Validation of impedance cardiography measurements of cardiac output during limited exercise in heart transplant recipients

Twenty-one patients were studied at rest and during exercise after heart transplantation to compare cardiac output measured by thermodilution and impedance cardiography. Exercise was performed on a bicycle ergometer over a limited range of work load (25 and 50 watt) whilst metabolic gas exchange was recorded. One patient was studied at rest whilst his circulation was maintained by a Jarvik-7 artificial heart. The values of cardiac output measured by impedance cardiography corresponded closely with the flow rate from the artificial heart. There was also close agreement between the impedance and thermodilution measurements of cardiac output at rest and during exercise. Both measurements followed the changes in heart rate and oxygen consumption. Both thermodilution and impedance cardiography methods elicited good reproducibility of cardiac output measurements at rest and during exercise. These observations suggest that the noninvasive and continuous record of cardiac output obtained by impedance cardiography can be used for the postoperative monitoring of heart transplant recipients.     

The Professor Merry Lecture: Endings and beginnings

Organ transplantation has become an established and worthwhile treatment for many otherwise intractable conditions in many countries around the world. For example, over 4000 patients have benefited from heart or lung transplants (or both) since the first heart transplant in Australia or New Zealand was carried out in 1984. However, there is thought to be a worldwide shortage of donors relative to the number of organs needed. Many people, notably many of those involved with situations in which organ donation might be possible, value the opportunity to contribute organs. This has led to interest in expanding the criteria for donation. Standard criteria donation (SCD) involves the formal diagnosis of brain death, and conservative criteria for donor eligibility. Extended criteria donation allows slightly more liberal eligibility criteria, thought acceptable in light of improved results in SCD. In donation after cardiac death (DCD), an alternative approach to increasing the pool of available donors, a formal diagnosis of brain death is not required. The formal diagnosis of brain death is very reliable, but prognosis in less definitive manifestations of severe brain damage is less so, as illustrated by numerous anecdotal reports. There is a tension between providing enough time between withdrawal of treatment and declaration of death for reasonable confidence to be maintained in the process of DCD and the desirability of keeping warm ischemic time to a minimum in the interest of organ survival. In Australia and New Zealand, DCD is undertaken only in the context of planned withdrawal of support in intensive care units (Maastricht category 3). There has been a considered and carefully implemented approach to DCD, and the educational initiatives associated with its introduction may have had incidental benefit to the SCD program as well. It is, nevertheless, important that all involved are cognizant of the practical and ethical issues at stake.     

Validation of impedance cardiography measurements of cardiac output during limited exercise in heart transplant recipients

Abstract. Twenty-one patients were studied at rest and during exercise after heart transplantation to compare cardiac output measured by thermodilution and impedance cardiography. Exercise was performed on a bicycle ergometer over a limited range of work load (25 and 50 watt) whilst metabolic gas exchange was recorded. One patient was studied at rest whilst his circulation was maintained by a Jarvik-7 artificial heart. The values of cardiac output measured by impedance cardiography corresponded closely with the flow rate from the artificial heart. There was also close agreement between the impedance and thermodilution measurements of cardiac output at rest and during exercise. Both measurements followed the changes in heart rate and oxygen consumption. Both thermodilution and impedance cardiography methods elicited good reproducibility of cardiac output measurements at rest and during exercise. These observations suggest that the noninvasive and continuous record of cardiac output obtained by impedance cardiography can be used for the postoperative monitoring of heart transplant recipients.     

二例原位心脏移植成功的围术期处理

目的总结２例原位心脏移植成功的围术期处理经验，探讨供心保护、免疫抑制剂应用、早期诊治急性排斥反应、预防右心功能不全、抗感染和营养支持等问题。方法１９９５年８月和１９９７年４月先后为２例终末期扩张型心肌病患者施行了原位心脏移植术。术后免疫抑制剂应用环孢素Ａ（ＣｙｃｌｏｓｐｏｒｉｎＡ）、硫唑嘌呤（Ａｚａｔｈｉｏｐｒｉｎｅ）、强的松（Ｐｒｅｄｎｉｓｏｎｅ）三联疗法。结果２例患者目前已分别存活３年和１年半，心功能正常、生活质量良好。结论围术期的处理是否得当是术后早期顺利康复的关键，亦直接影响着手术患者的存活率     

Thymoglobulin induction and steroid avoidance in cardiac transplantation: results of a prospective, randomized, controlled study

Abstract: Background: Chronic use of corticosteroids (CS) following transplantation is associated with significant long-term morbidities. Minimizing exposure to CS to improve long-term outcomes, without compromising allograft function, remains an important goal in transplantation. Objectives: This single-center, prospective, randomized, open-label study was designed to evaluate the efficacy of Thymoglobulin^® as part of a CS-sparing regimen in cardiac transplantation. Methods: Thirty-two low-risk cardiac transplant patients were randomized in a 1:1 ratio to receive either a Thymoglobulin-based CS-avoidance regimen (CS-avoidance group; n = 16) or a long-term CS-based regimen with no antibody induction (control group; n = 16). Pulse CS therapy was used for the treatment of acute cellular rejection in both groups. Results: Baseline characteristics were similar between groups. At one yr, there was no significant difference in the mean incidence of acute cellular rejection (≥3A) episodes between the CS-avoidance and control groups, 0.81 ± 1.05 and 1.07 ± 1.03, respectively. Importantly, the CS-avoidance patients had significant improvement in muscle strength and less bone loss compared with the control patients during the first six months post-transplant. Conclusions: CS-avoidance regimen with Thymoglobulin induction appeared to be safe and effective in cardiac transplantation. Further studies are required to demonstrate the long-term safety and benefits of such a regimen.     

Diagnosis of cardiac allograft rejection by the detection of circulating plasma cardiac myosin light chains

Twenty adult male Japanese monkeys of the species Macaca fuscata were randomly paired and subjected to heterotopic cardiac transplantation performed by the Ono-Lyndsey method. Without immunosuppression, graft survival ranged between 8 and 27 days, with a mean survival of 14 days. Plasma cardiac myosin light chains were measured by radio-immunoassay, which showed transient increases in myosin levels just following transplantation. Three hearts showed high values at this period and stopped beating when the myosin levels decreased (type 1). The other 7 hearts showed low myosin values after transient increases and 5 of them were rejected with a preceding reincrease in the myosin levels (type 2). Pathological study revealed myocardial necrosis, perivascular cuffing of mononuclear cells and/or neutrophils and/or plasma cells in the type 1 hearts. Measurement of the plasma myosin light chain level was therefore revealed to be of great value in the monitoring of cardiac allograft rejection.     

Acute rhabdomyolysis after cardiac transplantation: a diagnostic conundrum

A 13-year-old girl presented with right ventricular failure secondary to Ebstein's malformation (downward displacement of the tricuspid valve leaflets with adherence to the right ventricular muscle and redundancy or dysplasia of the tricuspid valve leaflets). She subsequently required a heart transplant but developed rhabdomyolysis early in the postoperative period and required ventilatory support for more than 3 weeks. A variety of causes were considered, but her condition improved only when cyclosporin was eliminated from the immunosuppression regimen. We believe it is likely that the rhabdomyolysis has been caused by cyclosporin. If so, this has occurred both earlier in the clinical course and at lower serum concentrations than previously described.     

10例心脏死亡器官捐献移植总结

目的通过分析我院实施的心脏死亡器官捐献(DCD)移植病例,探讨国内DCD器官和移植方面的问题。方法对我院2010～2011年期间参与实施的DCD器官移植的临床资料进行回顾性总结。结果本组有4例DCD者共实施了7例肾移植和3例肝移植。捐献者1属于中国DCD器官分类标准(中国标准)二类(MaastrichtⅣ类),热缺血时间40 min,经快速病理检查后放弃了肝脏和左侧肾脏,右侧肾脏进行了移植后患者出现移植肾功能延迟恢复,最终移植肾因破裂出血而被切除。捐献者2～4属于中国标准三类(MaastrichtⅢ类),热缺血时间分别为15、15、10 min,其中捐献者4在器官捐献前已经出现血压下降,需要大剂量多巴胺维持血压,供肝进行了快速病理检查,确认可以使用;捐献者2和3由于是在手术室进行可控性心跳及呼吸终止,热缺血时间均为15 min,未进行病理学检查;共实施了3例肝移植和6例肾移植,手术顺利,移植物功能恢复良好,无并发症发生,无移植患者死亡。结论通过选择符合中国标准三类的捐献者,实施可控的DCD程序,DCD器官移植可以获得满意的效果。供体器官的快速病理检查有利于器官质量的判断,减少移植手术后并发症的发生。     

原位心脏移植一例围手术期处理

１９９４年７月我们成功地完成了１例同种原位心脏移植，术后病人存活至今，并恢复了正常生活，现将围手术期的监测、治疗等处理作一简介，并回顾体会该病人围手术期处理与术后较顺利的可能关系，为进一步把好心脏移植病人围手术期这第一关总结经验。     

Evidence of allograft related transplantation antigen binding cells for detection of cardiac allograft rejection—Preliminary report

Zusammenfassung In 8 heart transplant recipients in follow-up checks we have evaluated the binding of transplantation antigen loaded methacrylate-carrier to peripheral mononuclear cells (rosette technique). All patients were treated with a triple-drug regimen for immunosuppression, consisting of steroids, azathioprine and cyclosporine A. The increase of the number of these antigen binding cells over a limit value of 30 RFC/10³ MNC is a reliable sign of a beginning immune reaction against the graft. The evidence is given by comparing the results with these of situation in endomyocardial biopsies (EMB). The test is predictive 3 to 6 days before infiltrating cells are visible in biopsies and donor independent (use of antigen mixture from cadaver spleens). Zusammenfassung In Verlaufsuntersuchungen an 8 herztransplantierten Patienten wurde die Bindung mononukle?rer Zellen an transplantationsantigenbeladene Methakrylattr?ger (Rosettentechnik) untersucht. Alle Patienten erhielten eine standardisierte Basisimmunsuppression (Triple-Drug), bestehend aus Steroiden, Azathioprin und Cyclosporin A. Ein Anstieg antigenbindender Zellen über einen Grenzwert von 30 RFC/10³ MNC signalisiert eine beginnende Anti-Transplantatimmunreaktion. Der klinische Nachweis erfolgte stets mittels Endokardbiopsie. Der Test ist pr?diktiv (3 bis 6 Tage vor einer positiven Biopsie) und spenderunabh?ngig (Benutzung eines Antigengemisches aus humanen Milzen).

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Anaesthesia for combined heart and lung transplantation

In December 1983, Harefield Hospital started a programme for combined heart and lung transplantation. Fifty-two transplants have been successfully performed, with 36 survivors (April 1986). Patient selection and anaesthetic management of both donor and recipient are discussed. Two case histories are presented which illustrate the principles of anaesthetic management and postoperative care.     

Heart-lung transplantation —Harefield experience

One hundred and fifty-nine combined heart and lung transplantations were performed on 152 patients at Harefield Hospital from 1980 to February 1988. The age of the recipients ranged from 10 weeks to 52 years. The transplantation was indicated for pulmonary vascular disease on 106 patients (69.7 per cent), and for parenchymal lung disease on 46 patients (30.3 per cent). Eisenmenger syndrome was the commonest disease that required the heart-lung transplantation. A combination of cyclosporin A and azathioprine was administered for immunosuppression therapy postoperatively, and oral steroids were not routinely used. The hospital mortality rate was 32.2 per cent, and 103 patients were discharged from the hospital. The first-year actuarial survival rate was 64 per cent, and the second-year was 61 per cent. Although pulmonary deterioration due to obliterative bronchiolitis was a serious late complication, most of the recipients enjoyed a good quality of life after transplantation. Heart and lung transplantation offers the patient a chance of marked improvement both in survival and in quality of life. This report is the gist of a paper read by M.H.Y. at the 88th Annual Meeting of the Japan Surgical Society, Niigata, Japan, 1988     

Impact of high-dose inotropic donor support on early myocardial necrosis and outcomes in cardiac transplantation

Nixon JL, Kfoury AG, Brunisholz K, Horne BD, Myrick C, Miller DV, Budge D, Bader F, Everitt M, Saidi A, Stehlik J, Schmidt TC, Alharethi R. Impact of high‐dose inotropic donor support on early myocardial necrosis and outcomes in cardiac transplantation.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01504.x.
© 2011 John Wiley & Sons A/S. Abstract: Background: Cardiac donors routinely require vasoactive agents for circulatory stability after brain death. Nevertheless, inotropes have been associated with direct cardiac toxicity. Our study evaluated whether the use of high‐dose inotropic support in potential donors was associated with increased early myocardial necrosis (MN) and worse clinical outcomes after cardiac transplantation. Methods: The UTAH Cardiac Transplant Program (UCTP) and Intermountain Donor Services databases were queried for records between 1996 and 2009. The high‐dose donor inotropic support (HDIS) group was defined as patients on dopamine >10 μg/kg/min. The incidence of early MN, intensive care unit (ICU) length of stay, length of ventilator support, and mortality was evaluated. Results: Two hundred and forty‐four recipients undergoing transplant met study criteria. The average donor age was 27 yr. The incidence of MN in the HDIS (n = 29) and non‐HDIS (n = 204) groups was 14.8% and 6.7%, respectively, OR 2.67. Total ischemic time, ventilator support time, ICU stay, and actuarial survival were similar between both groups. Conclusion: The use of high‐dose inotropic support to maintain donor stability appears to have a higher trend for early post‐transplant MN without an impact on clinical outcomes. With the current growing shortage of organ donors, it appears reasonable to use donors on high‐dose inotropic support.     

Modification of bicaval anastomosis: an alternative technique for orthotopic cardiac transplantation

We describe an alternative technique for orthotopic cardiac transplantation (OCT), which we use to combine the advantages of the conventional technique (Lower and Shumway) and the bicaval anastomosis. The modified technique was utilized in 31 consecutive patients undergoing heart transplantation by one surgeon in our hospital since 1998.     

脉搏指示连续心排血量技术在肝移植围术期的应用

目的 评价脉搏指示连续心排血量(PiCCO)技术在肝移植术中的应用价值.方法 25例行原位肝移植术的终末期肝病患者,ASA Ⅲ或Ⅳ级.记录术中PiCCO监测数据,并与Swan-Ganz漂浮导管血流动力学监测结果比较.结果 与切皮前比较,无肝前期各项监测指标无显著变化,无肝期全心舒张末期容积指数(GEDI)、胸腔内血容积指数(ITBI)、每搏输出量指数(SVI)和心脏指数(CI)均显著降低(P<0.01),每搏输出量变异(SVV)和脉压变异(PPV)较大(P<0.01),新肝期CI显著增加(P<0.01),肺血管通透性指数(PVPI)增加(P<0.05).通过温度稀释法共测得数据200组.其中,PiCCO所测得的CI(PCI)与导管法显示的CI相关良好(r=0.84,P<0.01).结论 PiCCO技术能较准确的反映心脏前负荷以及肺血管通透性的变化.