Extracoporeal Membrane Oxygenation to Rescue Cardiopulmonary Failure After Heart Transplantation: A Single-Center Experience

Extracorporeal membrane oxygenation (ECMO) can provide excellent mechanical circulatory support (MCS). Some case reports use ECMO to rescue heart transplantation (HTx) recipients with posttransplant cardiopulmonary failure. Herein reported a series of use of ECMO to rescue HTx recipients with refractory cardiopulmonary failure have during the posttransplant period. The causes of cardiopulmonary failure were right ventricular failure, primary graft failure, acute rejection, or sepsis. A retrospective review of 366 consecutive HTx recipients revealed 40 cases of cardiopulmonary failure requiring ECMO rescue in the posttransplant period. There were 14 patients diagnosed as right ventricular cardiopulmonary failure; 7 primary graft failure with a stunned donors myocardium, 8 as acute cellular or humoral rejection, and 11 as sepsis with positive blood cultures. ECMO-related variables were evaluated for association with mortality. The HTx recipients included 35 males and 5 females with overall median age of 42.3 years (range, 0.48-65.22). The weaning rate was 72.5% (29/40) and survival, 52.5% (21/40). ECMO provided temporary MCS rescuing some HTx recipients with posttransplant cardiopulmonary failure. None of the patients receiving ECMO support for >4 days survived.     

FTY720, an immunosuppressant that alters lymphocyte trafficking,abrogates chronic rejection in combination with cyclosporine A

BACKGROUND: Chronic rejection remains the leading cause of failure after transplantation (Tx). FTY720, a new immunosuppressant altering lymphocyte trafficking, is effective against acute rejection, but its activity against chronic rejection is not known. METHODS: A valid model of chronic rejection was produced. Heart transplantation (HTx) was performed using fully mismatched RA (RT1p) and PVG (RT1c) rats. Administration of donor-specific blood transfusion 12 days before HTx prolongs graft survival, but features of chronic rejection including intimal hyperplasia and vascular obliteration (VO) develop with time only in allogeneic Tx. This is therefore a valid model of chronic rejection. VO was assessed on post-Tx day 90 in six groups differing according to the maintenance immunosuppressive regimen administered. group 1, donor-specific blood transfusion only and no other treatment; group 2, FTY720 (0.3 mg/kg/day orally) for 90 days; group 3, cyclosporine A (CsA) (1 mg/kg/day orally) for 90 days; group 4, combined administration of FTY720 and CsA for 90 days; group 5, transient administration of combined FTY720 and CsA for 7 days; and group 6, syngeneic HTx (RA to RA). Graft infiltrate, endothelial immunoglobulin (Ig) G deposition, and complement binding were also examined on post-Tx day 90. RESULTS: In control group 1, severe VO was observed, compared with syngeneic HTx (group 6). Monotherapy with FTY720 (group 2) or with CsA (group 3) significantly but partially reduced VO. On the contrary, combined administration of FTY720 and CsA (group 4) abrogated VO. A 1-week treatment with combined FTY720 and CsA (group 5) reduced VO but only partially. In group 1, arteriosclerosis was accompanied by graft infiltrate, endothelial IgG deposition, and complement binding. In groups 2, 3, and 5, graft infiltrating scores were partially decreased compared with group 1 but remained higher than in syngeneic controls; endothelial IgG deposition and complement binding were still present. In group 4, continuous administration of combined FTY720 and CsA reduced graft infiltrate to the level of syngeneic control and abrogated both endothelial IgG deposition and complement binding. CONCLUSIONS: Maintenance treatment with either FTY720 or CsA monotherapy partially prevents chronic rejection; short-term treatment with combined FTY720 and CsA reduces chronic rejection only partially; and continuous treatment with combined FTY720 and CsA abrogates chronic rejection, and this is accompanied by dramatic reduction of graft infiltrating cells, endothelial IgG deposition, and complement binding. Prevention of chronic rejection by maintenance treatment with FTY720 and CsA represents indirect evidence that normal lymphocyte trafficking and function are mandatory for development of chronic rejection.     

Single-center experience of pediatric heart transplantation in taiwan

Heart transplantation (HTx) is a treatment for end-stage heart failure or a complex or inoperable congenital defect. The long-term survival and the adequate donor to recipient body weight (D/R BW) ratio remain to be determined. From March 1995 to May 2004, 14 children (6 months-16 years of age) underwent HTx due to underlying diseases of idiopathic dilated cardiomyopathy (n = 10; 71.4%), congenital heart disease (n = 3; 21.4%), and Kawasaki disease (n = 1; 7.1%). Donor-recipient body weight ratio ranged from 0.89 to 3.9. Big heart syndrome was present in one patient when D/R BW ratio was more than 3. Actuarial survival was 92.9% at 5 years after transplantation. Only the one patient who had Kawasaki disease died due to early primary graft failure. HTx is a feasible method with good long-term survival rates for end-stage heart failure or for complex or inoperable congenital defects. After careful pretransplant evaluation, a high D/R BW ratio (more than 3) is acceptable.     

Calcineurin inhibitor withdrawal and conversion to mycophenolate mofetil and steroids in cardiac transplant recipients with chronic renal failure: a word of caution

Abstract: Background: Chronic renal failure (CRF) is a common complication of calcineurin inhibitor (CNI)‐based immunosuppression following cardiac transplantation (HTx). The aim of this prospective study was to evaluate the impact of an immunosuppressive conversion from CNIs to mycophenolate mofetil (MMF) and steroids in cardiac transplant recipients with CRF on renal and cardiac graft function. Methods: Since 1999, 12 HTx recipients (10 men; 58 ± 3.6 yr of age; 8.7 ± 4.2 yr after HTx) with CNI‐based immunosuppression and a calculated creatinine clearance (CreaCl) <50 mL/min were included. Most patients (10/12) were on cyclosporine and two patients were on tacrolimus prior inclusion. MMF was started with 0.5 g/d and adjusted according to the target trough levels (2–4 ng/mL). Prednisone dosage was 0.4 mg/kg. Subsequently, CNIs were completely withdrawn. Acute rejection episodes were excluded one and three months after conversion by endomyocardial biopsy and by echocardiography every three months thereafter. Results: After a mean follow‐up of 20 ± 16 months, CreaCl improved significantly: pre‐conversion vs. post‐conversion: 32.8 ± 12.2 mg/dL vs. 42.8 ± 21.14 mg/dL, p = 0.03. However, four acute rejection episodes occurred and patients were reconverted to CNIs. Additionally, six patients had a new onset of graft vessel disease (GVD) one yr after conversion. As a result of these adverse events, the study was stopped after inclusion of only 12 of the scheduled 30 patients. Conclusions: Conversion to MMF and steroids after HTx improves renal function, but increases the risk for recurrent rejection and GVD. Therefore, MMF and steroids should only be considered in patients with a markedly low risk for rejection.     

Use of Anti-Thymocyte Globulin for Induction Therapy in Cardiac Transplantation: A Review

The most common causes of death after heart transplantation (HTx) include acute rejection and multi-organ failure in the early period and malignancy and cardiac allograft vasculopathy (CAV) in the late period. Polyclonal antibody preparations such as rabbit anti-thymocyte globulin (ATG) may reduce early acute rejection and the later occurrence of CAV after HTx. ATG therapy depletes T cells, modulates adhesion and cell-signaling molecules, interferes with dendritic cell function, and induces B-cell apoptosis and regulatory and natural killer T-cell expansion. Evidence from animal studies and from retrospective clinical studies in humans indicates that ATG can be used to delay calcineurin inhibitor (CNI) exposure after HTx, thus benefiting renal function, and to reduce the incidence of CAV and ischemia-reperfusion injury in the transplanted heart. ATG may reduce de novo antibody production after HTx. ATG does not appear to increase cytomegalovirus infection rates with longer prophylaxis (6–12 months). In addition, ATG may reduce the risk of lymphoproliferative disease and does not appear to confer an additive effect on acquiring lymphoma after HTx. Randomized, controlled trials may provide stronger evidence of ATG association with patient survival, graft rejection, renal protection through delayed CNI initiation, as well as other benefits. It can also help establish optimal dosing and patient criteria to maximize treatment benefits.     

Outcome after pediatric heart transplantation: two decades of a single center experience.

BACKGROUND: Twenty years after the first successful pediatric heart transplantation (HTx), the long-term outcome of this population is still unknown. Current study analyzes our results in pediatric HTx population. METHODS AND RESULTS: Between 1985 and 2005, we performed 604 HTx. Forty-three patients (7%) were less than 18-years old and six patients were less than 1-year old. Mean age at HTx was 9.7+/-6.3 years (38 days-18 years). Indications were: cardiomyopathy in 33 patients (76%), congenital in 9 (21%), tumor in 1 (3%). Chronic immunosuppression was Cyclosporine A and Azathioprine-based. Overall survival at Kaplan-Meier analysis (CI 95%) was 82.5% at 1-year post-HTx, 73.5% at 5 years, 72.2% at 10 years, 62.1% at 15 years, and 49.3% at 20 years, respectively. We had 14 deaths (32%): 7 within the first year after HTx (early mortality, EM), 7 occurred later (late mortality, LM). Causes of EM were: graft failure (43%), acute rejection (43%) and post transplant lymphoproliferative disease (14%). Causes of LM were: neoplasms (57%), infection (28%), graft vasculopathy (15%). At late follow-up, cardiac function, somatic and psycoaffective development were normal. Fifteen patients (34%) developed neoplasms, nine patients (21%) hypertension, and three patients (8%) developed kidney dysfunction. Neoplasms were found to be an independent predictor of outcome (p=0.039) (OR=7). CONCLUSIONS: Overall survival in the pediatric population is better than adults' population (62.1 vs 48% at 15 years after HTx). Neoplasms were the main comorbidities and causes of LM: at multivariate analysis, their incidence was related with hematic Cyclosporine A levels after 10 years from HTx (p=0.01).     

Factors predicting 10-year survival after heart transplantation.

BACKGROUND: We sought to identify factors predictive of long-term (>10-year) survival in heart transplant (HTx) recipients. METHODS: Four hundred fifteen adult patients underwent HTx at our institution between August 1982 and May 1997. The 158 patients who survived >10 years (Group A) and the 116 patients who died between 2 and 6 years (Group B) of HTx were compared in terms of gender, gender mismatch, ethnicity, age, height, weight, United Network for Organ Sharing status, type of induction therapy (OKT3 or anti-thymocyte globulin), infections (bacterial, viral, fungal and protozoal), cytomegalovirus (CMV) status, CMV mismatch, diabetes mellitus, hypertension and incidence of rejection episodes and transplant coronary artery disease within 2 years of HTx. RESULTS: Group A (135 men, 23 women; mean age 48 +/- 11 years) had significantly fewer post-HTx rejection episodes and viral, bacterial, fungal and total infections than did Group B (95 men, 21 women; mean age 49 +/- 12 years). Group A also had a significantly lower mean donor age, a lower incidence of pre-HTx diabetes, and a lower mean cholesterol level 1 year after HTx. In a multivariate analysis, fewer bacterial infections and rejection episodes after HTx, the absence of pre-HTx diabetes, and lower donor age were associated with longer survival. CONCLUSIONS: Pre-HTx diabetes, donor age and incidences of infection and rejection within 2 years of HTx predict long-term (>10-year) survival. Better control of infection and rejection during the first 2 years after HTx may improve survival.     

Early acute rejection does not affect chronic allograft nephropathy and death censored graft failure

BACKGROUND: Even with the development of modern immunosuppression, an acute rejection episode is a major complication after renal transplantation. Acute rejection episodes have been used as clinical indicators for chronic allograft nephropathy and graft loss. We investigated the timing and frequency of acute rejection episodes in relation to long-term graft survival and chronic allograft nephropathy. METHODS: The Long Term Efficacy and Safety Surveillance study of transplant patients receiving cyclosporin (Neoral) included 1706 adult renal transplants (1995 to 2003) with a functioning graft for at least 1 year. The impact on death-censored long-term graft survival was evaluated for acute rejection episodes (single or multiple) within 3 months, at 3 to 6 months, at 6 to 12 months, or at over 1 year posttransplant. A stepwise binary logistic regression was employed to identify independent risk factors for the time to occurrence of an acute rejection episode. RESULTS: An acute rejection episode occurring within 3 months posttransplantation had no effect on either death-censored long-term graft failure (P=.2157) or chronic allograft nephropathy (P=.9331). However, an acute rejection episode occurring at 1 year or later posttransplantation was significantly associated with death censored long-term graft failure (P <.0001) and chronic allograft nephropathy (P <.0001). The numbers of HLA-DR mismatches and younger recipient ages were independent risk factors for early acute rejection. CONCLUSION: Among patients whose graft survives at least 12 months, an early acute rejection episode within 3 months posttransplant was not associated with either death-censored long-term graft survival or chronic allograft nephropathy among adults treated with cyclosporin. However, an acute rejection episode occurring at 1 year or later posttransplantation showed a positive association with death-censored long-term graft survival or chronic allograft nephropathy. Lower numbers of HLA-DR mismatches sum to reduce the occurrence of acute rejection and the hospitalization time.     

Heart transplant coronary artery disease in Chinese recipients

BACKGROUND: Transplant coronary artery disease is the principle limiting factor for long-term survival of heart transplantation (HTx) recipients. We reviewed our data to assess the incidence of this disorder among Chinese HTx recipients and to compare it with the results of Western studies. MATERIAL AND METHODS: From July 1988 to May 2002, 182 patients received 184 orthotopic HTx. One hundred sixty-three recipients survived for at least 1 year with available SPECT scans or coronary angiogram studies. The data set included donor characteristics, recipient characteristics, active cytomegalovirus (CMV) infection rate, rejection episodes, immunosuppressants, and human leukocyte antigen (HLA) mismatches. RESULTS: Surgical mortality in our program was 4.3% and the actuarial freedom from coronary artery disease at 1, 3, and 5 years was 99%, 95%, and 92%, respectively. Angiogram results were stratified into coronary artery disease (n = 15) or absence of the disorder (n = 148) groups. Only older donor age showed statistical significance between the groups. Compared with the Western series, the present data show higher actuarial survival rates and freedom from coronary artery disease. There were statistically significant differences in regard to graft ischemia time, proportion of male recipients, ischemic heart disease, rejection episodes during the first year, and incidence of CMV infection. CONCLUSIONS: SPECT scan can detect coronary artery disease before there is significant stenosis of the coronary artery with acceptable survival rates. Chinese HTx recipients show a lower incidence of the disorder, lower rates of ischemia heart disease, lower proportion of male gender, lower incidence of CMV infection, fewer rejection episodes during the first year, and less ischemic time than Western recipients, which maybe the contributing factors to their better survival.     

Utility of the Biomarker CA125 in the Diagnosis of Cellular Rejection in Allogeneic Heart Transplantation

BackgroundTo analyze the relationship of the antigen carbohydrate 125 (CA125) biomarker with the cellular rejection of the heart graft during the first year after transplantation.MethodsRetrospective study of consecutive heart transplant (HTx) patients for 1.5 years. The total number of patients included in the study was 23 with a total of 103 follow-ups. In all patients, CA125 was determined before HTx and determined post-HTx in every follow-up. These were performed during months 1, 2, 4, 6, 9, and 12. Endomyocardial biopsy was performed in all revisions to assess the degree of graft rejection in the pathologic study. The biopsy results were grouped into 1. absence of rejection and 2. presence of some degree of rejection.ResultsThe mean pretransplant CA125 value presented a median of 120 U/mL with an interquartile range of 28.8 U/mL. One month after transplantation, the value was reduced by 20% and at 2 months by 81%. In subsequent reviews, plasma values were always between 10 and 20 U/mL. When comparing the values by periods and according to the presence or absence of rejection, no significant differences were found other than a slight elevation at the 6-month checkup (P = .03) but without clinical relevance, because the CA125 value was slightly higher in biopsy results without rejection.ConclusionThe rapid reduction of CA125 corroborates its usefulness as a marker of congestion in heart failure. This biomarker is not useful for predicting rejection. However, in cases of very severe rejections that occurred with systemic congestion, it could be raised. It would be necessary to corroborate this hypothesis in a larger study with a higher number of severe rejections.     

Differential characteristics of heart transplantation in patients older than 60 years

BACKGROUND: The effect of advanced age on the results of heart transplantation (HTx) is still controversial. The few articles addressing this issue have not been conclusive, due to either short follow-up periods or small numbers of patients. METHODS: We present a retrospective study of 560 HTx which were divided into group A, including patients of 60 or less years at HTx (n=465, 83%), and group B, of 95 recipients older than 60 years. A subgroup of the latter, named B1, includes 24 patients older than 65. More than 100 recipient, donor and surgical procedure variables were analyzed for their impact on actuarial survival and incidence of common causes of posttransplant morbidity and mortality during a follow-up period longer than 10 years. RESULTS: Group B showed a lower number of acute rejection episodes than group A, (1.53+/-1.87 versus 1.96+/-1.81, P<.04). Both groups showed a similar incidence of infection episodes, malignancies or graft vasculopathy, but older patients experienced fewer viral infections than younger ones (9% in group A versus 18% in group B, P<.05). Log-rank test showed a trend to shorter survival in group B (P=.08), a disadvantage that reached significance (P=.01) among patients older than 65 years. CONCLUSIONS: Patients who were older than 60 at HTx displayed a lower incidence of acute rejection episodes and viral infections, but a trend toward shorter long-term survival. This disadvantage in prognosis was statistically significant among recipients older than 65 years.     

Updates in heart transplantation

Heart transplantation (HTx) has been a successful therapy for patients with end-stage heart failure. Since 1987, we have performed 288 HTx. Thirty-six subjects needed mechanical support prior to HTx. We use anti-thymocyte globulin (ATG) as induction therapy and low-dose immunosuppressive agents for maintenance treatment. In June 1996, we performed combined heart and kidney transplantation after bridging for 14 days with an indigenous total artificial heart (TAH). The patient is still well. Our actuarial survival rates at 1, 5, and 10 years are 86%, 76%, and 61%, respectively. One recipient who voluntarily discontinued all treatment at 4 years after HTx is still alive and free of rejection in his ninth posttransplantation year. The longest surviving recipient is in her 18^th posttransplantation year. We also have used many suboptimal donor hearts, most with satisfactory outcomes. A 14-year-old boy had full recovery of heart function after receiving a donor heart after 13 hours of ischemia in 2003. Standard biatrial anastomotic technique is still our first choice. The incidence of tricuspid regurgitation (TR) and conduction disturbances is not higher than the bicaval technique reported by others. With low-dose therapy, our short-term and long-term results of HTx are satisfactory. The use of suboptimal donor hearts may expand the donor pool and save more patients' lives. A biatrial anastomosis remains our surgical technique.     

Extracorporeal photopheresis in the treatment of cardiac allograft rejection: A single-centre experience

Despite novel immunosuppressive (IS) protocols, adverse effects of IS drugs continue to have notable negative impact on patient and cardiac allograft survival after heart transplantation (HTx). Therefore, IS regimens with less toxic side effects are sorely needed. We aimed to evaluate the efficacy of extracorporeal photopheresis (ECP) in combination with tacrolimus-based maintenance IS therapy in the treatment of allograft rejection in adult HTx recipients. Indications for ECP included acute moderate-to-severe or persistent mild cellular rejection, or mixed rejection. Twenty-two patients underwent a median of 22(2–44) ECP treatments after HTx. Median duration of ECP course was 173.5(2–466) days. No relevant adverse effects of ECP were noted. Reduction of methylprednisolone doses was safe throughout the ECP course. ECP, used in conjunction with pharmacological anti-rejection therapy, had a successful reversal of cardiac allograft rejection, decreased the rates of subsequential rejection episodes and normalized the allograft function in patients completing the ECP course. Short- and long-term survivals were excellent (91% at 1 and 5 years post-ECP) and comparable to International Society for Heart and Lung Transplantation registry data on HTx recipient overall survival. In conclusion, ECP can be safely used for the treatment and prevention of cardiac allograft rejection in conjunction with traditional IS regimen.     

Impact of Acute Rejection Episodes on Long-Term Graft Survival Following Simultaneous Kidney-Pancreas Transplantation

Although it is well established that acute rejection is one of the major risk factors for chronic graft loss following kidney transplantation, its effect on long-term graft survival following simultaneous kidney-pancreas transplants (SKPTs) is less well known. We analyzed a large cohort of SKPTs and cadaver kidney transplants reported to the United Network for Organ Sharing database during 1988-97, to determine the impact of acute rejection episodes on long-term kidney and pancreas graft survival. Only patients whose kidney and pancreas grafts had survived for at least 1 year were included. Other potential risk factors influencing long-term graft survival were included in the analysis. Of the 4251 SKPTs, 45% had no acute rejection, 36% had kidney only rejection, 3% had pancreas only rejection, and 16% had both kidney and pancreas rejection within the 1st year post transplant. The 5-year kidney and pancreas graft survival rates adjusted for other risk factors were 91% and 85%, respectively; for those with no acute rejection episodes, 88% and 84%, respectively; for those with kidney only rejection, 94% and 83%, respectively; for those with pancreas only rejection; and 86% and 78%, respectively, for those with both kidney and pancreas rejection. The relative risk (RR) of kidney graft failure was 1.32 when acute rejection involved the kidney graft only, while the RR was 1.53 when the rejection involved both organs. We conclude that acute rejection episodes have a negative impact on the long-term kidney graft survival in the SKPT population similar to that in the cadaver kidney transplant population. Patients who had acute rejection episodes of both kidney and pancreas have the worst long-term graft survival.     

“Snowmelt Sign” and “Corkscrew Microvessels” Predicting Epithelium Regeneration After Acute Rejection of Small-Bowel Transplantation: A Case Report

Intestinal failure characterized by inadequate maintenance of nutrition via normal intestinal function comprises a group of disorders with many different causes. If parenteral nutrition dependency develops, which is associated with higher mortality and complications, it is considered for intestine transplantation. However, the graft failure rate is not low, and acute cellular rejection is one of the most important reasons for graft failure. As a result, early identification of rejection and timely modification of anti-rejection medications have been considered to be associated with better graft and patient survival rates. The diagnostic gold standard for rejection is mainly based on histology, but hours of delay by pathology may occur. Some researchers investigated the association of endoscopic images with graft rejection to provide timely diagnosis. In this study, we present the first case report with characteristic features under magnifying endoscopy with a narrow-band imaging system to predict epithelial regeneration and improvement of graft rejection in a patient with small-bowel transplantation.     

Time-dependent risk factors influencing the long-term outcome in living renal allografts: donor age is a crucial risk factor for long-term graft survival more than 5 years after transplantation

BACKGROUND: Most investigations have revealed that the improvement in early graft survival has not resulted in a corresponding improvement in long-term graft survival. The risk factors for long-term graft survival should be clarified. METHODS: A single-center experience of 1100 consecutive renal transplant recipients who received kidneys from living donors from 1983 to 1998 was reviewed to clarify the time dependency of risk factors for long-term graft survival. We examined various possible risk factors, including HLA-AB and -DR mismatches, ABO-blood group incompatibility, graft weight, donor age and sex, recipient age and sex, and the presence or absence of acute rejection by using the time-dependent, nonproportional Cox's hazards model. RESULTS: Acute rejection episode, donor age, HLA-AB 4-antigen mismatches, ABO-incompatible transplantation, smaller kidney weight compared with the patient's body weight (Kw/Bw ratio less than 2.67), and transplantation from an unrelated living donor were risk factors for long-term graft outcome. Multivariate analysis for time-dependent risk factors showed that donor age of more than 60 years was the most important risk factor for long-term graft failure after 5 years posttransplantation (hazard ratio: 2.57). In contrast, acute rejection, ABO incompatibility, and nonrelated donors were significant risk factors for short-term graft failure within 5 years after kidney transplantation (hazard ratios: 2.68, 1.57, and 1.69, respectively). CONCLUSIONS: Donor age of more than 60 years was a crucial risk factor affecting long-term graft survival. In contrast, acute rejection, ABO incompatibility, and nonrelated donors were significant risk factors for short-term graft failure.     

Medium-term results of heart transplantation using donors over 63 years of age

BACKGROUND: The continual shortage of hearts for transplantation (HTx) led to the expansion of the donor pool by accepting older donors. We compared the medium-term follow-up of patients after HTx with older hearts (over the age of 63 years) with those of patients after HTx with younger hearts. PATIENTS AND METHODS: Since April 1994 we have used hearts for HTx from donors older than the age of 63 years. Until November 1998, 309 HTx and 9 re-HTx were performed in 309 adults with a mean age of 50.7+/-10.9 years (range 17-68 years). There were 252 men and 57 women. The patients were divided into two groups: group I--donor age under 63 years (296 patients, mean age 50.4+/-11 years; mean donor age 38.1+/-13 years; mean follow-up 1.7+/-1.6 years); group II-donor age of more than 63 years (13 patients, mean age 57.4+/-5.6 years; mean donor age 65.1+/-2.1; mean follow-up 2.2+/-1.6 years). There were no differences in the etiology of heart failure, gender, or ischemia time between the groups. The patients in group II were significantly older (P = 0.008). Multiple factors were analyzed in the groups, which included changes in the left/right ventricle ejection fraction, early postoperative mortality (up to 30 days), cumulative survival rates and cardiac-dependent morbidity [myocardial infarction, malignant arrhythmias, coronary stenosis (>50% in one of the main coronary arteries) and transplant vasculopathy]. Additionally, freedom from cytomegalovirus infection (rise of titer or seroconversion) and freedom of acute rejection episodes grade > or =2 (International Society of Heart & Lung Transplantation [ISHLT]) were analyzed. RESULTS: After 1 year mean left and right ventricle ejection fraction were good in both groups and did not significantly change for up to 2 years. No Re-HTx was performed in group II. The early postoperative mortality was similar in both groups (P = 0.8). Also, the cumulative survival rates were similar in both groups (P = 0.87). Long-term cardiac morbidity was lower in group I (P = 0.03). The long-term freedom from cytomegalovirus infection in group I was significantly higher when compared with group II (P = 0.0002). The long-term freedom from severe rejection episodes was similar in both groups (P = 0.3) CONCLUSION: The study found a significant increase in long-term cardiac morbidity due to more focal coronary stenosis in group II, and freedom from cytomegalovirus infection, but did not find significant differences in the long-term survival between patients who received hearts from donors of up to 63 years of age and from those more than 63 years. The acceptance of donors older than 63 years old for HTx does not worsen the outcome of the recipients. The careful selection of older donors, with close monitoring of the coronary situation after HTx and expanded indications for revascularization of older hearts, could make HTx with older hearts, even in older recipients, a safe option.     

Management of aortopulmonary collaterals in children following cardiac transplantation for complex congenital heart disease.

BACKGROUND: Heart transplantation (HTx) is increasingly utilized as therapy for end-stage cyanotic congenital heart disease. This study investigates the presence and impact of aortopulmonary collaterals (APCs) associated with cyanotic heart disease on the early post-operative course of patients undergoing transplantation. High output cardiac failure due to residual aortopulmonary collaterals can affect outcome following heart transplantation. METHODS: Seven patients with hemodynamically significant APCs post-transplant were identified among 40 patients with cyanotic congenital heart disease undergoing HTx. The peri- and intra-operative courses of these patients were reviewed. All 7 patients required prolonged inotropic support despite normal ventricular function and no allograft rejection; 5 were ventilator-dependent due to significant pulmonary vascular congestion. Selective angiography demonstrated the presence of significant aortopulmonary collaterals at 7 to 19 days post-transplant. Coil embolization of aortopulmonary collaterals was performed in all patients; a mean of 6 (2 to 16) vessels/patient were embolized. RESULTS: After embolization, pulmonary edema resolved and heart size normalized in all patients; inotropic support was weaned within 2 to 10 days in 5 patients. One patient developed transient renal failure secondary to excessive contrast load and another had enterococcal sepsis within 24 hours after the procedure. All patients were asymptomatic from 4 to 10 years of follow-up post-HTx. CONCLUSIONS: Aortopulmonary collaterals should be considered a cause of early donor heart failure in children following HTx for cyanotic congenital heart disease. Early detection and treatment of aortopulmonary collaterals by coil embolization is necessary to improve the post-transplant course in these complex patients.     

Influence of time of rejection on long-term graft survival in renal transplantation

BACKGROUND: The aim of this analysis was to investigate the relationship of acute rejection episodes (ARE) at different times posttransplantation with reversibility of graft dysfunction and long-term graft failure using data from the Collaborative Transplant Study database. METHODS: A total of 28,867 patients receiving their graft between 1995 and 2005 from deceased donors were included in the analysis. The time from renal transplantation to first treated ARE was divided into intervals up to 3 years. Long-term graft survival and half-life rates were calculated and hazard ratios (HR) for failure were computed using multivariate Cox regression analysis. RESULTS: Compared with patients who did not receive rejection treatment during the first posttransplant year, HR for graft survival increased to 1.35 for patients with rejection 0 to 90 days (P<0.001), 2.05 with rejection 91 to 180 days (P<0.001), and 2.74 with rejection 181 to 365 days of posttransplantion (P<0.001). First rejections occurring during the second year were associated with HR 3.35 (P<0.001) and rejections during the third year with HR 3.17 (P<0.001). In addition to the time of rejection, the degree of functional recovery after rejection treatment was found to be important for subsequent graft survival. CONCLUSION: The time point of occurrence and the degree of functional recovery after rejection treatment were found to significantly influence the impact of ARE on long-term graft survival, and we were able to quantify the associated risks.