Long-Term Results of Heart Transplantation for End-Stage Valvular Heart Disease

Abstract   Background: In general, heart transplantation for patients with heart failure improves survival. However, the outcomes of heart transplantation for patients with end-stage valvular heart disease are less well reported. This is a substantial group of patients, many of whom have had previous cardiac surgery. They therefore may be considered a subgroup with a poor prognosis. This study reports on the outcomes of heart transplantation for patients with end-stage valvular heart disease. Patients and methods: From March 1989 to December 2004, 75 consecutive adult heart transplantations were performed for end-stage valvular heart disease. Clinical characteristics were retrieved from a computerized database. Results: The early mortality risk in heart transplantation for end-stage valvular heart disease was 13%, compared to 8% for other indications (p = 0.12). The main causes of early death were rejection (20%) and right ventricular failure (20%). The total follow-up time was 415 patient-years. During the follow-up, another 23 patients died (55/1000 patient-years of late mortality rate), mostly due to infection (43%) and multiorgan failure (22%). Multivariable analysis demonstrated that increased waiting time to heart transplantation correlated with increased survival (HR = 0.998, p = 0.04). The survival at 1, 5, 10, and 15 years was 70%, 64%, 56%, and 46% compared to 78%, 68%, 53%, and 41% for other indications, respectively (p = 0.5). Conclusion: The outcomes of heart transplantation for patients with end-stage valvular heart disease are similar to those for other patients. Apparently, the longer the waiting time to heart transplantation the better the outcome becomes.     

Heart Transplantation in Children and Adults With Congenital Heart Disease: 3 Decades of Evolution

Heart transplantation is the treatment of choice for children and adults with congenital heart disease. We report the heart transplant single-center experience. The number of transplantations has increased over the last 3 decades. The Kaplan-Meier survival curves in the first, second, and third decades at 5 and 10 years were 69% and 59%, 62% and 52%, and 66% and 60%, respectively.     

Evolutionary Description of Heart Transplantation and Heart-Lung Transplantation in Congenital Heart Disease

BackgroundCurrently, a high percentage of patients with congenital heart disease (CHD) reach adulthood. The consequence is that more and more patients will require a heart transplant (HTx) or heart-lung transplant (HLTx). The objective of the study was to analyze the evolution and temporary trend of the number of HTxs and HLTxs in patients with and without CHD.MethodsWe performed a retrospective analysis of all HTxs and HTLxs from a Spanish transplant hospital. Retransplant and other combined transplants were excluded. HTx and HLTx were divided into 2 groups (CHD or non-CHD). The number of procedures of each modality was grouped in 5 years.ResultsA total of 930 HTxs were analyzed between 1987 and 2020; 36 were CHD (18 HTxs and 18 HLTxs). HTx and HLTx in CHD showed a growing progressive trend, probably because of the greater number of these patients who reach adulthood and finally develop advanced heart failure. HTx in patients without CHD showed a very high rise in the first decade, reaching the maximum peak around the year 2000, with a poststabilization trend or even progressive reduction in the number of procedures. HLTx in patients without CHD showed a marked ascent during the first decade with a peak around 2005 and subsequent significant decline in recent years practically in disuse, probably because of the possibility of circulatory assistance in the case of right ventricular failure.ConclusionsThe number of HTxs and HLTxs in CHD has a progressive rise. The number of HTx in patients without CHD remains relatively stable. HLTx in patients without CHD shows a marked decrease.     

End-Stage Renal Disease After Orthotopic Heart Transplantation: A Single-Institute Experience

Orthotopic heart transplantation is the treatment of choice for end-stage heart failure, and calcineurin inhibitor agents allow for better allograft survival. However, pretransplantation low cardiac output status and posttransplantation immunosuppressants contribute toward deterioration of renal function. From 1987 to 2008, 350 patients underwent orthotopic heart transplantation in our hospital. Most of them received anti-thymocyte globulin (ATG) as the induction immunosuppressant. The introduction of mycophenolate mofetil (MMF) reduced the maintenance level of cyclosporine. The 26 patients who developed end-stage renal disease required dialysis. We reviewed the patient characteristics, including pretransplantation status, immunosuppressant regimens and drug levels, time and type of dialysis, and mortality rate. The mean age of these 26 patients was 53 years. Three patients underwent peritoneal dialysis. The overall 1-year survival rate was 96%, and the 5-year survival rate was 80%. The duration from heart transplantation to chronic dialysis correlated with the presence of a pretransplantation diagnosis of diabetes (P < .05) and an elevated pretransplantation blood creatinine level (P = .01), but there was no significant effect of the initial level of cyclosporine. In addition, the pretransplantation blood creatinine level was also related to the necessity of immediate postoperative hemodialysis (P = .01). There was no significant risk factor in relation to mortality. Regardless of modification of immunosuppressant regimens and initial drug levels, pretransplantation kidney function played an important inverse role in the duration from transplantation to dialysis: the higher the pretransplantation blood creatinine, the shorter the duration. While awaiting a heart transplant, more effort should be spent on protecting renal function to avoid early chronic dialysis.     

Heart Transplantation for End-Stage Heart Failure Due to Cardiac Sarcoidosis

Background

Cardiac sarcoidosis with end-stage heart failure has a poor prognosis without transplantation. The rates of sarcoid recurrence and rejection are not well established after heart transplantation.

Methods

A total of 19 heart transplant recipients with sarcoid of the explanted heart were compared with a contemporaneous control group of 1,050 heart transplant recipients without cardiac sarcoidosis. Assessed outcomes included 1st-year freedom from any treated rejection, 5-year actuarial survival, 5-year freedom from cardiac allograft vasculopathy (CAV), 5-year freedom from nonfatal major adverse cardiac events (NF-MACE), and recurrence of sarcoid in the allograft or other organs. Patients with sarcoidosis were maintained on low-dose corticosteroids after transplantation.

Results

There were no significant differences between the sarcoid and control groups in 1st-year freedom from any treated rejection (79% and 90%), 5-year posttransplantation survival (79% and 83%), 5-year freedom from CAV (68% and 78%), and 5-year freedom from NF-MACE (90% and 88%). Causes of death (n = 5) in the sarcoid group were coccidioidomycosis, pneumonia, rejection, hemorrhage, and CAV. No patient had recurrence of sarcoidosis in the cardiac allograft. Three of 19 patients (16%) experienced recurrence of extracardiac sarcoid, with no mortality.

Conclusions

Patients with cardiac sarcoidosis undergoing heart transplantation have acceptable long-term outcomes without evidence of recurrence of sarcoidosis in the allograft when maintained on low-dose corticosteroids. Progression of extracardiac sarcoid was uncommon, possibly related to immunosuppression. In patients with cardiac sarcoidosis, heart transplantation is a viable treatment modality.     

腹膜透析在儿童心脏病术后急性肾衰竭中的治疗体会

目的探讨腹膜透析（PD）治疗儿童先天性心脏病术后并发急性肾衰竭的疗效。方法对22例先心病术后ARF行PD治疗患儿的临床资料进行回顾性分析,观察肾功能指标变化情况。结果 22例患儿中治愈6例,占27.3%,死亡16例,占72.7%,本组病例K＋和HC03-指标在PD治疗48h后明显好转（P〈0.05）。治愈患儿平均动脉压、中心静脉指标呈好转趋势（P〈0.05）;死亡患儿无改善。结论小儿心脏手术后ARF应用PD治疗能够纠正电解质代谢紊乱和酸碱失衡,可降低死亡率。     

Heart Transplantation in Adolescent and Adult Patients With Congenital Heart Disease: A Case-Control Study

Background

The number of adolescent and adult patients with congenital heart disease undergoing heart transplantation is increasing. We aimed to better define the characteristics of these patients and their survival after transplantation.

Methods

We describe a group of patients with end-stage heart failure owing to congenital heart disease undergoing heart transplantation at a single tertiary center and compare their short- and long-term survival with a group of matched controls with dilated cardiomyopathy and the entire cohort of transplanted patients at our center.

Results

Between 1985 and 2006, a total of 322 orthotopic heart transplantations were performed at our center. Thirteen patients (mean age, 27.5 years) had a diagnosis of congenital heart disease with a wide spectrum of lesions. The survival of these 13 patients was 85% at 30 days, 1, 5, and 10 years and 77% at 20 years, which did not differ significantly to the short- and long-term survival of the entire cohort of patients with heart transplantation and to the survival of age-matched controls with dilated cardiomyopathy.

Conclusion

In our single-center experience, short- and long-term survival after heart transplantation in a selected, small group of patients with end-stage heart failure owing to congenital heart disease did not differ significantly compared with a group of age-matched controls and the entire cohort.     

Kidney-Alone Transplantation in Diabetic Patients with End-Stage Renal Disease

From January 1989 to December 1995, 5 diabetic patients with end-stage renal disease (1 woman, 4 men) underwent kidney-alone transplantation. The mean age of the recipients at the time of transplantation was 37.4 years (range, 32 to 43). Graft function and glucose tolerance was evaluated for 5 to 72 months after surgery. Postoperative complications were seen in 2 patients; nonspecific subcutaneous infections and an asymptomatic partial allograft infarction. All renal allografts were functioning 1 year after transplantation, with a mean serum creatinine level of 1.10mg/dL (range, 0.8 to 1.8mg/dL), and a mean urinary protein level of 1 7.8mg/dL (range, 5 to 27mg/dL). The postoperative daily dose of insulin was higher than the preoperative dose, while the level of glycated hemoglobin (HbA_1c) increased after surgery and peaked 6 months after transplantation; 1 year after transplantation it had reverted to the preoperative level. As long as the diabetic complications of the renal allograft recipients are not severe, the short-term survival and the renal function of diabetic patients with end-stage renal disease improves after kidney-alone transplantation, which is still the standard method of treatment in Japan.