Heart transplantation

While nearly 4,000 patients undergo heart transplantation (HTx) every year in the world, only 27 HTx were performed since February, 1999, because of very strict Organ Transplantation Law in Japan. All were treated with triple immunosuppressive regimen. Although two patients died of infection 4 months and 4 years after HTx, respectively, 23 were discharged and 16 returned to work or go to school. New immunosuppressive drugs, such as sirolimus and everolimus, treatment of presensitized patients before transplantation using cyclophosphamide and intravenous globulin infusion, compact implantable left ventricular assist supports and the future of pediatric HTx in Japan are discussed.     

Heart transplantation

Although the clinical outcome of heart transplantation in Japan is excellent in the past 11 years after establishment of the Organ Transplant Law, the total number of heart transplant is extremely limited in Japan, only 69 cases. The Law was revised and enforced in July 17, 2010, and pediatric heart transplantation is authorized in Japan from the legal point of view under the revised law. The most important revision of the law is that organs can be donated from brain death cadavers without written declaration of the donors themselves. We expect the number of the heart transplantation will be increased up to 30 to 50 cases per year, and social conditions are required also to be revised according to the revision of the Organ Transplant Law.     

Heart transplantation

Cardiac transplantation remains a life-prolonging process. Survival after heart transplantation has improved despite a sicker incoming patient population. The field of heart transplantation is constantly evolving. Advances in organ preservation, immune monitoring, and improved immunosuppressive regimens will continue to develop over time. The impact of the newest immunosuppressive agents and protocols, improved diagnostic testing, and new management strategies is yet to be determined. The potential of cell therapy is still under evaluation and the field is still in its infancy but rapidly evolving; the key to the future in this field may not be the delivery of the cells themselves but understanding how they interact with one another at a molecular level and, in particular, with resident stem cells in cardiac tissue. In addition to the medical advances, health care professionals need to educate the public about the benefits of transplantation as well.     

Heart transplantation

Although the number of available donor hearts severely limits the epidemiologic impact of heart transplantation on patients with heart failure, patients with end-stage heart failure unresponsive to medical management currently have no other viable alternatives. Destination therapy with a ventricular assist device is the closest toward approaching clinical reality but has been plagued with problems of infection and stroke. The purpose of this review is to summarize recent developments in the field that may broaden the clinical impact of heart transplantation. For example, novel methods of cardiac preservation are being designed to safely evaluate and utilize "extended criteria" donors. Surgical techniques and medical management have reduced the incidence of postoperative right heart failure, and immunosuppressive regimens promise to limit chronic graft vascular disease.     

心脏移植及术后随访

目的 总结3例心脏移植的初步经验.方法 3例扩张性心肌患者进行了双腔静脉法的同种原位心脏移植,围手术期间给予受体的维护、供心离体时间长的保护、血流动力学的支持、抗排异反应及感染方面的处理.结果 3例患者均存活,心功能由Ⅳ级提高到Ⅰ、Ⅱ级,分别随访19、28、49个月,2例因未正常服药发生排异反应.结论 选择合适的供体和受体、良好的供心保护技术、有效的血流动力学支持、抗排异反应方案得当、防止感染是围手术期处理的重要组成部分,是手术成功的关键.正规服用抗排异药物是避免或减少排异反应的基本条件.     

Heart transplantation in Japan

Since February 1999, organ transplantation from a brain-dead donor has been started in Japan. For more than 3 years, 91 patients underwent organ transplantation from 22 donors. Until November 2002, 132 patients have been registered to Japan Organ Transplant Network as a heart transplant candidate and 16 and 9 underwent heart transplantation (HTx) in Japan and abroad, respectively, while 37 died during waiting. 11 of 16 HTx recipients were implanted with left ventricular assist device (LVAS: Novacor in 2, TCI-IP in 2 and NCVC in 7). all 16 HTx recipients survived until now. 4 had several rejection episodes which were treated successfully. 5 had infection episodes (pneumonia in 3 and CMV infection in 2). 13 were already discharged and 9 returned to work.     

Heart and heart-lung transplantation

The fields of heart and combined heart-lung transplantation continue to evolve, allowing treatment of more individuals with end-stage heart and lung disease. The postoperative course and rehabilitation phase may be arduous, emphasizing the importance of selecting candidates who meet specific medical and psychosocial criteria. Life-long immunosuppression and meticulous long-term medical surveillance are mandatory practices to promote the health of the recipient. The major complications that contribute to morbidity and mortality, especially during the first post-transplant year, are infection and rejection. Graft atherosclerosis, obliterative bronchiolitis, and malignancy are long-term complications that may limit survival. In spite of the emotional and physical challenges related to potentially life-threatening complications and other disturbances in daily living, the quality of life for most recipients has markedly improved.     

Heart and heart-lung transplantation.

The fields of heart and combined heart-lung transplantation are in a constant state of evolution. As greater experience is gained in posttransplant management, more patients with end-stage heart and lung disease can be treated. Because the postoperative course and rehabilitation phase may be extremely difficult, only candidates who meet specific medical and psychosocial criteria are selected. During the waiting period, critical care nurses along with the transplant team are instrumental in stabilizing the emotional and physical condition of the transplant candidate. Postoperative complications requiring intensive therapy include decreased cardiac output, respiratory dysfunction, rejection, and infection. Graft atherosclerosis, obliterative bronchiolitis, and malignancy are long-term complications that may limit survival. Life-long immunosuppression and careful long-term medical surveillance are crucial to the health of the recipient. Although there are numerous emotional and physical challenges related to potentially life-threatening complications and other disturbances in daily living, the quality of life for most recipients has greatly improved.     

心脏移植及术后随访

目的总结3例心脏移植的初步经验。方法3例扩张性心肌患者进行了双腔静脉法的同种原位心脏移植，围手术期间给予受体的维护、供心离体时间长的保护、血流动力学的支持、抗排异反应及感染方面的处理。结果3例患者均存活，心功能由Ⅳ级提高到Ⅰ、Ⅱ级，分别随访19、28、49个月，2例因未正常服药发生排并反应。结论选择合适的供体和受体、良好的供心保护技术、有效的血流动力学支持、抗排异反应方案得当、防止感染是围手术期处理的重要组成部分，是手术成功的关键。正规服用抗排异药物是避免或减少排异反应的基本条件。     

Heart transplantation in pediatric cardiomyopathies

Cardiomyopathies represent an uncommon but serious cause of heart disease in the pediatric population and can be categorized as dilated, hypertrophic, restrictive and left ventricular non-compaction. Each of these subtypes has multiple potential genetic etiologies in addition to possible non-genetic causes. Many patients with cardiomyopathies can benefit from transplantation, although there is not insignificant morbidity and mortality for those patients. Outcomes both prior to and following transplantation depend on the underlying etiology, the amount of support needed prior to transplantation and the illness severity of the patient prior to transplantation. Mechanical circulatory support is frequently used to bridge patients to transplantation, and newer technologies are currently in development.     

Heart transplantation in childhood]

This report presents 5 children, in whom a heart transplantation was performed at the II. Chirurgische Universit?tsklinik of Vienna. At the time of transplantation the age of the children was 2, 3, 6, 10, and 14 years. The preoperative diagnosis was dilative cardiomyopathy in two patients, hypertrophic cardiomyopathy, right ventricular decompensation after atrial repair of TGA and a tumor of the heart in the other patients. Three children are alive and well. One child suffered from severe postoperative complications and 1 child died because of rejection of the heart. Indication, follow-up, complications of the therapy and the position of heart transplantation in children are discussed.     

Heart transplantation in idiopathic cardiomyopathy

Heart transplantation has just been resumed in Japan after 31 year's pause, whereas 2,400 cases per year have been carried in the United States. In the review article, several problems of this issue were discussed. For instance, the concept of brain death has not yet been accepted as a consensus in Japan. Therefore, we needed the legal support for the proceeding of heart transplantation. However, the recent success of heart transplantation will provide a new development of health care managements in the 21st century.     

Heart transplantation from an ethical perspective

Ethical issues in health care have increased during the past two decades, primarily in response to rapidly evolving advanced technologies. This increase in ethical dilemmas has been most felt by nurses because they are the primary health care providers to whom patients and family members turn for support, counseling, and empathy. Heart transplantation is an area of health care that evokes numerous ethical issues. Ethical beliefs must be examined from the aspects of everyone involved: the patient, family members, and health care providers. Some aspects of the transplantation process also warrant special consideration such as transplantation, lack of a viable support system for patients, and cultural issues. Future projections include a growth in the number and types of ethical dilemmas as technology continues to evolve, populations become more diverse and older, and the health care delivery systems continue to employ a more diverse group of health care providers. This article has attempted to give nurses some insight and guidance about the ethical issues currently being encountered. The article has also included the need for future education of nurses and society.