The clinical risk in heart transplantation: is it evaluable?

At the moment, there is no score to evaluate clinical risk in heart transplantation. There is a need for such an instrument due to the extended criteria for donations and for recipient evaluation for transplantation. We divided the 203 consecutive patients who underwent heart transplantation (HTx). Between January 1999 and December 2007 into two groups: high and low risk based on several common well-defined variables. Donors were also divided into high- and low-risk groups. We matched the four groups to obtain risk cohorts: GA (high risk), GB and GC (intermediate risk) versus GD (low risk). We analyzed the 30 day-mortality showing a significant difference between GD and the other groups (P = .05) in contrast to no significant difference in 1- and 3-year survival rates among GA, GB, GC, and GD. Although the development of a specific score for heart transplantation is desirable and would be useful, a careful, case-by-case evaluation is indispensable.     

Does multiorgan donation influence survival in heart transplantation?

Current heart transplant survival in Spain at 1, 5, and 10 years is 80%, 70%, and 60%, respectively. Our objective was to establish how donor type affects survival in heart transplantation. MATERIALS AND METHODS: This was a retrospective study of heart transplant recipients from 102 donors, divided into three types: (a) heart-liver-kidney donors (group I); (b) heart-liver-kidney-lung donors (group II); and (c) heart-liver-kidney-lung-pancreas donors (group III). We excluded retransplantations, pediatric transplantations, and cardiopulmonary transplantations. The outcome variable was the actuarial survival by type of donation. Statistical analysis was performed for event-free survival based on the Kaplan-Meier method (log-rank test). RESULTS: Groups I, II, and III included 63, 26, and 13 donors, respectively. The survival curves showed similar values for all three groups (P > .05). CONCLUSIONS: The different combinations of multiorgan donation do not entail a poorer prognosis in terms of cardiac transplant patient survival.     

Heterotopic heart transplantation: an expanding role in the twenty-first century?

Background

Heterotopic heart transplantation was first performed in humans in 1974, the main advantage being the continuing function of the patient's native heart, in the event of life-threatening acute rejection. The effect of cyclosporine on acute rejection saw the heterotopic transplantation technique wane. Our unit revisited heterotopic transplantation in response to a growing number of waiting list patients with high pulmonary artery pressures. We also anticipated an increased cardiac allograft utilization, and improvement of our waiting list times.

Methods

We retrospectively analyzed 151 patients undergoing heart transplantation by our unit between August 1997 and September 2003. Twenty received allografts in the heterotopic position. This cohort was compared with the 131 contemporary orthotopic heart transplant recipients with respect to their outcomes.

Results

The indication for transplantation was ischemic cardiomyopathy in 14 (70%) of the heterotopic cohort and 47 (36%) of the orthotopic cohort (p = 0.004), and dilated cardiomyopathy in 3 (15%) and 48 (37%) in the heterotopic and orthotopic groups, respectively (p = 0.06). Heterotopic recipients were significantly older than orthotopic recipients, and they had higher pulmonary artery pressures. The heterotopic donors were also older and the ischemic times were longer. A subgroup analysis was made among those patients who had high pulmonary artery pressures as these groups were better matched. Major morbidity in the heterotopic heart transplantation group consisted of reversible allograft dysfunction in 4 patients, renal dysfunction requiring hemofiltration in 3 patients, profound myopathy in 4 patients, and cerebrovascular events in 2 patients. There were two early deaths in the heterotopic transplant group and eight in the orthotopic group (p = 0.87). Kaplan-Meier survival analysis of survival was performed.

Conclusions

Heterotopic heart transplantation is a viable transplant option for selected high-risk heart transplant recipients in spite of somewhat poorer outcomes.     

Pre-transplant obesity in heart transplantation: Are there predictors of worse outcomes?

Objective. Morbid obesity is increasingly observed in patients being evaluated for heart transplantation and represents a relative contraindication. We sought to evaluate the influence of pre-transplant obesity on morbidity and mortality after heart transplantation. Design. We retrospectively reviewed 90 consecutive patients with preoperative obesity (BMI ≥ 30) and 90 age matched patients with normal weight (BMI 19 – 26) who underwent heart transplantation at our institution between January 1997 and December 2005. Results. Morbidly obese patients experienced higher rates of pre-transplant diabetes (29% vs 15%, p < 0.05) and prolonged waiting time before transplantation (191.4±136.1 vs 117.4±143.2 days, p < 0.001). There were no significant differences in post-operative complications including rejection and major and minor infections. There was no difference in actuarial survival between the obese and control groups after a mean follow-up of 4.26±2.95 years (p = 0.513, log-rank statistic 0.452). Causes of death did not differ. Cox proportional hazard analysis revealed increased association of peripheral vascular disease (HR 31.718, p = 0.001), and pre operative inotropic support (HR 33.725, p = 0.013) with increased mortality in the obese group. Conclusions. This study suggests morbid obesity does not affect survival or rates of infection and rejection after heart transplantation.     

Returning to school after heart or heart-lung transplantation: how well do children adjust?

BACKGROUND: Up to 40% of children and adolescents with chronic illness experience school-related problems, including learning difficulties and problems in social adjustment and peer relationships. Despite the life-threatening nature of heart and heart-lung transplantation and the severity of illness, which results in the necessity for surgery, there is little information on the school performance of children after transplantation. METHODS: Eighty-one children and adolescents were assessed with regard to their academic attainments and behavior at school at regular intervals after heart (n=47) or heart-lung (n=34) transplantation and comparisons made with a group of healthy children. RESULTS: Cognitive ability and performance on academic attainments were within the normal range and did not change significantly as a function of time since transplant. However, performance was at a significantly lower level than that of the healthy children. Although the prevalence of behavior problems was only 8% at 6 months posttransplant, at 3 years, it had increased to 29% and, at 5 years, it was still 27%. Children with an initial diagnosis of congenital heart disease had more academic and behavioral difficulties than those with either cardiomyopathy or cystic fibrosis. CONCLUSIONS: A significant number of children who had undergone successful transplantation experienced difficulties at school. Contrary to expectations, educational problems were more prevalent in the medium term, rather than short term, after transplant. Initial diagnosis was a salient factor in posttransplant psychological functioning at school. Early intervention and close liaison with schools is indicated to reduce psychological morbidity and enhance adaptation within the school environment.     

Xenogeneic orthotopic heart transplantation: Where are we now?

Cardiac xenotransplantation is a promising option for satisfying the unmet need for cardiac replacement. Mechanical hearts have been in development for over 40 years and only one device is currently available “off the shelf” for implantation in the United States. It took 39 years for this first approved device to be available. This device approval arose from outcomes from the rematch trial (2001) when survival in the ventricular assist device group was fifty‐two percent and twenty‐three percent at 1 and 2 years, compared with twenty‐five percent and eight percent in the medically treated group. Quality of life was significantly improved at 1 year in the ventricular assist device group. While mechanical support continues to improve, intrinsic disadvantages remain, such as thromboembolism, the need for careful anticoagulation, infection, lack of physiological response, durability and power supply. Pursuit of cardiac xenotransplantation therefore remains a potentially important contributor to the treatment of heart failure clinically. With the addition of human complement regulating proteins to the pig genome using a micro‐injection technique and the subsequent development of Gal knockout pigs using cloning technology, pre‐clinical median survival of heterotopic cardiac xenotransplants is now in excess of 3 months. A three months median survival of orthotopic cardiac xenotransplants has been proposed as a possible threshold for a clinical trial. Attention has therefore focused on the orthotopic cardiac xenotransplant pig to baboon model. There have been six operative survivors ranging from 2 to 57 days. Immunosuppression in these recipients consisted of ATG induction, tacrolimus, sirolimus, anti‐CD20 and a steroid taper. No anticoagulation was used. None of the animals died of rejection. The causes of failure largely related to the challenges of the model system. In four of the six cases rejection was minimal and the remaining two mild to moderate. Recipients were healthy and well during the post‐operative period. Biochemistry was stable. Challenges encountered during these studies have included early peri‐operative heart failure which has markedly improved with peri‐operative management. These studies have shown maintenance of normal cardiac function for up to 2 months following pig to baboon transplantation. In addition, hearts from the recipients who survived showed peri‐operative myocardial dysfunction that completely recovered post‐operatively within a few days. Outcomes of pre‐clinical orthotopic cardiac xenotransplantation continue to improve with this report describing the longest survivors to date. Porcine hearts can function normally in primates for at least 2 months. Peri‐operative cardiac dysfunction is likely avoidable and is recoverable. Reparative processes are intact in the xenotransplant setting. Cardiac xenograft rejection is well controlled on tolerable immunosuppressants. Model limitations remain a serious challenge. The powerful advantage of biologic cardiac replacement (complete implantability, intrinsic power supply, lack of need for anticoagulation and physiological responsiveness) justifies continued pre‐clinical studies. In the first instance the goal of clinical cardiac xenotransplantation will be to provide additional treatment alternatives for patients with end‐stage organ failure. The comparison on outcomes will be with other available treatments and not allotransplantation in the first instance. Research programme supported by NIH Grant A166310.     

Is an emergency heart transplantation justified?

INTRODUCTION: Emergency heart transplantation remains an important controversy due to the shortage of donors and the previously demonstrated results inferior to other patients. These recipients display a worse clinical status and their donors are more often considered suboptimal. Nevertheless, it is the only therapeutic option for patients with advanced cardiomyopathy and acute decompensation with no response to other therapies. We compared results among the emergency indication with those of elective transplants. METHODS: We analyzed the 213 patients who underwent cardiac transplantation in our center up to December 2004 to compare emergency with elective heart transplantations for preoperative and surgical variables as well as outcomes. RESULTS: A higher percentage of emergency patients were New York Heart Association class IV, displayed renal dysfunction, and were women. Regarding donors, a higher percentage were over 40 years of age. No differences were observed in the early and first-year mortality or morbidity rates, although we noted a greater 5-year mortality rate among emergency cases. CONCLUSIONS: In our center emergency heart transplantation was associated with only slightly worse results compared with elective transplantations. Both donors and recipients should be carefully selected to improve results.     

Dopamine in transplantation: Written off or comeback with novel indication?

Renal‐dose dopamine has fallen out of favor in the intensive care unit (ICU) during past years due to its ineffectiveness to prevent impending or to ameliorate overt renal failure in the critically ill. By contrast, growing evidence indicates that low‐dose dopamine administered to the stable organ donor after brain death confirmation improves the clinical course of transplanted organs after kidney and heart transplantation. Ensuring a thorough monitoring for potential circulatory side effects, employment of dopamine at a dose of 4 μg/kg/min is safe in the deceased donor. Among recipients, the advantageous effect is easy to achieve, inexpensive, and devoid of adverse side effects. The mode of action relies on dopamine’s propensity to mitigate injury in various cell systems from isolated transplantable organs under cold storage conditions. The present review article summarizes the clinical evidence of dopamine donor pretreatment in solid organ transplantation and focuses on the underlying molecular mechanisms of cellular protection. Introducing the routine use of low‐dose dopamine for the management of the brain‐dead donor in the ICU before procurement provides an evidence‐based strategy to improve graft outcome after kidney transplantation without conferring harm to non‐renal grafts, namely to livers and hearts, in cases of multi‐organ donation.     

Incidental prostatic cancer: repeat TURP or biopsy?

An incidental diagnosis of carcinoma is made in about 15% of patients undergoing transurethral or open surgery for prostatic adenoma. The importance of correct staging lies in the different clinical behaviors of the tumor according to the stage, which means that it will require different treatment. We present a review article on the diagnosis of residual neoplasia following transurethral resection of the prostate.