Donor-transmitted coronary atherosclerosis.

BACKGROUND: Autopsies show that coronary atherosclerosis is present frequently in the young and healthy. However, according to our former guideline, we performed pre-transplant evaluation without coronary angiogram in donors <60 years. The purpose of this study is to evaluate to what extent native coronary atherosclerosis is transmitted through heart transplantation. METHODS: Between April 1986 and December 2000, a total of 1253 patients underwent heart transplantation at our institution. If coronary evaluation with coronary angiogram or autopsy had been performed within 6 months after transplantation, we regarded focal and non-circumferential atherosclerosis with >or=50% stenosis in proximal segments of at least 1 coronary vessel of the donor heart as transmitted, native coronary atherosclerosis, rather than newly developed transplant vasculopathy. RESULTS: We excluded 85 of 1253 (6.8%) cases because coronary evaluation was not performed within 6 months (n = 45) or because hearts underwent angiography during pre-transplant evaluation (n = 40). Of these, 2 patients with significant coronary atherosclerosis underwent transplantation and concurrent coronary artery bypass grafting. The prevalence of significant (stenosis >or=50%) and inadvertently transmitted coronary atherosclerosis was 7.0% (82/1168). CONCLUSION: The prevalence of coronary atherosclerosis in patients who underwent angiography within 6 months after transplantation was 5.2% (49/950). Among subjects who had autopsies within the first 6 months after heart transplantation, we found significant coronary atherosclerosis (stenosis >or=50%) 15.1% (33/218), and among those with early graft failure (<10 days after transplantation), the prevalence was 22.8% (26/114).The prevalence of coronary atherosclerosis in the donor pool is high, and donor screening without coronary angiogram overlooks significant coronary atherosclerotic lesions (stenosis >or=50%) in a considerable number of cases (7.0%). Because donor-transmitted coronary atherosclerosis is a risk factor in short-term (early graft failure) survival after heart transplantation, we have now changed our policy to include coronary angiography as a standard in screening donors >or=40 years. However, to what extent donor coronary atherosclerosis is accepted undoubtedly must be made arbitrarily until an evidence-based algorithm becomes available.     

Status of Patients Presently Living 9 to 13 Years After Orthotopic Heart Transplantation

Background. Heart transplantation has a dramatic impact on both life expectancy and quality of life in patients with terminal heart failure. The aim of the study was to evaluate psychologic, social, occupational, and somatic status of patients living long-term, 9 to 13 years after orthotopic heart transplantation.

Patients and Methods. Seventy-seven of 182 patients who received transplants between July 1983 and January 1988 in Hannover (1983–1985; n = 69 patients) and Berlin (1986–1988; n = 113 patients) have survived up to now, 9 to 13 years after transplantation (mean, 10 years 4 months). The patients and their medical records (eg, cardiac catheter studies, echocardiography) were examined to assess their somatic status. Psychologic, social, and occupational status and quality of life data were assessed by combination of self-rating questionnaires (the Short Form Health Survey Questionnaire, Giessener Beschwerdebogen [the Giessen Subjective Complaints List], the Sickness Impact Profile, and the Hospital Anxiety and Depression Scale) and semistructured interviews.

Results. Ninety-one percent of the patients were in New York Heart Association functional class I (70%) or II (21%). The results of the psychologic investigation revealed a definite impact of the side effects of chronic immunosuppression; however, overall, the quality of life rating was within the normal range. Sixty-seven (86%) patients were married, 51 (66%) patients were retired, 17 (22%) worked full-time or part-time, and 9 (12%) were housewife or houseman. Four male patients have fathered five healthy children 1 to 10 years after the transplantation. More than 75% of the patients had normal systolic ventricular function (mean left ventricular ejection fraction, 0.63). Coronary angiograms were normal or with minor wall irregularities in 86% (n = 66 patients), and revealed severe obstructions in 14% (n = 11). Normal function of all valves was found in one-third of the patients, tricuspid valve incompetence was not found or was insignificant in 87% (n = 67 patients) and severe in 8% (n = 10). Six patients had undergone tricuspid valve replacement, invariably for structural valve defects attributable to biopsy injuries. Fifty-eight patients (75%) exhibited various degrees of compensated renal insufficiency, 7 of them were on chronic hemodialysis, and 2 patients have undergone kidney transplantation. Hepatic function was normal in 68% (n = 52) of the patients, and 1 patient has developed liver cirrhosis. Osteoporosis was diagnosed of the discrete form in 7 (9%) and of a significant degree in 24 patients (31%); 38.5% (n = 30) complained of symptoms of polyneuropathy.

Conclusions. The patients surviving 9 to 13 years after orthotopic heart transplantation are mostly in good physical status, the quality of life is comparable to the general population, and only a few of them have significantly limited in their life style. They do show the substantial chronic side effects of long-term immunosuppression, remaining treatment-dependent for a lifetime.     

Trans-catheter aortic valve implantation after previous aortic homograft surgery

In patients with previous heart surgery, the operative risk is elevated during conventional aortic valve re-operations. Trans-catheter aortic valve implantation is a new method for the treatment of high-risk patients. Nevertheless, this new procedure carries potential risks in patients with previous homograft implantation in aortic position. Between April 2008 and February 2011, 345 consecutive patients (mean EuroSCORE (European System for Cardiac Operative Risk Evaluation): 38 ± 20%; mean Society of Thoracic Surgeons (STS) Mortality Score: 19 ± 16%; mean age: 80 ± 8 years; 111 men and 234 women) underwent trans-apical aortic valve implantation. In three patients, previous aortic homograft implantation had been performed. Homograft degeneration causing combined valve stenosis and incompetence made re-operation necessary. In all three patients, the aortic valve could be implanted using the trans-apical approach, and the procedure was successful. In two patients, there was slight paravalvular leakage of the aortic prosthesis and the other patient had slight central leakage. Neither ostium obstruction nor mitral valve damage was observed. Trans-catheter valve implantation can be performed successfully after previous homograft implantation. Particular care should be taken to achieve optimal valve positioning, not to obstruct the ostium of the coronary vessels due to the changed anatomic situation and not to cause annulus rupture.     

Transcatheter aortic valve implantation and simultaneous closure of ostium secundum atrial septal defect

We were faced with a difficult question: how to treat a high-risk patient with severe aortic valve stenosis and a secundum atrial septal defect (ASD II). An 85-year-old woman with progressive dyspnea and pedal edema and in New York Heart Association class IV was treated with concomitant transapical aortic valve implantation and transcatheter closure of the ASD II. The combined procedure and postoperative course were completely uneventful. At 2 years after the clinical follow-up, the patient is doing well. This case report demonstrates, for the first time, the feasibility, safety, and effectiveness of simultaneous application of 2 transcatheter methods--aortic valve implantation and closure of an ASD II. As surgeons, we should consider percutaneous treatment of combined structural heart disease in patients at high risk for conventional surgery.     

Repair for active infective atrioventricular valve endocarditis: 23-year single center experience

Objectives  

We retrospectively compared early and long-term results of mitral (MV) and tricuspid valve (TV) repair in patients with isolated active infective atrioventricular valve (AV) endocarditis over a period of 23 years.     

Patients supported for over 4 years with left ventricular assist devices

Ventricular assist device implantation has become an established therapy in adults and children for bridging to heart transplantation or to aid myocardial recovery. Recently, implantation of left ventricular assist devices as definitive therapy has been recognized as a better option than pharmacological treatment in patients who are not candidates for heart transplantation. This study presents our institution's experience with five patients successfully supported by two different left ventricular assist devices for over 4 years. This unique experience shows that left ventricular assist device support can be extended beyond 4 years with good quality of life and low risk, making it a good alternative for non-transplant candidates.     

Prevalence and significance of neurocognitive dysfunction in hepatitis C in the absence of correlated risk factors

Neurocognitive morbidity has been reported in individuals with chronic hepatitis C virus (HCV) infection, but the magnitude of such dysfunction in the absence of disease-correlated factors known to affect the central nervous system (e.g., substance abuse, cirrhosis, depression, interferon treatment) and the impact of any such change on functioning is unclear. We investigated a cohort of individuals with HCV, all of whom were carefully screened to exclude relevant comorbidities, to elucidate virus-related changes in the brain using neuropsychological tests and magnetic resonance spectroscopy (MRS). A cohort of 37 patients with chronic HCV infection was culled from 300 consecutive patients presenting to a tertiary care liver clinic. A comparison group of healthy controls (n = 46) was also assessed. Of 10 neurocognitive measures evaluated, the HCV group showed marginally poorer learning efficiency compared with controls; only 13% of patients demonstrated a clinical level of impairment on this test (defined as 1.5 SD below the normative standard). Although patients reported greater levels of fatigue and symptoms of depression, these factors did not correlate with the degree of learning inefficiency. With respect to MRS, the HCV group demonstrated increased choline and reduced N-acetyl aspartate relative to controls in the central white matter. Indicators of liver disease severity did not correlate with either memory or MRS abnormalities. In conclusion, while our findings support an association between hepatitis C and indicators of central nervous system involvement in a cohort of patients carefully screened to eliminate other factors influencing neurocognitive integrity, the clinical significance of these effects is limited.