[Human herpesvirus-6 infection and hepatitis following heart transplantation]

OBJECTIVES

Human Herpesvirus-6 (HHV-6) has been implicated in hepatitis and HHV-6 infections have been reported in patients receiving heart transplants. We investigated the occurrence of such infections and their possible relation with post-transplantation hepatitis in 58 heart transplanted patients.

METHODS

The titre of HHV-6 antibodies was determined by anticomplement immunofluorescence assay and compared with the titre of CMV antibodies determined by using ELISA.

RESULTS

HHV-6 seroprevalence after transplantation did not differ significantly between hepatitis, control patients (without hepatitis) and the healthy general population. In three controls and five hepatitis patients we observed, after transplantation, a seroconversion or a significant increase of antibody titre which suggested active HHV-6 infection. In six cases, HHV-6-specific IgM were found whereas CMV-specific IgM were not detected.

CONCLUSION

These results indicate that HHV-6 infection is frequent after heart transplantation but not in relation with hepatitis. The mechanism of this infection needs to be clarified (either primo-infection or reactivation) and the question remains whether this infection is totally asymptomatic or could induce serious illness.

Nasal intermittent positive pressure ventilation. Long-term follow-up in patients with severe chronic respiratory insufficiency

Prior studies have shown that nasal intermittent positive pressure ventilation (NIPPV) can improve arterial blood gas values, prevent symptoms resulting from alveolar hypoventilation, and decrease hospitalization in patients with chronic respiratory failure. Most studies have involved small samples of patients followed up for a limited time. This study reviews our experience during 5 years use of NIPPV in 276 patients with kyphoscoliosis, posttuberculosis sequelae, Duchenne-type muscular dystrophy, COPD, and bronchiectasis followed up for > or = 3 years while receiving NIPPV. Outcomes were compared for patients who survived short term eg, died or converted to management with a tracheostomy and intermittent positive ventilation (TIPPV) during year 1 or year 2 on a regimen of NIPPV and long term, eg, survived more > or = 2 years on a regimen of NIPPV. The most favorable outcome was achieved by patients with kyphoscoliosis and posttuberculosis sequelae with improvement in PaO2 and PaCO2 (p < 0.0001) and a reduction in days of hospitalization for respiratory illness (p < 0.0001) for > or = 2 years while receiving NIPPV. Patients with Duchenne-type muscular dystrophy also had fewer hospital days during NIPPV (p < 0.003) but only 9 of 16 patients (56 percent) continued using NIPPV for the duration of followup. Benefit was also more short term for patients with COPD and bronchiectasis. NIPPV can sustain improvement in gas exchange, while reducing hospitalization for substantial periods of time. NIPPV can be an attractive and effective alternative to other methods of assisted ventilation such as TIPPV.

Long-term nasal ventilation in neuromuscular disorders: report of a consensus conference

Following the colloquium entitled "Nasal Ventilation and Neuromuscular Disease", which took place in Lyon, France, October 24, 1991, a group of authorities on neuromuscular disorders met to establish a consensus concerning the application of this technique, in the clinical setting, for patients with Duchenne's muscular dystrophy, non-Duchenne myopathies and the spinal muscular atrophies. This report summarizes recommendations issuing from this conference. The conclusions drawn from this work should not be applied to patients with other diagnoses.

Long-term nasal ventilation in neuromuscular disorders: report of a consensus conference

Following the colloquium entitled "Nasal Ventilation and Neuromuscular Disease", which took place in Lyon, France, October 24, 1991, a group of authorities on neuromuscular disorders met to establish a consensus concerning the application of this technique, in the clinical setting, for patients with Duchenne's muscular dystrophy, non-Duchenne myopathies and the spinal muscular atrophies. This report summarizes recommendations issuing from this conference. The conclusions drawn from this work should not be applied to patients with other diagnoses.

Survival prediction in staged heart transplantation using Jarvik-7 artificial heart

BACKGROUND

Because mechanical circulatory assist as a bridge to heart transplantation places a further strain on current donor shortage as well as on medical cost containment, safe and effective use of the device is essential.

METHODS AND RESULTS

To predict survival before undertaking staged heart transplantation with the Jarvik-7 artificial heart, our 58 attempts were reviewed retrospectively. Scores of 1-4 were given for six preoperative factors based on results obtained by univariate and multivariate analyses between survivors and nonsurvivors of staged heart transplantation: transplant rejection (scored 4: S4) or postoperative heart failure (S3) as the indication, recipient height < 175 cm (S3), body surface area < 1.8 m2 (S3), hyperbilirubinemia > 24 microM/l (S2), weight < 60 kg (S2), and age > 40 years (S1). Of 14 survivors, 13 had a total score < 4 (sensitivity, 93%), with an average score of 1.6 in contrast to 5.5 for 44 nonsurvivors (p < 0.001). Among 26 patients scored < 4, 21 had heart transplantation, of whom 13 left the hospital. Of 32 patients scored > or = 4, only four could be discharged after transplantation (specificity, 70%).

CONCLUSIONS

Multiple preoperative factors successfully predicted transplantability and survival in staged heart transplantation. The results underscore the importance of preoperative condition and patient selection to achieve successful and effective use of Jarvik-7 as a bridge to heart transplantation.

Chronic liver dysfunction in heart transplant recipients, with special reference to viral B, C, and non-A, non-B, non-C hepatitis. A retrospective study in 80 patients with follow-up of 60 months

In order to assess the prevalence, causes, and severity of chronic liver dysfunction (LD) in heart transplant patients, 80 transplanted patients followed for 60 months (median; range, 1.5-98 months) were reviewed. Sustained liver dysfunction was found in 50 patients, occurring during the first year after heart transplantation in 42 (84%) of them. Most patients were asymptomatic (80%). Causes for the liver dysfunction included non-A, non-B hepatitis in 16 cases (32%), viral B hepatitis in 13 (26%), delta hepatitis in one (2%), drug-induced hepatitis in six (12%), and cardiac failure in seven (14%). Anti-HCV antibodies were found in 56.2% of patients with non-A, non-B hepatitis and in 22% of patients with HBV hepatitis. It was found neither in patients with drug-induced hepatitis cardiac failure nor in patients with normal liver tests. This study outlines a high prevalence of LD (62.5%) in heart transplant patients, the high frequency of viral-related chronic LD (usually of moderate severity), and high incidence of HCV and HBV hepatitis.

Prognostic indices of survival in patients supported with temporary devices (TAH, VAD)

In an attempt to identify current indications and patient selection criteria for the use of mechanical circulatory support, we reviewed our experience in 83 patients who received a total artificial heart (TAH; n = 43), ventricular assist device (VAD) (n = 13), centrifugal pump (n = 17) or extracorporeal membrane oxigenation (ECMO) (n = 8) as a bridge to transplantation (Group I, n = 50) or for recovery from heart failure (Group II, n = 33). Comparing patients successfully transplanted (n = 20) or weaned (n = 9) who survived initial hospitalization, and those who died on mechanical support, there were no differences in preoperative renal, hepatic or pulmonary functions. Postoperative urinary output and bilirubin levels were the earliest variables affecting survival, and urinary output 24 hours after implant was discriminative in patients who survived (p less than 0.01). Age (above or below 40 years) and modality of terminal heart failure (acute versus chronic) were the most important factors affecting survival in the bridge to transplant group: 82% of young patients with acute decompensation were transplanted and 63% are long-term survivors while all patients over 40 years with chronic heart failure died on mechanical support (MS). In postcardiotomy patients, duration of cardiopulmonary by-pass (CPB) was significantly different comparing survivors with those who died in either bridge or recovery groups and all patients who had a CPB greater than 4 hours died on MS or after transplantation or weaning. In conclusion, preoperative indices indicating reversibility of multiple organ dysfunction remain to be identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting survival in total artificial heart recipients before transplantation

To identify factors affecting the successful bridge to transplantation, experience with 32 recipients of the Jarvik-7 artificial heart was reviewed. Between patients with and without a successful bridge, there were no significant differences in preoperative hepatorenal function or postoperative hemodynamics, but there were significant differences in body size. When recipients were divided according to body surface areas of less than or greater than 1.8 m2, the smaller patients more frequently developed respirator dependence (73% vs. 18%, p less than 0.01), renal failure (53% vs. 18%, p less than 0.05), and hepatic failure and sepsis, resulting in less frequent qualification for transplantation (20% vs. 65%, p less than 0.05). There were no successful bridge operations in seven patients with body surface areas of less than 1.7 m2, and only one success in nine patients who were less than 170 cm in height, despite use of a smaller stroke volume model. The smaller patients had poorer ventricular filling, which was largely compensated for by the drive controls set for significantly longer diastole and higher vacuum, resulting in similar hemodynamics between the groups. The results suggest that device fitting as manifested by body size is an important factor affecting major organ recovery and subsequent transplantation in recipients of the Jarvik-7 artificial heart. A paracorporeal device may be advisable for patients with body surface areas of less than 1.8 m2 or who were less than 175 cm in height until an even smaller model with a better fit in the thorax becomes available.

Liver and kidney function in patients undergoing mechanical circulatory support with Jarvik-7 artificial heart as a bridge to transplantation

Changes in liver and kidney function were reviewed in 32 patients who received a Jarvik-7 total artificial heart (TAH) as a bridge to transplantation. Preoperatively, seven (22%) had significant isolated kidney dysfunction, five (15%) had isolated liver impairment, and 13 (41%) had combined disorder, affecting 25 (78%) of the 32 recipients. Immediately after TAH implantation, vigorous diuresis occurred, and biochemical indices improved in 17 patients: 71% of isolated kidney, 60% of isolated liver, and 38% of combined organ disorder were reversed irrespective of severity in preoperative dysfunction. In contrast, urine output remained poor, and biochemical indices continued to deteriorate in 15 patients regardless of preoperative status; as a result, kidney (28%), liver (17%), and combined organ failure (33%) accounted for a total of 78% of failure in this series. Although preoperative liver and kidney dysfunction were frequent and severe, they did not correlate with postoperative functional recovery and later transplantation. Recipient body size and initial postoperative urine output were found to be the variables discriminating patients with or without subsequent transplantation. Because liver/kidney failure remained as the leading cause of death, knowledge of the underlying cause of the organ failure would increase the success of TAH as a bridge to transplantation.

Heart transplantation: La Pitié experience, 1968-1989

Heart transplantation is now an accepted therapeutic modality for end-stage heart disease. However, better immunosuppressive treatments and new methods to monitor rejection or detect early atherosclerosis must be developed to improve the long-term results after heart transplantation.

Mechanical circulatory support as a bridge to transplantation: current status of total artificial heart in 1989 and determinants of survival

Since April 1986, 40 total artificial hearts (TAH) were implanted as a bridge to transplantation in our institution. In an attempt to identify factors affecting survival of TAH recipients we reviewed our experience over 1000 days of mechanical support. There was no postoperative bleeding requiring surgery nor were there any clinical episodes of thromboembolic complications. Over a total functioning period greater than 3 years there were no mechanical failures in the driving system but one artificial ventricle had to be replaced because of mechanical dysfunction. Infections and multiple organ failure were the primary causes of morbidity and mortality during mechanical support. When the patients who underwent staged transplantation (no. 17) were compared with those who died during mechanical support (no. 23) there were no differences in TAH driving mode or hemodynamic variables between the groups. Although preoperative pulmonary, hepatic and renal functions were found to be similar between the groups, there were significant differences in the early evolution (3 days) of hepatic and renal functions following TAH implant (p less than 0.01). Urinary output was found to be the earliest variable discriminating recovery and survival (p less than 0.01). Finally, univariate analysis indicated age (less than 40 vs greater than 40 years) and modality of cardiac decompensation (acute vs chronic) as the most important factors affecting survival after TAH implantation. Since young patients (less than 40 years of age) with acute decompensation were successfully transplanted in 82% of cases while 100% of older patients with chronic decompensation died before or after transplantation, TAH should be advised in young patients with acute or chronic heart failure and in selected older candidates with recent, acute cardiac failure.

Effects of methylphenidate on early adolescent growth

Thirty-one hyperactive adolescents treated with methylphenidate for at least 6 months demonstrated no significant deviation from expected height and weight growth velocities. In contrast to findings in prepubertal children, these results suggest that early adolescent growth is insensitive to methylphenidate.

[Cardiac surgery in patients over 80 years of age. Experience of a series of 51 patients]

Between January 1980 and June 1988, 51 patients over 80 years of age underwent open heart surgery at the La Pitié hospital (26 women and 25 men; average age 82 +/- 2 years, range 80-90 years). The cardiac pathology was calcific aortic stenosis (AS) in 40 cases, associated with coronary artery disease in 7 cases, mitral valve prolapse in 3 cases, coronary artery disease alone in 6 cases [complicated by a post-infarction ventricular septal defect (VSD) in one patient] or associated with aortic regurgitation in 1 case, and degeneration of an aortic bioprosthetic valve in 1 case. Forty patients (78%) were in Stage III or IV or the NYHA Classification. There was no other major pathology associated with the cardiac disease. Aortic valve replacement (AVR) was carried out in 42 patients, with a bioprosthetic valve in 38 patients. This procedure was associated with coronary bypass surgery in 7 cases and carotid artery surgery in 1 case. A mitral bioprosthesis was implanted in 2 patients and mitral valvuloplasty was carried out in 1 patient. An isolated myocardial revascularisation procedure was performed in 5 cases; the VSD was closed in 1 case. The hospital mortality was 17.6 per cent (9 patients). All deaths were of cardiac origin. Eleven patients had no postoperative complications at all. The 3 year survival rate of those who survived surgery was 71 per cent. Of the current 31 survivors, 29 are in Stage I or II of the NYHA Classification. These results suggest that surgery can be offered to octogenarians with invalidating cardiac disease alone carrying a poor short term prognosis.

Approach to advanced aortic root infection

Among our first 11,620 cases of valvular replacement, we observed 285 cases of valvular endocarditis and 59 cases (20.7%) in which the importance of the infectious lesions of the aortic or mitral annulus required complex valvular repair. In 23 patients with aortic valvular endocarditis, the presence of an abcess of the aortic annulus required its closure with a patch resulting in one early and one late death and five reinterventions with one death. Twenty patients are alive and well, 1 to 9 years after operation. In 11 patients, the extent of annular abcesses required the insertion of a subcoronary valved conduit. After a maximum follow-up of 8 years there were two early deaths, two late deaths, one reoperation, and seven good results. Twelve patients had a supracoronary valved conduit resulting in four early deaths, one late death, and two reoperations; seven are alive and well, 2 to 6 years later. Three patients previously operated on had a left ventricular abdominal aorta valved conduit, two of them are alive and well up to 6 years later. Severe infectious lesions of the valvular rings (aortic root) can require complex repairs that can be lifesaving and provide excellent long-term results.

Atrial natriuretic peptide level and intracardiac pressure in cardiac transplant recipients

Blood pressures and plasma atrial natriuretic peptide (ANP) concentrations have been measured in venous and intracardiac sites in 11 patients (10 men and 1 woman) given cardiac transplants. The mean plasma ANP level was 214.4 pg.ml-1 in the superior vena cava and 281 pg.ml-1 in the right atrium. This significantly higher level was maintained in the right ventricle (269) and in the pulmonary artery (295). The level in controls was 25 pg.ml-1. Intra cardiac and mean arterial pressures were in normal range in all patients, and there was no correlation between plasma ANP level and intracardiac pressure. The data suggest that in cardiac transplant patients right atrial pressure does not have a primary role in releasing ANP. The transplanted heart is denervated and remains so for many months after operation, thus suggesting that innervation is not obligatory for ANP secretion. Further studies are required to determine the relative contribution of donor and recipient atrial tissues to ANP secretion.

Cardiac transplant recipients with preoperative pulmonary hypertension. Evolution of pulmonary hemodynamics and surgical options

Among 48 consecutive patients with pretransplant pulmonary vascular resistance (PVR) greater than 4 Wood units, 38 patients underwent orthotopic heart replacement (OHT), and the remaining 10 received a graft in a heterotopic position (HHT). The OHT recipients were smaller (63 vs. 73 kg, p less than 0.05) and received a larger donor heart (donor-recipient, 109% vs. 79%, p less than 0.001) with a shorter graft ischemic time (108 vs. 139 minutes, p less than 0.05) than HHT recipients, reflecting patient selection and surgical complexity. Comparison between the hospital survivors and nonsurvivors identified the selection of HHT and graft ischemic time in excess of 150 minutes as potent risk factors. Immediately after transplantation, pulmonary artery (PA) pressures dropped to almost one half of preoperative values regardless of the mode of transplantation. Within the next 24 hours, however, the OHT group required lower doses of inotropes, had lower left atrial pressure (12 vs. 16 mm Hg, p less than 0.05), and were more frequently extubated (58% vs. 10%, p less than 0.01). Catheterization at 10 days revealed a doubled cardiac index and a dramatic reduction in PVR for both groups. The higher the preoperative PVR value, the more substantial the reduction observed, resulting in normalization of PVR for all survivors. The incidence of early graft failure was similar between the groups, but HHT recipients frequently developed pulmonary complications and infection, resulting in a 30% hospital survival in contrast to 71% in OHT recipients (p less than 0.05). The results suggest that transplant candidates with pulmonary hypertension might better be treated by OHT with an oversized, on-site, viable donor heart than by HHT.

Factors affecting survival after heterotopic heart transplantation

In an attempt to identify the factors that influence survival after heterotopic heart transplantation, 42 consecutive recipients of heterotopic heart transplant were reviewed. Preoperative pulmonary artery pressures, pulmonary vascular resistance, and donor age significantly differed between hospital survivors and nonsurvivors. Postoperative survival analysis between pairs of groups of patients divided by each of these variables disclosed a significant difference, which confirmed the effects of these variables on survival. Evolution of pulmonary hemodynamics was compared between patients with preoperative pulmonary artery diastolic pressure greater than 25 mm Hg (pulmonary hypertension; n = 22) or less than 25 mm Hg (nonpulmonary hypertension; n = 20). Despite marked differences in preoperative pulmonary hemodynamics, pulmonary artery pressures were dramatically reduced immediately after transplantation, and pulmonary vascular resistance diminished to upper normal limits at 10 days when there were no longer differences in pulmonary vascular resistance between the two groups. Immediate deaths were related to left ventricular failure, and the incidence was similar between the groups. Despite such normalization of pulmonary hemodynamics, patients with preoperative pulmonary hypertension experienced more frequent ventricular fibrillation, required longer respiratory support, and developed lethal pulmonary or systemic infection, which resulted in a 32% (7/22) hospital survival rate compared with 90% (18/20) in patients without pulmonary hypertension. Despite the dramatic improvement in pulmonary hemodynamics, heterotopic heart failed to demonstrate the expected advantages because of frequent pulmonary complications and infection, which resulted in failure to improve the prognosis of patients with preoperative pulmonary hypertension.

Heterotopic heart transplantation: current status in 1988

Among the 480 patients who underwent heart transplantation in our institution (since 1968), 40 patients received an allograft in the heterotopic position. The recipients were evaluated by using hemodynamics and Doppler echocardiography before and after surgery. Ten to 30 days after surgery, preoperative pulmonary artery pressure, pulmonary artery wedge pressure, and pulmonary vascular resistance (PVR) decreased significantly (p less than 0.005). Cardiac output increased significantly (p less than 0.0001). Postoperative Doppler echocardiography showed that heterotopic hearts had an excellent ejection fraction (mean 73% +/- 11%). No improvement occurred in the left ventricular function of the native heart. Among the factors affecting short-term prognosis of heterotopic heart transplantation (HHT) recipients. PVR seems to be the most important determinant of survival. HHT does not seem to improve the prognosis of patients with elevated PVR. HHT, however, is still indicated in large patients and in emergency situations in which an available donor heart appears unable to support the recipient's circulation if used in the orthotopic position.

Hemodynamic characteristics of the Jarvik-7 total artificial heart

To identify the optimal means of artificial circulation, driving controls and resultant hemodynamics were correlated with clinical outcomes in 37 Jarvik-7 recipients up to 72 hours after implantation. When patients with subsequent transplantation (n = 16) were compared with those who died on the Jarvik-7 heart (n = 21), there were no significant differences in total artificial heart driving mode such as frequency, ventricular driving pressures, systolic-diastolic ratio, or vacuum use, nor were there any differences in the hemodynamics achieved, such as device output (cardiac output) or atrial filling pressures, throughout the observation. However, improvements of other organ functions, especially kidney and liver, were remarkable in that transplant patients immediately experienced increased urine output and reversal of secondary organ dysfunction. The nontransplant group failed to diurese and continued to deteriorate despite similar hemodynamics. When a smaller model of the Jarvik-7 (volume of 70 ml, n = 18) was compared with the standard model (volume of 100 ml, n = 19), again there were no significant differences except that ventricular stroke volume was consistently less for the 70-ml model. Because of a slightly higher heart rate in the smaller model, device output did not differ between recipients of the two types. The results suggest that once successfully implanted, the Jarvik-7 provides adequate perfusion without associated mortality from circulatory failure, regardless of the size of the ventricle. Recovery from other organ failure appears to be independent of postimplant hemodynamics, a phenomenon that suggests the importance of preimplant status and patient selection.

Heart and unilateral lung transplantation in patients with end-stage cardiopulmonary disease and previous thoracic operations

Orthotopic en bloc transplantation of the heart and one lung has been done in two patients with end-stage cardiopulmonary disease and a prior thoracic operation. The first patient had undergone right pulmonary thromboembolectomy with caval ligation 5 years earlier, and the second had had left lower lobectomy for bronchiectasis 15 years before the heart and contralateral lung transplantation. Surgical procedures followed the techniques that had been developed in animals. Transplantation of the unoperated contralateral lung made it possible to avoid dissection in the obliterated pleural space and to minimize bleeding, which simplified the procedure considerably. Dramatic reduction in pulmonary artery pressure and improved respiratory function allowed both patients to be weaned from cardiopulmonary bypass without problems. Although the first patient died of liver and renal failure soon after the operation, an intact cough reflex facilitated recovery in the second patient, who has been discharged with essentially normal respiratory function. This report describes heart and unilateral lung transplantation as a procedure of choice for patients with extensive pleural adhesions that made total cardiopulmonary replacement unfeasible.

Home positive pressure ventilation via nasal mask for patients with neuromusculoskeletal disorders

29 patients with chronic respiratory failure due to neuromuscular deficits and restrictive chest wall disorders were treated with nocturnal ventilation via nasal mask at home for at least one year. Home ventilation was provided by a volume cycled positive pressure ventilator attached to a nasal mask which was made to measure by modelling silicon paste onto the patient's face. This method was well tolerated. The majority of the symptoms of hypoventilation rapidly disappeared with nocturnal ventilation and the daytime PaO2 and PaCO2 improved significantly allowing the patients to perform more daily activities. Nocturnal nasal ventilation is efficient but needs strict supervision. The nasal mask can replace or postpone tracheostomy which, if needed, remains a possible and efficient method.

Respiratory effects of the Jarvik-7 artificial heart

In five anesthetized patients with a Jarvik-7 artificial heart, pulmonary volume displacements generated by cardiogenic oscillations were measured using an indirect spirometric method. Consequences on gas exchange were also evaluated during a 15-min period of apnea by use of a tracheal insufflation of pure O2 at a constant flow rate of 20 l/min. The Jarvik-7 artificial heart generated a mean pulmonary volume displacement of 105 +/- 29 (SD) ml/heart beat. After 15 min of apnea, arterial PCO2 (PaCO2) significantly increased from 29 +/- 5 to 47 +/- 6 (SD) Torr. PaCO2 increased by 0.8 Torr/min from the 5th to the 15th min of apnea. Mean arterial PO2, mean pulmonary shunt, mean O2 consumption, and mean metabolic production of CO2 did not change significantly during the apnea period. Because cardiac output was kept constant during the study, O2 transport was adequately maintained throughout the apnea period. In patient 1, where the period of apnea was continued for 60 min, PaCO2 progressively increased until the 45th min and then remained stable at 61 Torr during the last 15 min of apnea. This "plateau" corresponded to an alveolar ventilation of 3,907 ml/min, representing 69% of the alveolar ventilation calculated during conventional mechanical ventilation. In conclusion, the Jarvik-7 artificial heart provides a potent respiratory support through the cardiogenic oscillations it generates.

Orthotopic transplantation after implantation of a Jarvik 7 total artificial heart

A total artificial heart was used to support the circulation in 33 heart transplantation candidates who were expected to die before procurement of a donor heart. Twelve of these patients (mean age 35 +/- 10 years) underwent cardiac transplantation. Another patient is still being supported with the total artificial heart 90 days after implantation. The other 20 patients died during mechanical support because their condition could not be stabilized for transplantation, despite blood flow restoration. Fifty-six percent of the patients younger than 40 years underwent successful transplantation and six of nine patients are long-term survivors. By comparison, in the older group, 17.6% of patients underwent transplantation and one of three survived long term. Forty-four percent of patients in the acute decompensation group had successful transplantation and four of seven patients are long-term survivors. In the chronic decompensation group these figures were 29.4% and three of five patients. All patients who were heavily immunosuppressed (n = 4) died of sepsis. Transplantation was considered and performed only when the patient's condition was correct and stable. In six patients an infection developed in the immediate posttransplant period. Three of the infections were resolved with antibiotic therapy. One originated in the mediastinum and is still unresolved, although the patient's condition is improving. Another patient died of an anoxic coma caused by ventilatory problems. There were two late deaths at 14 and 19 months, one resulting from a combination of toxoplasmosis and rejection and the other from a Kaposi sarcoma caused by azathioprine treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Current problems in cardiac transplantation

Since our initial orthotopic heart transplant (OHT) in 1968, the first in Europe, 1130 patients with ages ranging from 1 month to 66 years have been referred to us. The cause of irreversible myocardial damage was idiopathic cardiomyopathy in 74%, ischemic heart disease in 19% and left ventricular failure after valvular replacement in 7%. A total of 540 transplantations, 463 orthotopic, 40 heterotopic and 37 heart-lungs were carried out. Features of the early post-operative course include temporary (first week) cardiac instability treated by isoproterenol. Later complications included rejection (95%) and side-effects of immunosuppressive therapy; infection (83%), osteoporosis, malignancy, graft atherosclerosis (2%). Cyclosporine (Cy) was responsible for diastolic hypertension, renal dysfunction, hirsutism, hyperplasia of the gingiva, hepatic dysfunction, and seizures. The survival rate of the Cy-treated patients was 68% at 7 years. All survivors have virtually normal social and professional lives, included the longest survivor 14 years after the operation. Recently in 34 patients in acute irreversible cardiac failure and who cannot have a transplant in time, we implant a total artificial heart (TAH) type JARVIK 7 during a period from 1-150 days. There has been no mechanical failure, hemolysis or thrombo-embolism and only one right ventricular device malposition; 20 patients died before transplantation, 13 were successfully transplanted, 1 is still on the artificial heart. Heart transplantation, and TAH used as a bridge to transplantation are now an accepted therapeutic means for irreversibly cardiac failure in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Total artificial heart: survival and complications

A total artificial heart was implanted in 28 patients as a bridge to transplantation. Mean time of mechanical support was 14.8 +/- 10 days. The 70-mL Jarvik-7 was used in 12 patients and the 100-mL Jarvik-7 in the remaining 16. No clinical thromboembolic complications occurred during implantation. There was no postoperative bleeding requiring operation. Both survival and the rate of complications were similar in the two Jarvik-7 groups. Eleven patients underwent successful transplantation, and 1 patient is still on mechanical support. Sepsis and multiple-organ failure were the most important causes of death. All patients receiving the total artificial heart for severe acute rejection after transplantation died of infection. Early implantation of the total artificial heart is advised in younger patients and in older patients with acute cardiac failure. The use of this device should be contraindicated in immunosuppressed patients because of the high risk of infection.

Clinical application and patient selection in the use of a total artificial heart as a bridge for transplantation

Between April 1986 and July 1987, 21 patients underwent orthotopic implantation of a total artificial heart (Jarvik 7) at La Pitié Hospital. There were 18 men and 3 women with a mean age of 37.3 +/- 11.4 years. The device implanted was the 70 ml version in 10 patients and the 100 ml version in 11 patients. In the results, three variables were analysed: age, acute myocardial decompensation or chronic myocardial failure, and aetiology of the 21 patients treated. 10 (47.6%) had adequate support and were successfully transplanted. Eleven patients (52.4%) died during circulatory support. The main causes of death were sepsis and multiple organ failure. In only one patient was a mismatch between the heart and chest cavity present. There was no clinical evidence of thromboembolic complications. Patients of 40 years of age and less have an 80% chance of being successfully transplanted in comparison with a 25% success rate in older patients. Patients that developed sudden cardiac decompensation have a 75% success rate for transplantation in comparison with 44.4% success rate in patients with a chronic illness. Early implantation of the device, before the development of irreversible damage in other organs, is recommended in younger patients with acute or chronic disease and in older patients with acute myocardial failure. The use of this device is contraindicated in immunosuppressed patients due to the high risk of infection.

Renal function and blood pressure in heart transplant recipients treated with cyclosporine

Cyclosporine, a cyclic endecapeptide of fungal origin, has been used for nine years in clinical transplantation to suppress allograft rejection. Nephrotoxicity represents the most frequent and severe complication associated with its use and may ultimately define the limits of its utility as a drug for long term immunosuppression. However, this nephrotoxicity cannot be truly assessed in kidney transplant recipients for obvious reasons. It has recently been reported in heart transplant recipients. In addition, cyclosporine therapy is responsible for a persistent elevation of blood pressure requiring intensive and combined anti-hypertensive regimens. This hypertension develops within the first weeks post-transplantation in 60% to 90% of heart allograft recipients. This study analyzes the renal function and blood pressure of patients operated on in our department where cyclosporine was introduced in 1981.