Heart transplantation: are there psychosocial predictors for clinical success of surgery?

50 adult patients were extensively psychosocially examined before undergoing heart transplantation. The data obtained and the clinical treatment data were compared with the clinical success of surgery (four groups ranging from excellent to unsatisfactory as determined by the surgeon one year after transplantation). Statistical evaluation by discriminant analysis resulted in the following predictors for successful surgery (all psychosocial): empathy, care and support by one partner (affective involvement), few demands for emotional communication (affective expression), self-control, ability to take stress, emotional stability, high frustration tolerance, low aggression level, and younger age. The following variables did not have predictive significance: schooling, occupation, social status, indication for transplantation, length of stay in intensive care and in hospital, extent of preoperative anxiety and depression, and the life-quality index according to Spitzer determined externally. The results show support by the partner to be the most significant psychosocial variable that can influence the clinical success of heart transplantation.

Aprotinin does not decrease early graft patency after coronary artery bypass grafting despite reducing postoperative bleeding and use of donated blood

Forty-five male patients with planned coronary artery bypass operation were randomized in a double blind fashion to receive either 6 million kallikrein inactivator units of aprotinin (high-dose group), 2 million kallikrein inactivator units of aprotinin (low-dose group), or placebo (control group). Postoperative bleeding was significantly decreased in both aprotinin groups in comparison to that in the control group (590 ml [290 to 1800 ml] high-dose group and 650 ml [280 to 1900 ml] low-dose group versus 920 ml (350 to 2700 ml) control group, p < 0.001). There was no difference between the two aprotinin groups. The need for postoperative blood transfusion was significantly lower in the aprotinin groups (1.46 [0 to 4] blood units high-dose group and 1.65 [0 to 5] blood units low-dose group versus 2.43 [0 to 7] blood units control group, p < 0.05). All patients underwent coronary angiography between the seventh and twelfth postoperative day. No difference was found among the three groups in patency of vein grafts-93.8% in the high-dose group, 94.5% in the low-dose groups, and 93.3% in the control group. Therefore, aprotinin significantly reduced postoperative bleeding and transfusion requirement after coronary artery bypass grafting without influencing early graft patency.

Myocardial protection with Bretschneider cardioplegic solution--an evaluation of full oxygenation

In the present study the effect of oxygenated Bretschneider cardioplegia on high-energy phosphates [adenosine triphosphate (ATP), adenosine diphosphate (ADP) and creatine phosphate (CP)] and hemodynamics was evaluated in the isolated working rabbit heart. Hearts were obtained from 37 adult white Elco rabbits (3,100 +/- 110 g). After a 20-min working period 14 hearts were arrested with Bretschneider cardioplegia (8 degrees C) oxygenated with 98% oxygen (O2) and 2% carbon dioxide in comparison to 14 hearts receiving Bretschneider solution saturated with 98% nitrogen (N2) and 2% carbon dioxide as a control group for either 60 or 90 min (O(2)60, O(2)90, N(2)60, N(2)90 groups, n = 7). Seven hearts were used to determine preischemic baseline values of ATP, ADP and CP, 2 were excluded. The results showed a significantly poorer preservation of high-energy phosphates in hearts receiving oxygenated Bretschneider cardioplegia as compared to hearts receiving nitrogenated cardioplegia (p < 0.05). Postischemic recovery of hemodynamics did not demonstrate any statistically significant differences between the groups. However, the intragroup analysis showed a tendency towards weaker hemodynamic recovery in hearts treated with oxygenated cardioplegia. in contrast to the beneficial effect of oxygenated St. Thomas solution. In conclusion our findings suggest that oxygenated Bretschneider cardioplegia leads to significantly poorer preservation of high-energy phosphates and depressed hemodynamic recovery.

Postischemic hemodynamic changes after piroximone administration in isolated rabbit heart

In an experimental study on 22 adult Elco rabbits, hemodynamic parameters were investigated using a working heart model. The study group (10 rabbit hearts) received 1 mg/kg i.v. of the phosphodiesterase inhibitor piroximone 15 min before thoracotomy. 12 untreated rabbit hearts served as a control group. Hemodynamic parameters were measured before and after 60 min of hypothermic ischemia. The pre-ischemic period showed no significant differences between the two groups, except the higher levels of coronary flow in the piroximone group. The postischemic period showed significant increases in heart rate, coronary flow, aortic flow and cardiac output in the piroximone group in comparison to the control group. These results indicate as a main effect the positive influence of piroximone on coronary flow, given as a single shot 15 min preoperatively. This study provides evidence of the vasodilative properties on the coronary arteries beside the documented effects on the periphery. Therefore, piroximone represents an alternative tool in weaning from the cardiopulmonary bypass.

New developments in the isolated working heart: a comparison of neonatal, immature, and adult rabbits after sixty minutes of ischemia in respect to hemodynamic and biochemical parameters

Hemodynamic and biochemical changes were studied on 36 white ELCO-rabbits, seven adult older than 150 days, seven immatures between 21 and 27 days, and seven neonatals between 7 and 14 days. Five supplementary hearts of each age group served for preischemic biochemical values. Protection during 60 min of global ischemia was provided by topical cooling and selective coronary perfusion with Bretschneider cardioplegia (8 degrees C). A comparison between pre- and postischemic results showed decreases in coronary flow in the adult (p < 0.004), aortic flow (p < 0.04), cardiac output (p < 0.02), and stroke volume (p < 0.02) in the neonate. The preservation of ATP and CP was sufficient in the adult and immature myocardium, whereas a significant decrease in neonatal ATP was found (p < 0.01). According to these findings we consider immature myocardium to be more resistant against ischemia than the two other age groups. The apparatus used is a development of the conventional working heart, but combines a physiological flow-pressure relation, with instruments guaranteeing high accuracy, devices for drug application, and fits for different sizes of hearts. Therefore, this new approach promises to be of clinical relevance for investigations on the improvement of myocardial protection in both adults and children.

Anomalous origin of the left coronary artery: a review of surgical management in 13 patients

Over the last decades, surgical management of anomalous left coronary artery originating from the pulmonary artery (ALCAPA) has seen a considerable evolution. Between 1965 and 1992, 13 children with age at operation ranging between 2 months and 11 years (mean 23 months) underwent one of 5 different surgical procedures: ligation (n = 3), direct aortic reimplantation (n = 7), subclavian (n = 1) or internal mammary (n = 1) artery anastomosis, or modified aortic implantation (Vigneswaran-procedure, n = 1). There were 3 early and one late deaths resulting in an overall mortality of 30.7%. Mortality was 66.7% in the ligation group, and 20% in the revascularization group (28.6% in the subgroup with direct aortic implantation). The one late death occurred 6 months after ligation. Follow-up ranges between 3 months and 21 years, mean 7.3 years. All but one survivors are in NYHA functional class I. Following operative correction, there was clear improvement in left ventricular performance. Our data give reason to suggest ALCAPA to be more frequent than considered so far. Early surgery is recommended in all patients with ALCAPA, regardless of age or symptomatic status. Reestablishment of a two-coronary system is considered the procedure of choice. All survivors require long-term follow-up controls of early recognition of residual or progressive cardiac problems.

Early experience with sequential bilateral lung transplantation

We performed 20 sequential bilateral lung transplantation in 19 consecutive patients from April 1990 to May 1992. Perioperative mortality was low (2 patients). One-year actuarial survival was 70%. All survivors had normal blood oxygen tension (82 mm Hg, mean) while breathing room air and continuing improvement of pulmonary function. Bronchial dehiscence did not occur. Stents were implanted in 7 patients to control bronchial stenosis. Aggressive treatment of graft rejection has been effective in preventing obliterative bronchiolitis.

[Cytomegalovirus infection following lung transplantation]

The significance of cytomegalovirus (CMV) infection after lung transplantation was investigated in 20 patients (ten women and ten men; mean age 46 [21-67] years). Indications for transplantation were emphysema (n = 6), cystic fibrosis (n = 2), primary pulmonary hypertension (n = 2), pulmonary fibrosis (n = 5), obliterating bronchiolitis (n = 2), cystic lung (n = 2) and bronchiectasis (n = 1). Incidence, diagnostic parameters (serology, virus isolation and histology) and efficacy of prophylactic and therapeutic measures were recorded. 16 of the 20 patients developed a CMV infection, which in 12 was clinically significant. CMV pneumonia developed in two patients, proving fatal in one. The infection occurred a median of 47 (17-200) days after the transplantation. Administration of Ganciclovir (5 mg/kg twice daily intravenously) brought about remission of symptoms in all but one of the patients and improved the clinical parameters.--This experience demonstrates that regular monitoring of the patients for possible CMV infection and its early therapy can achieve a low death rate.

Living with a donor heart: feelings and attitudes of patients toward the donor and the donor organ

For the patient, heart transplantation means more than an operation; adjustment to its rigors requires a high degree of personal strength and adequacy of coping skills. The goal of our study was to gain insight into how heart transplant patients cope with the fact that their own heart has been replaced by a donor organ from an unknown dead donor who was the target of disease, accident, or even suicide. Over a period of 2 years 44 transplant patients were interviewed after rehabilitation in a semi-structured interview regarding their feelings about and reactions to the graft and the donor. Their answers were recorded, transcribed, and analyzed as to content. Three groups of patients were identified: (1) the complete deniers (N = 15), who denied thinking about the donor; (2) the partial deniers (N = 17), who were aware of avoiding thinking about the donor; and those who coped (N = 12), who accepted the death of the donor as reality and also reported having more or less close connections with the donor. Eighty-two percent of the patients interviewed accepted the donor heart immediately as their own, whereas the remaining 18% avoided talking and thinking about the graft and donor. The findings are supported by verbatim statements of patients. The role of defense mechanisms in heart transplant patients is discussed.

Psychosocial problems of donor heart recipients adversely affecting quality of life

Heart transplantation has become an accepted therapy for patients suffering from terminal heart disease for whom neither standard forms of medication nor the usual surgery are of any benefit. Although results regarding postoperative quantity and quality of life are encouraging, it must not be overlooked that the patient and his family face, and have to overcome, profound psychosocial problems. The main stressors were identified in interviews with 47 heart transplant patients. The main preoperative problems were: the way of being informed about the diagnosis, the waiting period for transplantation, anguishing doubts about the decision to have a transplant, being a body without heart ('zombie'), guilt and shame regarding the donor, the reactions of others. Postoperatively the patients have to cope with: re-entering social systems, reactions of friends, neighbours and colleagues, rejection episodes, death of a fellow patient, the need to redesign family life. All the problems reported by the patients interviewed are discussed regarding their psychosocial implications, and hints are given on how to minimize them.

Does changing the heart mean changing personality? A retrospective inquiry on 47 heart transplant patients

Heart transplantation is not simply a question of replacing an organ that no longer functions. The heart is often seen as source of love, emotions, and focus of personality traits. To gain insight into the problem of whether transplant patients themselves feel a change in personality after having received a donor heart, 47 patients who were transplanted over a period of 2 years in Vienna, Austria, were asked for an interview. Three groups of patients could be identified: 79% stated that their personality had not changed at all postoperatively. In this group, patients showed massive defense and denial reactions, mainly by rapidly changing the subject or making the question ridiculous. Fifteen per cent stated that their personality had indeed changed, but not because of the donor organ, but due to the life-threatening event. Six per cent (three patients) reported a distinct change of personality due to their new hearts. These incorporation fantasies forced them to change feelings and reactions and accept those of the donor. Verbatim statements of these heart transplant recipients show that there seem to be severe problems regarding graft incorporation, which are based on the age-old idea of the heart as a centre that houses feelings and forms the personality.

The determinants of elevated total plasma cholesterol levels in cardiac transplant recipients administered low dose cyclosporine for immunosuppression

Elevated total plasma cholesterol level is a frequent finding after cardiac transplantation. To identify risk factors for the development of hypercholesterolemic states, we applied multivariate statistics in a logistic and linear manner. Six-month posttransplantation levels of total plasma cholesterol in 57 adult heart recipients were available for analysis. Maintenance immunosuppression was carried out with either cyclosporine and azathioprine or both agents plus low-dose steroids. Total plasma cholesterol levels were dichotomized for the logistic analysis (1) by the age- and sex-matched 75th and 90th percentiles of a reference population according to National Institutes of Health treatment guidelines and (2) by the cut point 250 mg/dl. Twelve potential risk factors were evaluated as covariates: recipient age, body weight after 6 months, body weight gain over 6 months, body mass index after 6 months, body mass index gain over 6 months, current cyclosporine dosage, trough level of cyclosporine in whole blood according to high-performance liquid chromatography after 6 months, cumulative cyclosporine dosage over 6 months, serum bilirubin, type of original cardiac disease, maintenance steroids, and steroid bolus treatment. Multivariate logistic regression yielded the type of original cardiac disease as a significant predictor of posttransplantation hypercholesterolemia exceeding the 90th percentile (p = 0.019) and of hypercholesterolemia exceeding 250 mg/dl (p = 0.032). Maintenance steroids were identified as a second significant cofactor (p = 0.069) for total plasma cholesterol levels exceeding 250 mg/dl. Multiple linear regression again revealed the type of original cardiac disease and maintenance steroids as significant predictors by p values of 0.005 and 0.013, respectively. Patients with coronary artery disease as the original cardiac pathology and low-dose maintenance steroids had the greatest risk for the development of elevated total plasma cholesterol levels after cardiac transplantation. However, the overall predictive quality of the linear model was limited (multiple r value 0.43), which indicates that other variables besides the tested ones attributed to elevated total plasma cholesterol levels. These results confirm the adverse role of maintenance steroids on posttransplantation hypercholesterolemia and demonstrate the type of original cardiac disease as the most important risk factor. They suggest that abnormalities of lipoprotein metabolism and dietary factors continue to affect total plasma cholesterol levels after cardiac transplantation.

One and one-half year experience with unilateral and bilateral lung transplantation

Lung transplantation has now become an established form of treatment for end-stage pulmonary parenchymal and vascular diseases. Despite its wide acceptance, technical aspects are still in discussion. We report on the initiation of our own lung transplant program and the technical changes we have performed during our first 1 1/2-year experience. During that period of time, we have performed 26 lung transplantations (16 single lung [SLTX] and 10 bilateral lung transplantations [BLTX]). Three-month survival for the whole group was 74% (69% for the SLTX group and 77% for the BLTX group). No instance of bronchial dehiscence was observed; however, there were eight cases of bronchial stenosis: six were managed by silicone stent insertion, one by bronchoplastic correction, and one by retransplantation. Changes in the technique of the bronchial anastomosis together with the addition of prednisone to the immediate postoperative immunosuppressive regime resulted in almost complete avoidance of these problems.

Early results with the anatomical correction of transposition of the great arteries

From November 1984 to April 1991, 38 children underwent an arterial switch operation for transposition of the great arteries (TGA). In 24 infants (mean age 8 days) TGA with intact ventricular septum was present, in 14 patients (mean age 75 days) TGA was combined with a ventricular septal defect (VSD). There were 11 in-hospital deaths with an overall mortality of 29%, mainly due to technical problems. Whereas the group TGA + VSD showed a mortality rate of 50%, simple TGA and the subgroup simple TGA younger than 14 days had a mortality rate of 16.7% and 17.4%, respectively. Mortality was not influenced by coronary artery morphology and age. In simple TGA, the data presented suggest that this operation can be performed with good short-term clinical results. Most children are asymptomatic and without medication at a mean follow-up time of 2.5 years; but as there are pathological postoperative findings in echocardiography, the long-term benefit remains a matter of concern. Considerable perioperative problems are present in cases of TGA + VSD so surgical management is more differentiated, including other options.

["You need a new heart". The problem of diagnostic disclosure from the viewpoint of the affected cardiologic patient]

Heart transplantation has become a reasonable therapeutic option in treatment of patients with terminal heart diseases. Though it offers increased quantity as well as improved quality of life, information about needing a donor heart is a turning point in the patient's life. The aim of the study was to evaluate through postoperative interviews how that information was given by the doctors and how the patients had coped with it. It could be shown that 19 of the 49 interviewed patients took the information about needing a new heart as an expected event and chance, while for the remaining 30 it absolutely meant an unexpected information and a shock. Furthermore, only 3 persons reported about having had a helpful and empathic talk to their doctors. 26 about nothing but a short, cool information, and 10 held the shock about the way of information given by the doctors responsible for their bad preoperative psychical condition. Statements of patients are given to elucidate the results, which were discussed from the point of psychosomatics as well as from the communication sciences. At last, summarizing, rules for a helpful pretransplant-information to the patients were given.

[Quality of life and personal satisfaction following heart transplantation: an indicator of treatment results]

Cardiac transplantation is an established method of treatment to prolong survival in terminally-ill patients with severe heart disease. This study was undertaken to evaluate the quality of life and its best expression as satisfaction in patients who had undergone cardiac transplantation one year previously. From a total of 47 patients (14 with coronary artery disease, 27 with dilated cardiomyopathy and six with valvular heart disease), self-assessment questionnaires were completed to judge postoperative improvement/deterioration (change of status) and satisfaction with the level achieved as designated on the basis of visual analogue scales. Quality of life and satisfaction were assessed in nine categories: physical, emotional, mental, vocational, sexual status, financial situation, leisure activities, partnership and overall quality of life. The data was analyzed with the Wilcoxon and Kruskal-Wallis tests. The patients reported a consistent improvement in quality of life and satisfaction with respect to all categories except financial situation. Accordingly, quality of life after cardiac transplantation can be regarded as substantially improved. While most marked improvement was incurred in physical status and, consequently, overall quality of life, there was also a meaningful salutary effect on psychosocial aspects of life such as emotional well-being and leisure time activities. There were significant differences between change of status postoperatively and satisfaction with the level achieved in the categories of mental and vocational status, financial situation and partnership as well as family relations. Statistical analysis showed that outcome with respect to quality of life and satisfaction was not dependent on the underlying disease or the age of the patient at the time of transplantation.

[Unilateral lung transplantation as an effective therapy in primary lung emphysema]

Unilateral lung transplantation is the treatment of choice for terminal restrictive lung disease. We report about three patients with end-stage pulmonary emphysema treated by single lung transplantation. All patients are alive 3, 6 and 7 months after the operation with good quality of life. Blood gases have normalized and lung function parameters have markedly improved. We conclude, that single lung transplantation can be an effective treatment for selected patients with end-stage obstructive lung diseases in the absence of chronic infections.

Domino transplantation of heart-lung and heart: an approach to overcome the scarcity of donor organs

The scarcity of donor organs remains the main restricting factor for heart, heart-lung, and lung transplantation. Recently new techniques for separate harvesting of the heart and the lungs from one donor for two recipients have been developed. These techniques enable the optimal use of available grafts. Another approach to this problem is combined heart-lung transplantation for patients with end-stage lung disease but still adequate heart performance, and the subsequent transplantation of the recipient's heart into a second patient with end-stage heart disease. The main advantages of this procedure are its technical simplicity compared with double lung transplantation; the preservation of aortobronchial collaterals, resulting in improved blood supply to the trachea; and the possibility of transplanting a conditioned right heart well adapted to chronically elevated pulmonary pressure. We recently have performed this procedure with good clinical results and suggest it as the method of choice whenever two well-matched recipients are available.

[The hyperventilation syndrome as psychosomatic components of heart transplantation: case study]

The case study presents a patient with severe disturbance of self-esteem, suicidal family-background, narcissistic trauma and psychosomatic illness in form of a hyperventilation syndrome in the light of his heart transplantation. Helplessness and hopelessness of his psychological situation, his fear of separation, his paralyzing inability to come to any decision are seen against the background of a situation of absolute stress in which he had to struggle against his anxieties and fears and presumptions about the donor organ. There also is discussed whether a patient with such severe disturbances should really be accepted as a donor organ recipient, as well as whether in this case a supportive or analytic therapy would have been the appropriate choice. Annotations of the author about personal difficulties in therapy and at last its failing are added.

Independent risk factors predicting acute graft rejection in cardiac transplant recipients treated by triple drug immunosuppression

To assess independent risk factors predicting the occurrence of clinically significant acute rejection episodes in the first 6 months after cardiac transplantation, we performed a multivariate stepwise logistic regression analysis. Forty-three recipients, undergoing transplantation between September 1986 and May 1988, were eligible for analysis and received standardized, low-dose triple drug maintenance immunosuppression with cyclosporine, azathioprine, and prednisolone. Immunoprophylaxis was supplemented perioperatively with either a polyclonal (antithymocyte globulin, N = 26) or a monoclonal (OKT3, N = 17) anti-T-cell antibody. Investigated, conceivable risk factors comprised recipient and donor age, ischemic time, perioperative anti-T-cell antibody prophylaxis, recipient preoperative status, underlying disease, previous cardiac operation, and histocompatibility parameter (mismatches for HLA-A, HLA-B, HLA-DR, HLA-B+DR, HLA-A+B+DR, and Rh0[D] antigen, HLA-DRw6 positive recipient, and identify for ABO system). Univariate analysis suggested significant influence of the type of antibody used perioperatively (p = 0.0024) and the number of mismatches for HLA-A+B+DR (p = 0.0037) and for HLA-B+DR (p = 0.0043). Stepwise logistic regression yielded the number of mismatches for HLA-B+DR (p = 0.0029) and the type of antibody used perioperatively (p = 0.0031) as being highly significant predictors of acute cardiac rejection. Six-month freedom from rejection was 100%, 41%, and 27% for recipients with two, three, and four mismatches for HLA-B+DR and 59% versus 22% for recipients with polyclonal versus monoclonal antibody prophylaxis. Similar to results with kidney transplantation, these results indicate that a poor donor/recipient match for combined HLA-B+DR loci constitutes an independent risk factor for acute graft rejection in low-dose triple drug immunosuppressed cardiac recipients, which stimulates the potential concept of prospective HLA matching. In our experience OKT3 prophylaxis provides significantly less effective prevention of acute rejection than a comparable course of antithymocyte globulin.