Cardiac transplantation in patients over 60 years of age

Clinical outcomes of older adults listed for heart transplantation in the United States

OBJECTIVE

To examine if older age (>70 years) should be a relative contraindication for heart transplantation, we evaluated the characteristics and outcomes of patients with age ≥70 years listed for heart transplantation; and whether post-transplantation survival was inferior to younger counterparts.

DESIGN

Retrospective cohort analysis.

SETTING

The scientific registry of transplant recipients (SRTR).

PARTICIPANTS

Adults (≥18 years) listed for heart transplantation in the SRTR between 2000 and 2018.

INTERVENTIONS

Heart transplantation.

MEASUREMENTS

Characteristics and outcomes were compared for adults ≥70 years and <70 years. We evaluated waitlist mortality and post-transplant 1-year and 5-year survivals.

RESULTS

The study included 57,285 patients (age range 18-79 years) listed for heart transplantation; 1203 (2.1%) age ≥70 years. Of these, 37,135 patients underwent heart transplantation; 806 (2.2%) were age ≥70 years. Yearly listing of those age ≥70 years has consistently increased from 2.5% (n = 30) in 2000 to 11% (n = 132) in 2017 (p < 0.01). As compared with the age <70 years group, those ≥70 years had a similar risk of death while waiting (sub-hazard ratio [SHR] 0.86, 95% confidence interval [HR] 0.68-1.08; p = 0.19) but were more likely to be transplanted (SHR 1.36, 95% CI 1.26-1.48; p < 0.01). Among the older patients, the overall post-transplant 1- and 5-year mortality rate was 10.4% and 19.2%, respectively. Older recipients had lower unadjusted survival compared with younger recipients (log-rank p = 0.03). However, after adjustment for relevant covariates, there was no significant difference in 5-year mortality between both groups (HR 1.06, 95% CI 0.91-1.254; p = 0.43).

CONCLUSIONS

Post-transplant survival up to 5 years among patients of age ≥70 years was similar to that of younger recipients. Older patients who received heart transplantation appear to have lower risk features but receive hearts from higher risk donors. Chronologic age alone should not constitute a contraindication for heart transplantation, although careful patient selection criteria should be applied.

Heart transplantation in patients aged 70 years and older: a two-decade experience

OBJECTIVE

Advanced age has been viewed as a contraindication to orthotopic heart transplantation (OHT). We analyzed the outcome of OHT in patients who were aged 70 years or older and compared the results with those in younger patients during a two-decade period.

METHODS

A total of 519 patients underwent first-time single-organ OHT at our institution from 1988 to 2009. Patients were divided into three groups by age: ≥70-years old (group 1, n=37), 60 to 69-years old (group 2, n=206), and ≤60-years old (group 3, n=276). Primary endpoints were 30-days, and 1-, 5-, and 10-years survival. Secondary outcomes included re-operation for bleeding, postoperative need for dialysis, and length of postoperative intubation.

RESULTS

There was no significant difference in survival between the greater than or equal to 70-year-old group and the two younger age groups for the first 10 years after OHT. Survival rates at 30 days, and 1-, 5-, and 10-years, and median survival in group 1 recipients were 100%, 94.6%, 83.2%, 51.7%, and 10.9 years (CI 7.1-11.0), respectively; in group 2 those numbers were 97.6%, 92.7%, 73.8%, 47.7%, and 9.1 years (CI 6.7-10.9), respectively; and in group 3 those numbers were 96.4%, 92.0%, 74.7%, 57.1%, and 12.2 years (CI 10.7-15.4; P=NS), respectively. There was no significant difference in secondary outcomes of re-operation for bleeding, postoperative need for dialysis, and prolonged intubation among the three age groups.

CONCLUSIONS

Patients who are aged 70 years and older can undergo heart transplantation with similar morbidity and mortality when compared with younger recipients. Advanced heart failure patients who are aged 70 years and older should not be excluded from transplant consideration based solely on an age criterion. Stringent patient selection, however, is necessary.

Partial left ventriculectomy in elderly patients not suitable for heart transplantation

BACKGROUND

Although donor scarcity and intolerance to immunosuppression tend to exclude elderly patients from transplantation, partial left ventriculectomy (PLV) has been performed without bias against advanced age.

METHODS

Among 392 patients undergoing PLV, 61 elderly patients aged 65 or older (> or =65) were compared with the rest of the patients in terms of underlying disease, postoperative course, and survival time.

RESULTS

The aged patients (> or =65) compared to younger patients (<65), had ischemic disease (37.7% vs. 19.3%, p < 0.05) more frequently than cardiomyopathy (34.4% vs. 43.2%) or valvular disease (23.9% vs. 16.4%) and underwent lateral PLV (74% vs. 79%) more frequently than extended PLV (26% vs. 21%). Although the elderly patients required coronary bypass grafting more frequently (39.3% vs.17.2%, p < 0.05), surgical complexity was similar in terms of bypass time (63 minutes vs. 63 minutes) and percentage requiring cardiac arrest (31% vs. 44%). Despite advanced age, they required comparable ICU care (6.6 days vs. 5.4 days) and postoperative hospital stay (12 days vs. 11 days), resulting in a low but similar hospital survival (57% vs. 62%) and functional capacity after discharge (NYHA class 1.5 vs. 1.4).

CONCLUSION

The results suggest that PLV can be performed in elderly patients (> or =65 years) with comparable risks and benefits with the younger patients, promoting its application in patients disqualified for heart transplantation because of age criteria.

A Comparative Analysis of Outcome after Heart Transplantation in Patients Aged 60 Years and Older:. The University of Alberta Experience

BACKGROUND

The Registry of the International Society for Heart and Lung Transplantation (ISHLT) 2001 Annual Report indicated that the vast majority of heart transplant recipients are between 50 and 64 years of age. However, patient age beyond 60 years may have higher long-term mortality compared to younger patients. The purpose of this study was to compare short- and intermediate-term results including rates of acute rejection, transplant coronary artery disease, infections, malignancy, and mortality in cardiac transplant recipients 60 years or older with those below the age of 60 years.

METHODS

We retrospectively analyzed the results of 50 patients aged 60 years and older who underwent heart transplantation at the University of Alberta from January 1990 to December 2000 and compared them with the results of 225 younger patients undergoing heart transplantation in the same time period.

RESULTS

The older and younger groups had similar rates for treated acute rejection episodes (20.0% vs. 12.6%), transplant coronary artery disease (4.0% vs. 1.1%), and mortality (10.5% vs. 14.3%), respectively. No differences were noted with regards to quality and quantity of infection or malignancy rates. Five-year actuarial survival between the older and younger patients was also comparable at 89.5% vs.86.9% (p > 0.05).

CONCLUSIONS

Heart transplantation in patients 60 years of age and older can be performed as successfully as in younger patients (< 60 years) with comparable morbidity and mortality, suggesting that patient age per se should not be an exclusion criterion for heart transplantation.

Long-term results of cardiac transplantation in patients 65 years of age and older: a comparative analysis

BACKGROUND

Advanced age is viewed by some transplant centers as a contraindication for heart transplantation secondary to concerns regarding decreased survival.

METHODS

Between January 1992 and June 2002, 63 of 881 (7.2%) orthotopic heart transplants were performed in patients above 65 years. These patients were compared to 63 recipients below age 65 who were matched for sex, etiology of heart failure, United Network for Organ Sharing status, and immunosuppression therapy era.

RESULTS

Mean age was 67.1 +/- 2.3 years (range, 65.0 to 74.8) for the older group and 48.1 +/- 14.5 years (range, 18.3 to 64.4) for the younger group (p < 0.001). There was no significant difference in the incidence of diabetes, hypertension, chronic obstructive pulmonary disease, or peripheral vascular disease between the groups (p = not significant) although there were more patients with prior myocardial infarctions in the older group (p < 0.001). There was no significant difference in overall survival between the groups, with 1-, 3-, 5-, and 10-year actuarial survival of 85.8%, 80.3%, 73.1%, and 49.9% for the older group; and 86.9%, 83.4%, 75.0%, and 57.0% for the younger group (p = 0.597). Postoperative intensive care unit stay and overall hospital stay were similar for the two groups (p = not significant). There was no significant difference between the groups in freedom from infection or rejection at 1, 3, or 5 years after transplant (p = not significant) although the incidence of transplant coronary artery disease was higher in the older group (p = 0.025).

CONCLUSIONS

These data demonstrate similar short-term and long-term results for elderly and young recipients undergoing cardiac transplantation. This supports proceeding with transplantation in carefully selected elderly patients.

Long-term results of heart transplantation in patients older than 60 years

BACKGROUND

Advanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years.

METHODS

Between 1986 and 2001, 81 patients aged between 60 and 70 years (mean, 63 +/- 2 years) underwent heart transplantation. These patients were compared with 403 adult recipients younger than 60 years (mean, 47 +/- 11 years) who underwent transplantation during the same period.

RESULTS

Thirty-day mortality was 6% (5/81) and 6% (25/403) in the older and younger patients, respectively (P = NS). Actuarial survival at 1, 5, and 10 years was 88% +/- 4% versus 83% +/- 2%, 75% +/- 5% versus 69% +/- 2%, and 50% +/- 9% versus 51% +/- 3% in the older and younger patients, respectively (P = NS). Older patients had significantly fewer rejection episodes (P =.003). Freedom from allograft coronary artery disease at 1, 5, and 10 years was 98% +/- 2% versus 92% +/- 2%, 85% +/- 6% versus 76% +/- 3%, and 81% +/- 7% versus 68% +/- 3% (P =.1). The incidences of infectious complication, cytomegalovirus infection, and posttransplant lymphoproliferative disorder were similar between the 2 groups, but older recipients were more likely to have a nonposttransplant lymphoproliferative disorder cancer (P =.002). Age at transplantation was not identified as an independent risk factor for early and late death.

CONCLUSION

Heart transplantation in selected patients aged 60 years and older results in survival comparable with that of younger patients. Older patients have a lower risk of rejection but an increased risk of development of a nonposttransplant lymphoproliferative disorder cancer. Advanced age per se should not be considered as an exclusion criterion for transplantation.

Heart transplantation in patients seventy years of age and older: A comparative analysis of outcome

OBJECTIVE

Advanced age has traditionally been considered a contraindication for heart transplantation because of the reported adverse effect of increased age on long-term survival. However, as the field of transplantation continues to evolve, the criteria regarding the recipient's upper age limit have been expanded and older patients are being considered as potential candidates. We analyzed the outcome of heart transplantation in patients 70 years of age and older and compared these results with those in younger patients (<70 years) over a 4-year period.

METHOD

We retrospectively analyzed the results of 15 patients 70 years of age and older who underwent heart transplantation between November 1994 and May 1999 and compared them with results in 98 younger patients undergoing transplantation during the same period

RESULTS

The older age group had a higher preoperative left ventricular ejection fraction (P =.02), higher incidence of female donors (P =.02), and longer cardiac allograft ischemic time (P =.01). No differences were found regarding incidence of diabetes mellitus, donor age, donor/recipient weight ratio, and mismatch (<0.80). The 30-day or to-discharge operative mortality was similar in both groups (0% in the older vs 5.1% in younger patients). Actuarial survival at 1 year and 4 years was not statistically different between the older and younger patients (93.3% +/- 6.4% vs 88.3% +/- 3.3% and 73.5% +/- 13.6% vs 69.1% +/- 5.8%, respectively). The length of intensive care unit stay and total post-transplantation hospital stay, incidence of rejection, and incidence of cytomegalovirus infection were similar between the groups.

CONCLUSIONS

Heart transplantation in selected patients 70 years of age and older can be performed as successfully as in younger patients (<70 years of age) with similar morbidity, mortality, and intermediate-term survival. Advanced age as defined (> or =70 years) should not be an exclusion criterion for heart transplantation. The risks and benefits of transplant surgery should be applied individually in a selective fashion.

An analysis of the effect of age on survival after heart transplant

BACKGROUND

Advances in immunosuppression and reports of improved survival after cardiac transplantation have led to a liberalization of traditional recipient eligibility criteria, especially age. While age alone is not a contraindication to transplantation, conflicting data exists regarding long-term survival of the older transplant recipient.

METHODS

One hundred-fifty three patients undergoing consecutive first time cardiac transplantation from June 7, 1985 through February 1, 1997 were studied. For purposes of analysis, patients were stratified according to age (<55 years vs. >55 years) and hospital and late outcomes determined.

RESULTS

The incidence of early and late acute cellular rejection was not different based up on age. The freedom from infection at 12 months was 54+/-5% for patients < or =55 compared to 32+/-8% for patients >55 years old (p = .04). Five year estimated survival for patients >55 years old was only 56+/-9% compared to 78+/-5% for patients < or =55 years old (p = .005). The hazard for death was highest within the first post-transplant year for older patients and was most commonly due to infection. Both advanced age and pre-transplant diagnosis of ischemic cardiomyopathy were found to be independently and additively predictive of reduced late survival.

CONCLUSIONS

In the present study, late survival was adversely influenced by advanced age. Older patients (>55 years) with pre-transplant diagnosis of ischemic cardiomyopathy were particularly at high risk (risk ratio 4.6:1) for death. Given little prospect of expanding the number of donor hearts, careful selection of patients over the age of 55 with pre-transplant ischemic cardiomyopathy is warranted.

The utility of exercise testing after cardiac transplantation in older patients

BACKGROUND

The criteria for cardiac transplantation recipient selection, including the appropriate recipient upper age limit, continue to expand with an increasing number of recipients greater than 60 years of age. While others have reported their transplant experience in older recipients in terms of quality of life assessment, we have examined the role of exercise cardiopulmonary testing post-transplantation in older cardiac transplant recipients.

METHODS

We reviewed inpatient and outpatient charts of 28 patients 60 years of age or older who underwent orthotopic heart transplantation at Vanderbilt University Medical Center.

RESULTS

In this population, perioperative mortality of 7.1% and Kaplan-Meier survival at 1 and 5 years of 89 and 77%, respectively, were similar to the institutional 1-year (89%) and 5-year (75%) survival among younger adult transplant recipients. Exercise cardiopulmonary testing results were available in 22/25 patients surviving greater than 1 year. Both peak oxygen consumption and percentage of maximum VO2 were significantly greater among patients reporting NYHA Class 1 or 2 functional status, in comparison with those NYHA Class 3 or greater.

CONCLUSION

Following cardiac transplantation, survival of patients greater than 60 years of age is equivalent to that of younger patients at our institution. Exercise testing provides an objective measure of performance and correlates with subjective status following heart transplantation. Most patients demonstrate good functional status, with minimal symptoms and good exercise capacity. These results, although retrospective, suggest that cardiac transplantation remains a reasonable therapeutic option for patients greater than 60 years of age with end-stage cardiomyopathy.

An update on transplantation in the geriatric heart transplant patient

Discussions of the ethics involved in allocating scarce resources often proceed without a grounding in factual experience. This study explored whether there was statistical evidence to support the use of set age limits in patient selection criteria for heart transplantation. Many transplant teams have selection criteria that include age limits, excluding patients more than 60 or 65 years of age from being considered as transplant candidates. The hypothesis was made that patients in the age bracket of 60-69 should have a comparable success rate with transplantation to that of younger recipients when selected by using the same medical and psychiatric criteria. Based on their clinical observations, the authors postulated that the elderly would report better quality of life postoperatively than younger control subjects.

Previous open heart operation: a contribution to impaired outcome after cardiac transplantation?

BACKGROUND

There is still debate about whether previous cardiac operations are a risk factor for patient outcome after cardiac transplantation. As waiting lists for cardiac transplantation increase, adverse outcome criteria should be identified.

METHODS

To assess this problem, we retrospectively analyzed 53 patients with previous cardiac operations before heart transplantation and compared them with 53 control patients matched for sex and age. Patient groups were analyzed regarding their preoperative, intraoperative, and postoperative variables and survival.

RESULTS

Ischemic times were comparable in both groups, but the duration of the operation was significantly longer in the study group (206.5 +/- 62.5 minutes, versus 156.0 +/- 36.7 minutes in controls; p < 0.05). In addition, postoperative blood loss was greater for the patients with previous cardiac operations (1,360 +/- 260 mL, versus 730 +/- 310 mL for controls; p < 0.01). Postoperatively, the rate of rejection episodes and the incidence of graft atherosclerosis were comparable within the first 2 years. However, survival was significantly reduced in the study group (60.1%) after 4 years (versus 83.1% for controls; p < 0.05).

CONCLUSIONS

Heart transplantation in patients with previous cardiac operations will lead to an impaired overall outcome. In addition, these patients have more postoperative complications.

Heart transplantation in patients 70 years of age and older: initial experience

BACKGROUND

Heart transplantation has become a highly successful therapeutic option for patients with end-stage cardiomyopathy. Consequently, the criteria for patient selection, particularly regarding recipients' upper age limits, have been expanded, with an increasing number of people older than 60 years of age now undergoing transplantation.

METHODS

A retrospective analysis of 6 patients 70 years of age and older who underwent heart transplantation was done; their clinical courses and outcomes were compared with those of younger patients, with a special emphasis on their posttransplantation quality of life.

RESULTS

All 6 patients are alive and clinically well at a mean follow-up of 12 months. No age-related complications have been observed, and their quality of life is excellent. There has been a very low incidence of rejection, as well as few episodes of rejection.

CONCLUSIONS

Heart transplantation in selected people 70 years of age and older can be performed successfully with a morbidity comparable to that seen in younger patients and excellent short-term survival. This initial experience is encouraging, but further studies and long-term follow-up are needed to validate the more routine application of this therapy.

Heart transplantation in patients 65 years of age and older: a comparative analysis of 40 patients

BACKGROUND

Advanced age has traditionally been considered a relative contraindication to heart transplantation because of the potential for increased morbidity and decreased long-term survival.

METHODS

We analyzed the results in 40 patients 65 years of age and older who underwent heart transplantation and compared them with those in 138 patients younger than 65 years.

RESULTS

The older age group had a higher incidence of diabetes mellitus (p = 0.01), donor-recipient weight mismatch (< 0.80) (p = 0.004), lower donor-recipient weight ratio (p = 0.02), and longer allograft ischemic time (p = 0.008), among other differences. However, the 30-day operative mortality was similar in both groups (2.5% in older versus 2.2% in younger patients). Actuarial survival at 12, 24, and 36 months was not statistically different between the older and younger patients (86% +/- 6% versus 93% +/- 2%, 78% +/- 8% versus 89% +/- 3%, and 72% +/- 9% versus 81% +/- 4%, respectively; p = 0.26). The posttransplantation intensive care unit stay, total hospital stay, and associated hospital costs were also similar. The incidence of rejection during the first posttransplantation year was similar in both groups.

CONCLUSIONS

Heart transplantation in selected patients 65 years of age and older can be performed successfully, with a morbidity and mortality comparable with those seen in younger patients. Advanced age should not be an exclusion criterion for heart transplantation, but selective criteria should be applied that identify risks and benefits individually.

Cardiovascular disease in elderly patients

OBJECTIVE

To provide an overview of the cardiovascular consequences of the normal aging process in humans and to review unique aspects of the diagnosis and management of heart disease in the elderly population.

DESIGN

We reviewed relevant published articles and summarized the diagnostic approaches and treatment recommendations for congestive heart failure, coronary artery disease, cardiac valvular disease, and arrhythmias in elderly patients.

RESULTS

The aging process is associated with predictable anatomic and physiologic alterations in the cardiovascular system. consequently, the manifestations of heart disease in the geriatric population differ from those found in younger patients. Additionally, outcomes of cardiac diseases and therapeutic options change with advancing age because of such factors as alterations in drug metabolism.

CONCLUSION

Age-related changes in the cardiovascular system result from intrinsic cardiac aspects of human senescence, primary cardiac disease, and influence of comorbid conditions on the heart. The natural history of heart disease is generally adversely affected by age. Although many treatment strategies with demonstrated efficacy in younger patients are relevant in the elderly age-group, careful attention to the influence of concomitant illness, the unique physiologic and pharmacologic changes, and the assessment of the potential effect of therapy on survival and quality of life is essential in treating elderly patients.

Long-term results of cardiac transplantation in patients older than sixty years. UTAH Cardiac Transplant Program

Advanced age has traditionally been a contraindication to cardiac transplantation. We have, however, offered cardiac transplantation to patients older than 60 years with end-stage heart failure if they were otherwise acceptable candidates. From 1985 to 1994, 527 patients underwent cardiac transplantation. Among these patients, 101 were older than 60 years at transplantation. The mean follow-up of this group is 6 years. Patients older than 60 years had significantly fewer rejection episodes per patient than those who were younger than 60 years at transplantation (1.9 +/- 1.3 vs 2.6 +/- 1.8, p = 0.009). No difference in the number of infectious complications per patient was detected between the two groups. Both short-term and long-term survival after transplantation were significantly lower for patients who were older than 60 years at transplantation than for younger patients (p < 0.05). The 6-year actuarial survival after transplantation for patients older than 60 years was 54% compared with 72% for patients younger than 60 years at transplantation (p < 0.05). Patients older than 60 years at transplantation were more likely to die of infectious complications or malignant disease after transplantation (p < 0.05). We believe caution is warranted in offering cardiac transplantation to patients older than 60 years. This group of patients should be carefully observed for the development of potentially life-threatening infectious complications or new malignant tumors after transplantation.

Determinants of hospital survival after cardiac transplantation

To identify the preoperative factors that influence hospital survival after transplantation we analyzed our consecutive experience of 183 transplantations in 179 patients over a 10-year period. There were 151 male and 29 female transplant recipients ranging in age from 10 days to 70 years (mean, 48 +/- 1 years). Diagnoses included coronary disease in 110 patients, cardiomyopathy in 55 patients, valvular disease in 6 patients, and congenital heart disease in 9 patients. Seventy-seven had undergone a previous cardiac operation, and 30 patients required preoperative mechanical support. Forty patients received hearts from donors who were 40 years old or older (range, 40 to 62 years). Ischemic time was greater than 240 minutes in 32 cases, and pulmonary vascular resistance was greater than 3 Wood units in 40 patients (range, 3.1 to 10.0 Wood units). Cyclosporine induction was used in 52 patients, whereas 128 recipients received polyclonal antibody prophylaxis. There were 25 hospital deaths. Recipient diagnosis, use of mechanical support, donor age, and the immune suppression protocol were related to hospital survival according to univariate analysis. Using multiple logistic regression, only the method of immune suppression induction and the use of mechanical assists were significant independent determinants of survival. In conclusion, we believe that extended ischemic times and donor age do not adversely affect the early success of transplantation, whereas induction with immune globulin may reduce early mortality. Patients requiring mechanical support before transplantation continue to be a challenge.

Cardiac transplantation: clinical aspects of recipient selection

The improved outcome following cardiac transplantation has produced changes in the traditional criteria for potential candidates. We have analyzed these changes and the clinical aspects involved in the selection process, which are of critical importance to assure an excellent result of cardiac transplantation in patients with advanced heart failure.

[Therapy of terminal heart failure using heart transplantation]

Heart transplantation (HTx) has now become an accepted treatment modality for end-stage heart disease. The limited supply of suitable donor organs imposes constraints upon the decision of who should be selected for transplantation. Usually patients are candidates for HTx, who remain NYHA functional class III or IV despite maximal medical therapy. Further criteria are low left ventricular ejection fraction (less than 20%) with heart rhythm disturbances class IIIA-V (LOWN), which are associated with poor prognosis. Additionally, the suffering of the patient and also the course of heart failure are essential for judging the urgency of HTx. Contraindications are absolute in patients with untreated infections, fixed pulmonary vascular resistance (PVR) above 8 WOOD-degrees, severe irreversible kidney and liver disease, active ventricular or duodenal ulcers and acute, psychiatric illness. HTx is relatively contraindicated in patients with diabetes mellitus, age over 60 years, PVR above 6 WOOD-degrees and an unstable psychosocial situation. To prevent rejection of the transplant heart, live-long immunosuppressive therapy is needed. Most immunosuppressive regimes consist of Cyclosporine A and Azathioprine (double drug therapy) or in combination (tripple drug therapy) with Prednisolone. For monitoring of this therapy, control of hole blood cyclosporine A level and white blood count is needed. Rejection episodes can be suspected if there is a greater than 20 mmHg decrease of systolic blood pressure, elevated body temperature, malaise, tachycardia or heart rhythm disturbance. The diagnosis of cardiac rejection can be established by endomyocardial biopsy. Measurement of the voltage of either the surface or intramyocardial ECG, echocardiography with special consideration to early left ventricular filling time as well as immunological methods are additionally used tools. Graft sclerosis as the main risk factor of the late transplant period remains an unsolved problem.

Cardiac transplantation. How recipients are selected

Your patients with heart disease may ask about transplantation. Those who are potential candidates need a physician who knows enough about the selection system to get them into it. For other patients, an explanation of why the procedure is contraindicated in their case can help them refocus on compliance with recommended therapy. The authors discuss the principles of recipient selection.

Cardiac transplantation beyond 55 years of age

Between January 1985 and December 1988, 20 patients over the age of 55 years (extremes 56-63 years; 15 men and 5 women) underwent cardiac transplantation. The cause of cardiopathy was ischemic in 70% of the cases. The immunosuppressive regimen consisted of cyclosporin A, corticoids, and azathioprine. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of corticoids or monoclonal antibodies (OKT3). The operative mortality was 10% (n = 2). The 1-year survival rate was 70%. The 1-year incidence of infection and/or rejection episodes was 1 and 1.53 episodes/patient, respectively. One patient was successfully retransplanted after 9 months because of intractable rejection. Age beyond 55 years is no longer a contraindication to cardiac transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.

Current status of cardiac surgery: a 40 year review

Cardiac surgery has undergone dramatic advancements during the past 3 decades. The introduction of cardiopulmonary bypass and cardioplegic arrest ushered in the true era of open heart surgery. Bioprostheses and mechanical valves as well as techniques for valve reconstruction permit routine repair or replacement of stenotic and regurgitant native valves. Progress in the disciplines of mechanical and electrical engineering has led to the development of pocket watch-sized, physiologically responsive pacemakers as well as a variety of circulatory assist devices that include the intraaortic balloon pump, ventricular assist device and total artificial heart. The synthesis of cardiotonic and vasoactive drugs and advancements in anesthetic management, postoperative monitoring and nursing care greatly facilitate perioperative patient management. This summary of state of the art cardiac surgery begins with a brief historical background followed by a review of recent advances in six main categories: coronary artery disease, acquired valvular heart disease, congenital cardiac disease, cardiac transplantation, myocardial preservation and mechanical circulatory assistance. In conducting the review of recent literature, particular attention was directed to large clinical series that document the results of contemporary surgical procedures, novel therapeutic approaches to current clinical problems and unresolved controversies in the field of cardiac surgery. The abundance of surgical literature and constraints on the length of this article do not permit an exhaustive review. Apologies are extended to clinicians and laboratory investigators whose important contributions to the understanding and treatment of cardiac disease are not included herein.

Effect of prior cardiac surgery on survival after heart transplantation

We conducted a retrospective analysis of 182 adult orthotopic heart transplant patients who underwent operations at our institution between July 1982 and October 1987 to determine whether prior cardiac operation affects survival. Group I included the 72 patients (39.6%) who had undergone a previous cardiac operation or operations and group II, the 110 (60.4%) who had not. The mean age of the patients in group I was 52.1 +/- 8.1 years and in group II, 46.1 +/- 10.2 years (p less than 0.01). The incidence of ischemic heart disease was 86.1% in group I and 29.1% in group II (p less than 0.01). All patients received cyclosporine-based immunosuppression. More patients in group I than in group II required reoperation for bleeding after transplantation: 18 (25.0%) versus 9 (8.2%) (p less than 0.01). The actuarial 1-year and 3-year survival rates were 77.6% and 66.5%, respectively, for group I and 77.1% and 66.3%, respectively, for group II. Because both groups had similar survival rates, we believe that prior cardiac operation in heart transplant recipients does not compromise long-term survival.