Risk factors for tricuspid valve regurgitation after orthotopic heart transplantation

Understanding Tricuspid Regurgitation Post Cardiac Transplantation; Why "Anatomical" and "Functional" Just Won't Cut It

Tricuspid regurgitation (TR) is common after cardiac transplantation and results in poorer outcomes. Transplant recipients are at high prohibitive risk for redo surgical procedures because of risks associated with a subsequent sternotomy, immunosuppression, and renal failure. Percutaneous therapies have recently become available and may be an option for transplant recipients. However, transplant recipients have complex geometry, and there is a myriad of causes of TR posttransplant. There is a need for careful patient selection for all percutaneous valve interventions, and this is particularly true in transplant recipients who suffer from right ventricular failure and rejection and may undergo repeated endomyocardial biopsies. Cognizant of the rapid developments in this space, this review article focuses on the causes of TR, treatments, and future therapies in heart transplantation recipients to the transplant cardiologist navigate this complex area.

Echocardiographic assessment of pediatric heart transplantation: A single-center experience in China

BACKGROUND

Pediatric heart transplant (HT) has become the standard of care for end-stage heart failure in children worldwide. Serial echocardiographic evaluations of graft anatomy and function during follow-up are crucial for post-HT management. However, evolution of cardiac structure and function after pediatric HT has not been well described, especially during first year post-HT. This study aimed to characterize the evolution of cardiac structure and function after pediatric HT and investigate the correlation between biventricular function with adverse clinical outcomes.

METHODS

A single-center retrospective study of echocardiographic data obtained among 99 pediatric HT patients was conducted. Comprehensive echocardiographic examination was performed in all patients at 1-, 3-, 6-, 9- and 12-months post-HT. We obtained structural, functional and hemodynamic parameters from both left- and right-side heart, such as left ventricular stroke volume (LVSV), left ventricular ejection fraction (LVEF), right ventricular fractional area change (RVFAC), etc. The cardiac evolution of pediatric HT patients during first post-HT year was described and compared between different time points. We also explored the correlation between cardiac function and major adverse transplant events (MATEs).

RESULTS

1) Evolution of left heart parameters: left atrial length, mitral E velocity, E/A ratio, LVSV and LVEF significantly increased while mitral A velocity significantly decreased over the first year after HT (P < .05). Compared with 1 month after HT, interventricular septum (IVS) and left ventricular posterior wall (LVPW) decreased at 3 months but increased afterwards. (2) Evolution of right heart parameters: right ventricular base diameter and mid-diameter; right ventricular length diameter, tricuspid E velocity, E/A ratio, tricuspid annular velocity e' at free wall, and RVFAC increased, while tricuspid A velocity decreased over the first year after HT (P < .05). (3) Univariate logistic regression model suggests that biventricular function parameters at 1-year post-HT (LVEF, RVFAC, tricuspid annular plane systolic excursion and tricuspid lateral annular systolic velocity) were associated with MATEs.

CONCLUSION

Gradual improvement of LV and RV function was seen in pediatric HT patients within the first year. Biventricular function parameters associated with MATEs. The results of this study pave way for designing larger and longer follow-up of this population, potentially aiming at using multiparameter echocardiographic prediction of adverse events.

Perioperative Management of Heart Transplantation: A Clinical Review

In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.

New Non-Invasive Imaging Technologies in Cardiac Transplant Follow-Up: Acquired Evidence and Future Options

Heart transplantation (HT) is the established treatment for end-stage heart failure, significantly enhancing patients' survival and quality of life. To ensure optimal outcomes, the routine monitoring of HT recipients is paramount. While existing guidelines offer guidance on a blend of invasive and non-invasive imaging techniques, certain aspects such as the timing of echocardiographic assessments and the role of echocardiography or cardiac magnetic resonance (CMR) as alternatives to serial endomyocardial biopsies (EMBs) for rejection monitoring are not specifically outlined in the guidelines. Furthermore, invasive coronary angiography (ICA) is still recommended as the gold-standard procedure, usually performed one year after surgery and every two years thereafter. This review focuses on recent advancements in non-invasive and contrast-saving imaging techniques that have been investigated for HT patients. The aim of the manuscript is to identify imaging modalities that may potentially replace or reduce the need for invasive procedures such as ICA and EMB, considering their respective advantages and disadvantages. We emphasize the transformative potential of non-invasive techniques in elevating patient care. Advanced echocardiography techniques, including strain imaging and tissue Doppler imaging, offer enhanced insights into cardiac function, while CMR, through its multi-parametric mapping techniques, such as T1 and T2 mapping, allows for the non-invasive assessment of inflammation and tissue characterization. Cardiac computed tomography (CCT), particularly with its ability to evaluate coronary artery disease and assess graft vasculopathy, emerges as an integral tool in the follow-up of HT patients. Recent studies have highlighted the potential of nuclear myocardial perfusion imaging, including myocardial blood flow quantification, as a non-invasive method for diagnosing and prognosticating CAV. These advanced imaging approaches hold promise in mitigating the need for invasive procedures like ICA and EMB when evaluating the benefits and limitations of each modality.

Tricuspid Regurgitation After Heart Transplantation: The Cause or the Result of Graft Dysfunction?

BACKGROUND

Tricuspid regurgitation (TR) is common following heart transplantation and has been shown to adversely influence patient outcomes. The aim of this study was to identify causes of progression to moderate-severe TR in the first 2 y after transplantation.

METHODS

This was a retrospective, single-center study of all patients who underwent heart transplantation over a 6-y period. Transthoracic echocardiogram (TTE) was performed at month 0, between 6 and 12 mo, and 1-2 y postoperatively to determine the presence and severity of TR.

RESULTS

A total of 163 patients were included, of whom 142 underwent TTE before first endomyocardial biopsy. At month 0, 127 (78%) patients had nil-mild TR before first biopsy, whereas 36 (22%) had moderate-severe TR. In patients with nil-mild TR, 9 (7%) progressed to moderate-severe TR by 6 mo and 1 underwent tricuspid valve (TV) surgery. Of patients with moderate-severe TR before first biopsy, by 2 y, 3 had undergone TV surgery. The use of postoperative extracorporeal membrane oxygenation (ECMO) in the latter group was significant (78%; P < 0.05) as was rejection profile ( P = 0.02). Patients with late progressive moderate-severe TR had a significantly higher 2-y mortality than those who had moderate-severe TR immediately.

CONCLUSIONS

Overall, our study has shown that in the 2 main groups of interest (early moderate-severe TR and progression from nil-mild to moderate-severe TR), TR is more likely to be the result of significant underling graft dysfunction rather than the cause of it.

The clinical impact of tricuspid regurgitation in patients with a biatrial orthotopic heart transplant

In this study, we aim to elucidate the clinical impact and long-term course of tricuspid regurgitation (TR), taking into account its dynamic nature, after biatrial orthotopic heart transplant (OHT). All consecutive adult patients undergoing biatrial OHT (1984-2017) with an available follow-up echocardiogram were included. Mixed-models were used to model the evolution of TR. The mixed-model was inserted into a Cox model in order to address the association of the dynamic TR with mortality. In total, 572 patients were included (median age: 50 years, males: 74.9%). Approximately 32% of patients had moderate-to-severe TR immediately after surgery. However, this declined to 11% on 5 years and 9% on 10 years after surgery, adjusted for survival bias. Pre-implant mechanical support was associated with less TR during follow-up, whereas concurrent LV dysfunction was significantly associated with more TR during follow-up. Survival at 1, 5, 10, 20 years was 97% ± 1%, 88% ± 1%, 66% ± 2% and 23% ± 2%, respectively. The presence of moderate-to-severe TR during follow-up was associated with higher mortality (HR: 1.07, 95% CI (1.02-1.12), p = 0.006). The course of TR was positively correlated with the course of creatinine (R = 0.45). TR during follow-up is significantly associated with higher mortality and worse renal function. Nevertheless, probability of TR is the highest immediately after OHT and decreases thereafter. Therefore, it may be reasonable to refrain from surgical intervention for TR during earlier phase after OHT.

Prevalence and Risk Factors of Post-heart Transplant Tricuspid Regurgitation

BACKGROUND

Tricuspid valve regurgitation (TR) is a common sequela immediately after heart transplantation, and its occurrence has decreased after the adoption of the bicaval anastomosis technique. However, the fate of the tricuspid valve in patients undergoing heart transplantation using the bicaval technique is uncertain.

METHODS

We identified patients who underwent orthotopic heart transplantation with bicaval technique at our institution between January 2001 and December 2018. Changes in TR on transthoracic echocardiography from the immediately posttransplantation period until 10 y posttransplant were investigated.

RESULTS

A total of 475 consecutive patients (mean age, 49.1 ± 12.7 y; 153 females) who underwent heart transplantation and followed-up for a median of 74.0 mo (interquartile range, 39.5-118.1) were examined. The severities of TR immediately after heart transplantation were less than mild in 194 patients (40.8%), mild in 253 patients (53.3%), moderate in 20 patients (4.2%), and severe in 8 patients (1.7%). The rates of significant TR at 1 mo, 1 y, 3 y, and 5 y were 4.6% (22 of 475), 2.0% (9 of 459), 1.6% (6 of 387), and 1.4% (4 of 289), respectively. Generalized mixed-effects model showed that the TR decreased over time within 1 y (odd ratio, 0.08; 95% confidence interval, 0.02-0.32; P < 0.001) and increased thereafter (odds ratio, 1.37; 95% confidence interval, 1.19-1.58; P < 0.001). There were no patients who required surgical tricuspid valve intervention.

CONCLUSIONS

In patients undergoing heart transplantation with the bicaval technique, significant TR was less common than the rates reported in previous studies and showed a trend of improvement within a year after surgery.

Epidemiological Study of Tricuspid Regurgitation After Cardiac Transplantation. Does it Influence Survival?

Background: Tricuspid valve disease is the most frequent valvulopathy after heart transplantation (HTx). Evidence for the negative effect of post-transplant tricuspid regurgitation (TR) on survival is contradictory. The aim of this study was to analyze the causes of post-transplant TR and its effect on overall mortality. Methods: This is a retrospective observational study of all transplants performed in two Spanish centers (1009 patients) between 2000 and 2019. Of the total number of patients, 809 had no TR or mild TR and 200 had moderate or severe TR. The etiology of TR was analyzed in all cases. Results: The prevalence of moderate and severe TR was 19.8%. The risk of mortality was greater when TR was caused by early primary graft failure (PGF) or rejection (p < 0.05). TR incidence was related to etiology: incidence of PGF-induced TR was higher in the first period, while TR due to rejection and undefined causes occurred more frequently in three periods: in the first year, in the 10-14-year period following HTx, and in the long term (16-18 years). In the multivariable analysis, TR was significantly associated with mortality/retransplantation (HR:1.04, 95% CI:1.01-1.07, p:0.02). Conclusion: The development of TR after HTx is relatively frequent. The annual incidence depends on TR severity and etiology. The risk of mortality is greater in severe TR due to PGF or rejection.

A Meta-Analysis on Prophylactic Donor Heart Tricuspid Annuloplasty in Orthotopic Heart Transplantation: High Hopes from a Small Intervention

(1) Background: Tricuspid regurgitation (TR) is the most frequent valvulopathy in heart transplant recipients (HTX). We aimed to assess the influence of prophylactic donor heart tricuspid annuloplasty (TA) in orthotopic HTX (HTX-A), comparing the outcomes with those of HTX patients. (2) Methods: Electronic databases of PubMed, EMBASE, and SCOPUS were searched. The endpoints were as follows: the overall rate of postprocedural TR (immediate, one week, six months, and one year after the procedure), postoperative complications (permanent pacemaker implantation rate, bleeding), redo surgery for TR, and mortality. (3) Results: This meta-analysis included seven studies. Immediate postprocedural, one-week, six-month and one-year tricuspid insufficiency rates were significantly lower in the HTX-A group. There was no difference in permanent pacemaker implantation rate between the groups. The incidence of postoperative bleeding was similar in both arms. The rate of redo surgery for severe TR was reported only by two authors. In both publications, the total number of events was higher in the HTX cohort, meanwhile pooled effect analysis showed no difference among the intervention and control groups. Mortality at one year was similar in both arms. (4) Conclusion: Our study showed that donor heart TA reduces TR incidence in the first year after orthotopic heart transplantation without increasing the surgical complexity. This is a potentially important issue, given the demand for heart transplants and the need to optimize outcomes when this resource is scarce.

Functional tricuspid valve insufficiency after cardiac transplantation: Which factor is the most important?

Objectives

Tricuspid insufficiency (TI) is the most common valvular complication following orthotopic heart transplantation (HTx) and in serious cases is associated with increased mortality. In this study, we analyze the possible variables influencing TI following HTx and aim to identify the most important risk factors and mechanisms responsible for functional TI development and progression.

Methods

We identified the incidence of TI within our institute in 857 of 1515 patients who underwent HTx using the biatrial anastomosis technique in the years between 1986 and 2010. The risk factors that could influence TI were retrospectively analyzed in detail in a representative group of 152 patients with identical TI distribution as found in the entire program. Patients of the group were subdivided into 2 groups according to the severity of TI: patients with TI grade ≤2 and those with TI grade >2. Impact on long-term survival (>15 years) was assessed.

Results

In univariable analysis, study variables such as age of recipient (P = .027), donor to recipient right atrium anterior wall ratio (P < .001), tricuspid annulus anterior to septal leaflet excursion ratio (P = .001), dialysis (P = .026), and total biopsy number (P = .003) showed significant differences. The variables, height of recipient (P = .080), body mass index donor to body mass index recipient ratio (P = .080), and number of biopsies with more than moderate grade (P = .067) showed a trend toward significance in the development of severe TI after HTx. In multivariable analysis, we found an independent significant association between TI after HTx and donor to recipient right atrium anterior wall ratio, number of biopsies, and dialysis.

Conclusions

Changes in tricuspid annulus geometry, number of biopsies, and dialysis are the most important risk factors for the development and progression of TI following cardiac transplantation. It could be prevented using modified operative techniques, noninvasive diagnostic modalities, and intensified ultrafiltration. In patients with biatrial anastomosis technique with generous atrial cuff, the presence of TI greater than grade 2 did not impact long-term survival.

Edge-to-edge tricuspid valve repair for severe tricuspid regurgitation 20 years after cardiac transplantation

Tricuspid valve regurgitation in orthotopic heart transplant recipients is common. Surgical corrections have been the mainstay of the treatment for diuretic‐refractory heart failure due to severe tricuspid regurgitation. However, post‐transplant patients inherently carry higher surgical risk owing to previous sternotomy and immunocompromised state. We report a case of successful percutaneous edge‐to‐edge tricuspid valve repair for severe tricuspid regurgitation after cardiac transplantation. A 27‐year‐old man with a history of idiopathic restrictive cardiomyopathy status after orthotopic heart transplant presented with severe right‐sided heart failure symptoms. A transthoracic echocardiogram showed bi‐atrial enlargement and moderate‐to‐severe tricuspid regurgitation, and an increase to the severe range with exercise. Percutaneous edge‐to‐edge tricuspid valve repair was performed. The patient's symptoms improved, and follow‐up echocardiogram showed mild tricuspid regurgitation. Percutaneous tricuspid valve repair can be considered as an alternative option to conventional surgery for symptomatic severe tricuspid regurgitation in orthotopic heart transplant recipients with suitable anatomy.

Current Expectations for Cardiac Transplantation in Patients With Congenital Heart Disease

Congenital heart disease accounts for 40% of pediatric heart transplants and presents unique challenges to the transplant team. Suitability for transplantation is defined in part by degree of sensitization, pulmonary vascular resistance, and hepatic reserves. The incremental transplant risk for patients with congenital heart disease occurs within the first 3 months, after which survival is equivalent to transplantation for cardiomyopathy. Single ventricle with prior palliation, and especially the failing Fontan, carry the highest risk for transplantation and are least amenable to bridging with mechanical circulatory support. More effective bridging to transplant with mechanical circulatory support will require improvements in the adverse event profile of available pumps and the introduction of miniaturized continuous flow technology. The major barriers to routine long-term survival are chronic allograft failure and allograft vasculopathy. Despite these many challenges, continuing improvements in the care of pediatric heart transplant patients have pushed the median posttransplant survival past 15 years for children and to 20 years for infants.

Predictors of Tricuspid Valve Anulus Dilation in a Heart Recipient Population

BACKGROUND

Tricuspid valve regurgitation in reported in >20% of heart recipients. It severity has not only clinical impact, but it is also associated with increased mortality. Risk factors for developing tricuspid valve dysfunction include allograft rejection, donor/recipient pericardial cavity mismatch, preoperative transpulmonary gradient and vascular resistance, biatrial anastomosis technique, and biopsy-induced injury. Tricuspid valve annulus distention is reported to causative factor for most common type of tricuspid valve dysfunction after heart transplantation. The aim of the study was to estimate possible early predictors for tricuspid valve regurgitation after orthotopic heart transplantation performed with standard Lower-Shumway technique on magnetic resonance imaging studies.

METHODS

A total of 20 patients (18 men and 2 women) with a mean age of 45 ± 12 years were enrolled into the study. Echocardiographic evaluation followed by magnetic resonance studies were performed. The mean duration from time of transplantation was 34 ± 12 months. Magnetic resonance and echocardiographic imaging focused on tricuspid valve annulus diameter and atrium dimensions.

RESULTS

The was a progressive distension of tricuspid valve annulus observed during the follow-up period. Mean tricuspid valve diameter increased from 3.0 ± 0.3 to 3.34 ± 0.3 mm (P < .05). There was a positive correlation observed between recipient native right atrium and overall right atrium diameter and tricuspid valve diameter distension.

CONCLUSIONS

Overall right atrium diameter and native recipient right atrium diameter were found to be a risk factor for tricuspid valve annulus distension.

Bicaval Anastomosis Reduces Tricuspid Regurgitation after Heart Transplantation

The standard surgical technique utilizing two atrial cuff anastomoses has been used in the majority of transplant centers until recently when bicaval anastomoses was introduced. The purpose of this study was to compare the prevalence of tricuspid regurgitation after the bicaval and standard techniques of anastomosis. Heart transplantation was performed in 43 patients at our institution from April 1994 to December 2003: 15 by the standard technique (group A) and 28 by the bicaval technique (group B). No differences in pre-transplant diagnosis, donor age, immunosuppression, rejection treatment, or graft ischemic time were evident between the two groups. The prevalence of tricuspid regurgitation (≥ moderate) was higher after the standard technique (36.4% vs. 10.5%; p < 0.05). Survival rates at 1 and 3 years in group A were 87% and 55%, and 86% and 78% in group B, with a significant difference in the 3-year mortality. The bicaval anastomosis technique was found to be associated with a lower incidence of tricuspid regurgitation during the late postoperative period, and should be preferred for heart transplantation.

Repair of early posttransplant endomyocardial biopsy-related tricuspid regurgitation in a child

We describe surgical repair of symptomatic tricuspid valve regurgitation in the early posttransplant period in a small child. The tricuspid valve regurgitation was due to injury to the valve and chordal apparatus during surveillance endomyocardial biopsy. The described surgical technique produced durable improvement in valve function.

Fate of atrioventricular valve function of the transplanted heart

BACKGROUND

Long-term echocardiographic data on quantitative assessment of tricuspid and mitral regurgitation after heart transplantation are scarce.

METHODS AND RESULTS

From November 1992 to December 2008, the medical records for 201 patients (mean age, 42.8±12.4 years, 47 females) who underwent heart transplantation were reviewed. Quantitative assessment of mitral and tricuspid valve function was performed using transthoracic echocardiography through long-term follow-up. A total of 196 (97.5%) patients were evaluated with echocardiography for more than 6 months postoperatively. During a mean echocardiography follow-up duration of 89.9±54.3 months, 23 (11.4%) patients showed either tricuspid regurgitation (TR >mild; n=21, 10.4%) or mitral regurgitation (MR >mild; n=6, 3.0%); 4 (2.0%) patients experienced both significant TR and MR. Freedom from moderate-to-severe TR at 10 years was 85.5±5.1% and 93.4±2.2% for the standard and bicaval techniques, respectively (P=0.531). Freedom from moderate-to-severe MR at 10 years was 96.0±2.7% and 98.6±1.0%, respectively, for the 2 techniques (P=0.252). In multivariate analysis, older-age donor emerged as the only independent predictor of significant TR (hazard ratio 1.06, 95% confidence interval 1.01-1.12, P=0.012).

CONCLUSIONS

The long-term results of atrioventricular function after heart transplantation in adults were excellent regardless of anastomotic technique. Older-age donor was significantly associated with the development of postoperative TR.

Tricuspid valve regurgitation after orthotopic heart transplantation: prevalence and etiology

Background. Tricuspid valve regurgitation (TR) after orthotopic heart transplantation (OHT) is common. The aims of this study were to determine the prevalence of TR after OHT, to examine the correlation between its development and various variables, and to determine its outcomes. Methods. All 163 OHT patients who were followed up between 1988 and 2009 for a minimal period of 12 months were divided into those with no TR/mild TR and those with at least mild-moderate TR, as assessed by doppler echocardiography. These groups were compared regarding preoperative hemodynamic variables, surgical technique employed, number of endomyocardial biopsies, number of acute cellular rejections, incidence of graft vasculopathy, and clinical outcomes. Results. At the end of the followup (average 8.2 years) significant TR was evident in 14.1% of the patients. The development of late TR was found by univariate, but not multivariate, analysis to be significantly correlated with the biatrial surgical technique (P < 0.01) and the presence of graft vasculopathy (P < 0.001). TR development was found to be correlated with the need for tricuspid valve surgery but not with an increased mortality. Conclusions. The development of TR after OHT may be related to the biatrial anastomosis technique and to graft vasculopathy.

Endomyocardial biopsy and selective coronary angiography are low-risk procedures in pediatric heart transplant recipients: results of a multicenter experience

BACKGROUND

No prior reports documenting the safety and diagnostic yield of cardiac catheterization and endomyocardial biopsy (EMB) in heart transplant recipients include multicenter data.

METHODS

Data on the safety and diagnostic yield of EMB procedures performed in heart transplant recipients were recorded in the Congenital Cardiac Catheterization Outcomes Project database at 8 pediatric centers during a 3-year period. Adverse events (AEs) were classified according to a 5-level severity scale. Generalized estimating equation models identified risk factors for high-severity AEs (HSAEs; Levels 3-5) and non-diagnostic biopsy samples.

RESULTS

A total of 2,665 EMB cases were performed in 744 pediatric heart transplant recipients (median age, 12 years [interquartile range, 4.8, 16.7]; 54% male). AEs occurred in 88 cases (3.3%), of which 28 (1.1%) were HSAEs. AEs attributable to EMB included tricuspid valve injury, transient complete heart block, and right bundle branch block. Amongst 822 cases involving coronary angiography, 10 (1.2%) resulted in a coronary-related AE. There were no myocardial perforations or deaths. Multivariable risk factors for HSAEs included fewer prior catheterizations (p = 0.006) and longer case length (p < 0.001). EMB yielded sufficient tissue for diagnosis in 99% of cases. Longer time since heart transplant was the most significant predictor of a non-diagnostic biopsy sample (p < 0.001).

CONCLUSIONS

In the current era, cardiac catheterizations involving EMB can be performed in pediatric heart transplant recipients with a low AE rate and high diagnostic yield. Risk of HSAEs is increased in early post-transplant biopsies and with longer case length. Longer time since heart transplant is associated with non-diagnostic EMB samples.

Tricuspid regurgitation after orthotopic heart transplantation

BACKGROUND

Tricuspid regurgitation (TR) is a relatively common abnormality in normal adults as well as after orthotopic heart transplantation (OHT). A few studies have shown reduction in the incidence of TR after OHT by total bicaval surgical anastomosis technique. Other studies reported no significant difference in the rates of TR between the standard and bicaval techniques.

OBJECTIVE

Evaluate and compare the degree of TR after OHT by standard and bicaval anastomosis techniques.

METHOD

Echocardiograms from the first 56 consecutive patients that had the total bicaval surgical technique performed were retrospectively reviewed and compared with the last 57 consecutive patients who had the standard biatrial technique performed. Patients with adequate two-dimensional and Doppler echocardiograms were included.

RESULTS

No statistical difference was observed for each grade of TR at both early and late time points. No significant difference was observed between the TR velocities of both biatrial and bicaval anastomosis patients at different periods.

CONCLUSION

There appears to be no difference between the TR severity and TR velocity at early and late time points regardless of anastomotic technique.

Limited utility of endomyocardial biopsy in the first year after heart transplantation

BACKGROUND

Surveillance endomyocardial biopsies (EMBs) are used for the early diagnosis of acute cardiac allograft rejection. Protocols became standardized in an earlier era and their utility with contemporary immunosuppression has not been investigated.

METHODS

We studied 258 patients after orthotopic heart transplantation comparing 135 patients immunosuppressed by mycophenolate mofetil (MMF) with 123 patients treated by azathioprine (AZA); both with cyclosporine and corticosteroids after induction therapy with rabbit antithymocyte globulin. Fifteen EMBs were scheduled in the first year. Additional EMBs were performed for suspected rejection, after treatment, or for inadequate samples. The MMF group had 1875 EMBs vs. 1854 in the AZA group.

RESULTS

The yield of International Society for Heart and Lung Transplantation (ISHLT) grade> or =3A biopsy-proven acute rejection (BPAR) was 1.87% per biopsy (35 of 1875) with MMF vs. 3.13% (58 of 1854) with AZA P=0.024. The number of clinically silent BPAR ISHLT grade > or =3A (the true yield of surveillance EMBs) was 1.39% (26 of 1875) of biopsies MMF vs. 2.1% (39 of 1854) AZA, P=0.48. There were five serious complications requiring intervention or causing long-term sequelae; 0.13% (5 of 3729) per biopsy and 1.94% (5 of 258) per patient. The incidence of all definite and potential complications was 1.42% (53 of 3729) per biopsy and 20.5% (53 of 258) per patient. There was no biopsy-related mortality.

CONCLUSION

The yield of BPAR was low in the AZA group and very low in the MMF group. The incidence of complications was also low, but repeated biopsies led to a higher rate per patient. Routine surveillance EMBs and the frequency of such biopsies should be reevaluated in the light of their low yield with current immunosuppression.

Prevalence and risk factors for tricuspid valve regurgitation after pediatric heart transplantation

BACKGROUND

Risk factors for tricuspid regurgitation (TR) after adult orthotopic heart transplantation (OHT) have been reported, although there are no pediatric data.

METHODS

This study was a single-center retrospective analysis of patients <or= 18 years of age who underwent OHT from January 1990 to December 2004. The impact of TR was evaluated with respect to outcomes (graft failure, etc.).

RESULTS

Echocardiograms were available for 99 patients (105 grafts with 6 re-transplants) at a median age of 4.5 years (range 18 days to 17.1 years): 51 (49%) were male; 46 (44%) were transplanted for congenital heart disease; and 76 (72%) had a biatrial anastomosis. Significant TR developed in 30 grafts (29.5%) within a median duration after OHT of 1.2 years (range 0 day to 8.2 years); persistent significant TR until last follow-up was present in 21 grafts (20%). Graft failure (death or need for retransplantation) occurred in 41 grafts (39%), including 14 of 21 grafts (67%) with significant TR. By Kaplan-Meier analysis, freedom from significant TR (95% confidence interval [CI]) at 1, 5 and 10 years was 91.0% (83.4% to 95.2%), 70.2% (55.4% to 80.9%) and 61.5% (39.2% to 77.6%), respectively. No risk factors were identified. Development of significant TR was highly associated with graft failure (p = 0.005).

CONCLUSIONS

Significant TR occurs with comparable frequency in pediatric and adult OHT populations; risk factors identified in adults were not present in our pediatric population. Development of significant TR in pediatric heart transplant recipients is highly associated with graft failure.

Usefulness and limitations of transthoracic echocardiography in heart transplantation recipients

Transthoracic echocardiography is a primary non-invasive modality for investigation of heart transplant recipients. It is a versatile tool which provides comprehensive information about cardiac structure and function. Echocardiographic examinations can be easily performed at the bedside and serially repeated without any patient's discomfort. This review highlights the usefulness of Doppler echocardiography in the assessment of left ventricular and right ventricular systolic and diastolic function, of left ventricular mass, valvular heart disease, pulmonary arterial hypertension and pericardial effusion in heart transplant recipients. The main experiences performed by either standard Doppler echocardiography and new high-tech ultrasound technologies are summarised, pointing out advantages and limitations of the described techniques in diagnosing acute allograft rejection and cardiac graft vasculopathy. Despite the sustained efforts of echocardiographic technique in predicting the biopsy state, endocardial myocardial biopsies are still regarded as the gold standard for detection of acute allograft rejection. Conversely, stress echocardiography is able to identify accurately cardiac graft vasculopathy and has a recognised prognostic in this clinical setting. A normal stress-echo justifies postponement of invasive studies. Another use of transthoracic echocardiography is the monitorisation and the visualisation of the catheter during the performance of endomyocardial biopsy. Bedside stress echocardiography is even useful to select appropriately heart donors with brain death. The ultrasound monitoring is simple and effective for monitoring a safe performance of biopsy procedures.

Influence of different implantation techniques on long-term survival after orthotopic heart transplantation: an echocardiographic study

BACKGROUND

Orthotopic heart transplantation (OHT) was initially done by the biatrial technique, although the bicaval technique has recently become more popular. The aim of this study was to compare OHT outcomes when using the bicaval technique vs the biatrial technique.

METHODS

A total of 615 patients were transplanted at the Cleveland Clinic Foundation from January 1993 and October 2003 (biatrial technique: n = 293; bicaval technique: n = 322). The average follow-up period was 4.2 +/- 2.9 years (range 1 to 11 years). Patients who were supported with a left ventricular assist device (prior to transplant) and who could not be weaned off respiratory support were excluded.

RESULTS

Patients in both groups were similar with regard to pre-operative characteristics. The peri-operative mortality showed no statistical significant differences between the two groups. The left atrium was significantly more enlarged in the biatrial group. The bicaval group showed a significantly reduced incidence of tricuspid regurgitation. Survival at 10-year follow-up was 87.3% in the bicaval group and 79.9% in the biatrial group (p < 0.05). Left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF) and moderate to severe tricuspid regurgitation were significant risk factors for death in both groups. The bicaval technique showed a significantly better mortality outcome.

CONCLUSIONS

This study showed that the bicaval technique for OHT offers a better outcome than the biatrial technique. The significant reduction of left atrial size and atrioventricular valve regurgitation in the bicaval group may have a major impact on the long-term preservation of cardiac function and survival.

Echocardiography in the cardiac transplant recipient

Despite the widespread use of echocardiography in the cardiac allograft recipient, the clinical usefulness of this practice is not well defined. In this article, the authors review the spectrum of echocardiographic findings in the adult heart transplant patient. Appreciation of typical alterations from "normal" allows the transplant physician to identify clinically significant changes and to avoid unnecessary invasive procedures based on misinterpretation of these differences. Though abnormalities of systolic and diastolic function correlate with episodes of acute rejection, the primary diagnostic usefulness of echocardiography in acute rejection is guiding the endomyocardial biopsy. Additionally, echocardiography has found a role as a supplement to invasive angiography in the diagnosis of cardiac allograft vasculopathy.

Geometric Disproportion of Cardiac Structure and Graft Ischemia Affect Tricuspid Valve Regurgitation Early After Neonatal Heart Transplantation

BACKGROUND

Although tricuspid valve regurgitation (TR) after heart transplantation is a known complication, there has been little discussion of this subject in neonatal heart transplantation. We aim to elucidate the prevalence, etiology, and evolution of TR early after transplant in neonates.

METHODS

Eighty-five neonatal recipients were studied retrospectively by two-dimensional and Doppler echocardiography. The semiquantitative grading of TR was based on the ratio of regurgitation jet area to right atrial area.

RESULTS

Immediately after neonatal heart transplantation, TR was recognized in 47 patients (grade 1, n = 18; grade 2, n = 22; grade 3, n = 7; and grade 4, n = 0). Tricuspid regurgitation prevalence diminished from 55% to 19% with reduction in severity 1 year after transplantation. The prevalence of TR (grade 2 and grade 3) was affected by a donor/recipient body weight ratio of more than 2.0 (p = 0.004) and graft ischemia for more than 3 hours (p = 0.014). The ratio of donor and recipient right atria portion, which had a correlation with donor/recipient body weight ratio (r2 = 0.415, p < 0.0001), separated the four subgroups in terms of TR grade immediately after transplantation (p = 0.0064) and also at 1 year after transplantation in all surviving grafts from 1.48 +/- 0.54 to 0.8 +/- 0.32 (p < 0.0001). The Cox model found no significance for early posttransplant TR as a risk factor for graft survival.

CONCLUSIONS

Early posttransplant TR was affected by atria geometrical disproportion and by graft ischemia. Tricuspid regurgitation was not a risk factor for graft survival because of its amelioration over time, perhaps induced by recipient growth and recovery of myocardial injury relating to graft procurement.

Tricuspid valve replacement after cardiac transplantation

PURPOSE OF REVIEW

Tricuspid valve regurgitation is the most frequent valvular complication following orthotopic cardiac transplantation. It leads to diminished quality of life and predicts shortened long-term survival. The optimal surgical management of refractory tricuspid valve regurgitation in this setting is unclear.

RECENT FINDINGS

Tricuspid valve regurgitation following cardiac transplantation is likely related to accumulated injury from repeated endomyocardial biopsies. Durability of repair in this setting was shown to be suboptimal. Replacement with a bioprosthesis was found to be durable and relieves symptoms of heart failure associated with tricuspid valve regurgitation in the majority of patients. Prophylactic tricuspid valve annuloplasty at transplantation was found to significantly decrease the incidence of early and late tricuspid valve regurgitation; long-term benefits remain unclear.

SUMMARY

Results of tricuspid valve repair in the post-cardiac transplant setting are not ideal, and this strategy is better suited to treating functional tricuspid valve regurgitation resulting from annular dilatation. Tricuspid valve replacement with a bioprosthesis is a safe, durable, and effective method of treating tricuspid valve regurgitation following transplantation and allows for future endomyocardial biopsies to be performed. Mechanical valves should be avoided. A randomized controlled trial examining the long-term outcomes of prophylactic tricuspid annuloplasty is warranted.

Donor Tricuspid Annuloplasty During Orthotopic Heart Transplantation: Long-Term Results of a Prospective Controlled Study

BACKGROUND

Development of tricuspid regurgitation after orthotopic heart transplantation can cause heart failure along with renal and hepatic impairment and portends a poor prognosis. If tricuspid regurgitation causes significant symptoms, tricuspid valve repair or replacement is often required. This study was designed to study the effects of prophylactic tricuspid valve annuloplasty (TVA) during orthotopic heart transplantation on long-term survival, renal function, and amount of tricuspid regurgitation.

METHODS

Between April 1997 and March 1998, 60 patients (aged 18 to 70 years; 22 female) randomly received either standard bicaval orthotopic heart transplantation (group STD; n = 30) or bicaval orthotopic heart transplantation with DeVega TVA (group TVA; n = 30). Tricuspid valve annuloplasty was performed on the donor heart before implantation using pledgeted 2-0 polypropylene and sized to an annulus of 29 mm. Echocardiographic measurements, laboratory values, and hemodynamics were obtained prospectively and reviewed by an independent data analyst.

RESULTS

Follow-up of patients as of December 2003 was complete. Although there was a perioperative mortality advantage in group TVA, there was no difference between groups in long-term survival. At the end of the study, however, there was a statistical difference (group STD versus group TVA, p < 0.05) with regard to cardiac mortality (7 of 30 versus 3 of 30), average amount of tricuspid regurgitation (1.5 +/- 1.3 versus 0.5 +/- 0.4), percentage of patients with 2+ or greater tricuspid regurgitation (34% versus 0%), serum creatinine (2.9 +/- 2.0 versus 1.8 +/- 0.7), and difference in serum creatinine over baseline (2.0 +/- 2.1 versus 0.7 +/- 0.8).

CONCLUSIONS

Prophylactic DeVega TVA of the donor heart is durable and decreases the incidence of cardiac-related mortality and tricuspid regurgitation after orthotopic heart transplantation. In addition, there is improved protection of renal function. Considering the ease and safety of TVA and its advantages, it should be performed as a routine adjunct to orthotopic heart transplantation.

Tricuspid valve chordal tissue in endomyocardial biopsy specimens of patients with significant tricuspid regurgitation

OBJECTIVES

Tricuspid regurgitation is the most common valvular abnormality after orthotopic heart transplantation, with multiple etiologic factors implicated. The purpose of this study was to determine if the endomyocardial biopsy specimens of patients who developed significant tricuspid valve regurgitation (TVR) after cardiac transplantation had evidence of chordal tissue.

METHODS

The echocardiograms of 98 patients who had cardiac transplantation between 1986 and 2002 were reviewed for evidence of significant TVR greater than mild. The biopsy specimens of all patients with significant TVR were then reviewed for histologic evidence of tricuspid chordal tissue and frequency and severity of rejection episodes. Clinical information collected included the presence of any systolic murmurs, significant dyspnea, and invasive hemodynamic measurements.

RESULTS

The incidence of significant TVR was 19% (n = 19 patients). Histologic evidence of chordal tissue was present in 9 patients (47%) with significant TVR. Patients whose biopsy specimens evidenced chordal tissue tended to have a greater degree of TVR, but this was not statistically significant (odds ratio, 2.07; 95% confidence interval, 0.537-8.01, p = 0.32). There was no statistically significant difference in the number of biopsy specimens (p = 0.798), the number of rejection episodes (p = 0.73), or overall left or right ventricular systolic function between the patients with and without biopsy specimen evidence of chordal tissue disruption. Most of the patients with evidence of significant TVR after chordal tissue biopsy were clinically asymptomatic, with no significant change in their hemodynamics.

CONCLUSION

Histologic evidence of chordal tissue in endomyocardial biopsy specimens was present in 47% of patients with significant TVR and did not relate to the number of biopsy procedures performed or the frequency of rejection episodes. This study provides histologic evidence that chordal tissue damage can occur after cardiac biopsy, resulting in significant TVR; however, it is clinically well tolerated by affected patients.

Chronic mitral valve rejection requiring replacement in a nine-year-old allograft

A 43-year-old woman underwent mitral valve replacement for severe mitral regurgitation nine years after orthotopic heart transplant. Histopathology showed chronic rejection of the mitral valve with lymphocytic infiltrates. The patient is well at one year follow-up. This report describes an identified case of chronic mitral valve rejection requiring valve replacement.

Tricuspid Regurgitation After Cardiac Transplantation: How Many Biopsies Are Too Many?

BACKGROUND

Tricuspid regurgitation (TR) is common in patients after orthotopic cardiac transplantation (OHT). Endomyocardial biopsy (EMB) used to monitor for rejection may be a cause of TR. The purpose of this study was to identify a correlation between the severity of TR and the number of EMBs.

METHODS

We studied 101 patients with OHT at our institution between May 1987 and August 2001. The number of EMBs performed in each patient was determined. Data on technique of anastomosis, liver and renal function, ejection fraction, and pulmonary artery pressure were also extracted. Echocardiography reports were reviewed to determine the presence and severity of TR. Symptoms of right heart failure were assessed by the amount of diuretic intake.

RESULTS

Twenty-five (25%) of 101 patients had evidence of severe TR, whereas 76 (75%) had non-severe TR. Multivariate analysis identified EMB as the only independent predictor of the severity of TR (p < 0.0001). At last follow-up, 60% of patients with more than 31 EMBs had developed severe TR, whereas none of the patients with less than 18 EMBs had severe TR. Of the 25 patients who had severe TR, 15 (61%) needed high doses of daily diuretics, and 4 (16%) required tricuspid valve replacement.

CONCLUSIONS

The development of TR after OHT is in large part due to EMBs used to monitor for rejection. There is a direct correlation between the number of EMBs and the severity of TR. We suggest a cutoff of less than 31 EMBs to reduce the risk of severe TR.

Tricuspid annuloplasty significantly reduces early tricuspid regurgitation after biatrial heart transplantation

BACKGROUND

The incidence of tricuspid annuloplasty (TR) observed early after cardiac biatrial implantation is unpredictable and in our experience not infrequently problematic. Although the bicaval method of implant may reduce the incidence of TR, its benefit has not been conclusively documented.

METHODS

In an attempt to reduce the incidence of TR observed early after cardiac transplantation, 25 consecutive patients undergoing cardiac transplantation received donor heart tricuspid annuloplasty (TA) with either a DeVega or Ring technique. Early transthoracic echocardiograms were analyzed and compared with an immediately prior and consecutive cohort of 25 patients undergoing transplantation without TA. The biatrial technique of cardiac transplantation with a Cabrol modification was used for donor heart implant in both groups. Echocardiograms obtained 5 days after cardiac transplantation were reviewed in blinded fashion. TR was scored 0 = none, 1 = mild, 2 = moderate, and 3 = severe.

RESULTS

Donor and recipient characteristics were not different between groups. No hospital deaths occurred in either group. Patients undergoing transplantation without TA had a higher TR score, 1.3 (range 0-3), than did patients with TA, 0.7 (range 0-1.5, p = 0.002). Moderate or severe TR was present in 8 of 25 patients without TA compared with 0 of 25 patients with TA (p = 0.004). No patients required permanent pacemaker.

CONCLUSIONS

TA can significantly reduce the incidence of early postoperative TR after biatrial cardiac transplant without adding to the complexity of operation.

Decreased recipient survival following orthotopic heart transplantation with use of hearts from donors with projectile brain injury

BACKGROUND

Fatal gunshot injury to the brain can cause significant alterations in the neuroendocrine state and myocardial dysfunction. Therefore heart allografts from these donors may result in graft failure following orthotopic heart transplantation (OHTx). We evaluated whether receiving a heart from a donor who died from fatal gunshot wound to the brain independently affected the outcome of transplantation.

METHODS

A retrospective review of 113 consecutive patients undergoing OHTx at a university hospital from 1996 to 2002 was performed. Group 1 received hearts from donors with fatal gun shot brain injury (n = 17), and Group 2 received hearts from donors who died from other causes (n = 96).

RESULTS

Recipient age, gender, United Network for Organ Sharing (UNOS) status, indication for transplantation, and other co-morbid conditions were similar in both groups. Young male donors pre-dominated in Group 1, but other donor characteristics were not significantly different. The incidence of Grade 3A rejection was higher in Group 1 than Group 2 (35% vs 6.3%, p = 0.003), as was the incidence of post-operative infection (35% vs 7.2%, p = 0.004). Actuarial survival at 1 and 5 years was significantly lower in Group 1 than in Group 2 (81% and 74% vs 97% and 94%, respectively, p = 0.005). Multivariate logistic regression analysis also demonstrated that fatal gunshot brain injury, as cause of donor death, was a risk factor for recipient mortality (p = 0.01).

CONCLUSION

Receiving a heart from a donor with fatal gunshot brain injury is a significant risk factor for recipient mortality following OHTx. Cautious use of heart allograft from these donors, especially in low-risk recipients, may lead to improved outcome following heart transplantation.

Surgical advances in heart and lung transplantation

The successes of thoracic transplantation have led to the expansion of indications and a subsequent growth in demand for a short supply of organs. In response to this disparity, the criteria for organ donation have been liberalized. Despite these difficult challenges, with advances in surgical techniques and perioperative care of both the donor and recipient, outcomes have continued to improve over time. This article focuses on the more recent surgical advances in donor selection and management, procurement and implantation, and the impact of these advances on patient outcome.

Biatrial or Bicaval Technique for Orthotopic Heart Transplantation: Which Is Better?

BACKGROUND

Orthotopic heart transplantation was done by the biatrial technique initially and the bicaval technique has become popular recently.

AIMS

This study aims to determine if bicaval technique is advantageous.

METHODS

Consecutive transplants performed between 1996 and 2001 were divided into two groups-37 patients done by bicaval and 38 by biatrial technique. Data accumulation was by retrospective study of patient charts.

RESULTS

Both groups had similar preoperative variables. There were no differences in low cardiac output (18.9% versus 26.3%, p = 0.62), intraaortic balloon pump insertion (16.2% versus 15.7%, p = 1.0), re-exploration (13.5% versus 18.4%, p = 0.79) and perioperative mortality (5.4% versus 7.9%, p = 1.0) in the bicaval versus biatrial groups. Temporary (13.5% versus 39.4%, p = 0.15) and permanent pacing (0 versus 3 patients) tended to be less frequent and central venous pressure measured at 1-week was lower in the bicaval group (mean 13.8 +/- 6cm versus 14.9 +/- 5.4cm, p = 0.42), but not attaining statistical significance. Severe tricuspid regurgitation was seen in one bicaval versus five biatrial patients at follow-up.

CONCLUSIONS

Though bicaval group tended to require less pacing, had less tricuspid regurgitation and had lower central venous pressures, these did not attain statistical significance. There were otherwise no obvious differences in outcome. SHORT ABSTRACT: Seventy five consecutive orthotopic heart transplantations done during the period 1996-2001 by bicaval or biatrial surgical technique were compared. There was no difference in low cardiac output, intraaortic balloon pump insertion and mortality but the bicaval patients tended to have less pacing and diuretic requirements and lower central venous pressures, though not attaining statistical significance.

Echo-guided endomyocardial biopsy in heart transplant recipients

After heart transplantation the effect of immunosuppression is monitored by histopathology of endomyocardial biopsy (EMB). EMB is usually carried out under X-ray guidance. Between January 1998 and March 2003, 1,262 biopsies were collected under echo-guidance in 156 patients. The biopsy access was gained through the internal jugular vein, by the standard catheterization technique. The average time of the procedure was 17 min. Four or five specimens were obtained from each patient, with a success rate of 96%. Complications involved two episodes of partial pneumothorax in one patient, atrial flutter in another and ventricular fibrillation in three patients. Conversion from echo to X-ray guidance was indicated in 11 patients. No case of significant tricuspid regurgitation related to the EMB procedure was recorded. The echo-guided endomyocardial biopsy appears to be a prospective alternative to the conventional approach under X-ray guidance. Its duration is comparable, it eliminates X-ray exposure, enables continuous echocardiographic monitoring and can be performed at the bedside.

A one-year comparison of prophylactic donor tricuspid annuloplasty in heart transplantation

BACKGROUND

The bicaval technique for orthotopic heart transplantation decreases the incidence of tricuspid valve regurgitation when compared with the standard biatrial technique. This study was designed to study the effects of prophylactic tricuspid valve annuloplasty during bicaval orthotopic heart transplantation on survival, renal function, and amount of tricuspid valve regurgitation.

METHODS

Between April 1997 and March 1998, 60 patients (age 18 to 70 years, 22 women) randomly received either bicaval orthotopic heart transplantation (n = 30) or bicaval orthotopic heart transplantation with DeVega tricuspid valve annuloplasty (n = 30). Tricuspid valve annuloplasty was performed on the donor heart before implantation using pledgeted 2-0 polypropylene suture and sized to an annulus of 29 mm. Echocardiographic variables, laboratory values, and hemodynamics were obtained prospectively and reviewed by an independent data analyst.

RESULTS

Intraoperatively, the group undergoing tricuspid valve annuloplasty had a shorter reperfusion time (46 +/- 29 minutes versus 65 +/- 48 minutes; p < 0.05) and higher mean pulmonary artery to central venous pressure difference (11.8 +/- 3.7 mm Hg versus 15.3 +/- 4.1 mm Hg; p = 0.001). Additional differences between the two groups included early mortality from donor dysfunction (4 of 30 patients versus 0 of 30 patients; p < 0.05), amount of tricuspid valve regurgitation at 1 year (1.3 +/- 1.0 versus 0.2 +/- 0.3; p < 0.05), and percentage of patients with 2+ or greater tricuspid valve regurgitation (34% versus 0%; p < 0.05).

CONCLUSIONS

Tricuspid valve annuloplasty of the donor heart before bicaval orthotopic heart transplantation improves immediate donor heart function as demonstrated by better right ventricular performance, lower perioperative mortality, and shorter reperfusion times. At 1 year, there is less tricuspid valve regurgitation but no difference in renal function. Considering the ease and safety of tricuspid valve annuloplasty and its advantages, it should be performed as a routine adjunct with bicaval orthotopic heart transplantation.

Severe tricuspid regurgitation after heart transplantation

BACKGROUND

Tricuspid regurgitation (TR) is common after heart transplantation. However, the incidence of severe TR and the incidence of symptoms after echocardiographic diagnosis of severe TR have not been documented. The purpose of this study is to determine the incidence of severe TR and its clinical significance in the heart transplant population.

METHODS

We reviewed echocardiograms (echo) of all heart transplant patients coming for regular echocardiographic follow-up between 1990 and 1995. We reviewed the charts of all patients who had echo diagnosis of severe TR.

RESULTS

A total of 336 patients had echo follow-up during this time period. The number of months post-heart transplant to last echo was 54 +/- 50 (range, 1 to 265 months). Ninety patients had moderate TR and 23 patients had severe TR. Mean time from heart transplantation to diagnosis of severe TR was 43 +/- 38 months (range, 1 to 132). Using Cutler-Ederer analysis, at 5 years, 92.2% of surviving patients were free from severe TR. At 10 years, 85.8% of surviving patients were free from severe TR. Of the 23 patients with severe TR, 17 had charts available for review. The mean number of prior endomyocardial biopsies was 28 +/- 21 (range, 3 to 88). These patients were followed for 35 +/- 18 months after diagnosis. During this period, they developed significant heart failure and peripheral edema. Six patients eventually underwent tricuspid valve replacement.

CONCLUSIONS

Moderate to severe TR commonly occurs following heart transplantation. Severe TR is associated with significant morbidity.

Techniques in orthotopic cardiac transplantation: a review

Cardiac transplantation currently is the most effective therapy for end-stage heart failure. Since the origination of the standard biatrial technique, alternative methods such as the bicaval and "total" techniques have been devised with the hope of improving postoperative physiologic and clinical parameters. In general, the newer techniques are at least as effective as the original technique with respect to arrhythmia, valvular function, hemodynamics, exercise capacity, and survival, but whether any one technique offers clear benefits over another has been controversial. The bicaval technique is most commonly used today, and the general consensus is that this technique ultimately will demonstrate clinical superiority.