Expanding the heart donor base:

Heterotopic rat heart transplantation (Lewis to F344): early ICAM-1 expression after 8 hours of cold ischemia

BACKGROUND

Primary graft dysfunction is a still poorly understood complication after cardiac transplantation. Ischemia/reperfusion injury contributes to different disorders resulting in impaired graft function.

METHODS

In a heterotopic rat heart transplantation model we extended graft ischemic time up to 8 hours.

RESULTS

Using immunohistochemistry we detected an up to 4-fold increase in intracellular adhesion molecule-1 (ICAM-1) expression during 4 hours of reperfusion, independent of ischemic time (30-minute ischemia: 7.65 +/- 2.15 without reperfusion, 19.46 +/- 4.6 after 4-hour reperfusion; 240-minute ischemia: 5.6 +/- 1.99 and 22.3 +/- 3.77; 480-minute ischemia: 3.7 +/- 1.56 and 13.1 +/- 2.2). Eight-hour ischemic allografts had an increase in CD8-positive cells (1.37 +/- 0.5 and 2.3 +/- 0.77) and a significant increase in MHC II expression (11.48 +/- 2.1 and 18.27 +/- 1.34) during 4 hours of reperfusion.

CONCLUSIONS

We hypothesize that these findings reflect an early inflammatory reaction in the allograft possibly triggered by oxidative stress. During therapeutic interventions, both of these pathways must be considered.

Levosimendan Treatment After Primary Organ Failure in Heart Transplantation: A Direct Way to Recovery?

Heart transplantation is considered nowadays the gold standard in the therapy of chronic and terminal heart insufficiency. Primary organ failure after heart transplantation is a severe complication generally related to prolonged ischemia time, poor quality of the organ, or acute rejection. All these factors can potentially lead to multiorgan failure. Pharmacological and mechanical support for these patients is limited and often related to side effects. Ca sensitizers have been proposed to increase cardiac contractility without altering intracellular Ca levels, thus avoiding the side effects of Ca overload. We report two cases of heart transplanted patients suffering from acute graft failure in the early postoperative period who recovered after intravenous administration of levosimendan, a Ca sensitizer.

Long-term results of cardiac transplantation

Heart transplantation is a successful therapeutic option for patients with end-stage heart cardiomyopathy. From April 1991 to December 2000, 345 patients underwent heart transplantation at the Juan Canalejo Hospital. The mean age of recipients was 54.5 +/- 11.4 years; 286 (83%) were male patients. Idiopathic (52.2%) and ischemic (34.9%) end-stage cardiomyopathy were the main causes leading to transplantation. Ninety-four patients had undergone a previous heart operation. The mean left ventricular ejection fraction was 22.8 +/- 11.4. Forty patients (11.5%) were transplanted in urgent (status I) condition. The mean time spent on the waiting list was 35.9 days. In-hospital mortality was 10.6% and 24% for transplantations performed on an elective and urgent basis, respectively. Operative (30-day), one-year and six-year survival was 87.2%, 81.3% and 64%, respectively. In terms of actuarial survival, there were no significant differences with regard to the recipient's age, sex, previous cardiac surgery, and the etiology of the end-stage cardiomyopathy. The six-year actuarial survival for recipients receiving hearts from female donors was 59% compared with 72% for male donors (p = 0.05). There has been a low incidence of rejection, as well as cardiac graft vasculopathy. Actuarial survival at six years was 66% for patients transplantated on an elective basis compared with 57% for patients transplanted on an urgent basis (p = 0.04). The aim of the study was to evaluate long-term results for patients who underwent orthotopic heart transplantation. In our experience, status I is associated with a higher mortality.

Use of two recipient lists for adults requiring heart transplantation

OBJECTIVE

An alternate (second) adult recipient list was used to match excluded potential recipients with nonstandard donor hearts that would otherwise be unused.

METHODS

The only absolute criterion for entering the alternate recipient list was age: 65 years old before 1998 and 70 years old after that. Group I consisted of alternates who underwent transplantation, and group II consisted of 401 contemporaneous recipients. Hearts were first offered to regularly listed patients. At least one of the following donor risks accounted for allocation to an alternate: coronary artery disease, reused transplanted heart, high-risk behavior, hepatitis seropositivity, decreased left ventricular ejection fraction, high inotropic requirement, left ventricular hypertrophy, age older than 55 years plus another risk, and small donor with no other matches.

RESULTS

Of 102 alternates, 82 were listed were because of age. After a median wait of 107 days, 62 alternates underwent transplantation. Median alternate recipient age was 67 years (vs 54 years, P <.001). Median donor age was 45 years (vs 31 years, P <.001). Survival for alternates at 90 days was 82% (vs 91%, P =.04). Significant recipient predictors of early mortality on multivariable analysis (n = 463) were previous cardiac surgery (odds ratio 2.74, 95% confidence interval 1.37-5.48) and renal dysfunction (odds ratio 1.39, 1.10-176). Alternate listing did not independently predict early or late mortality. Late (>90 days) death rates per 1000 person-months were 4.3 and 3.6 for groups I and II (relative risk 1.2, 0.62-2.36).

CONCLUSIONS

Use of two adult recipient lists facilitated allocation of unused donor organs. Satisfactory long-term survival supports the use of an alternate recipient list.

Seventeen-year experience with 1,083 heart transplants at a single institution

BACKGROUND

Heart transplantation is the most accepted treatment for end-stage heart disease. A review of 1,083 consecutive transplants (1984 to 2001) was undertaken.

METHODS

Adult recipients were divided into quartiles. The last 540 transplants were combined. Three eras were created from these, 1984 to 1991, 1991 to 1995, and 1995 to 2001, with three age groups: 0 to 18 years, 19 to 61 years, and 62 to 74 years. All patients have at least 1 year of follow-up time. End points were survival, rejection, and graft coronary artery disease.

RESULTS

There were 1,012 patients. Donor age, graft ischemic time, and the proportion of elderly recipients and nonstandard donor hearts have increased in the current era. Actuarial 60-month survivals of recipients after 1995 were 80.7% (0 to 18 years); 75.3% (19 to 61 years); and 76.2% (>62 years). The current era children and younger adult groups demonstrated improved results when compared with previous eras (p = 0.003 and p = 0.05). Rejection episodes equal to or greater than ISHLT grade 3A per person per year improved to 0.15 in the current era (p < 0.001). During the three eras, older recipients (>62 years) demonstrated fewer episodes of rejection when compared with other adults (0.13 versus 0.58, p = 0.03). Deaths attributed to graft coronary artery disease decreased from 11% to 5% from era 2 to era 3. Regression analysis revealed a mild effect of donor age on survival and graft coronary artery disease (hazard ratio = 1.02, p = 0.001; hazard ratio = 1.039, p < 0.001, respectively). Recipient predictors of graft coronary artery disease were diagnosis of ischemic cardiomyopathy (hazard ratio = 1.6, p = 0.014) and congenital heart disease (hazard ratio = 3.41, p = 0.02).

CONCLUSIONS

Improved survival in the current era may be attributed to better organ preservation, improved immunosuppression and control of infection, and less life-threatening graft coronary artery disease.

Hepatitis C-positive donors in heart transplantation

Hepatitis C virus (HCV) can be transmitted to heart transplant recipients by donor organs. Mid-term results were reported using HCV-positive donors in patients at risk of imminent death (group I, n = 10), or in patients who otherwise would not have been offered heart transplantation (group II, n = 10) because of age (9/10) or associated medical risk (1/10). Medical records pertaining to patients receiving HCV-positive allografts between July 1994 and December 1999 were reviewed. The recipients consisted of 19 males and one female, with a median age of 54 years for group I and 66 for group II. The HCV RNA level, seroconversion of anti-HCV antibody, biochemical liver dysfunction, and causes of death were examined. Older recipients received reduced immunosuppression. Two patients in group II were HCV positive and were also retransplants. The hospital mortality rate was 10% in group I and 20% in group II; both hepatitis C-positive recipients died postoperatively prior to discharge. All predischarge deaths were related to multi-system organ failure (MSOF). All 17 survivors were HCV negative prior to transplant. Of these, 4/17 seroconverted. HCV RNA was detected in two of them. At a median follow-up of 26.4 months, 2/11 current survivors continue to test anti-HCV positive and are RNA negative. Three-year actual survival was 40% for group I and 70% in group II. Transplant coronary artery disease (TCAD) accounted for one postoperative death in group I. Current data show that four out of 11 survivors had developed TCAD at 3-year follow-up, yielding an actual freedom from TCAD rate of 12/17 (70%) at 3-year follow-up. Hepatitis C transmission using a donor heart as the reservoir is moderate (25%). Limited use of such donors is justified in selected patients. The risk for hepatic disease may be reduced by tailoring immunosuppression specifically for such recipients, particularly if they are at low risk of rejection. Further studies are necessary to define a possible association between HCV and TCAD.