Amiodarone-induced QT prolongation in a newly transplanted heart associated with recurrent ventricular fibrillation

Anti-arrhythmic drugs such as amiodarone have the potential to prolong QT intervals, which can result in torsades de point arrhythmia. It is unknown whether amiodarone, given to a recipient prior to cardiac transplantation, can cause arrhythmia in a newly transplanted donor heart. We report on a case of a 71-year-old male patient who had received intravenous and oral amiodarone prior to transplantation, which was associated with QT prolongation in the transplanted heart after re-exposure to the drug during subsequent episodes of ventricular fibrillation. An ICD was implanted, which has not been described that soon after cardiac transplantation. Amiodarone, given to a recipient, might cause QT prolongation in a donor heart after transplantation, possibly due to its long half-life and increased bioavailability caused by interaction with immunosuppressive drugs.

Combined heart-kidney transplantation with single-donor allografts

OBJECTIVES

Combined heart-kidney transplantation with allografts from the same donor has been long proved to be a feasible approach for selected patients with coexisting end-stage cardiomyopathy and renal disease. The purpose of this retrospective study is to analyze our long-term results and compare these results with heart-only transplantation over a 7-year period.

METHODS

Between June 1992 and April 1999, 10 patients underwent combined heart-kidney transplantation at Cedars-Sinai Medical Center. They were all men from 44 to 70 years old (mean age, 59 +/- 8.3 years) who had a mean left ventricular ejection fraction of 19.4% +/- 5.0% (range, 9%-25%) and a mean creatinine clearance of 25.4 mL/min (range, 10-39 mL/min). Four patients underwent pretransplantation dialysis.

RESULTS

There was no operative mortality. The actuarial survival at 1, 2, and 5 years was 100%, 88% +/- 11.7%, and 55% +/- 20.1%, respectively. By comparison, the operative mortality of 169 patients who underwent heart-only transplantation during the same time interval was 2.4%, with an actuarial survival at 1, 2, and 5 years of 92% +/- 2.1%, 84% +/- 2.8%, and 71% +/- 3.9%, respectively (P =.37). Eight patients showed no evidence of significant (> or =1B) cardiac allograft rejection postoperatively, and the actuarial freedom from rejection at 30 days, 1 year, and 2 years was 90% +/- 9%, 80% +/- 13%, and 80% +/- 13%, respectively. Renal allograft survival was 90% at 1 and 2 years.

CONCLUSIONS

Combined heart-kidney transplantation yields satisfactory long-term results similar to those for heart-only transplantation, with a low incidence of cardiac allograft rejection and renal allograft survival when both allografts are from the same donor. This approach effectively expands the selection criteria for heart-only and kidney-only transplantation in potential candidates with coexisting end-stage cardiac and renal disease.

Twenty-year comparison of tissue and mechanical valve replacement

OBJECTIVE

We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period.

METHODS

Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 +/- 13.3 years (St Jude Medical valve, 64.5 +/- 12.9; tissue valve, 72.0 +/- 12.6).

RESULTS

There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement.

CONCLUSIONS

Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.

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.

Evidence of time-dependent autonomic reinnervation after heart transplantation

BACKGROUND

Confirming the clinical significance of reinnervation is important in understanding and anticipating how heart rate (HR) responses of transplant recipients to physiologic stress differs early and late after transplant from that of normal individuals.

OBJECTIVES

To evaluate the functional significance of cardiac reinnervation early and late after heart transplantation.

METHODS

Handgrip and deep breathing tests, passive 80 degrees head-up tilt, and heart rate (HR) responsiveness of 33 transplant recipients (n = 16 at < 5 months and n = 17 at > 1 year after transplant) were compared with those of 16 age- and sex-matched control participants.

RESULTS

HR responses to handgrip and passive tilt were absent early after transplant. HR acceleration normalized but was blunted late after transplant. These findings are consistent with late (>1 year) sympathetic reinnervation in transplant recipients.

CONCLUSIONS

When caring for transplant recipients, nurses should consider the time elapsed since transplant in evaluating HR responsiveness to common procedures and interventions.

The clinical significance of antibodies to human vascular endothelial cells after cardiac transplantation

BACKGROUND

Vascular endothelial cells are primary targets for injury during both cellular and humoral allograft rejection (AR). In cardiac transplantation, the role of humoral immunity in mediating AR has not been extensively characterized.

METHODS

Antibodies against human vascular endothelial cells (AECA) were measured using a cellular ELISA developed from human umbilical vein endothelial cells in 80 consecutive patients after cardiac transplantation. The aim was to determine the incidence of AECA formation after transplantation and their association with different types of AR, graft survival, and development of cardiac allograft vasculopathy (CAV). At least eight serum samples obtained from each patient were examined for AECA and an endomyocardial biopsy was performed at regular intervals during the first year after transplantation.

RESULTS

Of the 80 patients examined, 31 were AECA (+) and 49 patients were AECA (-). There were no significant differences between the AECA (+) and (-) groups when examined for age, sex, and pretransplantation ischemia time. A significant correlation was found between the presence of AECA and humoral AR (P<0.015). AECA positivity did not correlate with the presence of cellular AR or the number of rejection episodes. In addition, allograft survival at 2 years after transplantation was significantly better in the AECA (-) group compared with that in the AECA (+) group (89.8% vs. 71.0%, P<0.0004). The persistence of AECA positivity during the first year after transplantation was also associated with a significantly greater incidence of CAV when compared with the patients who were AECA (-) (25.8% vs. 14.3%, P<0.004).

CONCLUSIONS

AECA may be important in the mediation of humoral AR, may decrease allograft survival, and may identify a high-risk group for CAV.

Posttransplant therapy using high-dose human immunoglobulin (intravenous gammaglobulin) to control acute humoral rejection in renal and cardiac allograft recipients and potential mechanism of action

BACKGROUND

Intravenous gammaglobulin (i.v.IG) contains anti-idiotypic antibodies that are potent inhibitors of HLA-specific alloantibodies in vitro and in vivo. In addition, highly HLA-allosensitized patients awaiting transplantation can have HLA alloantibody levels reduced dramatically by i.v.IG infusions, and subsequent transplantation can be accomplished successfully with a crossmatch-negative, histoincompatible organ.

METHODS

In this study, we investigated the possible use of i.v.IG to reduce donor-specific anti-HLA alloantibodies arising after transplantation and its efficacy in treating antibody-mediated allograft rejection (AR) episodes. We present data on 10 patients with severe allograft rejection, four of whom developed AR episodes associated with high levels of donor-specific anti-HLA alloantibodies.

RESULTS

Most patients showed rapid improvements in AR episodes, with resolution noted within 2-5 days after i.v.IG infusions in all patients. i.v.IG treatment also rapidly reduced donor-specific anti-HLA alloantibody levels after i.v.IG infusion. All AR episodes were reversed. Freedom from recurrent rejection episodes was seen in 9 of 10 patients, some with up to 5 years of follow-up. Results of protein G column fractionation studies from two patients suggest that the potential mechanism by which i.v.IG induces in vivo suppression is a sequence of events leading from initial inhibition due to passive transfer of IgG to eventual active induction of an IgM or IgG blocking antibody in the recipient.

CONCLUSION

I.v.IG appears to be an effective therapy to control posttransplant AR episodes in heart and kidney transplant recipients, including patients who have had no success with conventional therapies. Vascular rejection episodes associated with development of donor-specific cytotoxic antibodies appears to be particularly responsive to i.v.IG therapy.

Heart transplantation with bicaval and pulmonary venous anastomoses. A hemodynamic analysis of the first 117 patients

BACKGROUND

A new surgical technique for orthotopic heart transplantation has been introduced into clinical practice. It accomplishes total atrioventricular transplantation as the recipient's atria are completely excised and the allograft is implanted using bicaval and pulmonary venous anastomoses.

MATERIALS AND METHODS

We retrospectively analyzed post-transplant hemodynamic and patient survival in our first 117 patients transplanted with this new operative approach and compared them with 64 patients transplanted with the standard biatrial technique.

RESULTS

Patients transplanted with the bicaval technique had a significantly lower right atrial mean, pulmonary arterial systolic, pulmonary arterial mean, and pulmonary capillary wedge pressures. In addition, a significant reduction in post-transplant tricuspid regurgitation and a trend towards less severe mitral regurgitation was observed. The need for permanent pacemaker implantation due to sinus node dysfunction after transplantation was completely eliminated with this new technique. Thirty-day operative survival and actuarial survival at 1, 2, 3, and 4 years was significantly greater in patients transplanted with the bicaval technique.

CONCLUSIONS

Orthotopic heart transplantation performed with bicaval and pulmonary venous anastomoses offers improved post-transplant hemodynamics, eliminates the need for permanent pacemaker, and has improved patient survival when compared with the standard biatrial technique. These differences can be related in part to improved hemodynamic function of the cardiac allograft due to preservation of the anatomic configuration and physiologic function of the atria.

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.

The effect of chronic alcohol use on the heart before and after transplantation in an experimental model in the rat

BACKGROUND

Alcohol has potential deleterious effects on donor heart function. This study was conducted in rats to determine whether long-term alcohol ingestion produces impaired hemodynamic performance while maintaining a normal left ventricular ejection fraction in donor hearts before transplantation and whether donor cardiac function is affected after heart transplantation.

METHODS

Rats fed 30% alcohol in their drinking water for 12 weeks were compared with rats fed a normal diet. Left ventricular ejection fraction was measured by echocardiography with Simpson and single plane Dodge formulas in living sedated rats after 10 and 12 weeks of alcohol feeding. Explanted heart function was assessed before and 3 days after heterotopic heart transplantation (no immunosuppression) with a Langendorff preparation.

RESULTS

Blood ethanol levels at 4 and 8 weeks were 0.08 +/- 0.04 and 0.08 +/- 0.09 gm/dl. Left ventricular ejection fraction was similar in the group fed an alcohol diet for 12 weeks when compared with the control group (65.4% +/- 1.6% vs. 66.5% +/- 2.9%, p = 0.33). Explanted alcohol-fed hearts before transplantation had significantly lower maximum and developed pressures and had a blunted response to 0.1 ml 10(-9) mol/L isoproterenol. After transplantation alcohol-fed hearts had significantly lower maximum and developed pressures and decreased maximum rates of pressure rise and pressure decline. Allografts (ACI to Lewis) exhibited decreased function in comparison with isografts (ACI to ACI).

CONCLUSIONS

Alcohol feeding for 12 weeks in rats does not affect pretransplantation left ventricular ejection fraction, but it impairs explanted heart function, both before and after transplantation, resulting in a subclinical cardiomyopathy that is worsened by the presence of allograft rejection. Long-term alcohol exposure and rejection have independent, additive detrimental effects on left ventricular performance of the transplanted heart. Alcohol-exposed hearts may not be suitable donors.

The duration of administration of monoclonal antibody OKT3 for induction immunosuppression after heart transplantation

The effective treatment of refractory allograft rejection with murine antihuman monoclonal antibody muromonab-CD3 (OKT3) and of patients with renal dysfunction has led to its use as induction therapy. The optimal protocol for OKT3 prophylaxis remains to be established. We compared 59 patients consecutively transplanted with the total orthotopic technique between 1/92 and 5/94. The first 21 patients were treated with OKT3 for 14 days, the next 19 for 10 days, and the last 19 for 7 days. Patients operated with different surgical techniques or other induction treatment were excluded. We compared length of stay (total and ICU), time to first rejection, rejection incidence and infection incidence (cytomegalovirus separately), and survival. Preoperative characteristics were similar except for significantly younger age in the 10-day group (p = 0.04). Preoperative hemodynamic parameters were similar except for a significantly higher left-ventricular ejection fraction (21%) in the 7-day group. Length of stays in the ICU and hospital were similar for the three groups (p = NS). Freedom from cellular rejection was lower with the 7 days course (p = 0.02), but freedom from humoral rejection was slightly higher (p = 0.11). However, patients in the 7-day group required treatment for rejection less frequently than patients in the other two groups (95% untreated at 2 months vs. 43% in the 14-day and 53% in the 10-day group; p = 0.002). There were no differences in incidence of infections, including cytomegalovirus. Survival was similar between the groups. There was one death in the 14-day and 1 in the 10-day group, both due to rejection. In conclusion, OKT3 therapy can be reduced safely to 7 days with a higher overall incidence of rejection but no increased necessity to treat for rejection, and no difference in infection incidence.

Resting hemodynamics after total versus standard orthotopic heart transplantation in patients with high preoperative pulmonary vascular resistance

OBJECTIVE

Pretransplant pulmonary vascular resistance > or = 4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires longer ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemodynamics in pts with high preoperative pulmonary vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart transplantation transplanted between 12/88 and 7/94. Of these, 18 with total and 15 with standard orthotopic heart transplantation had a preoperative pulmonary vascular resistance > or = 4 Wood-units.

METHODS

Right heart catheterization data were obtained at each endomyocardial biopsy. All data from biopsies at both 2 weeks and 1 year posttransplant that were free from humoral or greater than 1A cellular rejection (9 versus 13 pts) were included in a two way ANOVA. Pts with postop pacemakers, atrial fib or beta-blocker therapy at the time of biopsy were excluded.

RESULTS

Ischemic time was different (172 +/- 44 versus 142 +/- 28 min, P = 0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output and index were higher in the total orthotopic group at 2 weeks (6.5 +/- 1.7 versus 5.1 +/- 1.0 l/min; 3.4 +/- 0.9 versus 2.8 +/- 0.6 l/min per m2) and 1 year (7.1 +/- 2.0 versus 4.9 +/- 1.1 l/min, P = 0.002; 3.6 +/- 1.1 versus 2.6 +/- 0.5 l/min per m2, P = 0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orthotopic heart transplantation at 2 weeks (6 +/- 4 versus 9 +/- 5, P = 0.04; 22 +/- 3 versus 25 +/- 7, P = 0.1) and 1 year (5 +/- 2 versus 7 +/- 3, P = 0.02; 19 +/- 4 versus 25 +/- 7, P = 0.03). Pulmonary capillary wedge pressure (mmHg) was borderline nonsignificant (11 +/- 4 versus 13 +/- 7 at 2 weeks, 8 +/- 3 versus 14 +/- 5 at 1 year, P = 0.055), as well as pulmonary vascular resistance (1.9 +/- 1 versus 2.5 +/- 1 at 2 weeks, 1.5 +/- 0.6 versus 2.7 +/- 1.7 WU at 1 year, P = 0.051).

CONCLUSIONS

Total orthotopic heart transplantation improves cardiac output and index in pts with high preoperative pulmonary vacular resistance. There is a lower mean RA and PA pressure perhaps due to less tricuspid and mitral regurgitation. In view of the frequently observed restrictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsided by preserving atrioventricular synchrony and offering better atrial transport.

Absence of endocardial lymphoid infiltrates (Quilty lesions) in nonheart transplant recipients treated with cyclosporine

The clinical records and autopsy material from 14 patients treated with cyclosporine who were not recipients of cardiac allografts were reviewed to further study the nature of endocardial lymphoid infiltrates (quilty lesions). Although there was well-documented exposure to cyclosporine, no endocardial lymphoid infiltrates were identified in these cases, providing evidence that the endocardial-based Quilty lesion is not the result of the direct effect of cyclosporine and may represent a localized form of heart rejection confined to the endocardium.

Cytomegalovirus infection induces anti-endothelial cell antibodies in cardiac and renal allograft recipients

Cytomegalovirus (CMV) infection represents a significant morbidity factor for transplant recipients. CMV infection has an association with the development of allograft rejection (AR) through graft endothelial cell (EC) damage, but the mechanisms are not yet clear. There are few reports addressing the role of humoral immunity in vascular EC injury mediated by CMV infection whereas many reports are available regarding the mechanism(s) of CMV-associated allograft EC injury mediated by cellular immunity. Here we examine the incidence of CMV infection in 40 cardiac and 25 renal allograft recipients using polymerase chain reaction (PCR) techniques. We also monitored sera for the development of anti-EC antibodies (AECA) using an ELISA with human umbilical vein ECs as targets, and IL-2 levels using an ELISA. AECA levels (immunoglobulin-G and immunoglobulin-M) were significantly elevated in allograft recipients who demonstrated CMV-PCR positivity when compared with the CMV-PCR negative group (IgG: 23.1 +/- 16.4 vs 4.7 +/- 4.5, p < 0.0001; IgM: 47.0 +/- 53.6 vs 7.0 +/- 11.2, p < 0.0001). Serum AECA (IgG and IgM) levels increased one to four weeks after CMV DNA was detected and elevated AECA levels persisted for at least one to two months, and sometimes for several months. Elevated AECA levels correlated well with serum IL-2 levels. These results suggest that CMV infection is associated with an increased humoral immune response to EC antigens, which may be a risk factor for vascular rejection, chronic rejection and decreased allograft survival.

Correlation of cytomegalovirus DNA levels with response to antiviral therapy in cardiac and renal allograft recipients

BACKGROUND

Cytomegalovirus (CMV) infection represents a significant morbidity factor for transplant recipients. A rapid, sensitive, specific, and reliable test is desirable for early detection of CMV infection and for monitoring the efficacy of antiviral therapy.

METHODS

We examined the incidence of CMV infection in 95 cardiac and 25 renal allograft recipients followed for up to 3 years using qualitative and quantitative polymerase chain reaction (PCR) techniques. Results were subsequently correlated with clinical findings. Of the 236 samples analyzed by the CMV PCR, 84 and 20 were also analyzed by blood buffy coat culture and anti-CMV antibody IgM assays, respectively.

RESULTS

The sensitivity of the CMV PCR was found to be superior to that of the other assays, although the specificity of the blood buffy coat culture is as good as that of the CMV PCR, which is higher than that of the anti-CMV antibody IgM assay. CMV infection was detected by the CMV PCR in 17 of 95 cardiac and 9 of 25 renal transplant recipients. Clinical symptoms were observed when > or =500 copies of CMV DNA/1 microg of total DNA were detected by a quantitative CMV PCR assay using an external control CMV plasmid; however, some patients had symptoms when 50-100 copies were present. The levels of CMV DNA detected varied (50-1000 copies) in patients who developed asymptomatic CMV infection. The CMV DNA levels decreased to 50-100 copies 1-2 weeks after antiviral therapy was initiated and correlated well with disappearance of clinical symptoms. CMV DNA levels decreased to < or =5 copies at 4-7 weeks after treatment. This contrasts with patients who were unresponsive to anti-CMV therapy, in whom high levels of CMV DNA (> or =500 copies) persisted for at least 5 weeks and significant levels of CMV DNA (50-100 copies) were detected for several months afterward, despite multiple courses of anti-CMV therapy. Clinical symptoms also did not disappear during this period of observation.

CONCLUSIONS

(1) The CMV PCR represents a rapid, sensitive, specific, reliable test for detection of CMV infection, especially for detection of virus replication in an incipient phase. (2) The quantitative CMV PCR is useful for monitoring the efficacy of antiviral therapy to distinguish patients who respond to therapy from those who do not. (3) CMV DNA levels > or =500 copies/1 microg of total DNA analyzed by the quantitative CMV PCR can be used to differentiate CMV infection from other infections and rejection.

Heart transplantation in patients with diabetic end-organ damage before transplantation

Diabetes mellitus with preexisting end-organ damage (EOD) is considered a contraindication for heart transplantation. The outcome of such patients has not been well characterized. Among 138 patients transplanted between 12/88 and 7/94, 29 were diabetic (11 insulin-dependent); of these, 12 had preexisting EOD, defined as a creatinine clearance < or = 50 ml/min, a 24-hour urine protein concentration > or = 500 mg/L or typical symptoms of peripheral or autonomic polyneuropathy, and 17 had no EOD. We compared diabetics with and without EOD and non-diabetics (n = 109) for operative mortality, length of stay, serum creatinine, fasting glucose levels, and postoperative prednisone doses at 1,6, and 12 months. Actuarial survival and freedom from rejection and infection were analyzed. Both diabetic groups were significantly older than nondiabetics, Ischemic time, operative mortality, surgical technique, ICU- and total length of stay were similar. Actuarial survival and freedom from rejection were similar among the three groups. Infection rates including CMV did not differ. Serum creatinine levels increased in all groups compared to pretransplant levels (p = 0.001), but without significant differences among the groups. Post-transplant glucose levels at 6 and 12 months were higher for diabetic patients with EOD than for those without or for nondiabetics (183, 153, and 94 mg/dl at 6 months, p = 0.01; 202, 161, and 102 mg/dl at 12 months, p = 0.0001). Prednisone dosage was lower in diabetics with EOD at 6 months, but did not differ among the three groups at 12 months. The incidence of angiographically proven transplant vasculopathy did not differ at 1 and 2 years. Diabetics with preexisting EOD undergoing heart transplantation experience similar short- and intermediate-term results when compared to diabetics without EOD and nondiabetics. Metabolic control is more difficult to achieve, as indicated by higher fasting glucose levels. Larger and longer-term prospective studies have to confirm our findings, since the shortage of donor organs would increase if such patients were transplanted routinely.

Clinical experience with one hundred consecutive patients undergoing orthotopic heart transplantation with bicaval and pulmonary venous anastomoses

OBJECTIVE

Our objective was to assess survival, need for pacemaker insertion, and rejection frequency with a new surgical technique of orthotopic heart transplantation using bicaval and pulmonary venous anastomoses.

METHODS

We retrospectively reviewed 100 consecutive patients who had orthotopic heart transplantation with this technique between July 1991 and September 1995.

RESULTS

The mean age was 57.0 +/- 11.1 years, with 51 patients being 60 years or older. The mean donor/recipient weight ratio was 0.92, and in 28 patients the ratio was less than 0.8. The early (30-day) survival was 100% and the 1- and 2-year survivals were 98% +/- 2% and 96% +/- 2%, respectively. Survival was not affected by age or by the duration of the OKT3 therapy (p > 0.2 for each of these parameters). The seven late deaths were due to infection (n = 2), graft atherosclerosis (n = 3), acute rejection (n = 1), and nonspecific graft failure (n = 1). No permanent pacemaker was required in the first 6 months after the operation, and all the patients were discharged in normal sinus rhythm. Freedom from treated rejection was significantly greater in patients with 7 days of OKT3 therapy than in patients with 14 days of therapy (p < 0.0001).

CONCLUSIONS

Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers an improved alternative to the standard biatrial technique, with a 30-day mortality of 0,% in 100 consecutive patients, excellent intermediate-term survival, and elimination of the need for pacemaker insertion. More normal anatomic configuration and synchronous function of the atria may have contributed to these results.

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.

Hemodynamic adaptation to orthostatic stress after orthotopic heart transplantation

OBJECTIVES

The purpose of this study was to compare the effects of orthostatic stress on cardiovascular stability in heart transplant recipients early and late after transplantation and in healthy controls.

BACKGROUND

After transplantation, cardiac reinnervation is heterogeneous, with reports of sympathetic reinnervation after 5 months and parasympathetic reinnervation after 2 to 3 years.

METHODS

Sixteen heart transplant recipients early (less than 5 months) after transplantation, 17 recipients late (1 year or more) after transplantation, and 16 matched healthy controls were subjected to 45 minutes of passive upright tilt, with the following variables measured before, during, and after the procedure: cardiac output, heart rate, stroke volume, mean arterial pressure, systemic vascular resistance, and plasma norepinephrine.

RESULTS

At rest, heart rate (p < 0.0005) and mean arterial pressure (p = 0.003) were higher, and stroke volume was lower (p < 0.0005), in transplant recipients than they were in controls. With orthostasis, heart rate increased by 30% in controls and by 23% in the late posttransplantation group compared with 13% in the early posttransplantation group (p = 0.028); drop in stroke volume was three times more among controls than among those in either transplantation group (p < 0.001); late transplant recipients had higher norepinephrine increases than did the other two groups (p = 0.012).

CONCLUSION

With the exception of heart rate, patterns of hemodynamic response to orthostatic stress after transplantation remain consistent over time and differ from controls. Among transplant recipients, higher mean arterial pressure mitigates the force of gravity and prevents drops in stroke volume. Clinicians may anticipate that transplant recipients will tolerate postural maneuvers well. Later after transplantation, however, orthostatic tolerance is associated with increased norepinephrine release, consistent with enhanced sympathoactivation.

Isolated coronary artery transplantation in pigs: a new model to study transplantation arteriosclerosis and humoral rejection

BACKGROUND

Graft atherosclerosis is a major cause of death after heart transplantation; its causes are multifactorial and poorly understood. To determine whether specific sensitization to coronary artery antigens is a contributing factor, we developed an isolated coronary artery allotransplantation model in pigs.

METHODS

Of 46 Yucatan minipigs, 32 received a segment from a farm pig coronary artery into the common carotid artery (coronary allograft group) and 14 had a left to right common carotid artery autotransplant (carotid autograft group). No immunosuppressive drugs were given; all pigs received heparin for 5 days. We examined patency rates, histologic changes, and endothelial deposition of immunoglobulin G and M.

RESULTS

In the coronary allograft group, patency rates were 100% (11 of 11) at 1 to 29 days, 20% (2 of 10) at 30 to 89 days, and 0% (0 of 11) after 90 days (overall 40.6%, 13 of 32). Histologic findings included endothelial cell hyperplasia, intimal proliferation, medial necrosis, adventitial inflammation, and ultimately luminal thrombosis. Deposition of immunoglobulin G and M was examined in the patent grafts and was seen in 90.9% (10 of 11) of grafts from days 1 to 29 and in the two patent but partially occluded grafts at 41 and 56 days. All carotid autografts except one (92.8%, 13 of 14) were patent up to 140 days and showed no or mild focal intimal thickening with normal media and adventitia. Deposition of immunoglobulin could not be detected in the autograft group.

CONCLUSIONS

In this pig model of coronary artery allotransplantation, typical histologic findings of graft atherosclerosis are produced. Deposition of immunoglobulin G and M occurs early and is associated with endothelial cell hyperplasia and intimal proliferation. This model may be useful for the study of graft atherosclerosis and assessment of interventions designed to halt its progression.

Resting hemodynamics after total versus standard orthotopic heart transplantation

Total orthotopic heart transplantation (TOHT) requires longer surgery than standard orthotopic heart transplantation (SOHT), but offers normal anatomy and synchronous atrial contraction. We endeavored to test whether TOHT improves resting hemodynamics. We analyzed 60 patients with SOHT and 66 with TOHT transplanted between 12/89 and 7/94. Age, preoperative NYHA class, ejection fraction, and donor characteristics were similar. After applying exclusion criteria at 2 weeks postoperatively, 53 SOHT and 58 TOHT patients were accepted for further study. Right-heart hemodynamics were examined at 2 weeks and 6 months posttransplant. Despite a longer ischemic time (161 +/- 36 vs. 142 +/- 37 min, p = 0.004), cardiac output and index were higher in the TOHT group at 2 weeks (6.1 +/- 1.4 vs. 5.4 +/- 1.0 L/min, TOHT vs. SOHT, p = 0.01; and 3.3 +/- 0.7 vs. 2.9 +/- 0.6 L/min/m2, p = 0.005) but similar at 6 months (5.9 +/- 1.2 vs. 5.6 +/- 1.4 L/min; and 3.0 +/- 0.6 vs. 2.9 +/- 0.7 L/min/m2). Right-atrial pressure was lower with TOHT at both time points (7 +/- 4 vs. 9 +/- 4 mmHg, p = 0.02: and 5 +/- 2 vs. 7 +/- 3, p = 0.0006). Wedge pressure was similar at 2 weeks (12 +/- 5 vs. 13 +/- 5, p = 0.045). Heart rate (bpm) was higher at both time points with TOHT (84 +/- 10 vs. 75 +/- 12, p = 0.0003: and 90 +/- 12 vs. 82 +/- 9, p = 0.0006). Pulmonary vascular resistance was similar at both time points. Despite a longer ischemic time, total orthotopic heart transplantation does not impair postoperative cardiac function. There is an early improvement in cardiac output, a sustained higher heart rate reflecting preservation of donor sinus node function, and a lower right-atrial pressure.

Liposome-mediated transfer of genes containing HLA-class II alpha chain into cultured embryonic chick cardiac myocytes and COS7 cells

Rejection remains a major problem after cardiac transplantation. One hypothesis is that transfer of recipient HLA genes could lead to expression of the antigens on the surface of donor cells and so facilitate graft acceptance. This paper describes a pilot study for relevant gene-transfer (transfection) experiments on adult cardiac myocytes, investigating the feasibility of transfection using cationic liposomes. The plasmid pcDV1-pL2 vector containing HLA-DR-alpha chain gene was incubated with Lipofectin, a DOTMA and DOPE lipid mixture, for 10 minutes. Embryonic chick cardiac myocytes (ECCM) and COS7 monkey cells were incubated with DNA: Lipofectin ratios of 1:1, 1:2, 1:4, and 1:10 for 16 hours (hrs). Using a fixed ratio of 1:4, incubation periods of 4, 8, and 16 hrs were compared. Finally, cells were incubated for 16 hrs and consecutively cultured for 6 days. Expression of the HLA-DR-alpha chain antigen was detected by indirect immunohistochemical staining. Highest transfection rates were achieved with a DNA: Lipofectin ratio of 1:4 for ECCM and COS7 cells (2.7% +/- 0.6% and 2.4% +/- 0.3% after 16 hrs incubation) and a transfection time of 4 hrs (5.8% +/- 0.6% and 5.3% +/- 1.7%). Immunohistochemically positive cells were present after 6 days (2.0% +/- 1.2% and 2.1% +/- 0.3%). We found a low level of expression of HLA-DR-alpha chain gene, influenced by transfection time and DNA: Lipofectin ratio. To increase the efficiency of liposome-mediated gene transfer and assess potential applications in cardiac transplantation, further investigation of cell properties promoting transfection is necessary.

Surgical techniques for cardiac transplantation

The surgical technique for cardiac transplantation was introduced by Lower and Shumway more than 30 years ago. It is known as "biatrial technique for cardiac transplantation" and has been used in more than 20,000 patients. However, since the early days of cardiac transplantation, atrial arrhythmias and atrioventricular conduction disturbances were noted so frequently that Dr. Barnard suggested a modification of the original technique to the present biatrial technique, in which the inferior vena cava orifice is enlarged with an atriotomy incision curving toward the base of the right atrial appendage, away from the sinus node. Atrial arrhythmias and other conduction abnormalities have, however, persisted and have resulted in the need for pacemaker insertion in a significant number of patients. Over the past years, with the more frequent use of transthoracic and transesophageal echocardiography, other abnormalities have been noted on follow-up of transplanted patients. These include tricuspid and mitral regurgitation, enlarged left and right atria with thrombus formation in the atrial suture line, asynchronous contraction of donor and recipient's atria, and right ventricular dysfunction in the early postoperative period. In the last 5 years, a new surgical technique for cardiac transplantation has been used in a few centers. This technique requires total excision of the recipient's heart and individual's caval and pulmonary vein anastomosis, "bicaval technique for cardiac transplantation." This technique seems to avoid the problems encountered with the biatrial technique. A comparison of the two surgical techniques, based on recently published surgical series, is presented.

Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation

BACKGROUND

Careful donor and recipient selection are important factors for the success of heart transplantation. Currently, donors with a history of alcohol use are routinely accepted despite the potential deleterious effects of alcohol on the heart.

METHODS

We examined the frequency of chronic alcohol use (> 2 ounces of pure alcohol daily for > or = 3 months) among organ donors and the outcome of the receipients after heart transplantation. Of 99 consecutive patients who underwent transplantation between December 1988 and August 1993 with an adequate donor history, 17 (17%) had a history of chronic alcohol use (alcohol group), and 82 (83%) did not (nonalcohol group). All recipients received triple-drug immunosuppression, and 10 to 14 days of OKT3.

RESULTS

Survival rates at 1 and 2 years were significantly lower in the alcohol group (61% +/- 13% and 61$ +/- 13%) than in the nonalcohol group (95% +/- 3% and 91% +/-4%, p = 0.0001). Most deaths in the alcohol group occurred within 3 months after transplantation. The incidence of rejection episodes did not differ significantly. Fatal rejection occurred more frequently in the alcohol group and was associated with severe ventricular dysfunction before death. Cox multiple regression analysis identified donor alcohol use as an independent risk factor for death after heart transplantation.

CONCLUSIONS

A substantial proportion (17%) of heart donors have a history of chronic alcohol use. The unfavorable early outcome of patients receiving hearts from alcoholic donors suggests the presence of a subclinical alcoholic cardiomyopathy before transplantation and poor tolerance of rejection episodes after transplantation. Larger prospective studies are needed to determine the mechanism of fatal rejection and whether such hearts can be used safely for transplantation.

Revascularization alone or combined with suture annuloplasty for ischemic mitral regurgitation. Evaluation by color Doppler echocardiography

To determine the effectiveness of revascularization alone or combined with mitral valve repair for ischemic mitral regurgitation, we performed color Doppler echocardiography intraoperatively before and after cardiopulmonary bypass in 49 patients (mean age, 70 +/- 9 years) with concomitant mitral regurgitation and coronary artery disease (triple vessel or left main in 88%; prior infarction in 90%). After revascularization alone (n = 25), the mitral annulus diameter (2.88 +/- 0.44 cm vs 2.88 +/- 0.44 cm), leaflet-to-annulus ratio (1.44 +/- 0.30 vs 1.44 +/- 0.29), and mitral regurgitation grade (1.7 +/- 0.9 vs 1.8 +/- 0.7) remained unchanged (p = NS, postpump vs prepump); mitral regurgitation decreased by 2 grades in only 1 patient (4%). After combined revascularization and mitral valve suture annuloplasty (Kay-Zubiate; n = 24), the annulus diameter decreased (to 2.57 +/- 0.45 cm from 3.11 +/- 0.43 cm), the leaflet-to-annulus ratio increased (to 1.46 +/- 0.25 from 1.20 +/- 0.21), and the mitral regurgitation grade decreased significantly (to 0.9 +/- 0.9 from 2.8 +/- 1.0) (p < 0.01); mitral regurgitation decreased by 2 grades or more (successful repair) in 75%. The origin of the jet correlated with the site of prior infarction (p < 0.05), being inferior in cases of posterior or inferior infarction (67%), and central or broad in cases of combined anterior and inferior infarction (70%). Despite a slightly higher 30-day mortality in the repair group (p = 0.10), there was no significant difference in survival between the 2 surgical groups at 5 years or 8 years. Therefore, in this study of patients with mitral regurgitation and coronary artery disease, reduction in regurgitation grade with revascularization alone was infrequent. Concomitant suture annuloplasty significantly reduced regurgitation by reestablishing a more normal relationship between the leaflet and annulus sizes. The failure rate after suture annuloplasty was 25%; alternative repair techniques such as ring annuloplasty may have a lower failure rate.

Survival of acute intestinal infarction after cardiac transplantation

We report the case of a 52-year-old male who underwent total orthotopic heart transplantation for end-stage ischemic cardiomyopathy. The postoperative course was complicated by acute intestinal infarction which was diagnosed after surgical exploration, and treated with a subtotal colectomy with Brooke ileostomy and closure of the distal sigmoid three days posttransplant. The patient survived with nutritional support and broad antibiotic prophylaxis. Review of the literature on acute abdominal complications after operations involving cardiopulmonary bypass suggests that such complications are usually fatal. Detection and diagnosis may be obscured and treatment complicated by immunosuppression after cardiac transplantation. Because of the poor prognosis without appropriate management, a high level of suspicion, early and aggressive diagnostic measures, and swift surgical intervention are essential to survival.

Heart transplantation after repair of postinfarction ventricular septal defect

A 68 year-old man underwent surgical repair of a ventricular septal defect following an acute myocardial infarction. Recurrent interventricular septal rupture with significant left-to-right shunting led to progressive deterioration in cardiac function and intractable heart failure. The patient underwent orthotopic heart transplantation three months after his initial operation, and he is clinically well sixteen months after transplantation.

Heart transplantation for Chagas' cardiomyopathy

We present 2 patients who underwent orthotopic heart transplantation for end-stage Chagas' cardiomyopathy. Despite immunosuppressive therapy, postoperative prophylaxis with nifurtimox appeared to prevent Trypanosoma cruzi reactivation. Neither patient has shown signs of Chagas' myocarditis, and both are clinically well 12 and 72 months after transplantation. The successful outcome of our patients suggests that heart transplantation is a reasonable therapeutic option in patients with end-stage Chagas' cardiomyopathy.

Permanent pacemaker for rejection episodes after heart transplantation: a poor prognostic sign

BACKGROUND

The development of arrhythmias early or late after heart transplantation has been associated with acute and chronic rejection. This study aims to document the importance of this relationship and its value as a prognostic sign in those patients who required a permanent pacemaker for rejection episodes.

METHODS

A retrospective analysis of 158 orthotopic heart transplantations performed in 157 patients between December 1988 and April 1995 was done. The clinical course and the outcome of 6 patients who underwent insertion of a permanent pacemaker for bradyarrhythmias caused by acute or chronic allograft rejection were compared with the course and outcome of 9 patients who had pacemaker placement as a result of sinus node dysfunction not associated with rejection.

RESULTS

The mortality rate was 100% for patients whose indication for permanent pacing was severe acute or chronic rejection. Conversely, 8 of the 9 patients who underwent pacemaker placement for sinus node dysfunction not associated with rejection are long-term survivors; the one late death was due to a noncardiac cause.

CONCLUSIONS

We observed a strong relationship between bradyarrhythmias requiring a permanent pacemaker and severe acute or chronic allograft rejection. This association suggests a poor prognosis and indicates that these patients should be managed aggressively. Such management includes close immunologic surveillance for cellular and humoral rejection, increased frequency of endomyocardial biopsies and coronary angiography, and early consideration for retransplantation.

Pathogenesis of Quilty lesion in cardiac allografts: relationship to reduced endocardial cyclosporine A

BACKGROUND

Endocardial lymphocytic infiltrates, known as Quilty effect, are a common finding of uncertain pathogenesis in cardiac allografts. Quilty effect was not observed before the use of cyclosporine A for immunosuppression and is not generally regarded as a manifestation of rejection. We hypothesized that the endocardial localization of Quilty effect may be related to a relative absence of cyclosporine A in this region.

METHODS

We used an indirect immunofluorescence staining method with rabbit polyclonal anti-cyclosporine A antibodies to detect cyclosporine A in fresh frozen sections of 27 cardiac allograft endomyocardial biopsies. Staining was graded 0 to +3. Negative controls were from untreated transplant candidates and from biopsies with the primary antibody omitted.

RESULTS

On comparison of endocardial and myocardial fluorescence in biopsy specimens from patients treated with cyclosporine A, there was less endocardial (0.7 +/- 1.1, p < 0.0001) than myocardial (2.2 +/- 0.5) staining. However, in biopsy specimens with Quilty effect (n = 12), this difference was significantly greater (endocardial = 0.2 +/- 0.6 versus myocardial = 2.3 +/- 0.5; p = 0.005) than in specimens without Quilty effect (n = 10) (endocardial = 1.4 +/- 1.2 versus myocardial = 2.1 +/- 0.6; p = 0.7). Endocardial thickness as measured by ocular micrometry was significantly greater in regions with (32 +/- 19 microns) than without (7 +/- 4 microns) Quilty effect, with involved regions showing increased connective tissue (p < 0.0001). In patients with and without Quilty effect, no differences in donor or recipient demographics, prevalence of diabetes, or plasma cyclosporine A levels were found.

CONCLUSIONS

Although it has been postulated that Quilty effect is due to the presence of cyclosporine A in cardiac tissue (toxic effect or immunologic reaction), these data suggest that Quilty effect is related to reduced endocardial presence of cyclosporine A, leading to localized, contained, and usually not clinically significant endocardial rejection.

Superior vena cava stenosis after orthotopic heart transplantation: complication of an alternative surgical technique

Superior vena cava stenosis presented as a postoperative complication of orthotopic heart transplantation in a patient in whom a new surgical technique was used. This alternative technique consists of total excision of the recipient's atria, with donor heart implantation performed using bicaval and pulmonary venous anastomoses. This rare complication required surgical repair 1 month after transplantation. The patient remains well on long-term follow-up. The pathogenesis, surgical management and modifications of the alternative technique to prevent this potentially serious complication are discussed.

Combined antiviral and immunoglobulin therapy as prophylaxis against cytomegalovirus infection after heart transplantation

BACKGROUND

Cytomegalovirus is a frequent cause of infection and morbidity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%.

METHODS

To determine the efficacy of combined antiviral and intravenous immune globulin therapy for prevention of cytomegalovirus disease in transplant recipients receiving OKT3 and to compare two different antiviral drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intravenous ganciclovir for 2 weeks followed by oral acyclovir up to 3 months (group G); all received six infusions of 5% intravenous immune globulin over 2 months. All patients had OKT3 for 10 to 14 days and triple-drug immunosuppression.

RESULTS

Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patients (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositive recipients, there was a trend to less cytomegalovirus disease in group G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patients) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% (group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus disease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant).

CONCLUSIONS

Prophylaxis with combined antiviral and immune globulin therapy produces a low (10%) incidence of cytomegalovirus disease in OKT3-treated heart transplant recipients. In seropositive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive prophylactic strategies are needed in seronegative patients who receive hearts from seropositive donors.

Improved left atrial transport and function with orthotopic heart transplantation by bicaval and pulmonary venous anastomoses

Orthotopic heart transplantation (OHT) with bicaval and pulmonary venous anastomoses avoids the large atrial anastomoses of the standard biatrial technique. To determine whether the bicaval technique improves atrial performance, we used Doppler echocardiography to study 13 patients with bicaval OHT, 15 with biatrial OHT, and 8 normal subjects. All were in sinus rhythm and free of rejection. Left atrial size, transmitral (M) and late diastolic (A) mitral flow velocity integrals were measured. Atrial transport (A/M, %) and atrial ejection force (kilodynes, calculated from peak A-wave velocity and mitral orifice area) were assessed. Left atrial dimensions in the bicaval (4.3 +/- 0.5 cm) and biatrial groups (4.9 +/- 0.9 cm) were larger than in controls (3.3 +/- 0.8 cm, p < 0.05). Left atrial transport (37% +/- 12% and 35% +/- 12%) and ejection force (14.1 +/- 6.9 kdyne and 10.2 +/- 7.8 kdyne) were similar in the bicaval group and controls (p not significant) but were significantly lower in the biatrial group (20% +/- 19% and 3.6 +/- 4.0 kdynes, p < 0.05). The bicaval and pulmonary venous technique of OHT produces more physiologic atrial function compared with the biatrial technique as evidenced by greater atrial ejection force and more normal atrial transport.

Nature and significance of epicardial lymphoid infiltrates in cardiac allografts

BACKGROUND

Myocardial lymphocytic infiltration after transplantation is usually a manifestation of acute cellular rejection. However, purely endocardial infiltrates are generally not regarded as rejection (so-called "Quilty lesions"). The nature of epicardial lymphoid infiltration in cardiac allografts and its significance when observed in endomyocardial biopsies or autopsies are uncertain.

METHODS

Twenty-seven cases of transplant-associated epicardial lymphoid infiltration were identified; 16 cases were identified from 1602 consecutive transplant biopsy specimens from 125 patients, and 11 from 14 autopsies, ranging from 1 to 35 months (mean 7.8 months) after transplantation.

RESULTS

The infiltrates were composed of aggregates of lymphocytes and histiocytes distributed throughout the epicardium. Plasma cells were found in 52% of cases, with occasional eosinophils and rare neutrophils. Most were vascular, and four autopsy cases had follicle formation. Twenty-four cases (93%) showed a mixed population of cells in a random distribution consisting of T cells in association with fewer B cells and histiocytes. Fifteen cases (nine autopsies, six biopsies) had acute rejection, and nine autopsies had chronic vascular rejection. Fourteen of twenty-four cases (58%) showed concurrent Quilty lesion (nine autopsies, five biopsies), and the remainder showed at least one Quilty lesion in an earlier biopsy.

CONCLUSION

Epicardial lymphoid infiltrates occur with significant frequency after heart transplantation and can be associated with, and mimic, acute cellular rejection. However, they exhibit morphologic and immunophenotypic features which are distinguishable from rejection-associated infiltrates.

Atrial emptying with orthotopic heart transplantation using bicaval and pulmonary venous anastomoses: a magnetic resonance imaging study

OBJECTIVES

We hypothesized that orthotopic heart transplantation with bicaval and pulmonary venous anastomoses preserves atrial contractility.

BACKGROUND

The standard biatrial anastomotic technique of orthotopic heart transplantation causes impaired function and enlargement of the atria. Cine magnetic resonance imaging (MRI) allows assessment of atrial size and function.

METHODS

We studied 16 patients who had undergone bicaval (n = 8) or biatrial (n = 8) orthotopic heart transplantation without evidence of rejection and a control group of 6 healthy volunteers. For all three groups, cine MRI was performed by combining coronal and axial gated spin echo and gradient echo cine sequences. Intracardiac volumes were calculated with the Simpson rule. Atrial emptying fraction was defined as the difference between atrial diastolic and systolic volumes, divided by atrial diastolic volume, expressed in percent. All patients had right heart catheterization.

RESULTS

Right atrial emptying fraction was significantly higher in the bicaval (mean [+/- SD] 37 +/- 9%) than in the biatrial group (22 +/- 11%, p < 0.05) and similar to that in the control group (48 +/- 4%). Left atrial emptying fraction was significantly higher in the bicaval (30 +/- 5%) than in the biatrial group (15 +/- 4%, p < 0.05) and significantly lower in both transplant groups than in the control group (47 +/- 5%, p < 0.05). The left atrium was larger in the biatrial than in the control group (p < 0.05). Cardiac index, stroke index, heart rate and blood pressure were similar in the transplant groups.

CONCLUSIONS

Left and right atrial emptying fractions are significantly depressed with the biatrial technique and markedly improved with the bicaval technique of orthotopic heart transplantation. The beneficial effects of the latter technique on atrial function could improve allograft exercise performance.

Wolff-Parkinson-White syndrome in a cardiac allograft

A 61-year-old man underwent orthotopic heart transplantation for end-stage ischemic cardiomyopathy. The donor presented with Wolff-Parkinson-White syndrome and the allograft was successfully transplanted. The accessory pathway was interrupted postoperatively by radiofrequency current catheter ablation, and the patient is clinically well and free of preexcitation 24 months later.

Clinical-pathologic features of humoral rejection in cardiac allografts: a study in 81 consecutive patients

BACKGROUND

Humoral rejection is an infrequently reported, poorly understood form of cardiac allograft rejection.

METHODS

We reviewed 81 consecutive heart transplant recipients followed up to 3 years after transplantation to evaluate the frequency and significance of humoral rejection in this population. Histologic features evaluated included capillary endothelial cell swelling, interstitial edema and hemorrhage, and neutrophilic infiltration. Immunofluorescence studies with antibodies to immunoglobulin G, immunoglobulin A, immunoglobulin M, Clq, C'3, HLA-DR, and fibrinogen and immunoperoxidase staining for endothelial cells (factor VIII-related antigen) and macrophages (KP1 [CD68]) were performed. Minimal criteria for the diagnosis of humoral rejection were capillary endothelial cell swelling and any immunoglobulin and complement staining in capillaries. Findings were graded and compared with concurrent hemodynamic measurements.

RESULTS

Immunoperoxidase staining showed that most swollen cells in capillaries were macrophages and fewer were endothelial cells. Humoral rejection was detected in 102 biopsy specimens from 42 patients (52%), within 3 weeks of transplantation in 28, and 3 weeks to 4 months later in the other 14 patients. One patient had evidence of humoral rejection almost 3 years after transplantation. A third of biopsy specimens with humoral rejection were associated with abnormal hemodynamics; of these 33 specimens only five had significant (grade 3 or 4) coexisting cellular rejection. Histologic findings most often associated with hemodynamic abnormalities were diffuse capillary endothelial cell swelling and any interstitial hemorrhage or edema. Three patients died of humoral rejection; only 1 had coexisting cellular rejection (grade 3A).

CONCLUSIONS

In our experience humoral rejection (1) is not uncommon (52% of patients), (2) is often (33% of cases) associated with hemodynamic abnormalities, and (3) may be fatal.

Heart transplantation for Q fever endocarditis

A 30-year-old man underwent aortic and mitral valve replacement for the treatment of Q fever endocarditis. Postoperatively, paravalvular leak of the mitral prosthesis, progressive deterioration in cardiac function, and intractable heart failure developed. As a result, the patient underwent orthotopic heart transplantation 15 months after his initial valve operation. The patient is clinically well 14 months after transplantation.

Grade 2 cellular heart rejection: does it exist?

According to the International Society for Heart and Lung Transplantation, a single focus of lymphocytic infiltration associated with myocyte injury in a cardiac allograft endomyocardial biopsy is focal moderate cellular rejection (Grade 2). We reviewed 115 endomyocardial biopsy specimens that were completely negative (n = 17), had a Quilty A (n = 17) or Quilty B (n = 46) lesion, or had a lesion fulfilling the criteria of grade 2 rejection (n = 35). By studying step sections (mean = 18) or sections stained for elastic tissue and collagen, we showed continuity of the focus of grade 2 rejection with the endocardium in 32 of 35 cases; these results justify reclassification of these foci as Quilty B lesions, which are defined as endocardial infiltrates that encroach on the underlying myocardium and that may be associated with myocyte injury but are not generally considered to represent acute rejection. Immunohistochemical staining for T and B lymphocytes and histiocytes showed similar patterns in deeper zones of Quilty B lesions and lesions initially regarded as grade 2 rejection. Normal hemodynamics were observed with 16 of 17 completely negative biopsy specimens, 16 of 17 Quilty A biopsy specimens, 46 of 46 Quilty B biopsy specimens, and 35 of 35 grade 2 rejection biopsy specimens. No grade 2 rejection was treated; only 1 biopsy specimen progressed to grade 3A rejection in a subsequent biopsy 2 months later. Most, if not all, cases of grade 2 cellular rejection can be shown to be Quilty B lesions, are not associated with hemodynamic abnormalities, and do not require augmented immunosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses

We present our experience with an alternative technique for orthotopic heart transplantation. It consists of total excision of the recipient's atria, with the donor's heart implantation performed using bicaval end-to-end anastomoses as well as pulmonary venous anastomoses. Forty consecutive patients receiving transplants in this fashion were compared with 64 patients who underwent orthotopic transplantation with the standard technique. The incidence of postoperative tricuspid regurgitation was reduced in patients receiving transplants with the new surgical approach (p = 0.003). In addition, the need for pacemaker implantation for severe bradyarrhythmia in the early (0 to 6 weeks) posttransplantation period (p = 0.003) was eliminated. Although not statistically significant, there was a trend in the reduction of postoperative mitral regurgitation in patients who received transplants by the modified technique. Based on this experience, we believe this modified technique for orthotopic heart transplantation has an anatomic and physiologic advantage that may improve long-term hemodynamic results.

Donors with a history of cocaine use: effect on survival and rejection frequency after heart transplantation

The frequency of cocaine use among donors is currently unknown. Cocaine has cardiotoxic effects and could affect the outcome of heart transplantation. To examine the frequency of nonintravenous cocaine use in organ donors and the outcome of heart transplantation with such donors, we retrospectively analyzed the clinical, biopsy, and donor information on 112 consecutive patients who underwent transplantation between December 1988 and August 1993. Ten patients were excluded because of incomplete information regarding the donor's cocaine status. Of the remaining 102 patients, 16 (16%) had a positive donor history for nonintravenous cocaine use (cocaine group) and 86 patients (84%) had a negative history (noncocaine group). Survival, frequency of cellular rejection (grade > or = 1B), and humoral rejection were compared between the two groups. Survival rates at 30 days (100% versus 97% +/- 2%) and at 1 year (93 +/- 7% versus 89 +/- 3%) were similar (p = not significant, cocaine versus noncocaine group). Freedom from rejection was similar at 30 days (81% +/- 10% versus 79% +/- 4% cellular rejection-free, 33% +/- 14% versus 60% +/- 6% humoral-free) and 6 months (34% +/- 12% versus 55% +/- 5% cellular-free, 16% +/- 11% versus 36% +/- 6% humoral-free) (p = not significant). No significant difference was found in donor inotropic support before procurement, ischemic time, length of stay in intensive care unit, or total stay in the hospital. In conclusion, a high incidence of nonintravenous cocaine use exists among donors. The outcome of patients who receive transplanted hearts obtained from nonintravenous cocaine users is favorable, suggesting that the use of such hearts is safe.

Combined heart and kidney transplantation with allografts from the same donor

We present the cases of 3 patients who underwent simultaneous heart and kidney transplantation using allografts from the same donor. This combined approach offers a reasonable option for patients with coexisting end-stage heart and kidney disease. A review of all previously reported cases suggests that survival is similar to that of single-organ transplantation. In addition, there appears to be a low incidence of rejection when multiple allografts from the same donor are used. The heart and kidney can and frequently do reject asynchronously, so rejection monitoring and surveillance should be carried out separately for each transplanted organ.

Technical considerations of a new technique for orthotopic heart transplantation. Total excision of recipient's atria with bicaval and pulmonary venous anastomoses

An alternative technique for orthotopic heart transplantation is described. It consists of total excision of the recipient's atria with donor heart transplantation performed using bicaval end-to-end anastomosis, as well as pulmonary venous anastomoses. Thus, total atrial as well as ventricular transplantation is performed. This new surgical approach is technically simple and preserves the anatomic size, geometric configuration and physiologic function of the atria. This technique has the potential to improve the long-term hemodynamic results in heart transplant patients as it reduces the incidence of postoperative atrioventricular valve regurgitation. In addition, the incidence of early posttransplant bradyarrhythmias (within 4 to 6 weeks after transplantation) that require the insertion of a permanent pacemaker is also significantly reduced. This report describes some technical guidelines for harvesting the donor heart, as well as for the implantation of the cardiac allograft, in order to avoid the development of serious intraoperative and postoperative complications directly associated with this technique.

Heart transplantation in corrected transposition of the great arteries

Orthotopic heart transplantation was successfully performed in a patient with corrected transposition of the great arteries (L-type) who had end-stage cardiomyopathy. Technical modifications for the transplantation procedure were made accordingly. The cardiac allograft was implanted with an alternative technique consisting of bicaval and pulmonary venous anastomoses. Postoperative hemodynamics were normal, and the patient was well 9 months after transplantation.

Alternative technique for orthotopic heart transplantation

An alternative technique for orthotopic heart transplantation is described. The principle consists of total excision of the recipient's right atrium with donor heart implantation performed using bicaval anastomoses; the left atrium is done in the standard fashion. This approach is technically simple and preserves the anatomic and physiologic function and integrity of the right atrium, especially the conduction system.

Cytokine expression and endothelial cell and lymphocyte activation in human cardiac allograft rejection: an immunohistochemical study of endomyocardial biopsy samples

We used monoclonal antibodies and immunohistochemical staining of frozen tissue sections to study the expression of cytokines in human cardiac allograft rejection. The 113 endomyocardial biopsy samples were stained for interleukin (IL)-2, IL-6, and interferon-gamma. The findings were compared to expression of the endothelial cell adhesion molecule ICAM-1, and the lymphocyte receptor for the adhesion molecule VCAM-1, VLA-4. Four biopsy samples from patients with idiopathic cardiomyopathy served as controls. IL-2 was not expressed in lymphocytes of controls and only occasionally in mild or moderate cellular rejection, humoral rejection, and Quilty lesions. IL-2 expression was prominent in severe cellular rejection. Interferon-gamma expression increased in proportion to the severity of cellular rejection and was not expressed in other conditions. IL-6 staining, which was only observed in occasional cases, was mild. Cytokine and adhesion molecule expression tended to increase with the severity of cellular rejection. This study shows that cytokine expression can be documented in human allograft endomyocardial biopsy samples with immunohistochemical techniques. The findings support the concept of an important role for cytokines in human cardiac allograft rejection.

Comparative efficacy of ring and suture annuloplasty for ischemic mitral regurgitation

BACKGROUND

Patients with ischemic mitral regurgitation (MR) represent a therapeutic challenge, and results after combined valve replacement and revascularization have been poor. Valve repair is a promising approach, but the optimal method of repair is not known.

METHODS AND RESULTS

In 60 patients with coronary artery disease and 3+ or 4+ MR, we used intraoperative Doppler echocardiography to study the efficacy of Carpentier-Edwards ring (n = 27) and commissural suture (n = 33) annuloplasty. Patients with ruptured papillary muscles, torn chordae, and ballooning or scalloping of the leaflets were excluded. Ring and suture groups were similar in preoperative ejection fraction (35 +/- 14% and 34 +/- 17%), MR grade (3.5 +/- 0.5 and 3.4 +/- 0.6), and acuity of MR (41% and 33% acute) (p = NS). Postoperatively, the ring group achieved a lower residual MR grade than the suture group (0.5 +/- 0.5 versus 1.5 +/- 1.1; p < 0.001), and the mitral annular diameter was reduced to a greater extent in the ring group (by 1.5 +/- 0.5 cm versus 0.5 +/- 0.4 cm; p < 0.001). Success (> or = 2 grade MR reduction) was more frequent in the ring than in the suture group (96% versus 67%, p < 0.01). One-year survival was similar (74 +/- 9% ring, 71 +/- 8% suture). Follow-up Doppler studies showed a higher mean gradient (4.0 +/- 1.2 mm Hg) and smaller valve area (2.1 +/- 0.5 cm2) in the ring group, but the postoperative New York Heart Association class was similar in both groups (83% versus 74% class I-II).

CONCLUSIONS

Ring annuloplasty provides a more effective reduction of ischemic MR and a higher success rate than the suture technique. This may be related to uniform rather than localized shortening of the annulus and a greater reduction in annulus diameter.