Secular trends in cardiac transplant recipient and donor management in the United States, 1990 to 1994. A multi-institutional study. Cardiac Transplant Research Database Group

BACKGROUND

The growth of the US cardiac transplant waiting list has outpaced the increase in donors, resulting in a widening gap between the number of waiting recipients and available donors. These trends have generated concern that longer waiting times may result in more patients deteriorating to urgent status and that transplanting only patients who are in an advanced state of decompensation will reduce posttransplant survival. Furthermore, the shortage of donors may result in extending the guidelines for donor acceptability to a degree that increases graft failure and posttransplant mortality. We measured these secular trends in the Cardiac Transplant Research Database to provide current data on time-dependent changes in US cardiac transplant practice and survival.

METHODS AND RESULTS

At the time of this analysis, the Cardiac Transplant Research Database included all 2749 patients transplanted from January 1, 1990, to June 30, 1994, in the 25 participating transplant centers. During this 4.5-year period, the median waiting time for recipients who received a transplant increased from 2.7 to 3.5 months (P < .0001), and the proportion of recipients whose status was urgent at transplantation increased from 41% to 60% (P < .0001). Donor ischemic time increased from 150 to 166 minutes (P < .0001), and the proportion of donors requiring pressor support increased from 68% to 85% (P < .0001). Despite these changes in practice, the 1-year survival rate remained constant at 84% during this 4.5-year interval. There was no significant difference in 1-year survival rate between urgent status patients (83%) and nonurgent status patients (85%) (P = .08).

CONCLUSIONS

The widening gap between the number of waiting recipients and the number of donors has resulted in a continuing trend toward transplanting urgent status recipients and to a liberalization of donor acceptance criteria. Despite these changes, posttransplant survival has remained constant.

Risk factors for late recurrent rejection after heart transplantation: a multiinstitutional, multivariable analysis. Cardiac Transplant Research Database Group

BACKGROUND

Previous studies of allograft rejection have focused on early episodes and risk factors from pretransplant variables.

METHODS

This multiinstitutional study compared early (< 1 year) and late (> 1 year) rejection episodes and risk factors for recurrent rejection from variables both before and after transplantation among 1251 patients who underwent primary heart transplantation and available follow-up of greater than 1 year.

RESULTS

There were a total of 1882 rejection episodes over a mean follow-up of 26 +/- 0.3 months. The hazard function (instantaneous risk per patient per month) peaked at 1 month followed by a low constant risk of rejection after 12 months. By multivariable analysis, the most dominant risk factors for recurrent rejection during the first posttransplantation year were a shorter time interval since transplantation and a shorter time since a previous rejection episode. Other factors included young age, female gender, female donor, positive cytomegalovirus serology, prior infections, and OKT3 induction. In contrast, after the first year, the dominant risk factors for rejection were a greater number of rejections during the first year and the presence of prior cytomegalovirus infections.

CONCLUSIONS

These data show a striking time dependency for rejection episodes among heart transplant recipients. Factors that increase risk for rejection in the first year differ from risk factors for rejection in subsequent years. These data suggest that it may be possible to tailor rejection surveillance protocols and immunosuppression intensity, according to specific patient and time-related risk factors.

Coronary artery mapping: a method for three-dimensional reconstruction of epicardial anatomy

Evaluation of coronary anatomy with conventional coronary angiography requires visual integration of multiple images from different viewing orientations to generate a mental interpretation of three-dimensional (3D) structure. The epicardial surface is, in many ways, analogous to the earth's surface topography and may be effectively depicted using cartographic methods. To show coronary anatomy visualized as topographic maps, we used cartographic projection methods to analyze the coronary vessels of a canine heart after immediate postmortem injection with a radio-opaque gelatinous solution. A volumetric image data set was obtained with x-ray spiral computed tomography. The principal axis of the image volume was calculated and the image volume reformatted to a reference coordinate system defined by the principal axis as the ordinate. A cylindrical projection map of the epicardial surface was created using a maximum-intensity projection volume-rendering technique. After converting the Cartesian reference coordinate system to a polar coordinate system, additional mapping projections from user-defined orientations were generated. The results show that interpretative difficulties of coronary angiography may be diminished by generating 3D maps of coronary anatomy using volumetric datasets acquired noninvasively and displayed with cartographic methods.

Matching the heart donor and heart transplant recipient. Clues for successful expansion of the donor pool: a multivariable, multiinstitutional report. The Cardiac Transplant Research Database Group

Little information is available regarding donor-specific parameters that predict success or failure after heart transplantation. Furthermore, with increasing numbers of patients awaiting heart transplantation, there is tremendous pressure to expand the donor pool by stretching the margins of donor acceptability. To gain insight into donor-related and donor-recipient interrelated predictors of death after transplantation, 1719 consecutive primary transplantations performed at 27 institutions between Jan. 1, 1990, and June 30, 1992, were analyzed. Mean follow-up of survivors was 13.9 months, and actuarial survival was 85% at 1 year. By multivariable analysis, risk factors for death included younger recipient age (p = 0.006), older recipient age (p = 0.0005), ventilator support at time of transplantation (p = 0.0006), higher pulmonary vascular resistance (p = 0.02), older donor age (p < 0.0001), smaller donor body surface area (female donor heart placed into larger male patient) (p = 0.003), greater donor inotropic support (p = 0.01), donor diabetes mellitus (p = 0.01), longer ischemic time (p = 0.0003), diffuse donor heart wall motion abnormalities by echocardiography (p = 0.06), and, for pediatric donors, death from causes other than closed head trauma (p = 0.02). The overall 30-day mortality rate was 7% but increased to 11% when donor age exceeded 50 years and was 12% when inotropic support exceeded 20 micrograms/kg/min dopamine plus dobutamine and 22% with diffuse echocardiographic wall motion abnormalities. The interaction of donor risk factors was such that the heart of a smaller female donor given high-dose inotropes placed into a larger male recipient produced a predicted 30-day mortality rate of 26% and the heart of a 25-year-old male donor given high-dose inotropes with diffuse echocardiographic wall motion abnormalities transplanted into a 50-year-old male recipient led to a predicted 30-day mortality rate of 17%. This analysis supports cautious extension of criteria for donor acceptance but with an anticipated greater risk in the presence of diffuse echocardiographic wall motion abnormalities and long anticipated ischemic time, particularly in older donors given inotropic support.

Failure of high-dose oral acyclovir with or without immune globulin to prevent primary cytomegalovirus disease in recipients of solid organ transplants

PURPOSE

To assess the efficacy of acyclovir and intravenous immune globulin (IVIG) for cytomegalovirus (CMV) prophylaxis in high-risk recipients of solid organ transplants.

PATIENTS AND METHODS

We randomized 21 CMV-seronegative organ transplant recipients with seropositive donors (D+R-) to receive oral acyclovir, 800 mg four times daily, or, in addition to acyclovir, IVIG, 300 mg/kg, every 2 weeks for six doses. Patients were followed closely for the development of CMV infection and disease.

RESULTS

All but one prophylactically treated patient (95%) developed CMV infection. Fifteen of 21 patients (71%) who received prophylaxis fulfilled criteria for CMV disease. Disease onset was delayed in those who received IVIG, but this did not reach statistical significance. Ganciclovir was used for treatment in 15 of the 21 patients (71%).

CONCLUSIONS

Acyclovir, with or without IVIG, did not prevent primary CMV infection or disease in D+R- solid organ transplant recipients at our institution. Moreover, most patients were treated with ganciclovir despite the use of prophylaxis. Given the ready availability of ganciclovir to treat CMV disease, we recommend a reappraisal of the role of CMV prophylaxis by these means in the solid organ transplant population.

Prospective detection of vulnerability to sustained ventricular tachycardia in patients awaiting cardiac transplantation

This prospective study tested the hypothesis that abnormal signal-averaged electrocardiograms (ECGs) and inducible ventricular arrhythmias identify patients awaiting cardiac transplantation who are prone to sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Thirty-seven patients with advanced symptoms of heart failure and a mean left ventricular ejection fraction of 20 +/- 7 were studied. In response to programmed ventricular stimulation using up to 3 extrastimuli, sustained monomorphic VT was induced in 8 (22%) and polymorphic VT or VF was induced in 5 patients (13%). Patients with inducible arrhythmias underwent drug therapy guided by results of programmed ventricular stimulation or implantation of a defibrillator. Patients in whom ventricular arrhythmias could not be induced were not treated for arrhythmias. The signal-averaged ECG was abnormal and sustained VT or VF was induced in 10 patients (27%). Follow-up ranged from 1 to 33 months (mean 12). Four patients (11%) died suddenly and 4 (11%) had nonfatal sustained VT or VF. The positive predictive value for sudden death or nonfatal VT/VF was 27% for the signal-averaged ECG, 38% for programmed ventricular stimulation, and 50% if both tests were abnormal. The negative predictive values for these tests were 87, 88 and 88%, respectively. The actuarial incidence of arrhythmic events was significantly higher in patients with inducible ventricular arrhythmias (p = 0.017) and in patients in whom both the results of signal-averaged electrocardiographic analysis and the response to programmed ventricular stimulation were abnormal (p = 0.002). This study demonstrates that results of signal-averaged electrocardiographic analysis and the response to programmed ventricular stimulation improve risk stratification for sudden cardiac death in patients awaiting cardiac transplantation.

Relation between ST segment shifts during ischemia and thrombin activity in patients with unstable angina

This study was designed to determine in patients with unstable angina whether specific electrocardiographic abnormalities associated with ischemia, the presence of coronary lesions consistent with thrombosis on angiography or the presence of recurrent ischemia reflects increases in thrombin activity as manifested by increased plasma concentrations of fibrinopeptide A. The concentration of fibrinopeptide A in plasma was increased to 6.7 +/- 3.1 nM for the group as a whole (n = 29). Increases were greater in the 17 patients who exhibited reversible ST segment shifts (10.2 +/- 5.2 nM) than in the 12 patients exhibiting reversible T wave abnormalities alone (1.6 +/- 0.2 nM) (p less than 0.01). Nine of the 17 patients with reversible ST segment shifts who underwent coronary angiography had lesions with morphologic characteristics consistent with atherosclerotic plaque complicated by thrombosis compared with only 2 of 9 patients with T wave changes only (p less than 0.05). Plasma concentrations of fibrinopeptide A were markedly elevated in 7 of the 11 patients in whom complex lesions were noted on angiographic examination. Thus, the occurrence of reversible ST segment shifts identifies a group of patients with unstable angina in whom ongoing thrombosis is likely and who may be particularly likely to benefit from antithrombotic therapy.

Augmented myocardial perfusion reserve after coronary angioplasty quantified by positron emission tomography with H2(15)O

Effects of coronary angioplasty on myocardial flow reserve have been difficult to characterize noninvasively because conventional imaging techniques cannot quantitate blood flow in absolute terms. The effects of coronary angioplasty on myocardial perfusion and perfusion reserve were delineated with positron emission tomography and oxygen-15-labeled water (H2(15)O) in 13 patients before and after single vessel angioplasty. In 11 patients, angioplasty was successful (minimal cross-sectional area increased from 0.60 +/- 0.59 to 3.45 +/- 1.09 mm2, p less than 0.001). In these patients, regional H2(15)O radioactivity (the ratio of nutritional perfusion in regions distal to the stenosis compared with regions supplied by angiographically normal arteries) at rest before angioplasty was 55 +/- 22% of peak myocardial radioactivity and did not increase significantly afterward (70 +/- 16%, p = NS). However, after administration of intravenous dipyridamole, hyperemic perfusion in regions distal to a stenosis averaged only 39 +/- 18% of peak myocardial counts before angioplasty, but increased to 66 +/- 22% after angioplasty (p less than 0.02). Perfusion reserve in the two patients in whom angioplasty was angiographically unsuccessful showed no change. Quantitative estimates of perfusion in absolute rather than relative terms were obtained with positron emission tomographic data from seven of the patients with successful angioplasty. At rest, perfusion in regions distal to a stenosis was not different from the values in regions supplied by normal coronary arteries (1.54 +/- 0.54 compared with 1.46 +/- 0.38 ml/g per min, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Delineation of impaired regional myocardial perfusion by positron emission tomography with H2(15)O

Positron emission tomography with 15O-labeled water (H2(15)O) can be used to delineate abnormal regional myocardial blood flow in experimental animals. To determine the feasibility of this method in humans, we studied 33 subjects (9 normal volunteers and 24 patients with angiographically documented coronary artery disease) at rest and after myocardial hyperemia induced with intravenous infusion of dipyridamole. At rest, the myocardial region demonstrating the lowest relative H2(15)O activity exhibited 71 +/- 8% of activity in the region with peak activity in control subjects and 62 +/- 17% in patients (p = NS). After the dipyridamole infusion, differences between the two groups were accentuated. In control subjects, activity in the region with lowest relative radioactivity averaged 77 +/- 5% of that in the region with peak activity. In patients, it averaged 55 +/- 22% of activity in the region with peak activity (p less than 0.01). Results in patients with ischemia with or without a history of remote myocardial infarction were not significantly different. In 22 of the 24 patients, the region with lowest relative perfusion corresponded anatomically to the region of myocardium distal to a stenosis. Thus, delineation of regional myocardial perfusion in patients with coronary artery disease is possible with positron emission tomography and H2(15)O. Further studies will be necessary to prospectively determine sensitivity and specificity.

Cardiac dysfunction during acute lung injury induced by oleic acid in dogs

Circulatory abnormalities are common during the adult respiratory distress syndrome and contribute importantly to the high mortality seen with this illness, but what causes them is not well characterized. Oleic acid-induced acute lung injury is an experimental model of the human syndrome in which hemodynamic changes are also common. To characterize a possible link between lung injury and cardiac dysfunction in this model, we evaluated cardiac function in mongrel dogs after oleic acid administration. Stroke volume index decreased, the radionuclide ventriculographically determined ejection fraction decreased, and end-diastolic volume increased after oleic acid. These results suggested a decrease in myocardial contractility, a conclusion confirmed when other experiments demonstrated a consistent rightward displacement of the end-systolic pressure-diameter relationship after oleic acid. Histologic examination of the myocardium showed little evidence of vascular injury, and myocardial tissue wet-to-dry weight ratios were normal. Thus, although the pulmonary effects of oleic acid are due to microvascular injury, similar mechanisms are not responsible for the depression in myocardial contractility.

Effects of acetyl glyceryl ether of phosphorylcholine (platelet activating factor) on ventricular preload, afterload, and contractility in dogs

Acetyl glyceryl ether of phosphorylcholine (AGEPC), platelet activating factor, is a potent hypotensive agent that may mediate changes in blood pressure during anaphylaxis and may be involved in blood pressure variations of renal origin. This study was designed to characterize the hemodynamic mechanisms responsible for hypotension induced by this recently identified phospholipid. Intravenous administration of AGEPC to anesthetized open-chest dogs (n = 5) produced hemodynamic alterations which, for the purpose of analysis, were divided into three phases based on changes in the mean systemic blood pressure. During phase I (5-30 s) mean systemic blood pressure decreased to levels 5 to 10% below baseline values in association with a rise in cardiac output and a decrease in systemic vascular resistance. Phase II (30-90 s) consisted of a substantial reduction in systemic blood pressure to its nadir, 50% of baseline values, together with a decrease of similar magnitude in cardiac output and a rise in systemic vascular resistance. Phase III (90 s-60 min) exhibited a gradual recovery of mean systemic blood pressure toward normal with a several-fold rise in systemic vascular resistance and a continued low cardiac output. On the right side of the circulation, the predominant effect of AGEPC was a marked transient increase in pulmonary artery pressure in phase I, associated with an elevation of pulmonary resistance during phase II. Diethylcarbamazine blocked virtually all of these hemodynamic changes induced by AGEPC; FPL 55712 substantially blocked the rise in systemic vascular resistance in phase III. These results suggest that leukotrienes may mediate at least some of the hemodynamic effects induced by AGEPC, but further studies will be required when more specific leukotriene blocking agents become available. As assessed during phase III with the end-systolic pressure-dimension relation, myocardial performance itself was diminished. The occurrence of an AGEPC-induced negative inotropic effect was further confirmed in isolated Krebs-perfused guinea pig hearts and isolated blood-perfused rabbit hearts. The results indicate that the mechanism of AGEPC-induced hypotension is complex, affecting both vascular tone and the inotropic state of the myocardium.