Determinants of hospital survival after cardiac transplantation

Results of medium-term survival in patients undergoing cardiac transplantation: institutional experience

INTRODUCTION

The heart transplant became a consecrated therapy for patients with terminal heart failure, increasingly improving the survival.

OBJECTIVE

To identify the medium-term results in patients undergoing cardiac transplantation.

METHODS

This is a descriptive, documentary and retrospective study, using a quantitative approach, developed in a Unit of Transplant and Heart Failure, of a tertiary level public hospital, located in Fortaleza, CE, Brazil. The data were obtained from a sample of 188 patients (154 men and 34 women), submitted to the heart transplant, in the period from October 1997 to March 2011. There were calculated survival rates based on Kaplan-Meier methods.

RESULTS

There were identified information about the patient's gender (male 81.91%), medical diagnosis which determined the heart transplantation (idiopathic cardiomyopathies 23.98%, ischemic 23.4% and Chagasic 17.02%). The median age of patients was 48 years old (interquartile range = 17.25 years) and the median observation period was 877 days. During this period, 78 patients died, resulting in survival ratios of 72%, 59% and 47% after 1, 5 and 9 years of cardiac transplantation, respectively. Younger patients had longer survival (P=0.0418).

CONCLUSION

The medium-term survival of patients undergoing cardiac transplantation is significant, especially for younger patients.

New directions in cardiac transplantation

More than three decades of clinical experience in cardiac transplantation resulted in the spread of the procedure worldwide with a wealth of knowledge and advancements. Developments included liberalization of recipient and donor selection criteria, improved surgical techniques, novel immunosuppressive drugs and protocols, new rejection surveillance techniques, and better understanding of the pathophysiology of cardiac allograft vasculopathy to direct interventions for prevention and treatment.

Analysis of the Complex Effect of Donor’s Age on Survival of Subjects Who Underwent Heart Transplantation

BACKGROUND

Only half of the patients waiting for a heart transplant undergo surgery, whereas several patients continue to die while on the waiting list. Donor organ availability still represents a major problem with respect to reducing the length of the cardiac transplant waiting list. One option to improve donor availability is the use of so called "marginal donors." The aims of the present study are to analyze the short-mid term survival of cardiac transplanted patients in Italy, and investigate the effect of donor age on prognosis.

METHODS

A prospective cohort study including all adult patients who underwent heart transplantations in Italy was used to analyze the main factors contributing to organ survival.

RESULTS

From 1995-2002, 2,504 adult subjects underwent a cardiac transplant, and were followed up for a period of 540.9 days. Overall, 1-year graft survival was 83.1%. Organs from donors older than 55 years had a lower survival than organs from younger donors. By multivariate analysis, both donor's and recipient's age seem to be important determinants of graft survival. A more sophisticated analysis shows that the trend of the risk of graft failure according to donor's age is not linear, with a peak at age 47.3 years, and differs according to sex.

CONCLUSIONS

Results from the present analysis suggest that the association between heart transplant survival and donor's age is not a linear one, but follows a complex mathematical model, with influences of sex, at least in our sample.

Myocardial Protective Effect of Human Recombinant Hepatocyte Growth Factor for Prolonged Heart Graft Preservation in Rats

BACKGROUND

In heart transplantation, myocardial apoptosis during hypothermic storage contributes to graft dysfunction. On the other hand, hepatocyte growth factor (HGF) has been reported to be an antiapoptotic factor in the heart. Therefore, we assessed whether the administration of recombinant human HGF (rh-HGF) prevents apoptosis in the prolonged preserved myocardium, resulting in an improvement in the cardiac function of the graft.

METHODS

Isolated rat hearts were subjected to 4 hr (group A), 6 hr (group B), and 8 hr (group C: without rh-HGF vs. group D: with 100 microg of rh-HGF) of hypothermic storage followed by 60 min of normothermic reperfusion (n=5 in each group).

RESULTS

Compared with non-HGF-treated hearts (group C), HGF-treated hearts (group D) showed a significantly higher recovery rate of left ventricular developed pressure (38+/-5% vs. 58+/-6%, P<0.01) and maximum dp/dt (53+/-7% vs. 74+/-4%, P<0.01) and a lower rate of TUNEL-positive cardiomyocytes (7.8+/-6.0% vs. 25.3+/-8.9%, P<0.05) after 60 min of reperfusion. Western blot analysis revealed that c-Met/HGF receptor expression was stronger in the HGF-treated myocardium than in the non-HGF-treated myocardium after 8 hr of storage and was associated with a weaker expression of caspase-3 and a stronger expression of Bcl-xL after 60 min of reperfusion.

CONCLUSION

The administration of rh-HGF before storage improved cardiac function after prolonged myocardial preservation by preventing apoptosis through the c-Met/HGF receptor. Thus, the addition of rh-HGF in the storage solution may be a promising strategy for prolonged heart graft preservation.

Long-term results of cardiac transplantation

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

Effects of inhibition of myocardial extracellular-responsive kinase and P38 mitogen-activated protein kinase on mechanical function of rat hearts after prolonged hypothermic ischemia

BACKGROUND

Mitogen-activated protein kinases (MAPKs), including extracellular-responsive kinase (ERK) and p38 MAPK, are activated by stresses associated with hypothermia-rewarming and ischemia-reperfusion. Their activation in heart is associated with beneficial (preconditioning) and adverse effects (apoptosis and impaired contractility). This study determined whether ERK and p38 MAPK activities are altered by hypothermic ischemia and normothermic reperfusion and the consequences of their inhibition on recovery of myocardial function.

METHODS

Left ventricular work (L x min(-1) x mm Hg) was assessed during normothermic perfusion (30 min) of isolated rat hearts that were either freshly excised or previously subjected to hypothermic storage (8 hr, 3 degrees C) and rewarming (10 min, 37 degrees C) before normothermic reperfusion (30 min). Phospho-specific immunoblot analysis of p38 MAPK was performed in hearts and various cultured cells.

RESULTS

Compared with fresh hearts, hearts subjected to hypothermia and rewarming demonstrated impaired left ventricular work (1.96+/-0.53, n=12 vs. 8.37+/-0.46, n=4, <0.05) during reperfusion. The ERK inhibitor, PD98059 (20 microM), present during storage and rewarming, caused modest improvement (3.66+/-0.75, n=9, <0.05). The p38 MAPK inhibitor, SB202190 (10 microM), when present during reperfusion, improved recovery (to 6.12+/-0.75, n=6, <0.05); it was ineffective if present only during rewarming (1.52+/-0.88, n=4). In rat2 fibroblasts, hypothermia and rewarming activated p38 MAPK and its downstream kinase MAPK-activated protein kinase 2, but not c-Jun N-terminal kinase/stress-activated protein kinase.

CONCLUSIONS

Myocardial p38 MAPK and MAPK-activated protein kinase 2 are stimulated by hypothermia, ischemia, and rewarming and are detrimental to recovery of mechanical function of hearts subjected to prolonged hypothermic storage. Inhibition of p38 MAPK may be useful in protocols to improve the recovery of mechanical function of cold-stored hearts.

Heart transplantation with donors fifty years of age and older

OBJECTIVE

Limited availability of donor organs has led to the progressive expansion of the criteria for donor selection, particularly a higher age limit of potential donors. We retrospectively reviewed the outcomes of patients who underwent heart transplantation using cardiac allografts 50 years of age and older and compared them with patients who had donor organs younger than 50 years.

METHOD

Between September 1989 and May 2000, 20 patients underwent orthotopic heart transplantation using donor hearts 50 years of age and older (range 50-56 years, mean 52.7 +/- 1.8 years) and were compared with 267 patients who received donor organs less than 50 years of age (range 9-49.9 years, mean 27.2 +/- 8.6 years). Patient and donor criteria were identical in both groups. Follow-up was 4 to 128 months with a mean of 37.4 +/- 2.8 months in the older donor group and 52.6 +/- 2.4 months in the younger donor group.

RESULTS

There were no differences between these 2 cohorts of patients regarding age, sex, cardiomyopathy, preoperative cytomegalovirus status, New York Heart Association class, and transplant status at transplantation. Donor characteristics, including sex, left ventricular ejection fraction, diabetes, cytomegalovirus status, and allograft ischemic times, were also similar in the 2 groups. Donor/recipient cytomegalovirus matching showed no differences as well. Thirty-day or to discharge operative mortality was similar in the older and younger donor groups (5% +/- 4.8% vs 3.5% +/- 1.1%; P =.84). Actuarial survival at 1 and 5 years was also similar in both groups (89.7% +/- 6.9% vs 91% +/- 1.8% and 53.1% +/- 14.7% vs 71.0% +/- 3.1%, respectively; P =.59). No patient in the older donor group required coronary artery bypass grafting or retransplantation during the follow-up period, whereas 2 patients in the younger donor group required coronary artery bypass, and 5 patients underwent retransplantation (P > or =.50). Two patients in the older donor group died of nonspecific allograft failure, whereas 3 patients in the younger donor group experienced similar posttransplant complication (P > or =.50).

CONCLUSIONS

Carefully selected donor hearts 50 years of age and older can be used for heart transplantation with long-term survival and related outcomes similar to those of younger donor organs. This use of selective cardiac allografts maximizes donor organ usage and expands the donor pool effectively without an adverse impact on long-term results.

Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure

BACKGROUND

Cardiac troponin I and T (cTnI and cTnT) are sensitive and specific markers of myocardial damage. We evaluated them for the selection of heart donors and as predictors of early graft failure after heart transplantation.

METHODS

cTnI, cTnT, myoglobin, and creatine kinase (CK) levels and its isoenzyme MB (CKMB) activity and mass were measured in serum samples immediately before opening the pericardium from 126 consecutive brain-dead multi-organ donors over 10 years of age inspected by our harvesting team. Donors with serum creatinine >2.0 mg/dL (n=6) were excluded from the analysis. Donors for high-urgency status recipients (n=2) were also excluded. The remaining donors were retrospectively divided into three groups: group I (n=68), grafts with good function; group II (n=11), grafts with impaired function; and group III (n=39), grafts not accepted for transplantation.

RESULTS

No differences in donor and recipient characteristics were found among the groups. The mean values of cTnI (0.36+/-0.88 microg/L, 4.45+/-3.28 microg/L, and 3.02+/-7.88 micog/L, respectively) and cTnT (0.016+/-0.029 microg/L, 0.134+/-0.114 microg/L, and 0.123+/-0.245 microg/L, respectively) were lower in group I when compared with groups II or III (cTnI: P<0.0001, P=0.018; cTnT: P<0.0001, P=0.012). The cTnI value was higher in group II compared with group III (P=0.023). The cTnT values were similar in groups II and III. A cTnI value >1.6 microg/L as a predictor of early graft failure had a specificity of 94%, and a cTnT value of >0.1 microg/L had a specificity of 99%. The odds ratio for the development of acute graft failure after heart transplantation was 42.7 for donors with cTnI >1.6 microg/L and 56.9 for donors with cTnT >0.1 microg/L. No differences of myoglobin, CKMB activity, or CKMB/CK ratio were found among the groups.

CONCLUSIONS

Significantly higher cTnI and cTnT values were found in peripheral blood at the time of explantation in donors of hearts with subsequently impaired graft function and in not accepted donors. cTnI and cTnT are useful as additional parameters for heart donor selection.

Angiography of potential cardiac donors

OBJECTIVES

This retrospective review of organ donor records was designed to evaluate the practice of donor angiography in one organ procurement organization and determine the outcomes of angiography and its impact on the timing of the organ donation process.

BACKGROUND

Concerns about transmission of atherosclerosis from donor to recipient have been heightened by the increasing prevalence of older donors. Guidelines that advocate the use of angiography in specific settings have been published, but no formal large-scale review has been performed.

METHODS

For the period January 1993 through June 1997, we reviewed all New England Organ Bank records of donors between the ages of 40 and 65 including any from whom at least one solid organ was procured. Data abstracted included the presence of risk factors, timing of the evaluation process and angiographic findings.

RESULTS

Coronary angiography was performed in 119 donors aged 40 and older; 64.7% of these hearts were transplanted. Thirty-eight hearts were transplanted from donors not subjected to angiography and outcomes were poorer compared with donors who underwent angiography. Advanced donor age was the only significant predictor of coronary artery disease. The duration of the procurement process was not prolonged by the performance of angiography.

CONCLUSIONS

Donor coronary angiography does not complicate the donation process. Older donor age is the most powerful predictor of coronary artery disease and may explain prior observations of poorer outcome with older donor hearts. These factors should be considered when angiography is performed as part of the heart donor evaluation.

Medium-term results of heart transplantation using older donor organs

BACKGROUND

Donor heart shortage has necessitated the expansion of the donor pool by the use of older hearts.

PATIENTS AND METHODS

In a 13-year period, 1,070 heart transplants were performed in 1,035 adults at the German Heart Institute Berlin. We divided the patients into 3 groups: Group I, donor age <35 years (n = 524); Group II, donor age 35 to 50 years (n = 379); Group III, donor age >50 years (n = 167). We analyzed post-operative mortality (up to 30 days), cumulative survival rates, cardiac dependent morbidity, and changes in the left/right ventricular ejection fraction as well as freedom from cytomegalovirus infection and freedom from acute rejection episodes grade >/= 2 (International Society for Heart and Lung Transplantation). We also calculated the rate of cardiac interventions per patient in the groups.

RESULTS

Recipients in Group III were significantly older, compared with Groups I and II. The post-operative mortality was 16.8% in Group I, 29.8% in Group II, and 23.4% in Group III. The differences were significant (p = 0. 00001) between Group I and Group II. The long-term cumulative survival rates were significantly better in Group I when compared with Groups II and III (p < 0.00001, p = 0.014), but it did not differ between Groups II and III (p = 0.18). However, cardiac morbidity in Groups I and II was significantly lower when compared with Group III (p = 0.0009, p = 0.037). Mean left and right ventricular ejection fraction was >55% and did not significantly change in groups for up to 10 years. Freedom from cytomegalovirus infection was not significantly different between Groups II and III (p = 0.09). Significantly fewer percutaneous transluminal coronary angioplasties were performed in Group I, but comparable numbers were carried out in Groups II and III (p = 0.53). For retransplantation a similar situation occurred.

CONCLUSION

We did not find significant differences in the mid-term follow-up between patients who received hearts from 35- to 50-year-old donors and from those who had received hearts from donors >50 years, despite increased cardiac morbidity in Group III. Close monitoring of the coronary situation after heart transplantation and expanded indications for revascularization in Group III makes heart transplantation with older hearts a suitable option to save the lives of patients in end-stage heart failure.

Medium-term results of heart transplantation using donors over 63 years of age

BACKGROUND

The continual shortage of hearts for transplantation (HTx) led to the expansion of the donor pool by accepting older donors. We compared the medium-term follow-up of patients after HTx with older hearts (over the age of 63 years) with those of patients after HTx with younger hearts.

PATIENTS AND METHODS

Since April 1994 we have used hearts for HTx from donors older than the age of 63 years. Until November 1998, 309 HTx and 9 re-HTx were performed in 309 adults with a mean age of 50.7+/-10.9 years (range 17-68 years). There were 252 men and 57 women. The patients were divided into two groups: group I--donor age under 63 years (296 patients, mean age 50.4+/-11 years; mean donor age 38.1+/-13 years; mean follow-up 1.7+/-1.6 years); group II-donor age of more than 63 years (13 patients, mean age 57.4+/-5.6 years; mean donor age 65.1+/-2.1; mean follow-up 2.2+/-1.6 years). There were no differences in the etiology of heart failure, gender, or ischemia time between the groups. The patients in group II were significantly older (P = 0.008). Multiple factors were analyzed in the groups, which included changes in the left/right ventricle ejection fraction, early postoperative mortality (up to 30 days), cumulative survival rates and cardiac-dependent morbidity [myocardial infarction, malignant arrhythmias, coronary stenosis (>50% in one of the main coronary arteries) and transplant vasculopathy]. Additionally, freedom from cytomegalovirus infection (rise of titer or seroconversion) and freedom of acute rejection episodes grade > or =2 (International Society of Heart & Lung Transplantation [ISHLT]) were analyzed.

RESULTS

After 1 year mean left and right ventricle ejection fraction were good in both groups and did not significantly change for up to 2 years. No Re-HTx was performed in group II. The early postoperative mortality was similar in both groups (P = 0.8). Also, the cumulative survival rates were similar in both groups (P = 0.87). Long-term cardiac morbidity was lower in group I (P = 0.03). The long-term freedom from cytomegalovirus infection in group I was significantly higher when compared with group II (P = 0.0002). The long-term freedom from severe rejection episodes was similar in both groups (P = 0.3)

CONCLUSION

The study found a significant increase in long-term cardiac morbidity due to more focal coronary stenosis in group II, and freedom from cytomegalovirus infection, but did not find significant differences in the long-term survival between patients who received hearts from donors of up to 63 years of age and from those more than 63 years. The acceptance of donors older than 63 years old for HTx does not worsen the outcome of the recipients. The careful selection of older donors, with close monitoring of the coronary situation after HTx and expanded indications for revascularization of older hearts, could make HTx with older hearts, even in older recipients, a safe option.

Duration of preoperative amiodarone treatment may be associated with postoperative hospital mortality in patients undergoing heart transplantation

OBJECTIVE

To assess the effect of preoperative amiodarone treatment on patient mortality after heart transplantation.

DESIGN

Retrospective study.

SETTING

Single-institution university hospital.

PARTICIPANTS

One hundred six consecutive patients with heart transplants.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were grouped according to duration of preoperative amiodarone treatment, and posttransplant mortality before hospital discharge was compared with patients not treated with amiodarone. The authors collected cardiovascular data in the preoperative and postoperative periods. There was a significant increase in posttransplant mortality before hospital discharge in patients treated with amiodarone for more than 4 weeks in the preoperative period (p < 0.05). Patients treated with amiodarone had significantly lower (p < 0.05) heart rates (mean heart rate, 103+/-19 beats/min) in the early postoperative period than patients not treated with amiodarone (mean heart rate, 111+/-15 beats/min), but there was no relationship with mortality (p = not significant). Patients who died had a significantly lower (p < 0.05) postoperative cardiac index (2.2+/-0.7 to 2.5+/-0.7) in the first 24 hours after cardiopulmonary bypass compared with patients who survived to hospital discharge (3.0+/-0.7 to 3.1+/-0.9), but there was no relationship to amiodarone treatment (p = not significant).

CONCLUSION

Preoperative amiodarone treatment for more than 4 weeks may be associated with a significant increase in postoperative mortality in patients undergoing heart transplantation. Therefore, the indications for amiodarone must be carefully considered and, if needed, the maintenance dose should be kept to a minimum.

Extended donor criteria: hemodynamic follow-up of heart transplant recipients receiving a cardiac allograft from donors > or = 60 years of age

BACKGROUND

Heart transplantation (HT) has become a therapeutic option for patients suffering from endstage heart failure. The increasing demand for cardiac allografts has led to a shift toward extended donor criteria. In a retrospective analysis of 859 HT recipients, we report on the hemodynamic outcome of 19 HT patients who received cardiac allografts from donors > or =60 years of age.

METHODS

From March 1989 to December 1997, we performed 883 orthotopic HT in 74 children and 809 adults at our transplant center. Within this period, 19 patients (17 women and 2 men) received cardiac allografts from donors > or =60 years of age. Recipient age ranged from 57 to 78 years (mean, 65+/-5 years).

RESULTS

HT could be performed successfully in 19 cases. The early mortality rate was 16% (n=3). The late mortality rate was 37% (n=7). All long-term survivors are stable at New York Heart Association classification II (New York Heart Association Class II = resting hemodynamics: cardiac output normal; left ventricular end diastolic filling pressure elevated; clinically not compromised during mild to moderate workout). Although only 19 patients were retrospectively evaluated, there was a statistically significant (P<0.05) difference in survival among patients who received organs from male (11 vs. 8*) compared with female (8 vs. 2*) (*=death) donors.

CONCLUSION

In our experience, it is possible to increase the cardiac donor pool by accepting allografts from donors, preferably female, > or =60 years of age in selected cases without a coronary angiogram, if hemodynamic parameters are in a normal range on mild-to-moderate inotropic support. We do not recommend cardiac allografts from donors > or =60 if there are signs of coronary insufficiency in the electrocardiogram, if left ventricle filling pressures are above normal on mild-to-moderate inotropic support and optimum hemodynamic management, or if there are signs of segmental dysfunction or mitral insufficiency >I in the echocardiogram.

[Predictive variables of early mortality after orthotopic heart transplant in adults]

OBJECTIVE

The purpose of the study was to analyze some variables of donors, recipients and surgical procedures in order to discover factors that could predict mortality during the early stage (< 30 days) of orthotopic heart transplants.

MATERIAL AND METHOD

125 consecutive orthotopic heart transplants in adults were analyzed. The average age was 51 +/- 11 (range: 12-67), 109 (87%) were men, 16 were women (13%). Two groups were compared: 15 patients who died within 30 days after heart transplant and 110 who survived during that period. Immunosuppressive protocol: preoperative: Cyclosporin + Azathioprine. Intraoperative: Methylprednisolone Postoperative: Methylprednisolone (first 24 h), antilymphocyte monoclonal antibodies (7-10 days after heart transplant) + Cyclosporin + Azathioprine + Corticoids. The following parameters of the recipient were analyzed: sex, age, weight, size, thoracic perimeter, pretransplant cardiopathy, previous thoracic operations, functional stage or need for catecholamines during the days prior to the transplant, pulmonary artery pressure and resistance, history of systemic arterial hypertension, elevation of creatinine, blood type, urgent transplant indication, receptor/donor weight relationship. The following parameters of donors and operation were analyzed: sex, age, weight, thoracic perimeter, period in intensive care unit, dose of dopamine and dobutamine, blood type, origin of the organ, cause of death, ischaemia time, cardiopulmonary by-pass time and cardioplegia type.

RESULTS

The rate of early mortality was 12%. The univariate analysis showed differences in: prior cardiovascular surgery, receptor blood type, need for urgent transplantation, pulmonary artery resistance > 2.5 Wood Units, cardiopulmonary by-pass time, weight relationship between receptor and donor. The death cause of the donor proved significant. On multivariate analysis, the following parameters independently predicted early mortality: history of operation with extracorporeal circulation, high pulmonary artery resistance, urgent transplant, receptor/donor weight relation and time of extracorporeal circulation.

CONCLUSIONS

We believe that the results of our experience can help to stratify the risk in the orthotopic heart transplant recipient and even to contraindicate the procedure in some cases showing an accumulation of poor prognostic factors in borderline recipients.

Cardiac transplantation after mechanical circulatory support: a Canadian perspective

BACKGROUND

To assess the relative efficacy of cardiac transplantation after mechanical circulatory support with a variety of support systems, we analyzed our consecutive series of patients who had and did not have mechanical support before transplantation.

METHODS

A review of 209 patients undergoing cardiac transplantation from 1984 to May 1995 was performed. Group 1 consisted of 110 patients who were maintained on oral medications while awaiting transplantation, and group 2 consisted of 60 patients who required intravenous inotropic support. Group 3 included 39 patients who had transplantation after mechanical circulatory support for cardiogenic shock. The indication for device implantation was acute onset of cardiogenic shock in 38 patients and deterioration while awaiting transplantation in 1 patient. The support systems were an intraaortic balloon pump in 13 (subgroup 3A), a ventricular assist device in 7 (subgroup 3B), and a total artificial heart in 19 patients (subgroup 3C).

RESULTS

After transplantation, infection was more common in group 3 (56%) than in group 1 (28%) or group 2 (32%) (p = 0.005). Survival to discharge was lower for group 3 (71.7%) than for group 1 (90.9%) or 2 (88.3%) (p = 0.009). For mechanically supported patients, survival to discharge was 84.6% in subgroup 3A, 71.4% in subgroup 3B, and 63.1% in subgroup 3C (p = not significant).

CONCLUSIONS

Transplantation after mechanical support offers acceptable results in this group of patients for whom the only alternative is certain death. Patient selection and perioperative management remain the challenge to improving these results.

Steroid administration in heart and heart-lung transplantation: is the timing adequate?

BACKGROUND

The release of cytokines after cardiopulmonary bypass may play an important role in postoperative morbidity. The release of proinflammatory cytokines, such as tumor necrosis factor alpha, interleukin (IL)-6 and IL-8, is even greater in patients undergoing heart transplantation (HTx) than coronary artery grafting. We tested the hypothesis that in HTx patients the earlier administration of steroids, before rather than after cardiopulmonary bypass as usual, can reduce the inflammatory response.

METHODS

In 20 consecutive patients who underwent HTx or heart-lung transplantation (HLTx), plasma levels of tumor necrosis factor alpha, IL-6, IL-8, and anti-inflammatory cytokine IL-10 were measured before heparin administration, at aortic cross-clamping and declamping, and 0.5, 1, 1.5, 2, 4, 12, and 24 hours after aortic declamping. In 10 patients (group I, 6 HTx and 4 HLTx), 500 mg of methylprednisolone was first given as usual at 1.5 hours after aortic declamping (at the end of cardiopulmonary bypass). In the next 10 patients (group II, 6 HTx and 4 HLTx), the first doses of methylprednisolone were given 1 hour before operation. In both groups, 125 mg of methylprednisolone were given every 8 hours thereafter during the first postoperative day.

RESULTS

The ischemic time and cardiopulmonary bypass time were similar in the two groups (166 +/- 16 minutes versus 157 +/- 13 minutes, and 192 +/- 21 minutes versus 186 +/- 20 minutes, respectively, mean +/- standard error of the mean). At 30 minutes after aortic declamping and throughout the next 4 hours, tumor necrosis factor alpha levels were significantly lower in group II than in group I (all p < 0.03). Interleukin-8 values 1 hour after declamping were also lower in group II than in group I (49 +/- 15 pg/mL versus 130 +/- 38 pg/mL, p < 0.02). Interleukin-10 levels were significantly higher in group II than in group I from 30 minutes after declamping through 2 hours after (all p < 0.03). Interleukin-6 levels were similar in the two groups.

CONCLUSIONS

Earlier steroid administration in the immunosuppressive protocol for HTx or HLTx may be preferable to reduce the inflammatory response to cardiopulmonary bypass, as reflected by a lower production of tumor necrosis factor alpha and IL-8, and a greater release of IL-10.