Distribution and declines in cardiac allograft radionuclide left ventricular ejection fractions in relation to late mortality

Coronary imaging of cardiac allograft vasculopathy predicts current and future deterioration of left ventricular function in patients with orthotopic heart transplantation

BACKGROUND

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) improve sensitivity of cardiac allograft vasculopathy (CAV) detection compared to invasive coronary angiography (ICA), but their ability to predict clinical events is unknown. We determined whether severe CAV detected with ICA, IVUS, or OCT correlates with graft function.

METHODS

Comparison of specific vessel parameters between IVUS and OCT on 20 patients attending for angiography 12-24 months post-orthotopic heart transplant. Serial left ventricular ejection fraction (EF) was recorded prospectively.

RESULTS

Analyzing 55 coronary arteries, OCT and IVUS correlated well for vessel CAV characteristics. A mean intimal thickness (MIT)_OCT  > .25 mm had a sensitivity of 86.7% and specificity of 74.3% at detecting Stanford grade 4 CAV. Those with angiographically evident CAV had significant reduction in graft EF over 7.3 years follow-up (median ΔEF -2% vs +1.5%, P = .03). Patients with MIT_OCT  > .25 mm in at least one vessel had a lower median EF at time of surveillance (57% vs 62%, P = .014). Two MACEs were noted.

CONCLUSION

Imaging with OCT correlates well with IVUS for CAV detection. Combined angiography and OCT to screen for CAV within 12-24 months of transplant predicts concurrent and future deterioration in graft function.

Heart transplantation in heart failure: The prognostic importance of body mass index at time of surgery and subsequent weight changes

BACKGROUND

Heart transplantation is an important treatment for end-stage chronic heart failure. We studied the effect of body mass index (BMI), and the effect of subsequent weight change, on survival following transplantation in 1902 consecutive patients.

METHODS AND RESULTS

Patients were recruited from: London (n=553), Berlin (N=971) and Boston (N=378). Patients suitable for transplantation due to symptoms, low left ventricular ejection fraction (<or=30%) and peak oxygen consumption (<or=16 ml kg(-1) min(-1)) (N=237) were used as a comparator. In surviving transplanted patients, average duration of follow-up was 80 (SD 34) months. There were 805 deaths. One year survival was 72.7% (95% CI 72.68-72.72) and 5 year survival was 60.96% (61.94-61.99). Baseline BMI did not effect survival either as a continuous variable (hazard ratio (95% CI): 1.02; 0.99-1.04). Weight loss between transplant and 3 months was associated with worse survival (HR (95% CI) 2.6 (1.42-4.74)) compared with those who gained weight. In the reference group, increasing body mass index was related to survival.

CONCLUSIONS

Chronic heart failure patients with very low body weight can be transplanted successfully. The presence of underweight need not be an exclusion criterion for heart transplantation. Underweight patients appear to have a greater benefit from transplantation. Body weight increases after transplantation are not associated with adverse prognosis.

Risk stratification for renal transplantation after cardiac or lung transplantation: single-center experience and review of the literature

BACKGROUND

Long-term survival after heart (HTx) or lung (LuTx) transplantation increases the risk for end-stage renal disease (ESRD). After HTx ESRD was reported to enhance mortality, and kidney transplantation (KTx) was shown to improve survival. However, prognostic factors in ESRD after HTx or LuTx are largely unknown.

METHODS

Single-center observational study in HTx and LuTx patients who accessed the KTx waiting list; baseline characteristics were correlated with mortality.

RESULTS

KTx was performed in 15 of 65 study patients. Survival was comparable on the KTx waiting list and in reference patients from the same center without ESRD. KTx significantly improved survival (5 years' survival 84.6% with KTx vs. 56.5% on the KTx waiting list, p = 0.030). None of the baseline parameters predicted mortality in the KTx group. Only on the KTx waiting list BMI (median 24.7 vs. 20.7; p < 0.05) and left ventricular ejection fraction (LVEF, median 63 vs. 53%, p < 0.008) significantly correlated with survival.

CONCLUSIONS

The risk for mortality after HTx or LuTx is not increased by ESRD, provided that patients meet access criteria for the KTx waiting list. KTx improves survival in ESRD after HTx or LuTx. BMI and LVEF may predict outcome in HTx/LuTx patients on the KTx waiting list.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Treatment of allograft vasculopathy in heart transplantation

Cardiac allograft vasculopathy remains one of the main causes of morbidity and mortality after heart transplantation, although its impact is becoming somewhat smaller as prophylactic measures are implemented. Advances in the understanding of the molecular and cellular mechanisms involved in the genesis and development of cardiac allograft vasculopathy are opening ways for new diagnostic and therapeutic strategies. Successful prophylaxis of the early stages of the disease has been demonstrated with the use of newer immunosuppressive agents, such as sirolimus and everolimus, that will probably be included in future protocols. For most patients with established cardiac allograft vasculopathy, currently available revascularisation methods and retransplantation are not appropriate options. Antiproliferative agents could provide significant improvement in terms of symptom relief and prognosis, but their definite value must be proven in well-designed trials.

The Prognostic Validity of the Ventricular Evoked Response (VER) Signals in Cardiac Transplantation

INTRODUCTION

Computerized heart allograft rejection monitoring (CHARM) used for non-invasive rejection monitoring in heart transplant recipients is based on the analysis of ventricular evoked response (VER) signals. The aim of this study was to evaluate the prognostic validity of the Tslew(C), a parameter calculated from the VER.

METHODS

During orthotopic heart transplantation, 2 unipolar fractally coated screw-in leads were implanted epimyocardially, one to the left and one to the right ventricle, and connected to a telemetric pacemaker. Recordings of intramyocardial electrograms were performed routinely at the hospital. Data processing was done, artifacts were eliminated, and trend curves of the patients were displayed. Tslew(C) was calculated from the tangent of VER and evaluated from 105 patients. The patients were divided into survivor and non-survivor groups. For statistical analysis, the 2-tailed t-test was performed.

RESULTS

Patients in the non-survivors group compared with the control group showed a significantly lower Tslew(C) in the final follow-up (p < 0.001). The differences were even more impressive in patients with recorded intramyocardial electrograms 30 days before death or with a cardiac reason for death. Tests were performed to find an optimal prognostic threshold of the Tslew(C), and the value of 26 mV was finally found.

CONCLUSION

Tslew(C) can function as prognostic factor after orthotopic heart transplantation. Further studies should be initiated to provide the prognostic threshold so that patients would not be forced to show up routinely every 4 weeks for follow-up visits. Patients would only have to be admitted to the hospital if the Tslew(C) were less than this prognostic threshold.

Stability of Right and Left Ventricular Ejection Fractions and Volumes After Heart Transplantation

BACKGROUND

The long-term stability of right ventricular (RV) and left ventricular (LV) volume and function after heart transplantation has not been well characterized. Accordingly, the objective of this study was to assess time- and rejection-dependent changes in RV and LV function and volume after cardiac transplantation by means of a recently validated 3-dimensional tomographic equilibrium radionuclide ventriculography approach.

METHODS

A total of 71 consecutive patients (age, mean +/- SD, 57 +/- 12 years; 62 men; 9 women) were studied 5 +/- 4 years (range 1--16 years) after heart transplantation. The mean frequency of >Grade 2 rejection was 1.7 +/- 1.8 episodes (range 0--7 episodes). RV and LV ejection fraction (EF) and end-diastolic volume (EDV) in transplant patients were compared with data from 34 subjects at low likelihood for coronary artery disease.

RESULTS

No significant differences in RV or LV EF or EDV compared with controls were observed (RV EF=54 +/- 9 vs 53 +/- 9; RV EDV [ml]=109 +/- 35 vs 120 +/- 32; LV EF=72 +/- 8 vs 73 +/- 9; and LV EDV [ml]=108 +/- 28 vs 98 +/- 20 for controls and patients with transplants, respectively; p=NS for all comparisons). There was no significant effect on RV or LV EF or volumes with rejection, or with time after transplantation.

CONCLUSIONS

RV as well as LV EF and EDV are stable more than 1 year after heart transplantation for up to 16 years. Thus, changes in EF or EDV in the transplanted heart are abnormal and should prompt a clinical evaluation.