Pacemaker Implantation Following Heart Transplantation - Incidence and Risk Factors. Single-Center Experience

BACKGROUND

Bradyarrhythmias, requiring pacemaker (PM) implantation, are common complications following orthotopic heart transplantation (HTx). Currently used heart transplantation methods are primarily the bicaval technique and the total heart transplantation technique. The aim of the study was to assess the incidence and risk factors, including donor parameters, of conduction disorders requiring pacing after HTx.

METHODS

A population of 111 (52 ± 13 years, 91 (82%) men) heart recipients was divided into a group requiring PM implantation post-HTx and a group not requiring PM. We compared groups in terms of donor parameters, time of graft ischemia, transport and transplantation, and surgical techniques as the potential risk factors for significant bradyarrhythmias.

RESULTS

Ten of 111 patients with HTx (9%) required PM implantation. The indication in 7 cases was sinus node dysfunction (SND), in 3 patients it was complete atrioventricular block (AV-block). In the PM group, the age of 48 ± 6 vs 40 ± 11 years (P = .0227) and the body mass index (BMI) 28 ± 3 vs 26 ± 4 kg/m2 (P = .0297) of the donor were significantly higher. There was no influence of organ transport time, ischemia time, and transplantation time. All patients requiring PM implantation were transplanted using the bicaval anastomosis: 10 (100%) vs 71 (70%) in the group not requiring PM (P = .044).

CONCLUSIONS

The need for PM implantation post-HTx despite using new techniques is still common, especially in the group operated with the bicaval method. In addition, higher donor's age and BMI are risk factors of PM implantation, what is of importance as qualification criteria of donor hearts have been gradually extended.

The early safety profile of simultaneous vaccination against influenza and Respiratory Syncytial Virus (RSV) in patients with high-risk heart failure

The safety of simultaneous vaccination for Respiratory Syncytial Virus (RSV) and influenza in vulnerable high-risk heart failure (HF) patients remains unclear. In an open-label, prospective study, 105 patients received concurrent influenza (Vaxigrip Tetra, season 2023/2024, Sanofi) and RSV (Arexvy, GSK) vaccinations from September 15th to November 17th, 2023. Adverse events were collected on the fourth-day post-vaccination. Overall, the vaccination was well tolerated, with the most common reaction being injection site pain (63 %). General symptoms occurred in 33 % of patients, predominantly fatigue (23 %), myalgia (12 %), and headache (9 %). Grade 3 reactions were observed in 6 % of patients, and a few experienced temperature elevation or flu-like symptoms, managing them with antipyretics. Notably, there were no exacerbations of HF, hospitalizations, or deaths within a week post-vaccination. This study indicates the safety of simultaneous influenza and RSV vaccination in high-risk HF patients, with a low incidence of mild adverse events.

Does the induction immunotherapy (basiliximab) influence the early acute cellular rejection index after orthotopic heart transplantation?- Preliminary assessment report

The study aimed to determine the influence of induction therapy on the acute cellular rejection (ACR) index in adult heart transplant recipients during the one-year observation. The study population consisted of 256 consecutive adult patients (pts), aged 51.5 (±11.9) years, 199 (77%) men treated with orthotopic heart transplantation (OHT) in the period between 2015 and 2020 in a single high-volume heart transplant center. The endomyocardial biopsies (EMBs) were performed according to the protocol consisting of 7 protocolary EMBs for up to 3 months and 10 EMBs for up to one year after OHT. The rejection index (ACRI) was calculated as the number of scheduled EMBs with the ACR ≥ 2 divided by the total number of protocolary EMBs. The study population was divided into two groups according to the application of basiliximab. The total number of pts. who received basiliximab was 10 (3.9%). The main indications for the usage of the induction therapy were heart retransplantation, mechanical circulatory support (MCS), severe renal insufficiency (eGFR <30 mL/min/1.73 m2), and a panel of reactive antibody (PRA) > 10%. In the group with induction, the mean age was 49 (±14) years; 3 (30%) patients had the MCS prior to OHT, and 3 (30%) patients had heart retransplantation. Four (40%) patients had diabetes mellitus, and 4 (40%) patients had severe renal insufficiency. As maintenance therapy during the observation period, tacrolimus was given to 10 (100%) patients, everolimus to 2 (20%) patients, and MPA to 9 (90%) patients. In the group with no induction, the mean age was 51.8 (±12) years, MCS was used in 56 (23%) patients, 2 (0.8%) patients were retransplanted; 10 (4%) patients had eGFR <30 mL/min/1.73 m2 and 58 (24%) patients had diabetes. Tacrolimus was administered to 243 (99%) patients, cyclosporine to 3 (1%), everolimus to 40 (16%), and mycophenolate to 245 (99.6%) heart recipients. The median one-year ACRI was 0.0, IQR:0.0-0.08 in the group with induction vs. 0.077, IQR: 0.0-0.154 with no induction; p = 0.11. ACRI up to three months was significantly higher in the entire cohort in comparison to up to one year (P < 0.01). The multivariate analysis showed that only everolimus implementation and younger age at the time of transplant influenced patients' mortality rate (P < 0.01). Significant graft rejections (≥ 2R ISHLT) are most common in the first three months after OHT. Patients who are initially at high risk of significant cellular rejection may benefit from induction therapy.

Native Renal Arteries Denervation as a Therapy of Refractory Hypertension in Patient after Heart and Kidney Transplantation-5 Years of Observation

This case report describes a 59-year-old male patient after heart and kidney transplantation, subsequently diagnosed with refractory hypertension since implemented antihypertensive pharmacotherapy consisting of six agents did not provide a substantial therapeutic response. Elevated blood pressure and its impact on a hypertrophied transplanted heart and impaired renal graft function have led to a significant deterioration in the patient's cardiovascular risk profile. To address this issue, a native renal arteries denervation was performed. It resulted in a noteworthy decrease in both systolic and diastolic pressure values, thus manifesting a positive hypotensive effect. Furthermore, a sustainable reduction of left ventricular mass and stabilization in kidney graft function were noticed. The presented case provides evidence that renal denervation can be an efficacious complementary treatment method in individuals who received kidney and heart grafts as it leads to a decrease in cardiovascular risk.

Patient-Related Preoperative Clinical Factors Influencing 1-Year Survival After Orthotopic Heart Transplantation – A Single Center Polish Experience

Background

End-stage heart failure is a growing problem in Poland. Orthotopic heart transplantation remains the best treatment option. Although increasing, the number of heart transplants is disproportionately low compared with patient need. Therefore, it is crucial to identify factors contributing to improvement of heart transplantation outcomes. To find factors providing best survival and optimal recipient selection, we analyzed pretransplant patient-related clinical factors.

Material/Methods

Between May 2015 and May 2020, we performed 258 cardiac transplants at our institution. We reviewed possible patient-related clinical factors affecting the 1-year survival of our patients and analyzed factors related to survival. Mean age at transplant was 53.5 (±11.8) years; 22.9% of patients were women. Preoperative factors were analyzed using univariable and multivariable analyses.

Results

In this cohort, 31.8% were diabetic, 43% had ischemic etiology of heart failure, and 15.3% had reversible pulmonary hypertension. Mechanical circulatory support was used in 22%. During 1-year observation, 64 (24.8%) patients died. Univariable analysis showed ischemic etiology (hazard ratio [HR]=2.05, CI=1.227–3.429; P=0.01) and left ventricular assist device were associated with 1-year risk of death (HR=1.953, CI=1.090–3.499; P=0.02). Urgent listing trended toward worsened prognosis (HR=1.509, CI=0.95–2.397; P=0.08). Multivariable analysis showed ischemic etiology (HR=1.81, CI=1.075–3.059; P=0.03), total mechanical circulatory support (HR=1.93, CI=1.080–3.437; P=0.03), decreased eGFR (HR=0.987, CI=0.975–0.998; P=0.03), and protein level (HR=0.97, CI=0.951–0.998; P=0.04) were independently associated with worse 1-year survival after transplantation.

Conclusions

Ischemic etiology and mechanical circulatory support were the most important preoperative factors. Malnutrition and renal failure were additional risk factors. Age alone did not influence 1-year survival.

Short- and long-term outcomes of continuous-flow left ventricular assist device therapy in 79 patients with end-stage heart failure

INTRODUCTION

An increasing number of patients with end‑stage heart failure, along with a shortage of heart donors, necessitates the use of mechanical circulatory support.

OBJECTIVES

This single‑center retrospective study evaluated short- and long term outcomes of continuous‑flow left ventricular assist device (CF LVAD) therapy in patients with end stage heart failure.

PATIENTS AND METHODS

We collected and assessed data of 79 patients (77 men, 2 women; mean age, 50.3 years; mean INTERMACS profile, 3.1) implanted with a CF‑LVAD between 2009 and 2017 (HeartMate 3 in 19 patients [24%]; HeartMate 2 in 9 [11.4%]; and HeartWare in 51 [64.6%]).

RESULTS

The mean time on CF-LVAD support was 604 days (range, 1–1758 days). There were 2 device exchanges due to pump thrombosis and 1 explantation due to heart regeneration; 9 patients (11.4%) underwent heart transplant. Stroke (nondisabling, 48%) occurred in 27.8% of patients (ischemic in 9 patients; hemorrhagic, in 14; both types, in 1) despite the standardized anticoagulation regimen. Major gastrointestinal bleeding and pump thrombosis were reported in 13 patients (16.5%), while 18 patients (22.8%) developed driveline infections (recurrent in 15 patients [19%]). Hemorrhagic stroke and bacteremia had a negative impact on survival. Hemorrhagic stroke was the main cause of death. Survival probability was 0.9 at 1 month and 0.81, 0.71, 0.61, and 0.53 at 1, 2, 3, and 4 years, respectively.

CONCLUSIONS

Although CF‑LVAD support is associated with substantial adverse events, they do not significantly affect mortality (except hemorrhagic stroke and bacteremia). Novel devices seem to overcome these limitations, but larger studies are needed to support these findings.

Prevalence and Risk Factors of New-Onset Diabetes After Transplantation (NODAT)

Background

New-onset diabetes after transplantation (NODAT) is a serious complication after a solid organ transplant. NODAT occurs in 2% to 53% of all solid organ transplant recipients. The identification of high-risk patients and the implementation of measures to limit the development of NODAT can improve the long-term patient prognosis.

Material/Methods

Our study group consisted of 336 patients undergoing heart transplant. Patients with prior diabetes (60 patients) were excluded from analysis. The remaining 276 patients were divided in 2 groups: with NODAT (n=109) and without NODAT (n=167). Logistic regression analysis was used for NODAT risk factor assessment.

Results

NODAT occurred in 109 (32%) out of 336 patients without diagnosed diabetes before heart transplantation. Risk factors for post-transplant diabetes mellitus, which was shown by the analysis of the collected data, were BMI at discharge (OR=1.082, CI 1.011–1.158, p=0.0233), history of diagnosed CMV infection (OR=1.464, CI 1.068–2.007, p=0.0179), and age over 51 years (OR=1.634, CI 1.274–2.095, p=0.0001).

Conclusions

1. New-onset diabetes after transplantation (NODAT) or long-lasting hypoglycemia (over 2 years after transplantation) was diagnosed in 32% patients after heart transplantation developed. 2. The risk factors of NODAT were BMI at discharge and history of diagnosed CMV infection, and age over 51 years was an independent risk factor.

Left Ventricular Assist Device Implantation in Patients With Optimal and Borderline Echocardiographic Assessment of Right Ventricle Function

BACKGROUND

Left ventricular assist devices (LVADs) are used for treatment of end-stage heart failure. Outcomes are dependent on right ventricle (RV) function. Prediction of RV function after LVAD implantation is crucial for device selection and patient outcome. The aim of our study was to compare early LVAD course in patients with optimal and borderline echocardiographic parameters of RV function.

MATERIAL AND METHODS

We retrospectively reviewed 24 male patients with LVAD implantation. The following echocardiographic data of RV function were collected: FAC (fractional area change) with optimal value > 20%, tricuspid annulus plane systolic excursion >15 mm, RV diameter < 50mm, and right-to-left ventricle ratio < 0.57 (RV/LV). Patients were divided into group 1 (12 patients) with transthoracic echocardiography parameters in optimal ranges and group 2 (12 patients) with suboptimal transthoracic echocardiography findings. Study endpoints were mortality, discharge from the intensive care unit, and RV dysfunction. Demographics, postoperative clinical outcomes, comorbidities, complications, and results in a 30-day period were analyzed between groups.

RESULTS

Echocardiography parameters differed significantly between groups 1 and 2 according to FAC (31.8% vs 24.08%; P = .005), RV4 (45.08 mm vs 51.69 mm; P = .02), and RV/LV ratio (0.6 vs 0.7; P = .009). Patients did not differ according to course of disease, comorbidities before implantation, or complications. One patient from each group died. Patients in group 2 experienced more pulmonary hypertension, required increased doses of catecholamines, and stayed in the intensive care unit longer. No RV dysfunction was noted.

CONCLUSIONS

Borderline FAC, tricuspid annulus plane systolic excursion, and RV4 add RV/LV ratio prolonged recovery after LVAD implantation even with no RV failure. Parameters chosen for qualification are in safe ranges.

Predictive Value of Models for End-Stage Liver Disease Score in Patients With Pulsatile Flow POLVAD MEV Left Ventricular Assist Device Support

BACKGROUND

Model for End-Stage Liver Disease (MELD) score predicts multisystem dysfunction and death in patients with heart failure (HF). Left ventricular assist devices (LVADs) have been used for the treatment of end-stage HF.

AIM OF THE STUDY

We evaluated the prognostic values of MELD, MELD-XI, and MELD-Na scores in patients with POLVAD MEV LVAD.

MATERIALS AND METHODS

We retrospectively analyzed data of 25 consecutive pulsatile flow POLVAD MEV LVAD patients (22 men and 3 women) divided in 2 groups: Group S (survivors), 20 patients (18 men and 2 women), and Group NS (nonsurvivors), 5 patients (4 men and 1 woman). Patients were qualified in INTERMACS class 1 (7 patients) and class 2 (18 patients). Clinical data and laboratory parameters for MELD, MELD-XI, and MELD-Na score calculation were obtained on postoperative days 1, 2, and 3. Study endpoints were mortality or 30 days survival. MELD scores and complications were compared between Groups S and NS.

RESULTS

20 patients survived, and 5 (4 men and 1 woman) died during observation. Demographics did not differ. MELD scores were insignificantly higher in patients who died (Group 2). Values were as follows: 1. MELD preoperatively (21.71 vs 15.28, P = .225) in day 1 (22.03 vs 17.14, P = .126), day 2 (20.52 vs 17.03, P = .296); 2. MELD-XI preoperatively (19.28 vs 16.39, P = .48), day 1 (21.55 vs 18.14, P = .2662), day 2 (20.45 vs 17.2, P = .461); and 3. MELD-Na preoperatively (20.78 vs 18.7, P = .46), day 1 23.68 vs 18.12, P = .083), day 2 (22.00 vs 19.19, P = .295) consecutively.

CONCLUSIONS

The MELD scores do not identify patients with pulsatile LVAD at high risk for mortality in our series. Further investigation is needed.

One‑year survival of ambulatory patients with end‑stage heart failure: the analysis of prognostic factors

INTRODUCTION    An increasing number of ambulatory patients are placed on orthotopic heart transplantation (OHT) waiting lists, which results in an extended waiting time and a higher mortality rate. OBJECTIVES    The aim of this study was to identify the factors associated with reduced survival during a 1‑year follow‑up in patients with end‑stage heart failure listed for an OHT. PATIENTS AND METHODS    We retrospectively analyzed the data of 221 adult patients, who were accepted for OHT in our institution over a 2‑year period between 2013 and 2014. RESULTS    The mean (SD) age of the patients was 54.7 (9.6) years, and 90.1% of them were male. The mortality rate during the follow‑up period was 43.3%. The modified Model for End‑Stage Liver Disease (modMELD) score (odds ratio [OR], 1.70; P <0.001), as well as the plasma levels of high‑sensitivity C‑reactive protein (hs‑CRP; OR, 1.10; P <0.01), sodium (OR, 0.74; P <0.001), and uric acid (UA; OR, 1.003; P <0.05) were independent factors affecting death. The receiver‑operating characteristic (ROC) analysis indicated that a modMELD cut‑off of 10 (area under the ROC curve [AUC], 0.868; P <0.001), hs‑CRP cut‑off of 5.6 mg/l (AUC, 0.674; P <0.001), plasma sodium level cut‑off of 135 mmol/l (AUC, 0.778; P <0.001), and a plasma UA cut‑off of 488 μmol/l (AUC, 0.634; P <0.001) were the most accurate factors affecting death. CONCLUSIONS    In conclusion, although limited to a single center, our study demonstrated that an elevated modMELD score, incorporating a combination of renal and hepatic laboratory parameters, as well as plasma sodium, UA, and hs‑CRP levels at the time of listing are associated with reduced survival in ambulatory patients with end‑stage heart failure, accepted for OHT.

Renal Artery Denervation in Patient After Heart and Kidney Transplantation With Refractory Hypertension

We describe the case of a 54-year-old patient after renal and heart transplantation in whom uncontrolled hypertension was diagnosed. Despite combined antihypertensive therapy, no significant therapeutic effect was achieved. Clinical assessment of ambulatory blood pressure monitoring (ABPM) revealed the ineffectiveness of a bisoprolol, nitrendypin, klonidyn, ramipryl, furosemide, and doxasosine combination used at high doses. High blood pressure levels with their effect on a hypertrophic transplanted heart (left ventricular mass 254 g) and poor renal graft function (39 mL/kg/min) posed an extremely high risk of future cardiovascular complications, and were the reason to perform a native renal arteries denervation. The procedure was carried out through the right femoral artery with the use of a 6F guiding catheter. During a 1-year observation, significant decreases in ABPM systolic and diastolic blood pressures were observed after the procedure (168/88 mm Hg vs 154/77 mm Hg, respectively). Moreover a significant regression of left ventricular mass (215 g/m(2)) and stable renal graft function were noted. The presented case shows that native renal arteries denervation may be successful and safe in kidney and heart transplant recipients. Moreover, during the 1-year follow-up, the reduction in blood pressure was followed by a reduction in transplanted heart hypertrophy, both leading to regression of cardiovascular risk for the patient.

Professional and social activity of patients after heart transplant

OBJECTIVES

The aim of the study is to describe both professional and social activities of patients after heart transplant.

MATERIAL AND METHODS

Ninety-five heart transplant patients treated at the Silesian Center for Heart Diseases in Zabrze were surveyed, comprising 29 women (30.5%) and 66 men (69.5%). The average age of respondents was 54.3 years old (standard deviation (SD) = 15 years); the average period that had elapsed since the heart transplant was 7.1 years (SD = 4 years). We designed a questionnaire as a tool for collecting information from patients.

RESULTS

Twenty-five percent of patients worked at the time of completion of the questionnaire. Eighty percent of those patients were working before and after the transplant, 20%--only after transplantation (p < 0.05). A different job position at a new workplace had 47.8% of patients, 34.8% of them had the same job position at the same work place as they had had before, 63.4% of the heart transplant respondents were pensioners. Eighty-two percent of patients had a certificate with a designated degree of disability--among them: 69% had a certificate for a significant degree of disability, 22%--for a moderate degree of disability. Among those surveyed, 52.5% said that their financial situation had not changed whereas 34.5% of those surveyed reported a change for the worse. Thirty-seven percent of respondents reported changes in family relationships. Seventy-seven percent reported that they received help from family members, as compared with 19% who did not.

CONCLUSIONS

Only 25.3% of the patients treated at the Silesian Centre for Heart Diseases after heart transplant are employed and it is one of the lowest employment rates in this category of patients in Europe. One third of working patients have the same work place as they had before their operation. Heart transplant is a cause of changes in family relationships. Most often family bonds are strengthened but sometimes family members become nervous, impatient and unwilling to talk about the transplant.

Activated Hemostatic Biomarkers in Patients with Implanted Left Ventricle Assist Devices: Are Heparin and/or Clopidogrel Justified?

BACKGROUND

Adequate anticoagulation represents a major problem for left ventricle assist device (LVAD) utilization in patients awaiting heart transplantation as well as for regeneration of the native heart. The proper management of hemostatic abnormalities during LVAD support may improve survival by reducing the incidence of hemorrhagic and/or thromboembolic complications.

CASE REPORT

A 40-year-old man with implanted pulsatile LVAD due to dilated cardiomyopathy received aspirin and warfarin. The patient underwent serial weekly monitoring of hemostatic biomarkers including international normalization ratio, prothrombin time, prothrombin activity, activated partial thromboplastin time, fibrinogen, D-dimer, platelet aggregation induced by adenosine diphosphate and arachidonic acid, platelet count, and mean platelet volume. The external pump was exchanged three times - twice because of a clot formation in the blood chamber of the pump, and once according to the standard protocol.

RESULTS

LVAD use was consistently associated with enhanced adenosine diphosphate-induced platelet aggregation independent from the timing of clot formation or external pump exchange. Among coagulation indices, increased D-dimer holds predictive value for clot formation. The fibrinogen level peaked before the first pump exchange and was twice as high than the average values. Gradual improvement in exercise capacity was observed 2 years after implantation, after which the patient underwent a controlled stress test in the stop mode of the LVAD and the device was successfully explanted.

CONCLUSIONS

Serial assessment of hemostatic biomarkers may benefit and triage LVAD patients. Consistent platelet activation during long-term LVAD may justify the addition of clopidogrel, while high D-dimer and/or elevated fibrinogen may indicate adding heparin to the conventional antithrombotic regimen. Randomized evidence is needed to test such a hypothesis.

Association of transforming growth factor β1 (TGF- β1) with gingival hyperplasia in heart transplant patients undergoing cyclosporine-A treatment

BACKGROUND

Gingival hyperplasia is a common complication of immunosuppressive therapy with cyclosporine A (CyA). However, the association of CyA with increased tissue concentrations of TGF- β(1), a potential causative factor of hyperplasia, remains unknown. The aim of the study was to assess the impact of TGF- β(1) and IL-2 on the development and maintenance of gingival hyperplasia in patients treated with CyA after orthotopic heart transplantation (OHT).

MATERIAL/METHODS

Gingival hyperplasia was indexed in 60 patients, in accordance with McGraw and Potter scale. Patients were divided and comparisons were made among 3 groups: Group A (18 patients; 49.0 ± 12.1 y/o) after OHT with gingival hyperplasia (score 1, 2, 3), Group B (12 patients; 40.0 ± 15.1 y/o) after OHT without gingival hyperplasia (score 0), and Group C - the control group - (30 patients; 42.0 ± 10.8 y/o) with clinically healthy paradentium. Cytokines (TGF- β(1) and IL-2) were marked in gingival tissue homogenate. The concentration of CyA was marked in the patients' blood (Groups A and B).

RESULTS

The highest mean concentration of TGF- β(1) was obtained in Group A and the lowest concentration was in the control group. A positive correlation was found between TGF- β(1) in gingival tissue and CyA blood concentration in Groups A and B.

CONCLUSIONS

TGF- β(1) is associated with gingival hyperplasia in patients treated with CyA after OHT procedure.

Restrictive pattern in spirometry as a predictor of poor survival in chronic heart failure patients on betaceptor-antagonist, with possible indications for heart transplantation

BACKGROUND

Restrictive spirometry pattern is commonly associated with chronic heart failure (CHF), but its prognostic value is poorly documented. Utility of Lower Limit of Normal (LLN)-based spirometry interpretation has not yet been evaluated in CHF patients. Impact of restrictive pattern defined according to classic or LLN criteria on prognosis in CHF patients was therefore addressed.

MATERIAL/METHODS

171 CHF patients on long-term beta-antagonist treatment with PeakVO2 >12 ml/kg/min (147 men, 49±9 years, LVEF 26±8%, 51% ischemic) were divided into groups based on their spirometry: Group 1A (N=129) - classic criteria: no restriction, Group 2A (N=12) - classic criteria: restrictive pattern, Group 1B (N=90) - LLN criteria: no restriction, Group 2B (N=26) - LLN criteria: restrictive pattern. PeakVO2 in the study groups equaled 12.1-19.9 ml/kg/min. Control group (N=30) - PeakVO2 >20 ml/kg/min, absence of restriction or obstruction (FEV1%FVC ≥70) defined by classic criteria. Classic criteria: VCin% <70 and FEV1%FVC ≥70. LLN criteria: VCin% <LLN and FEV1%FVC ≥LLN. LLN is the 5th percentile of spirometry values' normal distribution in the reference population. End-points: time to death, 1- and 2-year mortality, number and duration time of cardiac and all-cause hospitalizations. P<0.05 was considered significant.

RESULTS

Significantly worse survival was observed in groups 2A and 2B when compared to the control group. One-year and 2-year mortality were significantly higher in group 2B (19.2 and 40.9%; control group: 0% and 0%, respectively) and 2-year mortality was higher in group 2A (40.0%).

CONCLUSIONS

Restrictive spirometry pattern is associated with worse survival in CHF patients with PeakVO2 above the cutoff point for OHT listing. Use of LLN criteria may be useful to predict poor 1-year prognosis.

Pivotal karyometric measurements in different types of cardiomyopathic morphology: study of hearts explanted from transplant recipients

BACKGROUND

Morphometric studies based on the measurement of cardiocyte nuclei have focused on progressive hypertrophy rather than shape, which is a deciding factor for the diagnosis of hypertrophy in myocardial diseases. The aim of this research was to demonstrate how the digital morphology of cardiocyte nuclei change correlated with the type of myocardial pathology.

MATERIALS AND METHODS

The study groups encompassed 7 hearts with dilated cardiomyopathy (DCM) and 8 hearts with ischemic heart disease (IHD) which were explanted. A comparative group consisting of myocardial hypertrophy was contrasted with a control group of donor heart fragments. Cardiocyte nuclei were evaluated morphometrically on histologic slides. We calculated the nuclear area, length, breadth, perimeter, roundness, elongation, fullness factors, and nuclear chromatin mean gray level. The results were subjected to discriminant analysis.

RESULTS

All karyometric measurements analyzed by backward discriminant analysis showed only 2 powerful factors: nuclear breadth and chromatin mean gray level. The Mahalanobis distance showed the proximity of control and hypertrophy groups, whereas differences between IHD and DCM were nonsignificant.

CONCLUSION

The lack of karyometric differences between IHD and DCM suggested a common morphologic response for long-lasting progressive injury. The main morphologic differences were dependent on nuclear chromatin activity/stainability and nuclear breadth, suggesting darker and thinned nuclei in normal and adaptative stages and irregular brighter nuclei in cardiomyopathies.

The occurence of mood and anxiety disorders in heart transplant recipients

Fortynine heart transplant recipients were evaluated during the first weeks after orthotopic heart transplantation. Using the ICD-10 (International Classification of Diseases-10th revision) criteria, we studied the incidence of anxiety disorders as well as 17 demographic and medical factors potentially influencing the probability of their occurrence. A smaller 36-person group was evaluated using standard psychopathologic scales for anxiety and mood disorders. Cox regression analysis was used to specify which of 11 demographic and medical factors influenced the time to occurrence of the first episode of a mental disorder. Anxiety episodes occurred in 25 patients, depressive episodes in 27, (hypo)manic in 3, and 12 manifested a slightly elevated mood. The risk of occurrence of anxiety and mood disorders was highest during the first 3 weeks after OHT. "False alarms," namely, calls to the clinic not ending up in transplantation, and coexisting illnesses were related to higher incidences and earlier appearance of anxiety and mood disorders. The risk of occurrence of an anxiety syndrome was greater among older patients. Anxiety syndromes were manifested earlier in patients who underwent transplantation due to ischemic cardiomyopathy than in patients with heart failure caused by other factors. A greater number of false alarms, of long-lasting hospitalizations, and of low mean cyclosporine levels were risk factors for depressive episodes.

Comparison of long-term results of drug-eluting stent and bare metal stent implantation in heart transplant recipients with coronary artery disease

BACKGROUND

Transplanted heart coronary artery disease (TxCAD) may occur in a significant proportion of patients following cardiac transplantation. Drug-eluting stents (DES) have been successfully used in patients with CAD, but their efficacy in TxCAD patients has not been well established.

AIM

To compare long-term results of intracoronary implantation of DES and BMS in patients suffering from TxCAD.

METHODS

We performed a retrospective analysis of all intracoronary stent implantations for TxCAD with at least one control coronary angiography performed during follow-up. We identified 28 DES (all sirolimus-eluting stents, SES) and 28 BMS implantations in 23 patients. The mean follow-up time was 410+/-58 days after DES, and 572+/-434 days after BMS implantation (p=0.004). We compared the occurrence of in-stent restenosis (ISR) in DES and BMS, and survival of patients in the context of risk factors that were identified for each stent implantation separately.

RESULTS

There were 2 (7%) ISR revealed in DES patients (mean time from PCI to restenosis 492+/-58 days) vs. 17 (61%) ISR in BMS patients (mean time from PCI to restenosis 475+/-345 days) (p<0.001). There were 3 (18%) deaths in patients with DES, 4 (31%) in patients with BMS, and 1 (14%) in a patient with DES and BMS (NS). The risk factor profile was comparable, except for higher age at the time of transplantation (46+/-7 vs. 41+/-6 years, p=0.011) and stent implantation (54+/-7 vs. 49+/-6 years, p<0.001) for DES.

CONCLUSION

Favourable long-term results of DES compared with BMS implantation for TxCAD suggest the preferential use of DES in heart transplant recipients.

Risk stratification of patients with severe heart failure awaiting heart transplantation-prospective national registry POLKARD HF

Most methods used in the risk assessment of heart transplant candidates do not include new biomarkers.

AIMS

The aim of the study was to examine the value of NTproBNP and hsCRP and their combined use together with HFSS score in the risk assessment of patients with heart failure enlisted for heart transplantation.

METHODS

Data of 658 patients enlisted for heart transplantation in all active transplantation centers were stored in a prospective registry. The composite end point-death or urgent transplantation was recorded during the follow-up.

RESULTS

Death or urgent transplantation was recorded in 161 (24%) of pts. 102 (15%) patients died and 59 (9%) were transplanted urgently. Kaplan-Meier curves for risk of death or urgent transplantation where highly significant when pts were stratified by the quartiles of NT proBNP (P < .000001) or quartiles according to the hsCRP level on admission (P < .002). In the multivariate Cox proportional hazard model, the significance was observed for NTproBNP (P < .01) and HFSS (P < .02), and borderline significance for hsCRP (P = .057). When ROC analyses of the area under the curve (AUC) values were considered, AUC area was for HFSS - 0.645, for NTproBNP - 0.653 and for hsCRP - 0.566. When all those variables were included together in the model, the AUC value rose to 0.6943. Based on those results a weighted risk model with all three parameters was proposed.

CONCLUSION

HFSS, NTproBNP and hsCRP levels are independent stratification variables of survival or need for urgent heart transplantation. Their predictive value is moderately increased when they are analyzed together.

Differences in antiapoptotic, proliferative activities and morphometry in dilated and ischemic cardiomyopathy: study of hearts explanted from transplant recipients

BACKGROUND

Antiapoptotic as well as replacement and proliferative mechanisms take place in the myocardium in dilated cardiomyopathy (DCM) and ischemic heart disease (IHD). We sought to estimate antiapoptotic, proliferative and replacement activities in cardiomyopathies.

MATERIALS

The study groups included seven hearts with DCM and eight with IHD, which had been explanted at the time of transplantation. The comparator group consisted of cases of myocardial hypertrophy and the control group, donor fragments.

METHODS

Antiapoptotic and proliferative responses were determined immunohistochemically as Bcl-2 and Ki67 expression by semiquantitative assessment of the intensity of staining. We also measured and statistically analyzed the integrative morphometric measurements of the fraction of fibrosis area, the nucleosarcoplasmic ratio, and cardiocyte diameter.

RESULTS

No Bcl-2 expression was observed in the controls. The strongest reaction was seen in the DCM group, then in the IHD, and in the comparator group of myocardial hypertrophy. Proliferative activity was seen only in endocardial and interstitial fibroblasts in DCM and IHD cases. The cardiocyte diameter showed no statistical association between myocardial hypertrophy and IHD, or IHD and DCM, whereas the nucleosarcoplasmic ratios were significantly different from control groups for all comparisons. Myocardial fibrosis showed the highest values in DCM and IHD. Discriminant analysis showed the value of interstitial fibrosis and cardiocyte diameter to categorize the analyzed groups.

CONCLUSIONS

Antiapoptotic Bcl-2 activity seemed to play an important role in cardiocyte preservation, while proliferative activity was resticted to interstitial connective tissue cells as a replacement process. Myocardial Bcl-2 expression, the extent of myocardial fibrosis, and cardiocyte diameter may serve as additional diagnostic tools to differentiate cardiomyopathies.

Is there a difference between patients with peak oxygen consumption below 10 ml/kg/min versus between 10 and 14 ml/kg/min? Does the "Grey Zone" really exist?

BACKGROUND

Cardiopulmonary exercise testing is an important component of evaluation when orthotopic heart transplantation (OHT) is considered for chronic heart failure (CHF) patients. However there is a question about the accuracy of interpretations of peak oxygen consumption (VO(2)max) used at present.

MATERIALS AND METHODS

We analyzed 302 CHF patients stratified into 3 groups according to VO(2)max (mL/kg/min): group 1 = <10 (n = 37); group 2 = 10-14 (n = 121) and group 3 = >14 (n = 144). We compared the mortality rate, the OHT rate, time to OHT, time to death and pulmonary function tests (PFT) among the groups using ANOVA Kruskal-Wallis tests for analysis in Statistica 7.1.

RESULTS

No important differences were observed between groups 1 and 2 (P > .05), but first in comparison with group 3 (P < .05) in terms of mortality (48.6% vs 33.1% vs 21.5%), number of OHT (24.3% vs 32.2% vs 14.6%), time to death (15.4 vs 16.6 vs 34.4 months) or PFT results (forced expiratory volume in the first second forced vital capacity and peak expiratory flow, all as direct or as percent of normal values). In contrast, time to OHT (4.6 vs 6.9 vs 10.9 months) and percent of normal vital capacity (72% vs 81% vs 91%) differed significantly among all groups (P < .05).

CONCLUSION

Patients with VO(2)max between 10 and 14 or <10 mL/kg/min are at similar risk of death.

The influence of the recipient's body weight on the probability to obtain a heart transplant-POLKARD HF registry

INTRODUCTION

The aim of the study was to analyze the influence of body weight of the adult heart recipient on the chance to obtain a transplant.

METHODS

We analyzed the data from all 658 patients listed for heart transplantation.

RESULTS

During the follow-up period, 325 (49%) of listed patients underwent transplantation with 102 (15%) succumbing before heart transplantation. The mean weight of transplanted patients was 73.7 +/- 13.7 kg and 81.2 +/- 15.4 kg for those not transplanted (P < .00001). Patients were divided according to body weight in two groups: light = below 80 kg (n = 360) or heavy > or = 80 kg or above (n = 297). On the transplant list, 111 heavy patients (37%) versus 213 light patients (59%) underwent the procedure, a significant difference. The waiting time among light patients was 255 versus heavy patients of 395 days (P < .005). There was a similar number of deaths before transplantation among the light (n = 56 360 patients; 15.5%) versus the heavy group (49/297; 16%). Upon multivariate Cox mode analysis independent factors related to not receiving a heart transplant were greater weight, systolic blood pressure, pulmonary vascular resistance, Heart Failure Survival Score (HFSS) score and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels.

CONCLUSIONS

Among adult heart transplant candidates, the chance to receive a heart transplant significantly decreased when the recipient's weight exceeded 80 kg. Patients with a body weight more than 110 kg had a poor chance to receive a heart transplantation.

Additional spirometry criteria predict postoperative complications after coronary artery bypass grafting (CABG) independently of concomitant chronic obstructive pulmonary disease: when is off-pump CABG more beneficial?

INTRODUCTION

Concomitant chronic obstructive pulmonary disease (COPD) is associated with an increased rate of post-coronary artery bypass grafting (CABG) complications. The ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) <70%, proposed by the Global Initiative for Chronic Obstructive Lung Disease as a criterion for the diagnosis of COPD, is criticized for not considering physiological, age-related changes in lung function.

OBJECTIVES

The aim of the study was to evaluate which of the additional spirometric parameters, adjusted for age and the distribution of values in the population, represent the best predictors of post-CABG complications and to identify patients who are more likely to benefit from off-pump cardiac bypass (OPCAB) than from CABG.

PATIENTS AND METHODS

In the retrospective cohort study, data from a total of 3617 CABG or OPCAB patients were recorded. Patients with COPD, diagnosed prior to admission, were classified according to the spirometry results: group 1 with FEV1/FVC <70%, group 2 with FEV1/FVC below the mean normal value adjusted to age, group 3 with FEV1/FVC below the lower limit of normal (LLN), group 4 with FEV1 <LLN. The control group comprised subjects with no history of COPD. The occurrence of post-CABG complications was analyzed using the chi2 and Mann-Whitney U tests.

RESULTS

FEV1 below LLN predicted a higher incidence of reoperation, readmission to intensive care unit (ICU), sternal wound infection, pulmonary complications, and pulmonary edema after surgery (p <0.05). CABG patients with FEV1 below LLN stayed in the ICU significantly longer than OPCAB patients, and tended to require prolonged mechanical ventilation and more time from operation to discharge.

CONCLUSIONS

FEV1 <LLN is the best prognostic marker for post-CABG complications independently of concomitant COPD. Patients with FEV1 <LLN have better outcomes after OPCAB compared with those post-CABG.

Cardiocyte nuclear chromatin density correlates with transplanted heart left ventricular mass

INTRODUCTION

Cardiocyte hypertrophy is accompanied by polyploidy, seen as a decrease in chromatin density in the enlarged nucleus. Repeated biopsies of a transplanted heart offer the possibility of a dynamic evaluation of these phenomena. The aim of this work was an evaluation of cardiocyte nuclear chromatin density in transplanted hearts during long-term follow-up.

MATERIALS AND METHODS

The material encompassed myocardial biopsy specimens taken during the first week, first month, and then on an annual basis up to 10 years after surgery. Only biopsy specimens with no rejection were considered (grade "0" International Society for Heart and Lung Transplantation [ISHLT] 122 biopsy specimens). The control group consisted of 7 donor heart specimens. We evaluated the optical density-mean gray level-of cardiomyocyte nuclear chromatin. We determined correlations of this index with the nuclear area, and with left ventricle ultrasound measurements, using correlation analysis.

RESULTS

The chromatin mean gray level decreased with time, correlating positively with interventricular septum thickness, left ventricle posterior wall diameter, and left ventricular mass. Analysis of individual periods showed a significant positive correlation of the mean grey level with the cardiocyte nuclear surface in year 3, 4, and 9 after transplantation, thereby suggesting the occurrence of polyploidy at those times. The significant negative correlation of these values (1 week and 1 year) indicated normalization of early cardiocyte hypertrophy.

CONCLUSIONS

With the passage of time chromatin condenses, leading to pyknosis. The activity of cardiocyte chromatin correlated with left ventricular hypertrophy. Compensatory cardiomyocyte polyploidy is a periodical phenomenon.

Remodeling of human transplanted myocardium in ten-year follow-up: a clinical pathology study

Remodeling taking place in transplanted myocardium leads to a change in the number of cardiocytes. Ultrasound measurements and biopsy evaluation should reflect their loss and compensation. We sought to evaluate the morphology of the transplanted heart upon long-term follow-up.

MATERIAL AND METHODS

Myocardial biopsies were obtained in the first week, first month, and then annually for 10 years from transplantation that did not show rejection (grade "0" ISHLT, 122 biopsies). The control group encompassed 7 donor heart fragments. Proliferation in biopsies was evaluated with Ki67 (M7240, DAKO), cardiocyte hypertrophy by measuring their diameter, the surface area of the nuclei, nuclear-sarcoplasmic index, and stromal fibrosis evaluated as the surface area fraction. Ultrasound measurements included diastolic thickness of the interventricular septum, posterior wall of the left ventricle, and left ventricular mass. The correlation of measurements with time from transplantation was evaluated using Spearman's test.

RESULTS

A positive Ki67 reaction was observed in fibroblasts and endothelial cells. The increased cardiocyte nuclear area correlated with the time elapsed since transplantation (r = 0.2; P < .05) with a simultaneous decrease in cardiocyte thickness (r = -0.3; P < .05), without changes in the nuclear-cytoplasmic index (r = 0.02; P > .05). Stromal fibrosis also increased (r = 0.1; P < .05). Ultrasound measurements of the left ventricle showed a decreased tendency with the passage of time (r = -0.2 to -0.3; P < .05).

CONCLUSION

A transplanted heart does not undergo hypertrophy but rather fibrous atrophy with apparent compensatory hypertrophy of the cardiomyocytes.

Anti-ox-LDL and anticardiolipin autoantibodies in patients after cardiac transplantation

INTRODUCTION

Among cardiac transplantation (OHT) of coronary arterial disease, the pathogenesis can be associated with autoimmunologic effects due to oxidative lipoprotein modification and their change in antigenicity. These factors may lead to lipoprotein vascular changes observed in antiphospholipid syndrome or systemic lupus erythematosus. The aim of the presented study was to evaluate anticardiolipin autoantibodies (ACA) and anti-ox-LDL (antibodies against oxidized LDL) levels in the plasma immunoglobulin IgG class.

MATERIALS AND METHODS

The study group consisted of 90 OHT patients (79 men/11 women, age 44 +/- 13); 35 individuals were chosen as a control group. Blood samples were taken twice, in years 2002 and 2004. The investigated group was divided into 2 smaller groups: OHT patients in 2002 and OHT patients before 2002.

RESULTS

OHT patients showed significantly higher ACA concentrations compared with the control group (3.53 vs 1.10 GPL U/mL), whereas anti-ox-LDL levels did not differ considerably (494 vs 385 mU/mL). During long-term observation the significant increase in ACA concentration was observed in both patients groups. Significant differences between the 2 OHT patient groups regarding anti-ox-LDL concentration were demonstrated among samples taken in 2002.

CONCLUSIONS

The results may indicate the possible role of autoimmunological processes in OHT development. It is necessary to focus further research on the possibilities of developing secondary antiphospholipid syndrome.