Adult heart transplantation: a general review of current strategies

Cardiac transplantation has become established as the therapeutic option of choice in the management of terminal cardiac failure. By year 2003, a cumulative total of over 70, 000 cardiac transplants have been reported from 304 cardiac transplant centers worldwide. The overall one-year and five-year survival of cardiac transplantation is 86% and 71%, respectively. The recipient factors that have a negative impact on outcome include prior transplantation, the need for a ventricular assist device or ventilator support prior to heart transplantation, a diagnosis not coronary or cardiomyopathic, and increasing age. Donor risk factors include increasing ischemic time, and donor gender and age. Infectious complications are the most common cause of death after transplantation. Cardiac allograft vasculopathy is the most common cause of death after the first year post transplantation. The most common protocol of post-transplantation treatment involves triple-drug therapy with cyclosporine, mycophenolate mofetil, and prednisone. Over 75% of patients are still on corticosteroids at 1 year post transplantation

Does the age limit the implantation of mechanical aortic valves in septuagenarians?

Reduced life expectancy of elderly has been traditionally used as a major criterion to choose a bioprosthesis over mechanical valves to avoid anticoagulation-related hemorrhagic risk. The aim of this study was to investigate the appropriateness of using a mechanical valve in the septuagenarians for aortic valve replacement. A retrospective chart review was performed on 322 patients undergoing aortic valve replacement [AVR] from 1980 through 1998. The study group consisted of 86 patients >/= 70 years of age [mean, 73 +/- 0.4 yrs; range 70 to 83 yrs]. Of these, a mechanical aortic valve was implanted in 42 patients [group 1]: 27 had St. Jude Medical, 6 Medtronic-Hall, and 9 Bjork-Shiley valves. A bioprosthetic aortic valve was placed in 44 patients [group 2]: 28 had Carpentier-Edwards and 16 Hancock II valves. Early [30-day] mortality and actuarial survival up to 10 years for each group were compared. Results: The 30-day mortality was 0.0% [0/42] and 2.3% [1/44] for the patients with mechanical and bioprosthetic valves, respectively. Long-term actuarial survival estimates at 5 and 10 years were 63 +/- 9.8%, and 39 +/- 11.1%, respectively, for mechanical group, and 57 +/- 8.2%, and 23 +/- 8.3% for the bioprosthesis group [p = 0.15]. Neither the age > 75 years with or without coronary artery bypass grafting, nor the left ventricular ejection fraction < 45% was the independent predictor of late death. The actuarial-freedom from valve-related deaths was 100% for both groups. Bleeding and thromboembolism did not occur in any of the patients in present series. Conclusions: Safety and favorable outcome support the justification for using mechanical aortic prostheses in selected septuagenarians