ABSTRACT
Heart transplantation is an established procedure with acceptable, predictable long-term results and good quality of life for more than 20 years. However, it is only available for a limited number of patients. The fate of the patients is determined by the side effects of immunosuppressive drugs, increased tumor incidence and chronic vascular transplant disease. Patients living 10 to 20 years after heart transplantation show physical status equal to that of patients with various chronic illnesses. They suffer from chronic side effects of long-term medication and mainly report fears of renal insufficiency followed by osteoporosis-associated pain, cortisone-induced myopathy and risk for tumors. Only moderate psychological impairment is reported despite somatic problems. In the period 10-20 years post-heart transplantation, there is even a surprising increase in emotional well-being. The 20-year survivors are active and satisfied with daily life. They experience their own life as meaningful and have good partner, family and social relations. Heart transplantation, the most ambitious project in medicine in the 20th century has been made a reality. Its development has the strongest impact on cardiac surgery, immunology, pharmacology, medical logistics, defining life and death, ethics in medicine, acceptance of medical progress by the public and by health care systems. It has provided a strong solidarity among politicians, sociologists, physicians and citizens. Ethical concerns will last and will make heart transplantation an important, yet temporary episode in human medicine. It has stimulated research and development of mechanical circulatory support systems as an alternative to treat end-stage heart failure.
ABSTRACT
It is anticipated that as many as 10-20% of patients alive with anatomical congenital heart lesions may eventually develop heart failure. Most of these patients have undergone previous palliative or corrective surgeries. The Fontan procedure, although it has helped many patients with single-ventricle physiology to become hemodynamically functional, it is associated with protein-losing entropathy, intractable atrial arryhythmia and systemic ventricular dysfunction. In patients with transposition of the great arteries, physiological or intra-atrial repair techniques (Mustard and Senning) or anatomical correction (arterial switch) have been used. The majority of these patients are clinically well throughout their adult life but, as a consequence of the potential for right ventricular failure, some may develop cardiac insufficiency. Although long-term survival and quality of life in children and adults with complex congenital heart disease have remarkably improved due to advances in operative techniques and perioperative management, as well as the increasing experience of congenital heart surgeons, a growing number of these patients eventually develop end-stage heart failure and will require another treatment. Surgical options for treatment of these patients are limited. Heart transplantation has become a well-established treatment option for children as well as adults with end-stage congenital heart disease. Because of organ donor shortage, another option is mechanical circulatory assist device implantation, either as a bridge to transplantation, or as a permanent therapy.
ABSTRACT
Ever since the early days of homograft implantation in 1956, and the introduction into clinical practice by Ross and Barrat Boyes, homograft heart valves have proven to have many advantages. Its disadvantages became evident during long-term follow up. Factors, such as donor and recipient morbidity, tissue banking techniques, and the often complex surgical technique required to implant, are of great influence on the long term results. Because of European Directives, legally binding quality assurance regulations have been introduced in homograft banks. However, still not all processing methods have been scientifically sub-structured on their effects on the final product and its durability. The donor shortage has stimulated researchers and industries to develop and improve mechanical and biological valve substitutes such as the stentless bioprostheses. In general, candidates for homograft valve implantation include patients with: endocarditis, congenital defects and women who wish to become pregnant. For each category of patients different implantation techniques are required. The results of homograft banking and homograft transplantation in the German Heart Institute Berlin are satisfactory. Freedom of re-infection rate after homograft implantation is 91.9% +/- 3.6% after 15 years. Current developments show an increased interest in tissue engineered as well as in de- and re-cellularization of heart valve homografts. The advantages and disadvantages of the several processing techniques have not yet been proven in long term clinical results. For homograft bankers these developments pose as a challenge to join forces and to initiate cooperate projects aimed at scientific and organizational development.
ABSTRACT
INTRODUCTION: In the past 50 years, human cardiovascular tissue allografts, also called homografts, have been implanted into patients with different valvular diseases. The use of these allografts and the number of cardiovascular tissue banks and their respective techniques increased. We conducted a survey to establish the quantity of allografts processed, and issued by, European tissue banks. The survey also included the collection of other relevant statistics. METHODS: In 2011, the Foundation of European Tissue Banks collected data from 19 different cardiovascular tissue banks in 11 European countries. RESULTS: From 2007 to 2010 the data show a decrease in the number of hearts received, from 1700 to 1640 in 18 tissue banks; the average number of hearts received for cardiovascular tissue processing decreased from 113 to 91. The number of heart valves issued for transplantation increased from 1272 in 2007 to 1486 in 2010. The average rate of discard because of microbiological contamination was 20.7%, while 4.2% of the grafts were not used because of positive serology. Half of the tissue banks issued arterial grafts, while 3 banks also issued veins and pericardium. An overview of decontamination methods shows considerable methodological differencesbetween 17 cardiovascular tissue banks. CONCLUSIONS: From the experience in Europe, it can be concluded that cardiovascular tissue banks have an established place in the domain of cardiovascular surgery. The statistics show fluctuating data concerning the demand for human cardiovascular allografts and methodological questions. There is room for growth and improvement with respect to validation of decontamination methods.
ABSTRACT
INTRODUCTION: Pulmonary stenosis remains the most frequent complication and cause of reintervention after the arterial switch operation for transposition of the great arteries We investigated the onset, incidence, and outcome of pulmonary stenosis after arterial switch operation in neonates with transposition of the great arteries and intact ventricular septum. METHODS: Arterial switch operation using Lecompte maneuver was performed in 222 neonates with transposition of great arteries and intact ventricular septum. Complete medical records with serial echocardiograms were available for 174 (73%) patients and were reviewed for incidence of postoperative pulmonary stenosis defined as a thickened and doming pulmonary valve and/or a pressure gradient of >25 mmHg. RESULTS: During a mean follow-up of 14.4 ± 0.54 years, 31 children developed pulmonary stenosis. Onset of significant stenosis occurred as early as 30 days and as late as 10 years after arterial switch operation. Uncomplicated interventional balloon/stent angioplasty was performed in 11 patients with supravalvular stenosis (mean pressure gradients of 65 mmHg). Severe restenosis occurred in these patients post-angioplasty (range 2-7 years). In other 10 patientseither patch enlargement of the area involved or angioplasty were performed. Freedom from intervention was 68.6±8.7% at 1 year and 42.8.1±9.5% at 15 years and onwards. CONCLUSION: Over time, pulmonary stenosis developed after arterial switch operation. Balloon angioplasty for supravalvular pulmonary stenosis could be the initial treatment of choice owing to the high success rate. Surgical intervention is offered to those with pulmonary valve stenosis having pressure gradients of >50 mmHg, and for re-stenosis after intervention/stent implantation.
ABSTRACT
The number of "older" patients undergoing cardiac surgery is steadily increasing. In the year 2000, 37% of all patients who underwent a cardiac operation in Germany were 70 years of age or older. Looking at data form our institution, we focused on the topic, whether age on its own is an independent determinant for mortality in cardiac surgery. Data from 8769 patients who underwent cardiac surgery in our institution from January 1996 until January 2002 were analyzed. For all patients, EuroScore and the corresponding age-stripped value was calculated. All recorded postoperative complications and 30-day mortality were statistically analyzed. EuroScore as well as the age-stripped EuroScore showed a significant rise with increasing age in the total number of patients as well as in the patients, who did not die during the first 30 days after the operation. The 30 day mortality and the incidence of postoperative complications increased significantly with age. While the EuroScore showed a significant age-dependent increase in patients who died within 30 days after the operation, the age-stripped EuroScore did not reveal a significant discrepancy in mortality with respect to age. Arterial hypertension, diabetes mellitus and atrial fibrillation, parameters not mentioned in EuroScore, showed significant differences among age groups. According to univariate analysis, arterial hypertension and diabetes mellitus were significant predictors of mortality. Entered into a multivariate logistic regression analysis, only diabetes mellitus achieved statistical significance. Our data and the known age-associated functional and structural changes of different organ systems show that age integrates risk factors together. In order to limit mortality in the steadily growing number of older and multi-morbid patients undergoing cardiac surgery, exceptional emphasis has to be put on patient selection and therapeutic measures to improve preoperative status.
