Long-term morbidity and quality of life after surgical repair of transposition of the great arteries: atrial versus arterial switch operation.

Since a growing number of patients after surgical repair of transposition of the great arteries (TGA) survive until adulthood the focus of attention has shifted to the management of associated long-term morbidity and quality of life (QoL). Therefore, we reviewed all patients that underwent surgical repair of TGA at our institution and compared long-term results after atrial and arterial switch operation. Between 1973 and 2000, a total of 302 patients underwent either atrial switch operation (n=222) or arterial switch operation (n=80). Mean follow-up was 14.5±10.1 years. The arterial switch repair was associated with a higher early mortality whereas long-term survival was comparable between both groups. Postoperative arrhythmias including loss of sinus rhythm and pacemaker implantation occurred significantly more often after atrial switch repair. There was a trend towards a more favourable outcome of the arterial switch group concerning freedom from re-interventions, severe systemic ventricular dysfunction and need for heart failure medication. However, also the arterial switch operation was associated with an increased incidence of loss of sinus rhythm and neo-aortic valve regurgitation during late follow-up. Health related QoL according to the SF-36 questionnaire was not significantly different between both groups and comparable to a healthy population.

Pulmonary retransplantation in paediatric patients: a justified therapeutic option? A single-centre experience.

OBJECTIVE: Pulmonary retransplantation remains controversial due to the increased morbidity and mortality compared with primary lung transplantation. So far, only few data about paediatric retransplantation are available. We retrospectively analysed our experience with retransplantations in children. METHODS: Since 1994, seven pulmonary retransplantations in children were performed at our institution. We analysed pretransplant characteristics, operative parameters as well as the post-transplant outcome of these recipients and compared them to 29 patients who underwent primary lung transplantation during the same period. RESULTS: Indications for retransplantation were bronchiolitis obliterans syndrome in six patients and primary graft failure in one patient. Pretransplant characteristics, perioperative morbidity and mortality were similar in both groups. Hospital mortality was 2/7 (29%) after retransplantation and 6/29 (21%) after primary transplantation (p = 0.64). Actuarial 3-year survival was 71% and 60% after redo and primary transplantation, respectively (p = 0.50). Development of bronchiolitis obliterans syndrome did not differ between both groups (p = 0.99). CONCLUSIONS: In our small cohort of paediatric patients, pulmonary retransplantation was associated with an acceptable long-term outcome comparable to primary pulmonary transplantation. This differs from currently available data. However, further long-term studies including more patients and longer follow-up intervals are required.

Lung and heart-lung transplantation in children and adolescents: a long-term single-center experience.

BACKGROUND: Pediatric lung transplantation (LTx) remains a challenge for a highly selected group of patients. The requirements for immunosuppressive therapy and the associated risks must be weighed against the long-term prognosis of this operation. Therefore, we retrospectively analyzed our experience after 53 lung and heart-lung transplantations (HLTx) in children. METHODS: All pediatric patients <18 years of age who underwent LTx (n = 37) and HLTx (n = 16) at our institution were included in this study. We analyzed indications for transplantation, survival rates and causes of death. Herein we assess pediatric-specific challenges in comparison to adults. RESULTS: Thirty-day mortality was 13.2%. Kaplan-Meier survival rates at 1, 3, 5 and 10 years were 69%, 64%, 44% and 39%, respectively. Main indications for transplantation were cystic fibrosis and congenital heart disease with Eisenmenger syndrome. Other diagnoses were retransplantation, primary pulmonary hypertension and pulmonary fibrosis. The main causes of death were infection and chronic graft failure. Reduced-size transplantation was performed in 42% of double-lung transplantation (DLTx) patients without negatively impacting survival. Six patients received pulmonary retransplantation, 1 of whom died early. CONCLUSIONS: Pediatric transplantation is a feasible therapeutic option when undertaken by an experienced team. It should be offered to the small patient population suffering from end-stage pulmonary disease. The limited number of pediatric donor organs can be overcome by using reduced-size organs. However, the management of pediatric-specific complications and therapeutic requirements is essential for positive long-term results after LTx in these patients.

[Heart transplantation and assist devices]. / Herztransplantation und Assist Devices.

BACKGROUND: Although drug therapy of patients with chronic heart failure has improved significantly over the years, mortality still remains high. At present, heart transplantation is the gold standard therapy for patients with end stage heart disease. Due to the limited number of organs, a growing number of patients require the implantation of mechanical assist devices. HEART TRANSPLANTATION: Because of the excellent long-term survival after cardiac transplantation, current studies focus on long-term complications. The aim of these studies is the establishment of an immunosuppressive strategy that effectively prevents cardiac allograft vasculopathy in combination with a low incidence of negative side effects. Furthermore, quality of life is a major focus of current interest. ASSIST DEVICES: Assist device implantation has changed from an experimental to a routine procedure in several centers. Still, many problems have to be solved. Especially because of recurrent infections the long-time use of assist devices is limited. For final judgment, results of current studies have to be awaited.

Functional neointima characterization of vascular prostheses in human.

BACKGROUND: The purpose of this study was to evaluate neointimal functionality of synthetic vascular grafts repopulated by host cells after implantation. METHODS: We obtained reseeded inflow and outflow cannulas of 2 patients undergoing orthotopic heart transplantation after left ventricular assist device implantation 9 and 10 months before. After cell isolation we examined cellular function of reseeded cells and their capability to form a functional endothelial layer applying immunohistologic markers and quantitative Western blot for endothelial nitric oxide synthase activity. RESULTS: Neointima formation in inflow and outflow cannulas differs macroscopically and by histologic appearance. The neointima formation on the surface of the polyethylene terephthalate fiber (Dacron) grafts differs substantially from native aortic vessel wall with respect to cellular and extracellular matrix composition and cellular function. CONCLUSIONS: The neointima of Dacron prostheses is composed of cells with rudimentary physiologic endothelial function. We conclude that synthetic matrices are not suitable scaffolds for generating functional cardiovascular implants.

[Surgery in advanced heart failure]. / Chirurgie bei fortgeschrittener Herzinsuffizienz.

BACKGROUND: ACE inhibitors and beta blockers have reduced morbidity and mortality from chronic heart failure significantly during the last years. Apart from medical therapy several surgical strategies for the treatment of heart failure are available. PREREQUISITES OF SURGICAL TREATMENT: Surgical treatment should be directed towards the underlying etiology and mechanisms. To decide for a special surgical therapy indications and contraindications must be considered. SURGICAL PROCEDURES: The surgical therapy of heart failure can be performed with or without replacement of the heart. Especially concerning the organ-conserving techniques there has been significant progress during the last years: left ventricular aneurysmectomy, mitral valve surgery as well as high-risk coronary artery bypass surgery and electrostimulating procedures. Concerning heart replacement therapy, cardiac transplantation with a 10-year survival of 50% still remains superior to all available mechanical devices at the moment.