Symptom distress in cardiac transplant candidates.

OBJECTIVE: To examine symptom frequency and distress in heart transplant candidates. DESIGN: Prospective, two-site study with a correlational design. SETTING: Large Midwestern and large Southern medical center. SAMPLE: Convenience sample of 175 adult patients (mean age 52 years, 85% men) awaiting heart transplantation. Fifty percent of the patients had ischemic cardiomyopathy and 47% had dilated cardiomyopathy. INSTRUMENTS: The Heart Transplant Symptom Checklist (Grady, Jalowiec, & Grusk, 1988), a 92-item self-administered instrument that measures how much patients are bothered by symptoms on a four-point rating scale, was developed by the research team for the study. Cronbach alpha reliability for the total scale was 0.95. RESULTS: The most frequent and distressing symptoms for patients awaiting heart transplantation were tiredness, difficulty breathing when walking or doing something, difficulty sleeping, and weakness in the whole body. Patients who had more symptom distress were unable to work. Higher symptom distress correlated significantly with higher stress, less life satisfaction, lower quality of life, and more functional disability. SUMMARY: Heart transplant candidates experience symptoms that may affect their ability to work and are associated with more functional disability and lower quality of life. IMPLICATIONS: Identification of the most frequent and distressing symptoms helps nurses and other health care providers to better assess and intervene with patients who are heart transplant candidates.

Oversizing of donor hearts: beneficial or detrimental?

To determine the effects of donor/recipient weight mismatch on allograft function and survival after orthotopic heart transplantation, we retrospectively compared the clinical and the hemodynamic characteristics of recipients weighing more than their donor ("undersized") with those of recipients weighing less than their donor ("oversized"). The median follow-up period was 24 months (range, 0 to 67 months). In 88 patients (59%) donor weight was 1% to 46% less than recipient weight (13.5 +/- 8.9 means +/- SD). In 61 patients (41%) donor weight exceeded recipient weight by 0% to 139% (20% +/- 23%). When recipient ideal body weight was used in the analysis, 75 patients (51%) were undersized by 1% to 59% (13% +/- 10%), and 72 patients (49%) were oversized by 0% to 67% (19% +/- 18%). Preoperative transpulmonary gradient, ventricular function, and exercise tolerance were similar in the two groups. The number and severity of episodes of rejection and infection after transplantation were also similar in the two groups 1, 6, and 12 months after transplantation. When recipient ideal weight was used in the analysis, right ventricular (RV) and left ventricular (LV) ejection fractions (EFs) were within normal limits (RVEF greater than 40%; LVEF greater than or equal to 45%) and similar in the two groups. When recipient actual weight was used in the analysis, the LVEF measured at 12 months after heart transplantation was higher in the oversized than in the undersized group (52 +/- 11 vs 46 +/- 10; p less than 0.05). Postoperative hemodynamic values and exercise tolerance were similar in the two groups regardless of whether recipient weight or ideal body weight were used in the analysis. Forty-six recipients died 0 to 46 months (median, 7 months) after orthotopic heart transplantation. In a Cox regression model, recipients with donor weight greater than recipient ideal weight had a significantly greater risk of death within the follow-up period than did recipients with donor weight less than recipient ideal weight (relative risk = 2.19; p less than 0.05). When percent donor weight/recipient ideal weight mismatch was used as a continuous variable, donor heart oversizing was negatively related to survival, independent of preoperative transpulmonary gradient values (p less than 0.05). In contrast to common belief, oversizing of donor hearts does not improve the outcome of orthotopic heart transplant recipients who have reversible preoperative pulmonary hypertension. Acceptance of undersized donor hearts is not detrimental to allograft function and recipient survival. Use of undersized donor hearts may maximize the use of critically scarce donor organs.

Predictors of hospital length of stay after heart transplantation.

Factors that predict hospital length of stay after heart transplantation were identified from retrospective data of 65 patients (82% male, mean age, 43.3 years). Multiple regression analysis with a stepwise procedure was used to generate three predictive models for length of stay: (1) a model to be used before operation, (2) a model that combines preoperative and donor information, and (3) a model that takes preoperative, donor, and postoperative factors (complete model) into consideration. Hospital length of stay ranged from 15 to 45 days after heart transplantation (median length of stay, 22.5 days; mean length of stay, 24.4 +/- 6.4 days). In the preoperative model, diagnosis, duration of cardiac symptoms, severity of heart failure, and pulmonary vascular resistance were significantly related to length of stay and together accounted for 36% of the variance in length of stay. When donor information (for example, size and ischemic time) was added to preoperative information, the resultant model failed to account for appreciably more of the variance in length of stay. A model that considered preoperative, donor, and postoperative factors accounted for 71% of the variance in length of stay. Significant variables in the model were the month in which the patient had transplantation in the program, duration of cardiac symptoms before transplantation, preoperative severity of heart failure, pulmonary vascular resistance, and postoperative incidence of severe acute rejection. Patient age, sex, and postoperative infections were not related to length of stay. In conclusion, there are cardiopulmonary and immunologic factors that can predict length of stay. The model also suggests that a program's experience with heart transplantation affects length of stay.

Reversal of recalcitrant cardiac allograft rejection with methotrexate.

Refractory cardiac transplant rejection is a major therapeutic dilemma. The effectiveness of methotrexate (MTX) in autoimmune diseases prompted us to explore its efficacy in 10 cardiac transplant recipients, aged 20-53 years (39 +/- 13 years; mean +/- SD), with biopsy evidence of drug-refractory cardiac allograft rejection. Nine cardiac transplant recipients were maintained on triple antirejection therapy (cyclosporine, azathioprine, and prednisone), and the remaining recipient was maintained on cyclosporine and prednisone. Rejection episodes treated with MTX occurred 20-422 days (165 +/- 137 days) after transplantation and were the sixth episode of rejection for one recipient, the third for four recipients, the second for four recipients, and the first for one recipient. Before MTX administration, cardiac allograft rejection persisted despite intensified immunosuppression including OKT3 antibody. MTX, given intravenously, orally, or by both routes at a dose of 10-175 mg (85 +/- 62 mg), reversed rejection in nine of 10 recipients (90%) within 7-63 days (26 +/- 18 days). Elevated pulmonary artery wedge pressures were reduced to normal levels after MTX therapy (15.2 +/- 3.5 before vs. 10.6 +/- 3.0 mm Hg after; p less than 0.05). Leukopenia occurred in five cardiac transplant recipients after treatment with MTX. Adverse reactions to MTX resolved after MTX therapy was discontinued in all but one recipient. This recipient received one of the larger MTX doses (150 mg) and developed fatal Pseudomonas pneumonia. Twelve moderate rejection episodes recurred in nine recipients, seven episodes of which were successfully re-treated with MTX. Two of these seven recipients have now been rejection-free for 15 months. Of five recurrent episodes of cardiac transplant rejection not treated with MTX, two could not be reversed and were fatal. MTX may be a valuable drug for reversing refractory cardiac allograft rejection. Before MTX therapy gains wider use, however, a clearer understanding of its enhanced ability to suppress the bone marrow is needed.