Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study.

BACKGROUND: The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. METHODS: A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. RESULTS: Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. CONCLUSION: In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry.

OBJECTIVES: Degeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration. METHODS: Data provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed. RESULTS: Between 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P < .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P < .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group. CONCLUSIONS: In both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

Endocarditis at a large community hospital with on-site cardiac surgery.

OBJECTIVE: Infective endocarditis (IE) is still a serious disease. The currently published EURO-ENDO registry showed a rate of surgery of 51.2% and a lower mortality in operated IE patients. We hypothesized differences between our data and the registry. METHODS: Retrospective single centre registry on the hospital course of patients with IE. RESULTS: In four years, 171 IE patients were treated at our hospital. Mean age of patients was 66.5 ± 13.8 years and 62.6% of patients were transferred from other hospitals. There were 85 (49.7%) patients with native valve IE (NVE), 53 (31%) with prosthetic valve IE (PVE) and 33 (19.3%) with either intra-cardiac device related IE (n = 29) or IE associated with central access lines (n = 4) (DRE). A total of 81.3% (n = 139) of patients were sent to cardiac surgery. Using a logistic regression model to analyse predictors of conservative instead of surgical therapy the only independent variables were: presence of large vegetation or abscesses (OR: 0.36, 95%CI 0.15-0.83; p = 0.016) and age (for each ten years) (OR: 1.61, 95%CI 1.11-2.32, p = 0.01). Hospital mortality was 21.6% (n = 37/171), with no difference (p = 0.97) between those who were operated (21.6%, n = 30/139) and those treated conservatively (21.9%, n = 7/32). Comparing those treated conservatively without an indication for surgery with those with an indication, mortality was 9.5% versus 45.5%, p = 0.02. CONCLUSIONS: In this registry from a hospital with on-site cardiac surgery more than half of patients were referred. The rate of patients treated surgically was 81.3%. Hospital mortality was 21.6%, with no difference between operated and conservatively treated patients.

Fibroelastoma Recurrence in Left Ventricle: Rarity of Primary Cardiac Tumor.

Cardiac papillary fibroelastoma (CPF) is a primary cardiac neoplasm usually detected by echocardiography. Left ventricular fibroelastomas are extremely rare. The incidence of CPF is between 0.0017 and 0.33% during autopsy studies. We report a 70-year-old man who had papillary fibroelastoma discovered and resected in 2005 that recurred in 2013. The tumor grew rapidly from 2013 to 2014. A bioprosthetic mitral valve was placed in 2014. Due to the location and nature of the recurrent tumor, mitral valve replacement was the treatment of choice to prevent a third recurrence of the fibroelastoma. The patient was discharged from the hospital on postoperative day 9.

Clinical impact of a new bioprosthetic aortic valve: the St. Jude Medical Trifecta™.

BACKGROUND: The St. Jude Medical (SJM) Trifecta™ aortic valve was designed to face common issues such as high transvalvular pressure gradients and low effective orifice areas (EOAs), which lead to prosthesis-patient mismatch after implanting small valve sizes. To reduce the obstruction of the left ventricular outflow tract, the Trifecta™ was designed as a stented valve for supraannular placement. The aim of this study was to evaluate the early hemodynamic performance of this new valve. METHODS: Between September 2010 and February 2013, 380 patients underwent an aortic valve replacement (AVR) using the SJM Trifecta™. Patients were subsequently followed up for two years and data records were analyzed retrospectively. Mean patient age was 73 years (range 33-93 years), 58% were male. The average mean preoperative pressure gradient was 45mmHg, with an EOA of 0,73cm2. The majority of patients (62%) were in NYHA class III. Indication for AVR was valve stenosis or insufficiency in 95%, presence of endocarditis caused the AVR in 5%. RESULTS: The 30-day-mortality was 4% (n=16; mean log EuroSCORE 20.9%), including two intraoperative non-valve-related cardiac deaths (0.52%) and one valve-related death due to lethal aortotomy bleedings (0.26%). 25 patients died during the follow-up period, 9 of them in a valve-related manner. At discharge, no valve thromboses or prosthesis failures could be identified. The average EOA and mean pressure gradient at discharge was 1.36cm2 and 11mmHg for 19mm valves and 2.1cm2 and 7mmHg for 25mm valves. CONCLUSIONS: The new SJM Trifecta™ demonstrates excellent early hemodynamics over all valve sizes. In particular, large EOAs and low gradients in small valves attest a satisfying outcome after implantation. Further data is needed to investigate the stableness of these results over long-term follow up.

Telemedicine-guided, very low-dose international normalized ratio self-control in patients with mechanical heart valve implants.

AIM: To study in patients performing international normalized ratio (INR) self-control the efficacy and safety of an INR target range of 1.6-2.1 for aortic valve replacement (AVR) and 2.0-2.5 for mitral valve replacement (MVR) or double valve replacement (DVR). METHODS AND RESULTS: In total, 1304 patients undergoing AVR, 189 undergoing MVR and 78 undergoing DVR were randomly assigned to low-dose INR self-control (LOW group) (INR target range, AVR: 1.8-2.8; MVR/DVR: 2.5-3.5) or very low-dose INR self-control once a week (VLO group) and twice a week (VLT group) (INR target range, AVR: 1.6-2.1; MVR/DVR: 2.0-2.5), with electronically guided transfer of INR values. We compared grade III complications (major bleeding and thrombotic events; primary end-points) and overall mortality (secondary end-point) across the three treatment groups. FINDINGS: Two-year freedom from bleedings in the LOW, VLO, and VLT groups was 96.3, 98.6, and 99.1%, respectively (P = 0.008). The corresponding values for thrombotic events were 99.0, 99.8, and 98.9%, respectively (P = 0.258). The risk-adjusted composite of grade III complications was in the per-protocol population (reference: LOW-dose group) as follows: hazard ratio = 0.307 (95% CI: 0.102-0.926; P = 0.036) for the VLO group and = 0.241 (95% CI: 0.070-0.836; P = 0.025) for the VLT group. The corresponding values of 2-year mortality were = 1.685 (95% CI: 0.473-5.996; P = 0.421) for the VLO group and = 4.70 (95% CI: 1.62-13.60; P = 0.004) for the VLT group. CONCLUSION: Telemedicine-guided very low-dose INR self-control is comparable with low-dose INR in thrombotic risk, and is superior in bleeding risk. Weekly testing is sufficient. Given the small number of MVR and DVR patients, results are only valid for AVR patients.

Objectifying acupuncture effects by lung function and numeric rating scale in patients undergoing heart surgery.

Rationale. Poststernotomy pain and impaired breathing are common clinical problems in early postoperative care following heart surgery. Insufficiently treated pain increases the risk of pulmonary complications. High-dose opioids are used for pain management, but they may cause side effects such as respiratory depression. Study Design. We performed a prospective, randomized, controlled, observer-blinded, three-armed clinical trial with 100 patients. Group 1 (n = 33) and Group 2 (n = 34) received one 20 min session of standardized acupuncture treatment with two different sets of acupoints. Group 3 (n = 33) served as standard analgesia control without additional intervention. Results. Primary endpoint analysis revealed a statistically significant analgesic effect for both acupuncture treatments. Group 1 showed a mean percentile pain reduction (PPR) of 18% (SD 19, P < 0.001). Group 2 yielded a mean PPR of 71% (SD 13, P < 0.001). In Group 1, acupuncture resulted in a mean forced vital capacity (FVC) increase of 30 cm(3) (SD 73) without statistical significance (P = 0.303). In Group 2, posttreatment FVC showed a significant increase of 306 cm(3) (SD 215, P < 0.001). Conclusion. Acupuncture revealed specific analgesic effects after sternotomy. Objective measurement of poststernotomy pain via lung function test was possible.

Preoperative hemostasis and its association with bleeding and blood component transfusion requirements in cardiopulmonary bypass surgery.

BACKGROUND: Variables of hemostasis before surgery might indicate an elevated risk of bleeding. We determined hemostasis tests and standardized bleeding history and their association with bleeding and transfusion requirements in cardiopulmonary bypass (CPB) surgery. STUDY DESIGN AND METHODS: In a prospective trial, variables from 104 patients were associated with postsurgical bleeding and with red blood cells (RBCs) and platelet concentrate (PC) transfusions. Variables included standardized bleeding history, prothrombin time (PT), fibrinogen, fibrin monomers, Factor VIII, von Willebrand factor (VWF), multiple electrode aggregation (MEA), and the day of aspirin or thienopyridine withdrawal before operation. RESULTS: Multiple linear regression revealed bleeding history score, ADP-induced MEA, CPB time, and hemoglobin (Hb) independently associated with postoperative bleeding and bleeding history, arachidonic acid (AA)-induced MEA, CPB time, and PT associated with RBC transfusions. The logistic regression model for the outcome of bleeding within 24 hours after operation indicated ADP-induced MEA, the day of aspirin withdrawal before operation, and CPB time as predictors. AA-induced MEA, CPB time, Hb, and PT were predictors of RBCs transfusion. ADP-induced MEA, the day of aspirin withdrawal, PT, and VWF were associated with PC transfusion. CONCLUSIONS: A standardized bleeding history may help to identify patients undergoing CPB surgery whose risk of bleeding is elevated. ADP-induced MEA appears to predict postoperative bleeding and PC transfusion requirements, while AA-induced MEA and preoperative Hb indicate the need for RBCs. The time of aspirin withdrawal before surgery influences perioperative blood loss and PC transfusion.

Efficacy and safety of very low-dose self-management of oral anticoagulation in patients with mechanical heart valve replacement.

BACKGROUND: Self-management improves oral anticoagulation control. Here we provide data of a preplanned interim analysis of very low-dose early self-controlled anticoagulation. METHODS: In a prospective, randomized, multicenter trial, 1,137 patients performed low-dose international normalized ratio (INR) self-management with a target INR range of 1.8. to 2.8 for aortic valve replacement recipients and 2.5 to 3.5 for mitral or double valve replacement recipients for the first six postoperative months. Thereafter, 379 patients continued to achieve the aforementioned INR target range (LOW group), whereas the INR target value was set at 2.0 (range, 1.6 to 2.1) for the remaining patients with aortic valve replacement and 2.3 (range, 2.0 to 2.5) for the remaining patients with mitral valve or double valve replacement. One half of this latter group had to check their INR values once a week (VL1 group) the other half twice a week (VL2 group). Patients were followed up for 24 months. RESULTS: Beyond study month six, the incidence of thromboembolic events that required hospital admission was 0.58%, 0.0%, and 0.58% in the LOW, VL1, and VL2 groups, respectively (p = 0.368). The incidence of bleeding events per patient-year was 1.16%, 1.07%, and 0.58% in the LOW, VL1, and VL2 groups, respectively (p = 0.665). Mortality rate did not differ among study groups. CONCLUSIONS: Data demonstrate the efficacy and safety of very low-dose INR self-management.

Negative pretransplant serostatus for Toxoplasma gondii is associated with impaired survival after heart transplantation.

Chronic Toxoplasma gondii infection is known to trigger potentially adverse immunoregulatory changes, but limited data exist on long-term implications for heart transplant (HTX) recipients. We evaluated the risk of all cause mortality regarding T. gondii serostatus prior to HTX. Pre-HTX T. gondii serostatus was obtained in 344 recipients and 294 donors. Mean age was 52.1 +/- 10.2 years and mean follow-up time after HTX was 5.7 (+/-5.5, median 3.5) years. All seronegative patients received prophylaxis with pyrimethamine/sulfomethoxazole or cotrimoxazol for 6 months after transplantation. Multivariate survival analysis adjusted for diabetes mellitus, pre-HTX renal function, recipient age, type of primary immunosuppression (i.e. HTX before 2001), cytomegalovirus (CMV) high-risk status, ischemic time, and number of treated rejection episodes was performed. Overall, 190 recipients (55.2% of total) were seronegative and 154 (44.8% of total) were seropositive for T. gondii prior to HTX. One hundred and fifty-two recipients died during follow-up (44.2% of total). Negative recipient Toxoplasma serostatus was associated with a significantly higher risk of all-cause mortality (P = 0.0213). Recipient T. gondii serostatus did not influence the number of cellular or humoral rejection episodes. Analyses of specific causes of death showed a trend toward a higher number of infection-related deaths in the seronegative subgroup (P = 0.13). No statistically significant effects of T. gondii donor/recipient seropairing, or seroconversion were observed. Negative preoperative serostatus for T. gondii in HTX recipients appears to be an independent risk factor associated with increased all-cause mortality. The cause of impaired survival in Toxoplasma seronegative recipients is currently unclear; possible explanations include an alteration of immune-reactivity/-regulation or adverse effects of prophylactic medication.

Deferoxamine, the newly developed iron chelator LK-614 and N-alpha-acetyl-histidine in myocardial protection.

During cold storage of donor hearts, reactive oxygen species produced by intracellular redox-active chelatable iron potentially alter myocardial function. To reduce this cold-induced injury we investigated the efficacy of two new modifications of the well established histidine-tryptophan-ketogluterate (HTK) solution (Custodiol) with the addition of N-alpha-acetyl-l-histidine and iron-chelators in a heterotopic rat heart transplantation model. The donor hearts were cardioplegically arrested with 20 ml cardioplegia and stored for 1 h. Then the hearts were anastomosed to the abdominal aorta and vena cava of the recipient (n=30). After 1 h reperfusion, myocardial function and energy charge potential were measured in three groups: HTK-1: addition of l-arginine and N-alpha-acetyl-l-histidine; HTK-2: addition of iron-chelators deferoxamine and LK-614; traditional HTK - control. After 1 h reperfusion, left ventricular systolic pressure (106+/-33 vs. 60+/-39, vs. 67+/-8 mmHg, P<0.05) and dP/dt minimal (-1388+/-627 vs. -660+/-446, vs. 871+/-188 mmHg/s, P<0.05) were significantly higher in the HTK-1 group. Energy charge potentials were not significantly different. This study showed that the novel modified HTK-1 solution improves myocardial contractility and relaxation after heart transplantation. Nevertheless, addition of the iron-chelators deferoxamine and LK-614 diminished these beneficial effects.

High prevalence of amyloid in 150 surgically removed heart valves--a comparison of histological and clinical data reveals a correlation to atheroinflammatory conditions.

INTRODUCTION: The prevalence, pathophysiology, and clinical indicators of valvular amyloid deposition have not been clarified yet. METHODS: One hundred fifty surgically resected heart valve specimens [67.4+/-1.0 years; aortic stenosis (AS), n=100; aortic regurgitation, n=19; mitral stenosis, n=7; mitral regurgitation, n=24] were qualitatively, semiquantitatively, and immunohistochemically analyzed and correlated with clinical data. RESULTS: Amyloid was found in 83/150 specimens with highest prevalence in AS (74/100), intermediate prevalence in mitral stenosis (2/7) and regurgitation (7/24), and lowest prevalence in aortic regurgitation (2/19). Severe and polymorphic amyloid deposits were almost exclusively found in AS (35/100). Filamentous cloudy amyloid patterns occurred with the same frequency in AS (29/100). A combination of both was found only in AS (n=7/100). By immunohistochemistry, none of the most common amyloid proteins was identified except for a weak staining by the apolipoprotein AI antibody, but more intense adjacent to amyloid deposits. Amyloid correlated with valvular thickening (P<.05), hyperlipidemia (P=.07), coronary artery disease (P=.084), and obesity (P=.082). CONCLUSIONS: Localized valvular amyloid is predominantly found in stenotic aortic valves. It appears to depend on atheroinflammatory conditions and high shear-stress hemodynamics. Further studies are needed to identify the underlying protein.

Heart rate reduction for 12 months with ivabradine reduces left ventricular mass in cardiac allograft recipients.

BACKGROUND: Graft denervation in heart transplant recipients causes sinus tachycardia, occasionally requiring pharmacologic heart rate reduction. Currently, no 12-month data regarding effects of the novel I(f) channel antagonist ivabradine on heart rate control, effects on left ventricular mass, tolerability, and safety are available in patients after heart transplantation (HTX). METHODS: Mean heart rate, left ventricular mass indexed (LVMI) to body surface area, tolerability, and safety of ivabradine therapy were evaluated at baseline and after 12 months in 30 HTX recipients with marked sinus tachycardia. RESULTS: In three patients (10.0% of total), ivabradine medication was discontinued. Further analysis was based on 27 patients with 12-month drug exposure. Mean patient age was 53.3+/-11.3 years, and mean time after HTX was 5.0+/-4.8 years. Mean ivabradine dose was 12.5 mg/day (+/-3.3 mg). Mean heart rate was reduced from 96.2+/-8.6 beats per minute (bpm) at baseline to 80.9+/-8.1 bpm at follow-up (P<0.0001). A statistically significant effect of heart rate reduction on LVMI was observed (104.3+/-22.7 g at baseline vs. 95.9+/-18.5 g at follow-up, P=0.04). No statistically significant changes in immunosuppressive drug dosage or blood levels were observed, except from a lower mycophenolate mofetil dose at follow-up (P=0.01). Safety laboratory values were unchanged. No phosphenes were observed. CONCLUSIONS: Heart rate reduction with ivabradine is effective and safe in heart transplant recipients. After 12 months, significant effects on LVMI were observed. Therefore, ivabradine may offer a beneficial effect on left ventricular remodelling in HTX patients.

Staged heart transplantation and chemotherapy as a treatment option in patients with severe cardiac light-chain amyloidosis.

AIMS: The prognosis of advanced cardiac light-chain amyloidosis is poor. Heart transplantation might enable causative therapy and ultimately improve prognosis. METHODS AND RESULTS: Nineteen patients with cardiac amyloidosis but no obvious involvement of other organs were scheduled for heart transplantation. Four to 6 months later, high-dose melphalan chemotherapy and autologous stem cell transplantation (HDM-ASCT) was planned in patients not in complete remission. Seven of nineteen patients died while waiting for heart transplantation. The remaining 12 patients (complete remission, n = 4) underwent surgery. Chemotherapy in patients not in complete remission consisted of HDM-ASCT (n = 5/12; subsequent complete remission, n = 2; partial remission, n = 3) or melphalan-prednisolone (partial remission, n = 1). Two of twelve patients were ineligible for any chemotherapy. Three of twelve patients died [423.5 (105-2131) days] from progressive disease, relapse, or sepsis. The 1- and 3-year survival rates were 83 and 83%, respectively, similar to those of patients undergoing heart transplantation for standard indications. Corresponding survival rates stratified by haematological response were 100 and 100% for complete remission (partial remission, 100 and 100%; progressive disease, 0 and 0%). CONCLUSION: Heart transplantation in advanced cardiac amyloidosis is a promising approach to interrupting the vicious circle of ineligibility for potential curative chemotherapeutic treatment and extremely poor prognosis of cardiac amyloidosis without chemotherapy. Highly urgent heart transplantation combined with subsequent HDM-ASCT appears to offer a successful treatment option to improve the poor outcome of cardiac amyloidosis. However, it should be restricted to highly selected patients in specialized centres.

Return to work after heart transplantation: discrepancy with subjective work ability.

BACKGROUND: This study evaluates the objective rate of return to work after heart transplantation (HTX) in comparison with the patients' subjective rating of their work ability and identifies predictors for return to work in a German heart transplant center. METHODS: A questionnaire covering demographics, clinical data, and professional aspects was sent to 200 heart transplant recipients at least 12 months after HTX. Participation was strictly anonymous enabling reliable results concerning subjective work ability. RESULTS: Response rate was 150 of 200 (75%). During the time after HTX, 45 of 150 (30.0%) patients had ever been in a job. Thirty-five of 95 (36.8%) patients of formal working age (<65 years) were employed after 12.6+/-1.9 months: 18 of 95 (18.9%) in full-time work, 9 of 95 (9.5%) in part-time work, and 6 of 95 (6.3%) in casual employment. Two of 95 (2.1%) patients worked as handicapped employees; only 1 of 95 (1.1%) patients was currently seeking work. Patients obtained financial benefits from their illness (n=54; 36%) or age-related annuity (n=8; 5.3%). Forty-two of 95 (44.2%) patients did not feel capable of working, three patients did not answer, and 50 of 95 patients (52.6%) felt fit for employment. Employment after HTX depended on age, duration of unemployment, diabetes mellitus, and financial need for paid employment. Financially independent patients (n=66) more often felt unable to work by subjective judgement (n=34/67; 50.7%) than patients who depended on paid employment (8/28; 28.6%; P<0.05). CONCLUSIONS: The rate of employment after HTX in Germany is significantly lower than the subjective perception of the individual ability to work; underscoring the importance of sociodemographic and psychologic aspects during rehabilitation of HTX recipients.

Who needs 'bridge' to transplantation in the presence of the Eurotransplant high-urgency heart transplantation program?

INTRODUCTION: The purposes of this study are to identify a patient cohort that would benefit from the use of mechanical circulatory support (MCS) in the presence of the Eurotransplant high-urgency (HU) program. METHODS: Sixty-five patients (heart transplantation (HTx) group, 77%) underwent heart transplantation and 17 patients (D group, 20%) died while on the HU waiting list. These 82 patients were included in this retrospective study. RESULTS: The mean waiting time on HU list was 18.3+/-17.7 days in HTx group and 12.5+/-9.4 days in D group (p=0.075). The average weekly allocation rate from the active HU list was 27.7%, and the mean weekly waiting-list mortality was 12.1%. The use of intra-aortic balloon pumping (p=0.005), mechanical ventilation (p=0.007), higher dose of dobutamine (0.005), lower serum level of sodium (p=0.046), and higher serum level of C reactive protein (CRP) (0.040) at the registration of HU listing were associated with waiting-time mortality, and the serum creatinine level more than 1.5mg/dl (p=0.007, odds ratio; 14.5, 95% CI; 2.1-102.0) and the serum CRP level more than 10mg/l (p=0.026, odds ratio; 6.3, 95%CI; 1.2-31.4) were identified as significant predictors. CONCLUSION: It would be appropriate that a patient who would not be able to tolerate one or two weeks waiting time to be considered as a candidate for MCS implantation in the presence of the HU program. The patient selection criteria for MCS implantation should include not only hemodynamic parameters, but also the aspect of a beginning multi-organ failure.

Epstein-Barr virus load in whole blood is associated with immunosuppression, but not with post-transplant lymphoproliferative disease in stable adult heart transplant patients.

Development of Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disease (PTLD) is a serious complication following heart transplantation (HTX). This study investigates EBV DNA load in adult heart transplant recipients, its association with immunosuppression, and its potential as a marker for development of PTLD. EBV DNA load was measured prospectively by quantitative real-time polymerase chain reaction (PCR) in 172 stable HTX patients. Sixty-seven patients (39.0% of total) had a positive EBV PCR at initial examination [median 4.9 (range 1.1-16.9) years post-HTX]. In follow-up testing of 67 positive patients 6 months later, 36 patients continued to have a positive EBV PCR. Overall incidence of EBV DNA was significantly associated with calcineurin inihibitors, azathioprine medication, and with the absence of mycophenolate mofetil (MMF) treatment. In patients with positive EBV DNA levels at initial examination and negative levels at retesting, cyclosporine A levels were found to be significantly higher at initial examination (148.4 +/- 70.2 vs. 119.6 +/- 53.5 ng/ml, P < 0.05). Three patients (1.7%, 3/172) were diagnosed with PTLD during the course of the study (mean follow up 4.0 years). EBV DNA viral load determination does not appear to be useful for risk prediction or early diagnosis of PTLD in adults after HTX, but an association of EBV DNA load with qualitative and quantitative immunosuppression is demonstrated.