An update on transplantation in the geriatric heart transplant patient.

Discussions of the ethics involved in allocating scarce resources often proceed without a grounding in factual experience. This study explored whether there was statistical evidence to support the use of set age limits in patient selection criteria for heart transplantation. Many transplant teams have selection criteria that include age limits, excluding patients more than 60 or 65 years of age from being considered as transplant candidates. The hypothesis was made that patients in the age bracket of 60-69 should have a comparable success rate with transplantation to that of younger recipients when selected by using the same medical and psychiatric criteria. Based on their clinical observations, the authors postulated that the elderly would report better quality of life postoperatively than younger control subjects.

Combined antiviral and immunoglobulin therapy as prophylaxis against cytomegalovirus infection after heart transplantation.

BACKGROUND: Cytomegalovirus is a frequent cause of infection and morbidity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%. METHODS: To determine the efficacy of combined antiviral and intravenous immune globulin therapy for prevention of cytomegalovirus disease in transplant recipients receiving OKT3 and to compare two different antiviral drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intravenous ganciclovir for 2 weeks followed by oral acyclovir up to 3 months (group G); all received six infusions of 5% intravenous immune globulin over 2 months. All patients had OKT3 for 10 to 14 days and triple-drug immunosuppression. RESULTS: Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patients (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositive recipients, there was a trend to less cytomegalovirus disease in group G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patients) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% (group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus disease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant). CONCLUSIONS: Prophylaxis with combined antiviral and immune globulin therapy produces a low (10%) incidence of cytomegalovirus disease in OKT3-treated heart transplant recipients. In seropositive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive prophylactic strategies are needed in seronegative patients who receive hearts from seropositive donors.

Atrial emptying with orthotopic heart transplantation using bicaval and pulmonary venous anastomoses: a magnetic resonance imaging study.

OBJECTIVES: We hypothesized that orthotopic heart transplantation with bicaval and pulmonary venous anastomoses preserves atrial contractility. BACKGROUND: The standard biatrial anastomotic technique of orthotopic heart transplantation causes impaired function and enlargement of the atria. Cine magnetic resonance imaging (MRI) allows assessment of atrial size and function. METHODS: We studied 16 patients who had undergone bicaval (n = 8) or biatrial (n = 8) orthotopic heart transplantation without evidence of rejection and a control group of 6 healthy volunteers. For all three groups, cine MRI was performed by combining coronal and axial gated spin echo and gradient echo cine sequences. Intracardiac volumes were calculated with the Simpson rule. Atrial emptying fraction was defined as the difference between atrial diastolic and systolic volumes, divided by atrial diastolic volume, expressed in percent. All patients had right heart catheterization. RESULTS: Right atrial emptying fraction was significantly higher in the bicaval (mean [+/- SD] 37 +/- 9%) than in the biatrial group (22 +/- 11%, p < 0.05) and similar to that in the control group (48 +/- 4%). Left atrial emptying fraction was significantly higher in the bicaval (30 +/- 5%) than in the biatrial group (15 +/- 4%, p < 0.05) and significantly lower in both transplant groups than in the control group (47 +/- 5%, p < 0.05). The left atrium was larger in the biatrial than in the control group (p < 0.05). Cardiac index, stroke index, heart rate and blood pressure were similar in the transplant groups. CONCLUSIONS: Left and right atrial emptying fractions are significantly depressed with the biatrial technique and markedly improved with the bicaval technique of orthotopic heart transplantation. The beneficial effects of the latter technique on atrial function could improve allograft exercise performance.

Clinical-pathologic features of humoral rejection in cardiac allografts: a study in 81 consecutive patients.

BACKGROUND: Humoral rejection is an infrequently reported, poorly understood form of cardiac allograft rejection. METHODS: We reviewed 81 consecutive heart transplant recipients followed up to 3 years after transplantation to evaluate the frequency and significance of humoral rejection in this population. Histologic features evaluated included capillary endothelial cell swelling, interstitial edema and hemorrhage, and neutrophilic infiltration. Immunofluorescence studies with antibodies to immunoglobulin G, immunoglobulin A, immunoglobulin M, Clq, C'3, HLA-DR, and fibrinogen and immunoperoxidase staining for endothelial cells (factor VIII-related antigen) and macrophages (KP1 [CD68]) were performed. Minimal criteria for the diagnosis of humoral rejection were capillary endothelial cell swelling and any immunoglobulin and complement staining in capillaries. Findings were graded and compared with concurrent hemodynamic measurements. RESULTS: Immunoperoxidase staining showed that most swollen cells in capillaries were macrophages and fewer were endothelial cells. Humoral rejection was detected in 102 biopsy specimens from 42 patients (52%), within 3 weeks of transplantation in 28, and 3 weeks to 4 months later in the other 14 patients. One patient had evidence of humoral rejection almost 3 years after transplantation. A third of biopsy specimens with humoral rejection were associated with abnormal hemodynamics; of these 33 specimens only five had significant (grade 3 or 4) coexisting cellular rejection. Histologic findings most often associated with hemodynamic abnormalities were diffuse capillary endothelial cell swelling and any interstitial hemorrhage or edema. Three patients died of humoral rejection; only 1 had coexisting cellular rejection (grade 3A). CONCLUSIONS: In our experience humoral rejection (1) is not uncommon (52% of patients), (2) is often (33% of cases) associated with hemodynamic abnormalities, and (3) may be fatal.

Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses.

We present our experience with an alternative technique for orthotopic heart transplantation. It consists of total excision of the recipient's atria, with the donor's heart implantation performed using bicaval end-to-end anastomoses as well as pulmonary venous anastomoses. Forty consecutive patients receiving transplants in this fashion were compared with 64 patients who underwent orthotopic transplantation with the standard technique. The incidence of postoperative tricuspid regurgitation was reduced in patients receiving transplants with the new surgical approach (p = 0.003). In addition, the need for pacemaker implantation for severe bradyarrhythmia in the early (0 to 6 weeks) posttransplantation period (p = 0.003) was eliminated. Although not statistically significant, there was a trend in the reduction of postoperative mitral regurgitation in patients who received transplants by the modified technique. Based on this experience, we believe this modified technique for orthotopic heart transplantation has an anatomic and physiologic advantage that may improve long-term hemodynamic results.

Grade 2 cellular heart rejection: does it exist?

According to the International Society for Heart and Lung Transplantation, a single focus of lymphocytic infiltration associated with myocyte injury in a cardiac allograft endomyocardial biopsy is focal moderate cellular rejection (Grade 2). We reviewed 115 endomyocardial biopsy specimens that were completely negative (n = 17), had a Quilty A (n = 17) or Quilty B (n = 46) lesion, or had a lesion fulfilling the criteria of grade 2 rejection (n = 35). By studying step sections (mean = 18) or sections stained for elastic tissue and collagen, we showed continuity of the focus of grade 2 rejection with the endocardium in 32 of 35 cases; these results justify reclassification of these foci as Quilty B lesions, which are defined as endocardial infiltrates that encroach on the underlying myocardium and that may be associated with myocyte injury but are not generally considered to represent acute rejection. Immunohistochemical staining for T and B lymphocytes and histiocytes showed similar patterns in deeper zones of Quilty B lesions and lesions initially regarded as grade 2 rejection. Normal hemodynamics were observed with 16 of 17 completely negative biopsy specimens, 16 of 17 Quilty A biopsy specimens, 46 of 46 Quilty B biopsy specimens, and 35 of 35 grade 2 rejection biopsy specimens. No grade 2 rejection was treated; only 1 biopsy specimen progressed to grade 3A rejection in a subsequent biopsy 2 months later. Most, if not all, cases of grade 2 cellular rejection can be shown to be Quilty B lesions, are not associated with hemodynamic abnormalities, and do not require augmented immunosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Donors with a history of cocaine use: effect on survival and rejection frequency after heart transplantation.

The frequency of cocaine use among donors is currently unknown. Cocaine has cardiotoxic effects and could affect the outcome of heart transplantation. To examine the frequency of nonintravenous cocaine use in organ donors and the outcome of heart transplantation with such donors, we retrospectively analyzed the clinical, biopsy, and donor information on 112 consecutive patients who underwent transplantation between December 1988 and August 1993. Ten patients were excluded because of incomplete information regarding the donor's cocaine status. Of the remaining 102 patients, 16 (16%) had a positive donor history for nonintravenous cocaine use (cocaine group) and 86 patients (84%) had a negative history (noncocaine group). Survival, frequency of cellular rejection (grade > or = 1B), and humoral rejection were compared between the two groups. Survival rates at 30 days (100% versus 97% +/- 2%) and at 1 year (93 +/- 7% versus 89 +/- 3%) were similar (p = not significant, cocaine versus noncocaine group). Freedom from rejection was similar at 30 days (81% +/- 10% versus 79% +/- 4% cellular rejection-free, 33% +/- 14% versus 60% +/- 6% humoral-free) and 6 months (34% +/- 12% versus 55% +/- 5% cellular-free, 16% +/- 11% versus 36% +/- 6% humoral-free) (p = not significant). No significant difference was found in donor inotropic support before procurement, ischemic time, length of stay in intensive care unit, or total stay in the hospital. In conclusion, a high incidence of nonintravenous cocaine use exists among donors. The outcome of patients who receive transplanted hearts obtained from nonintravenous cocaine users is favorable, suggesting that the use of such hearts is safe.

Combined heart and kidney transplantation with allografts from the same donor.

We present the cases of 3 patients who underwent simultaneous heart and kidney transplantation using allografts from the same donor. This combined approach offers a reasonable option for patients with coexisting end-stage heart and kidney disease. A review of all previously reported cases suggests that survival is similar to that of single-organ transplantation. In addition, there appears to be a low incidence of rejection when multiple allografts from the same donor are used. The heart and kidney can and frequently do reject asynchronously, so rejection monitoring and surveillance should be carried out separately for each transplanted organ.