Health insurance as a requirement to undergo cardiac transplantation: a national survey of transplant program practices.

BACKGROUND: Recent limitations in Medicaid coverage of transplantation in Arizona jeopardized transplantation of potential recipients in that state and called attention to financial barriers inherent in the present organ allocation system. Policies of cardiac transplant centers regarding insurance requirements for transplantation have not been previously assessed. We sought to determine the policies of adult cardiac transplant programs nationwide regarding insurance requirements for evaluation and listing for cardiac transplantation. METHODS: From December 15, 2008 to November 16, 2010, all active adult cardiac transplant programs in the United States were surveyed regarding insurance requirements for evaluation and listing for cardiac transplantation. RESULTS: Surveys were completed by 62 of 101 programs, accounting for 71% of adult cardiac transplants in 2007. Only 2% of recipients were uninsured. Insurance was required by 48% of programs to evaluate and 84% to list for transplantation. For uninsured patients, 81% of programs required a large amount of money upfront (median, $200,000; interquartile range, $10,000-$300,000) to list for transplantation and often (84%) educated patients about fundraising to acquire these resources. CONCLUSIONS: Adult cardiac transplant programs generally require candidates to have adequate health insurance to undergo transplantation. Uninsured patients typically need a significant amount of money upfront to be listed for transplantation and often are advised to fundraise to gather such resources.

Respiratory syncytial virus pneumonia treated with lower-dose palivizumab in a heart transplant recipient.

Respiratory syncytial virus (RSV) is an important community-acquired pathogen that can cause significant morbidity and mortality in patients who have compromised pulmonary function, are elderly, or are immunosuppressed. This paper describes a 70-year-old man with a remote history of heart transplantation who presented with signs and symptoms of pneumonia. Chest computed tomography (CT) imaging demonstrated new patchy ground glass infiltrates throughout the upper and lower lobes of the left lung, and the RSV direct fluorescence antibody (DFA) was positive. The patient received aerosolized ribavirin, one dose of intravenous immunoglobulin, and one dose of palivizumab. After two months of followup, the patient had improved infiltrates on chest CT, improved pulmonary function testing, and no evidence of graft rejection or dysfunction. There are few data on RSV infections in heart transplant patients, but this case highlights the importance of considering this potentially serious infection and introduces a novel method of treatment.

Successful use of the TandemHeart percutaneous ventricular assist device as a bridge to recovery for acute cellular rejection in a cardiac transplant patient.

In this report, we presented a patient who benefited from hemodynamic support with the TandemHeart percutaneous ventricular assist device (pVAD; Cardiac Assist, Inc) implantation in the setting of early acute graft rejection 2 months after orthotopic heart transplant. The TandemHeart initially had been used for temporary hemodynamic assistance during postcardiotomy heart failure and high-risk coronary interventions. More recently, its use in patients with cardiogenic shock from acute myocardial infarction, fulminant myocarditis, and critical aortic stenosis has been reported. To our knowledge, this is one of the first reported cases in which the TandemHeart pVAD served as a successful device for support during acute cardiac transplant rejection.

Interventional radiologic treatment of complications following gastric bypass surgery for morbid obesity.

Complications of gastric bypass surgery include leakage from the gastrojejunal anastomosis with abscess formation and anastomotic stenosis. Using interventional radiologic techniques, we have treated 18 patients with such complications following surgery for morbid obesity, with clinical success in 11. Procedures included 9 abdominal abscess drainages and 7 balloon dilatations of stenotic or occluded gastrojejunal anastomoses. Eight of 9 abscesses resolved completely; 3 of 7 balloon dilatations resulted in long-term clinical improvement. We describe the techniques used as well as problems encountered in these patients.

Percutaneous transluminal angioplasty of subclavian arteries.

The clinical records and procedural details of 30 subclavian angioplasty procedures attempted in 27 patients were reviewed. Long-term follow-up was obtained through referring physician records and direct telephone contact with the patients. Eight patients presented with neurologic symptoms only, six had arm claudication only, nine had both neurologic and arm symptoms, three underwent dilations to provide graft inflow, and one was asymptomatic. Procedural complications included a stroke in the contralateral carotid distribution, occurring during follow-up arch aortography, and an embolus in the fifth digit of the left hand, which was of no clinical significance. Long-term success did not correlate well with degree of stenosis, lesion length, or postangioplasty appearance. The patients with arm and neurologic symptoms who were followed up for 3 years experienced immediate relief and remained symptom free or improved, except for the patient who suffered the stroke and one patient with labyrinthitis.

Coiled-spring sign of appendiceal intussusception.

Appendiceal intussusception has been considered a rare entity that is difficult to diagnose radiographically. However, a characteristic coiled-spring appearance in the cecum with nonfilling of the appendix has been observed on double-contrast barium enema (DCE) examinations in 11 cases of apparent or proved appendiceal intussusception. In two surgically proved cases, the intussusception was precipitated by an appendiceal mucocele and by endometriosis implants in the appendix. In four other cases, the intussusception was transient and the coiled-spring defect in the cecum disappeared with filling of the appendix on the DCE examination (three cases) or on a subsequent barium enema study (one case). The remaining five cases were unproved, although two patients had undergone prior appendectomy and the coiled-spring finding presumably resulted from an intussuscepted appendiceal stump. Only one patient was found to have appendiceal-related symptoms. It appears that appendiceal intussusception often occurs as a transient phenomenon in asymptomatic patients, and that it can be diagnosed on the routine DCE examination by a characteristic coiled-spring defect in the cecum.

Glk: a locus controlling galactokinase activity in the mouse.

Inbred strains of mice exhibited significant variation in whole blood galactokinase (GALK) activity. Activities tend to cluster into two classes, one class having approximately twice the activity of the other. Hybrids (F1) between "high" and "low" strains have activity intermediate between the parental activities. Two sets of recombinant inbred (RI) lines were developed by brother-sister mating, beginning with F2 generations of crosses between different pairs of high and low GALK activity strains. The RI lines segregated in terms of GALK activity, indicating single gene inheritance; this galactokinase locus has been designated Glk. The strain distribution patterns of both RI series agreed closely with esterase-3 (Es-3) alleles of the respective parental strains (31/34 independently derived strains were concordant for Es-3 and Glk genotypes), a finding consistent with a map distance between loci of 2.5 cM. Es-3 has been located on the distal end of chromosome 11. Glk, with its alleles Glka (lower activity) and Glkb (higher activity), is therefore assigned to the same region.