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.

Resting hemodynamics after total versus standard orthotopic heart transplantation.

Total orthotopic heart transplantation (TOHT) requires longer surgery than standard orthotopic heart transplantation (SOHT), but offers normal anatomy and synchronous atrial contraction. We endeavored to test whether TOHT improves resting hemodynamics. We analyzed 60 patients with SOHT and 66 with TOHT transplanted between 12/89 and 7/94. Age, preoperative NYHA class, ejection fraction, and donor characteristics were similar. After applying exclusion criteria at 2 weeks postoperatively, 53 SOHT and 58 TOHT patients were accepted for further study. Right-heart hemodynamics were examined at 2 weeks and 6 months posttransplant. Despite a longer ischemic time (161 +/- 36 vs. 142 +/- 37 min, p = 0.004), cardiac output and index were higher in the TOHT group at 2 weeks (6.1 +/- 1.4 vs. 5.4 +/- 1.0 L/min, TOHT vs. SOHT, p = 0.01; and 3.3 +/- 0.7 vs. 2.9 +/- 0.6 L/min/m2, p = 0.005) but similar at 6 months (5.9 +/- 1.2 vs. 5.6 +/- 1.4 L/min; and 3.0 +/- 0.6 vs. 2.9 +/- 0.7 L/min/m2). Right-atrial pressure was lower with TOHT at both time points (7 +/- 4 vs. 9 +/- 4 mmHg, p = 0.02: and 5 +/- 2 vs. 7 +/- 3, p = 0.0006). Wedge pressure was similar at 2 weeks (12 +/- 5 vs. 13 +/- 5, p = 0.045). Heart rate (bpm) was higher at both time points with TOHT (84 +/- 10 vs. 75 +/- 12, p = 0.0003: and 90 +/- 12 vs. 82 +/- 9, p = 0.0006). Pulmonary vascular resistance was similar at both time points. Despite a longer ischemic time, total orthotopic heart transplantation does not impair postoperative cardiac function. There is an early improvement in cardiac output, a sustained higher heart rate reflecting preservation of donor sinus node function, and a lower right-atrial pressure.

Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation.

BACKGROUND: Careful donor and recipient selection are important factors for the success of heart transplantation. Currently, donors with a history of alcohol use are routinely accepted despite the potential deleterious effects of alcohol on the heart. METHODS: We examined the frequency of chronic alcohol use (> 2 ounces of pure alcohol daily for > or = 3 months) among organ donors and the outcome of the receipients after heart transplantation. Of 99 consecutive patients who underwent transplantation between December 1988 and August 1993 with an adequate donor history, 17 (17%) had a history of chronic alcohol use (alcohol group), and 82 (83%) did not (nonalcohol group). All recipients received triple-drug immunosuppression, and 10 to 14 days of OKT3. RESULTS: Survival rates at 1 and 2 years were significantly lower in the alcohol group (61% +/- 13% and 61$ +/- 13%) than in the nonalcohol group (95% +/- 3% and 91% +/-4%, p = 0.0001). Most deaths in the alcohol group occurred within 3 months after transplantation. The incidence of rejection episodes did not differ significantly. Fatal rejection occurred more frequently in the alcohol group and was associated with severe ventricular dysfunction before death. Cox multiple regression analysis identified donor alcohol use as an independent risk factor for death after heart transplantation. CONCLUSIONS: A substantial proportion (17%) of heart donors have a history of chronic alcohol use. The unfavorable early outcome of patients receiving hearts from alcoholic donors suggests the presence of a subclinical alcoholic cardiomyopathy before transplantation and poor tolerance of rejection episodes after transplantation. Larger prospective studies are needed to determine the mechanism of fatal rejection and whether such hearts can be used safely for transplantation.

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.

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.