Outcome following heart transplantation in Maori and Polynesian patients: a comparison with European New Zealanders.

AIM: To compare demographic, clinical and outcome data of Maori and Polynesian with New Zealand European heart transplant patients. METHODS: A retrospective analysis was made of data from the 104 patients who underwent heart transplantation at Green Lane Hospital over a period of twelve years, of whom 79 were European, 23 Maori/Polynesian, and two Asian. Clinical characteristics, blood group, HLA matching and outcomes of recipients were compared. RESULTS: There was no significant difference in age and gender between the two groups. Maori and Polynesian patients were heavier, had a greater body mass index and were more likely to have rheumatic heart disease than their European counterparts. Maori/Polynesian patients were predominantly blood group A, whilst European patients were mainly group O. The waiting time for a donor heart was similar in both groups. There was no significant difference in number of rejection episodes and survival. CONCLUSIONS: Green Lane Hospital has the largest international experience of heart transplantation in Maori and Polynesian patients. Although there are some differences in clinical profile, outcome in terms of rejection episodes and survival is similar in the two groups.

Blunt chest trauma and the heart.

The Green Lane Hospital experience of patients presenting with cardiac damage as a result of chest trauma has been reviewed following the recent referral of a patient with tricuspid regurgitation due to trauma. A retrospective search of surgical records was made over the preceding 28 years which yielded a further nine patients. Our group has experienced a number of unusual causes of non-fatal cardiac trauma that have followed accidents. In nine out of ten cases closed chest injury resulted in damage to the heart. In some, diagnosis had been delayed for years. Echocardiography is a very useful diagnostic tool. Surgery was undertaken in all cases.

Cardiac allograft vasculopathy: the green lane hospital experience 1987-1998.

AIMS: To determine the prevalence of cardiac allograft vasculopathy in heart transplant recipients at Green Lane Hospital and to examine potential risk factors for vasculopathy. METHODS: We retrospectively reviewed the coronary angiograms of all cardiac transplant recipients. Angiography was usually performed one, two and five years after operation. The diagnosis of allograft vasculopathy was made if there was any evidence of coronary artery disease. Patients' medical records were reviewed for potential risk factors. RESULTS: Ninety-one patients underwent cardiac transplantation between December 1987 and March 1998. One year survival was 87%. Angiographic evidence of coronary disease was present in 30 patients and in three patients coronary lesions were first identified at post mortem. Vasculopathy was present in 25%, 35% and 61% of patients at one two and five years following transplant. Donor-acquired lesions could not be excluded as few patients had immediate postoperative angiograms for comparison. Five late deaths have been due to vasculopathy. Recipient age, race, donor age and ischaemic time were similar for those with and without vasculopathy. Frequency or severity of acute rejection episodes, cytomegalovirus infection, lipid profiles, diabetes and hypertension were not significantly different in patients with vasculopathy. CONCLUSION: Cardiac allograft vasculopathy is a common finding after heart transplantation. No definite risk factors were identified in this patient group.

Heart donation: the New Zealand experience, 1987-1996.

AIMS: To audit all donor hearts offered to our unit, assess the outcome, identify factors which might enhance the acceptance rate and provide data on which to base and modify acceptance criteria. METHODS: Demographic, clinical and outcome data were collected retrospectively and analysed for all patients in whom brain death had been established and permission for organ donation obtained from the family prior to referral to the transplant donor coordinator. RESULTS: Over a nine year period (1987-96) 267 hearts were offered for transplantation. The mean donor age was 31.2 years (2-72), 163 being male and 104 female. The cause of death was secondary to trauma in 52%, neurological in 44% and due to hypoxia in 4%. The mean donor weight was 68 kg and the distribution of ABO blood group similar to the New Zealand population. Seventy-six hearts (28%) were implanted. Of the 191 not implanted no suitable recipient was available for 98 (51%) according to blood group and body weight criteria, 38 donors (20%) were medically unsuitable, 37 (19%) were declined because of donor age, 16 (8%) because of a markedly abnormal echocardiogram and 2 (1%) for logistical reasons. CONCLUSIONS: Enhanced efforts are needed to increase public awareness of the benefits of organ donation. However, a greater number of heart transplants may be achieved by increasing the recipient pool.

Cardiac transplantation in New Zealand: eight years experience.

Between December 1987 and December 1995, 62 patients underwent orthotopic cardiac transplantation at Green Lane Hospital. Their cardiac dysfunction resulted from dilated cardiomyopathy (32), coronary artery disease (21), rheumatic heart disease (7), congenitally corrected transposition of the great arteries (1) and hypertrophic cardiomyopathy (1). Before transplantation all patients were in New York Heart Association (NYHA) functional class III or IV. Eight patients (13%) died in the perioperative period and a further seven (11%) died 1 to 4 years after transplantation. Actuarial 1 and 3 year survival was 87% and 80% respectively. Forty-five of forty-seven surviving patients were in NYHA functional class I at the time of analysis. The results confirm that cardiac transplantation has a limited but valuable role in the treatment of end stage myocardial dysfunction.

Waiting lists for coronary artery surgery: can they be better organised?

AIM: To determine whether a numerical ranking system can provide an equitable basis for prioritising patients awaiting coronary artery bypass grafting. METHODS: A review of the current coronary surgery waiting list was undertaken using a newly developed scoring system. The factors included in the score were age, symptoms, results of exercise testing, coronary anatomy, employment status and perceived surgical risk. This score was compared with a Canadian consensus system. Rankings were then compared with the clinical priorities given by clinicians when the patients were placed on the waiting list. RESULTS: There was excellent correlation between the two priority ranking systems using only those items included in the Canadian system (r = 0.9179). However, correlation between the Canadian system and the full Green Lane Hospital (GLH) scoring system was weaker (r = 0.6869). The Canadian system assigned higher surgical priorities than Auckland clinicians. Comparison between the GLH system and clinical priority gradings (O, urgent out of hospital), (A) and (B) showed considerable scatter. Waiting times for these three categories considered acceptable by the Canadian consensus group were two to six weeks for priority (O), six weeks to three months for priority (A) and three to six months for priority (B). The mean times on the waiting list for the 260 patients still awaiting surgery at GLH were two months for (O), 11 months for (A) and 22 months for (B). CONCLUSIONS: The Canadian and expanded GLH ranking systems are no more than aids to establishing priorities. They cannot replace clinical judgement because the importance of individual scoring items is heavily influenced by the ranking of other items. Waiting times for surgery are now grossly excessive despite the use of criteria for entry to the waiting list which are very conservative by international standards. There is no equitable or clinically acceptable way to modify priorities to reduce waiting times, and institution of a booking system is impractical.

Survival after heart transplantation without regular immunosuppression.

The case of a young woman who discontinued regular immunosuppression 4 years after heart transplantation is described. A year later she became unwell and explained her actions. A cardiac biopsy showed changes of focal moderate rejection, which responded to treatment, and she is presently in good health.

Coronary artery surgery in the elderly: long-term follow-up.

BACKGROUND: There has been controversy concerning the indications for coronary artery surgery in the elderly, particularly in countries where health resources are restricted. AIMS: To assess the results of coronary artery bypass grafting (CABG) in a large group of elderly subjects with regard to initial risks and long term follow-up. METHODS: Ninety-six consecutive patients aged 70 years or older underwent isolated CABG between January 1981 and December 1985. Long term follow-up was obtained in 94 (98%). RESULTS: The mean age was 71.6 years (70-78) and mean duration of follow-up 73 months. Seventy (73%) were male. In 80 cases the myocardial score was > 10. In 22 of 90 who had left ventricular angiography the ejection fraction was < 50%. Hospital survival was 96% and the five year survival 77%. It was not influenced by gender, myocardial score, ejection fraction or age at the time of operation. The status of survivors was reviewed in 1991. Of the 55 long term survivors 35 (64%) were free of angina. Eight (15%) and ten (18%) were in the Canadian Cardiovascular Society Angina classes 1 and 2 respectively. Seventeen patients (31%) had symptoms of heart failure with 14 (25%) in NYHA class 2 and 3 (5%) in class 3. Eight patients (15%) had survived a cerebrovascular event during follow-up. There were 35 late deaths (37%). Sixteen of these were cardiac, 18 due to other causes and one unknown.

Aortic valve replacement in the elderly.

Aortic valve replacement is an established mode of therapy that enhances and prolongs life in patients with significant aortic valve disease. This is true for the elderly, but with a higher reported mortality and morbidity than in younger patients. One hundred and eighty-three elderly patients aged 70 years and over were considered suitable candidates for isolated aortic valve replacement (n = 97) or aortic valve replacement combined with coronary artery bypass surgery (n = 86) in the decade 1980-89. The mean age at surgery was 73.2 years (70-80). The hospital mortality and morbidity of this group were compared to 340 consecutive patients aged 60-69 who underwent similar surgery over the same period. There was no significant difference in hospital mortality: 4.4% for elderly patients and 4.1% for those aged 60-69. Measures of hospital morbidity were similar except for the perioperative stroke rate, which was 4.4% in the elderly patients and 1.5% in the younger group (p < 0.05). Detailed long term follow up was obtained in 75 of the 76 elderly patients who underwent aortic valve replacement or aortic valve replacement combined with coronary artery bypass surgery in the first five year period. Hospital survival was 99% (one hospital death). The overall five year actuarial survival was 81% and greater than the age and sexmatched general population (73%). Of the 44 patients alive at the time of review, 35 (80%) were free of angina and 32 (73%) had no significant symptoms of heart failure. Additionally, these patients were questioned about their quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of dipyridamole in addition to low dose aspirin in the prevention of occlusion of coronary artery bypass grafts.

One hundred and one subjects were randomised to receive either aspirin 100 mg or aspirin 100 mg + dipyridamole 300 mg daily before undergoing coronary bypass surgery. The drugs were commenced at least 36 hours before operation and patients were followed for one year. There were three perioperative deaths and 37 withdrawals, of which 14 were drug related (aspirin four, aspirin + dipyridamole ten). Cineangiocardiograms at nine weeks and one year showed vein graft patency rates of 93% and 87% for subjects treated with aspirin alone; and 90% and 89% in those who received aspirin+dipyridamole. During the follow-up period 14% of 232 coronary lesions in the aspirin treated group advanced by more than two grades compared with 15% of 315 lesions in the aspirin+dipyridamole group. The study did not establish superiority of one regimen over another in terms of graft patency or progress of lesions in native vessels. However, low dose aspirin was better tolerated than combination therapy.

Cardiac transplantation in New Zealand: an initial report.

During the first 18 months of its establishment, the cardiac transplant unit at Green Lane Hospital has undertaken 10 transplant operations. Fifty potential recipients have been referred and 15 were accepted for transplantation. Of the ten who have had surgery, 2 are making good progress at school, 1 is active at home and 5 have returned to work. Two patients have died.

The results of surgical treatment of left ventricular aneurysms. An assessment of the risk factors affecting early and late mortality.

The surgical results of left ventricular aneurysmectomy have been examined in 145 patients during a 13 year period. In 113 patients (78%) coronary artery bypass grafting (CABG) was also undertaken. There were 22 hospital deaths (15%) and 44 late deaths (30%). Stepwise, multiple regression analyses were used to examine many variables and to establish risk factors for hospital and late mortality. The chances of hospital death were increased by worsening New York Heart Association (NYHA) class, severe congestive heart failure (CHF), and extensive coronary disease. The risk of late mortality was increased by a significant right coronary artery stenosis and by poor contractility of the posterobasal segment. The probability of late death was reduced by a history of preoperative angina and an increasing number of grafts.

Sudden cardiac death: results of resuscitation begun outside hospital.

A retrospective review was undertaken to determine the influence of the St John Ambulance life support units on the the incidence of sudden cardiac death during a 12 month period in Auckland. In 65 instances subjects who collapsed with either ventricular fibrillation or cardiac arrest were resuscitated and transported alive to a hospital accident and emergency department in the Auckland area. Twenty patients died within 24 hours of admission and a further 14 died in hospital. There were seven late deaths and 24 survivors (37%). Ten patients are asymptomatic and the remainder are troubled by angina or breathlessness. Only three of the surviving patients have suffered severe cerebral damage as a result of their collapse.

Infective endocarditis: a lethal disease.

One-hundred-and-eighty-nine episodes of infective Endocarditis were seen in 177 patients in the Green Lane Cardiology Unit over a 18-year period. Hospital survival was 79% and 13-year actuarial survival was 47%. A number of factors including the underlying cardiac lesion, infecting organism, clinical features and surgical intervention were related to outcome. No patient with extreme heart failure survived without operation. Hospital survival in patients with severe heart failure was 69% (9/13 patients) where surgery was carried out before completion of antibiotic treatment, and 40% (6/15 patients) where the antibiotic course was completed. Survival was 53% in patients who still had a fever after one week of antibiotic treatment and 96% if the temperature was normal. In 61% of patients with a fever at one week, extended infected pannus was present compared with 6--10% where the temperature was normal. In patients undergoing operation before completion of antibiotics, the surgical mortality was higher but neither the incidence of recurrence of endocarditis nor the need for re-operation was increased. We believe that better results will be achieved with a policy of surgical intervention when signs of infection and heart failure have not settled within one week of treatment.

Coronary surgery after recurrent myocardial infarction: progress of a trial comparing surgical with nonsurgical management for asymptomatic patients with advanced coronary disease.

A randomized trial of surgical vs nonsurgical management was carried out in men 60 years of age or younger who had recovered from a recurrent myocardial infarction. Of 205 patients considered, 100 had few or no symptoms and had coronary vessels favorable for bypass grafting; these patients fulfilled the trial conditions and were randomized (50 surgical and 50 nonsurgical). In 41 patients (elective nonsurgical group), randomization was not considered justifiable because of relatively unfavorable coronary anatomy or severe left ventricular dysfunction. Nineteen patients had elective surgery because of disabling angina despite full medical treatment or because of significant left main coronary stenosis. In 45 patients, coronary angiography was not undertaken because of medical contraindications or reluctance of the patient to enter the study. Actuarial survival curves (mean follow-up 4.5 years) show an annual mortality rate of 3-4% per year for all investigated patients, and no advantage for the randomized surgical over the randomized nonsurgical group. The results suggest that in the absence of disabling angina or left main coronary artery stenosis, coronary artery surgery need not be advised for survivors of recurrent infarctions who have severe coronary artery disease. Moreover, the prognosis for the group of patients not treated surgically appears to be better than has been previously described.