Short-term Results of Heartmate 3 Ventricular Assist Device Implantation for End-Stage Heart Failure.

OBJECTIVE: To report our initial experience with Heartmate 3 ventricular assist device (HM3) in cases with end-stage heart failure (ESHF). METHODS: Charts of 8 ESHF patients who underwent HM3 implantation in our clinic from January to June 2016 (group 1) and 16 patients who underwent HM2 implantation during 2015 (group 2) were reviewed retrospectively. Demographics as well as pre- and early postoperative medical data were noted and statistically analyzed between the 2 groups. RESULTS: No statistical difference was found in age or sex distribution between groups (P > .05). Mean Interagency Registry for Mechanically Assisted Circulatory Support scores were 2.13 ± 0.99 and 3.38 ± 0.72 in groups 1 and 2, respectively (P = .020). Mean cardiopulmonary bypass time, and chest tube drainage fluid volume and blood product requirement during intensive care unit (ICU) stay were 64.0 ± 13.9 minutes, 1,112.5 ± 516.7 mL, and 318.8 ± 271.2 mL, respectively, in group 1 and 89.0 ± 33.3 minutes, 2,081.3 ± 1,696.0 mL, and 1,118.8 ± 1,010.8 mL in group 2 (P = .027, P = .019, and P = .040, respectively). Need for surgical revision and early mortality were not evident for group 1, although 4 cases (25.0%) required revision surgery, and early mortality was seen in 3 cases (18.8%) in group 2 (P = .121 and P = .190, respectively). Mean durations of ICU stay and total postoperative hospitalization were 5.9 ± 2.0 and 18.3 ± 5.5 days, respectively in group 1 and 6.2 ± 4.3 and 18.0 ± 6.9 days in the surviving 13 patients of the group 2 (P = .645 and P = .697, respectively). CONCLUSIONS: With its shorter implantation time and reduced blood product requirement in the early postoperative period, the HM3 system was found to be safe and effective in ESHF treatment.

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey.

INTRODUCTION: HeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center. METHODS: Twenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation. RESULTS: Mean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus. DISCUSSION: Mechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Transthoracic echocardiographic and cardiopulmonary exercise testing parameters in Eisenmenger's syndrome. Association with six-minute walk test distance.

OBJECTIVE: The six-minute walk test (6MWT) evaluates the functional exercise capacity in patients with cardiopulmonary disease. We aimed to investigate the association between 6MWT distance and transthoracic echocardiographic (TTE) findings as well as cardiopulmonary exercise testing (CPET) parameters in Eisenmenger's syndrome (ES) patients waiting for heart-lung transplantation on their initial admission to our center. PATIENTS AND METHODS: A total of 23 patients with ES (12 women, 11 men; mean age, 28.2 ± 8.1 years) were included in the study. The correlation between 6MWT distance and CPET and TTE findings was retrospectively analyzed. RESULTS: The most frequent underlying heart diseases were ventricular septal defect (VSD) with complex congenital heart disease (n = 10, 43 %) and isolated VSD (n = 7, 30 %). The 6MWT distance was 349.7 ± 77.4 m in the study group. An inverse correlation was found between 6MWT distance and systolic pulmonary arterial pressure (SPAP) measured with TTE (r = - 0.445; p = 0.03). All patients underwent CPET at the first visit. Mean VO2 max was 14.9 ± 3.3 ml/kg/min and the VE/VCO2 rate was 50.4 ± 9.2 %. No significant correlation was observed between 6MWT and CPET findings. SPAP, which did not display any correlation with CPET findings, was the only independent predictor of 6MWT distance. CONCLUSION: We suggest that 6MWT distance may be more suitable than CPET in the follow-up of ES patients. Further prospective, randomized, controlled trials are necessary to make more robust interpretations of this issue.

Efficacy of the cardiac rehabilitation program in patients with end-stage heart failure, heart transplant patients, and left ventricular assist device recipients.

OBJECTIVE: The objective of this study was to assess the effects of cardiac rehabilitation on the functional capacity, pulmonary functions, quality of life, and psychological state of patients who had heart failure (HF), heart transplantation (HTx), or a left ventricular assist device (LVAD). METHODS: An 8-week exercise program was undertaken by 46 patients diagnosed with end-stage heart failure, 40 of whom had a heart transplantation and 11 were implanted with an LVAD. The patients' functionality was assessed with a maximal oxygen consumption test (pVO2), their psychological state with the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI), their quality of life (QOL) with the Short Form 36 (SF 36), and their pulmonary condition with pulmonary function tests (PFTs). RESULTS: A significant improvement was observed in all forced vital capacity (%), forced expiratory volume in 1 second (%), pVO2, BDI, and most of the subscores of the SF 36 scores at the end of the exercise, compared with the pre-exercise period (P < .05). The intergroup evaluations showed no significant differences among the 3 groups in terms of all assessed changes (P > .05). CONCLUSION: An 8-week supervised exercise program was observed to improve functional capacity, PFT, QOL, and depression among patients who had HF, HTx, or LVAD. Supervised exercise should be recommended for every patient included in a heart transplant program.

Long-term paracorporeal ventricular support systems: a single-center experience.

BACKGROUND: The Berlin Heart EXCOR is a first-generation paracorporeal, pneumatic ventricular assist device that creates pulsatile flow. It can be used for long-term support of the left and/or right ventricule during end-stage heart failure. The aim of this study was to share our clinical experience in 54 patients. METHODS: Between April 2007 and August 2012, 54 patients with end-stage heart failure underwent Berlin Heart EXCOR ventricular assist device implantation, including 5 females and 9 children. Twenty-four patients (44%) were in Intermacs level 1, 11 (21%) in level 2, and 19 (35%) in level 3. Biventricular support was applied to 13 patients. Device implantation was performed with an "on pump" beating heart technique while 6 other patients underwent intervention operations while the aortic valve has under cross-clamp. Tricuspid annuloplasty was performed in 6 patients. RESULTS: There was no peroperative death. Nine patients (17%) underwent re-exploration because of hemorrhage in the early postoperative period. Heart transplantation was performed in 32 patients (59%), while 10 (19%) are still under pump support with a mean follow-up of 13 months. Although 1 was successfully weaned from the system, 11 patients (20%) died during the support. Pump-head exchange was required 19 times in 17 patients because of visible thrombus or fibrin deposit in the pump head or due to membrane rupture. DISCUSSION: The use of long-term paracorporeal assist devices has decreased in recent years because of the increased popularity of implantable devices that permit longer survival and a better quality of life. We believe that the Berlin Heart EXCOR has a special role because it can be used in pediatric patients and especially in critical conditions like Intermacs levels 1 and 2.

Effect of aortic valve movements on gastrointestinal bleeding that occured in continuous flow left ventricular assist device patients.

BACKGROUND: Gastrointestinal (GI) bleeding is one of the recently reported complications with continuous flow left ventricular assist devices (LVAD). The pathophysiology and etiology are unclear. We sought to describe the relationship between aortic valve movements and GI bleeding among patients with a new generation of LVAD. METHODS: We evaluated the data of 30 patients who underwent LVAD (HeartWare VAD) implantation from December 2010 to September 2012. The most common etiologic diagnosis was dilated cardiomyopathy. Patients were considered to show GI bleeding if they had hematemesis, melena, or hematochezia. RESULTS: Among 3 patients, 2 displayed upper GI bleeding and 1 had lower GI bleeding based on endoscopic and colononoscopic examinations. Pathological reports showed arteriovenous malformations in patients diagnosed with upper GI bleeding. The absence of aortic valve movements and a history of previous GI bleeding were significant risk factors (P = .021 and P = .007, respectively). CONCLUSION: In addition to aortic valve movements, we believe that a GI bleeding history was an equally important factor predisposing to this complication.

Clinical characteristics of obstructive sleep apnea syndrome in heart transplant recipients.

AIM: We investigated the prevalence and clinical characteristics of obstructive sleep apnea syndrome (OSAS) among heart transplantation patients. METHODS: Among 86 surviving patients of mean age 43.07 ± 13.23 years including 35 men transplanted from April 1999 to November 2010, 43 (50%) agreed to participate in this study. Patients with apnea-hypopnea index (AHI) < 5 were labeled as "normal", with an AHI > 5, as obstructive surgeon (OSA). According to the AHI, subjects were classified as with OSA (group 1; n = 25 of mean age 49.0 ± 12.1 years and including 21 men versus non OSA group 2; n = 18) of mean age 34.8 ± 10.1 years with 14 men. We recorded patient demographic features, medications, polysomnographi observations, laboratory measurements, as well as echocardiographic and angiographic parameters. RESULTS: Prevalence of OSA (AHI > 5) was 58% (n = 25) with 30% (n = 14) as moderate or severe OSA (AHI > 15) OSA patients were significantly older, and showed a greater value of body mass index (BMI) and waist circumference. Echocardiographic findings revealed the only significant difference to be systolic arterial pressure. The apnea-hypopnea index showed significant correlation with age, BMI, waist circumference, neck circumference, Epworth score, duration of apnea episode, time of SaO(2) under 90% and systolic arterial pressure (SPAP). An inverse correlation was observed between AHI and sleep efficiency, oxygen saturation, and percentage of time in random eye movement (REM) sleep. Multivariate backward logistic regression analysis indicated waist circumference, sleep efficiency, percentage of time in REM sleeps and duration of apnea episode to be independent predictors of AHI. CONCLUSION: OSA is prevalent among heart transplantation patients. Obesity is a risk factor and waist circumference, and independent predictor for OSA.

Changing face of heart failure surgery.

BACKGROUND: Heart failure is a serious disease ending with death if untreated. Although heart transplantation is the best therapy for end-stage heart failure, most candidates die in the waiting period due to the lack of donor organs. This condition represent a new era of heart failure surgery. METHODS: We retrospectively investigated 159 patients from 1998 to 2011 with a mean age of 40.0 years (range = 5-65), who were mostly diagnosed as dilated cardiomyopathy (n = 113). After April 2007, 67 patients underwent vascular assist device (VAD) implantation surgery for acute or chronic end-stage heart failure. We performed 69 heart transplantation with 27 on VAD systems before transplantation. RESULTS: Early mortality was 13.3% with 21 patients after the heart transplantation. The 67 patients supported with VAD did not experience an intraoperative death. The mean support time was 214 days (range = 3-1035). Twenty-four patients (35.8%) are still on pump support. The overall survival until transplantation or weaning was 77.6% at mean of 250.7 days survival reached 90% with Heartware (Hartware Inc, Miramar, Fla, USA) continuous flow pumps. CONCLUSION: After the introduction of VAD in 2007, the overall picture has been restructured radically for heart failure surgery, reducing patient loss on the waiting list. Especially, since 2009 nearly 80% of donor hearts were used for patients on mechanical circulatory support.

Valvular procedures during ventricular assist device implantation.

BACKGROUND: Increased experience and success with ventricular assist devices (VAD) has permitted more aggressive use in patients formerly believed to be inappropriate for mechanical circulatory support (MCS). There is no clearly proven policy to manage end-stage heart failure patients with valvular pathologies. The aim of this report was to analysis our experience with combined approach of VAD implantation and valvular procedures among patients with valvular heart disease and end-stage heart failure. METHODS: We evaluated the clinical records of 67 patients who underwent MCS from April 2007 to September 2011. We identified 12 patients (17.9%) who received concomitant valvular procedures, four of whom had significant aortic insufficiency and received a simple coaptation stitch at the center to approximate the fibrous nodules of Arantius. The mechanical aortic valve was replaced with a stentless bioprosthesis in three patients. Mitral valve commissurotomy was performed in one patient with mitral stenosis and seven patients underwent tricuspit valve repair using an annuloplasty ring. RESULTS: All 12 patients were males, of mean age 50.3 ± 11.5 years (range = 25-66). Eleven of them (91.6%) survived the early and late postoperative periods. Ten subjects (83.3%) continue to be supported with VAD; 1 (8.3%) was successfully bridged to transplantation. Each study participant regression of the valvular pathologies by early echocardiography demonstrated. CONCLUSION: Concomitant valve surgery during VAD implantation appeared to be a reasonable option in end-stage heart failure patients with valvular heart disease.

To bridge or not to bridge?

OBJECTIVE: Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs. METHODS: Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support. RESULTS: Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥ 130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar. CONCLUSION: Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.

New circulatory support system: heartware.

INTRODUCTION: Through the new developments in medicine, heart failure therapy has advanced to mechanical circulatory support systems. The HeartWare Ventricular Assist System HVAD; HeartWare, Inc.; Miramar, Fla, USA) is a new device that is a centrifugal, intracorporeal, miniaturized and continuous flow pump that serves simple patient use and enhanced life quality. This article reports the midterm results of patients who underwent the heartware support system. MATERIALS AND METHODS: We retrospectively compiled our data from December 2010, including 10 patients of mean age 51.8 years with 90% males, 70% of the overall patient cohort had dilated cardiomyopathy and remaining ones, ischemic disease. Mean left ventricular ejection fraction was 20.1% and mean systolic pulmonary artery pressure was 49.2 mm Hg. A single patient was grade 1; seven were grade 2; and remaining ones, grade 3 according to the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale. All patients were operated with cardiopulmonary bypass (CPB) with moderate hypothermia. Tricuspid ring annuloplasty was performed in 3 (30%) patients. In one patient we removed a left ventricular thrombus. In a case with severe aortic regurgitation, we placed a simple coaptation stitch at the central portion of the three aortic cusps under the aortic cross clamp. The mean CPB duration was 95.5 minutes. RESULTS: There was no operative or in-hospital mortality. Mean support time was 250.67 days. During the early postoperative period, one patient experienced a minor hemorrhagic neurological event also requiring a tracheostomy due to pneumonia. This patient has completely healed and on follow-up continues a normal life. All patients were asymptomatic regarding heart failure. One patient unfortunately died because of possible pancreatic cancer and sepsis. Two patients underwent transplantations on days 159 and 172 of support. CONCLUSION: The HVAD system provided effective circulatory support for patients with end-stage heart failure with low adverse event rates. Long-term results are needed particularly for destination therapy candidates.

Comparison of heart transplantation patients with ischemic and idiopathic dilated cardiomyopathy.

OBJECTIVE: We retrospectively analyzed our data to compare preoperative demographic, laboratory, echocardiographic, hemodynamic findings mortality and survival rates of heart transplantation patients with ischemic (ICM) and idiopathic dilated (IDCM) cardiomyopathy. METHODS: The data of 144 patients transplanted from February 1998 to January 2011 were analyzed. 38 patients with ischemic ICM and 86 patients with IDCM were compared. RESULTS: Recipient age, preoperative creatinine, recipient body mass index, intraoperative cross-clamp time, donor male sex ratio, recipient male sex ratio, hyperlipidemia ratio, and previous nitrate use were significantly higher and left ventricular end systolic diameter significantly lower in patients with ICM. Major causes of death after heart transplantation were infections (31.9%), right ventricle failure (14.8%), and sudden cardiac death (14.8%). Causes of death were not different between the groups. Overall mortality in the entire population was 37.9% (47/124), and it was not different between the groups (39.5% vs 37.2%; P=.48). Early mortality (<30 days) rate was 11.2% (14/124), late mortality rate was 26.6% (33/124), and no statistically significant difference was observed between the groups. Survival analysis showed that ICM patients were not associated with worse survival compared with IDCM (71.1% vs 81.1% after 1 year, 68.1% vs 73.0% at 2 years, and 54.2% vs 62.3% at 5 years; log rank=0.57). Multivariate analysis showed that the only predictor of mortality was preoperative urea level and that heart failure etiology was not a predictor of this end point. CONCLUSIONS: Patients with ICM had similar survival and mortality rate compared with IDCM.

Ventricular assist system applications in end-stage heart failure.

BACKGROUND: Mechanical circulatory support has an important role in the surgical therapy for heart failure. Patients deteriorating on transplantation waiting lists or those unsuitable for transplantation have been treated with ventricular assist devices. In this report, we have presented application of ventricular assist systems for patients with end-stage heart failure. METHODS: Between April 2007 and September 2010, we treated 37 patients with end-stage heart failure with mechanical circulatory support, including 5 children younger than 16 years of age. Three patients were females, and the overall mean age was 40 ± 18 years (range, 1.5-67). In 29 patients we implanted paracorporeal pneumatic ventricular assist devices. Axial flow pumps were chosen to support the left ventricle in 8 patients. Biventricular support was applied in 9 patients because of their poor preoperative clinical conditions and advanced evidence of right ventricular failure. RESULTS: Heart transplantation was performed in 16 patients (43%). One subject, who was managed with a left ventricular assist device implantation and coronary bypass grafting, was weaned from the system because of recovery of ventricular functions. Eleven patients (30%) are still on pump support. Nine patients (24%) died during mechanical circulatory support. The most prevalent cause of mortality was multiorgan failure (n = 5; 13.5%). Cerebrovascular hemorrhage was the cause of death in 2 patients. One patient died due to acute lung injury, and an other due to malignant melanoma. CONCLUSION: Use of a ventricular assist device as a bridge-to-transplantation or as destination therapy can be performed with acceptable mortality. It may be the most promising option for patients with end-stage heart failure. Development of device technology, advanced monitoring of anticoagulation and anti-aggregation therapy, and greater clinical experience may yield better results.

Long-term results of autologous stem cell transplantation in the treatment of patients with congestive heart failure.

BACKGROUND: The aim of this study was to assess the long-term efficacy of stem cell transplantation with revascularization for patients with ischemic cardiomyopathy. METHODS: We enrolled 17 patients with ischemic cardiomyopathy who had undergone autologous stem cell treatment. To assess myocardial ischemia and viability they underwent coronary angiography, stress tests with dobutamine, echocardiography, and positron emission tomography. Peripheral stem cells mobilized using granulocyte colony-stimulating factor (G-CSF) were collected by aphseresis for transplantation transmyocardially into the areas of injury during coronary artery bypass surgery to increase blood flow to the engrafted areas. RESULTS: Three patients died in the early follow-up period and 4 patients with cardiac failure died during mid-term follow-up; they all underwent stem cell transplantation at 6 months after acute myocardial infarction. The mean follow-up period of the remaining 10 patients was 85.8 ± 9.2 months (range, 70-100). Mean left ventricular ejection fraction improved to 30.0 ± 6.7, whereas the preoperative mean left ventricular ejection fraction of the surviving patients was 25.6 ± 4.5 (P = .035). Mean New York Heart Association (NYHA) functional class decreased from 3.2 to 1.5 (P = .006). When the study population was divided into 2 subgroups according to the interval between acute myocardial infraction and surgery, the patients who underwent autologous stem cell transplantation within the first 6 months after myocardial infraction (Group 1) showed significantly lower NYHA scores at the last follow-up (P = .024 in Group 1 and P = .102 in Group 2). No side effects were observed to be due to the stem cell or G-CSF injections. CONCLUSION: Treatment of ischemic cardiomyopathy with autologous stem cell transplantation is easy and safe, opening a new window in the treatment of "no hope" patients.

Ege University experience in cardiac transplantation.

BACKGROUND: End-stage heart failure can result from many cardiac and noncardiac entities that produce a poor prognosis. Medical and interventional modalities are widely used to treat this condition, although the ultimate therapy remains heart transplantation. Herein we present our clinical experience with 140 patients who underwent orthotopic heart transplantation. METHODS: Between February 1998 and September 2010, we transplanted 140 patients with a mean age of 40 ± 13 years, including 109 men (77.8%) and 31 women (22%). There were 101 patients (73%) with dilated cardiomyopathy and 39 (27%) with ischemic cardiomyopathy. Two patients were retransplanted owing to graft failure. Sixteen patients on assist device support were successfully bridged to transplantation. RESULTS: Eighteen patients (12.8%) died within 30 days with the most common causes being right ventricular failure (8/18, 44%) and infection (4/18, 22%). Overall mortality of 39% (55/140) was most commonly caused by infection (29%, 16/55) or right ventricular failure (20%, 11/55). Nine patients (16%) died suddenly outside of the hospital. Three patients died of rejection; 4 of graft failure, and 4 of malignant disease. CONCLUSIONS: Heart transplantation remains the standard treatment modality for end-stage cardiac failure. But significant waiting list mortality rates are due to the worldwide shortage of donors. Heart transplantation in Turkey is feasible for a small and strictly selected number of patients with nonreversible congestive heart failure. In recent years, ventricular assist device applications have successful bridged subjects to transplantation, saving many patients on active waiting lists.

Does pretransplantation etiology have any effect on exercise results in heart transplant patients?

OBJECTIVE: The objective of this study was to analyze the effect of pre-transplantation etiology and post-transplantation exercise on pulmonary function tests, functional capacities, psychological symptoms and quality of life among heart transplant patients. METHODS: An eight-week exercise program was applied to 35 heart transplant patients with histories of ischemic heart failure (HF; n = 20) or dilated HF (n = 15). All patients were evaluated before and after exercise in terms of breathing function tests, functional capacity (FVC; maximal oxygen consumption, pVO2), psychological symptoms (Beck Depression Scale (BDS), Spielberger's State-Trait Anxiety Inventory (STAI)) and quality of life (Short Form 36, SF-36). RESULTS: At the end of the exercise compared to the pre-exercise period significant improvements were observed in all FVC%, FeV1%, FeV1/FVC%, pVO2, SF 36 scores reflecting physical function, physical role, pain, general health, vitality, social function, and emotional role (P < 0.05) among heart transplant patients who were operated due to ischemic or dilated heart failure. In contrast, no significant improvement was observed in the BDS and STAI scales (P > 0.05). There was no significant etiology-related difference between the groups in terms of the evaluated parameters (P > 0.05). CONCLUSION: We demonstrated improvements in function tests, functional capacity and quality of life for both ischemic and dilated heart transplant patients following a supervised exercise program. We concluded that the positive effect achieved by exercise was not related to pre-transplantation etiology. Whatever the preoperative etiology, a regular exercise program is recommended for heart transplant patients in the rehabilitation unit.

Effect of levosimendan on right ventricular systolic and diastolic functions in patients with ischaemic heart failure.

OBJECTIVES: Levosimendan is a novel positive inotropic calcium sensitiser agent used in acute left heart failure. In this study, the effect of levosimendan on the right ventricular systolic and diastolic functions was evaluated by tissue Doppler comparing them with dobutamine in patients with ischaemic heart failure. METHODS: Patients having an acute decompensated heart failure with ischaemic cardiomyopathy and left ventricular ejection fraction <40% were included in the study. Before and 24-h after treatment, peak systolic (Sa), peak early (Ea), peak late (Aa) diastolic annular velocities and Ea/Aa ratio from tricuspid lateral annulus by tissue Doppler and systolic pulmonary artery pressure (SPAP) were measured. RESULTS: Sa, Ea and the Ea/Aa ratio were significantly increased in the levosimendan group whereas SPAP was significantly reduced. In the dobutamine group, no significant differences were observed in the Sa, Ea, Aa and Ea/Aa ratio in spite of a significant reduction in SPAP. Decrease in SPAP was greater in the levosimendan group (p=0.002). CONCLUSION: Levosimendan improves right ventricular systolic and diastolic functions.

The relationship between depressive symptoms and anxiety and quality of life and functional capacity in heart transplant patients.

OBJECTIVE: To establish the relationship between depressive symptoms and anxiety with both the quality of life and functional capacity of heart transplant patients. METHODS: Thirty-four patients were included. Outcome measures were the Beck Depression Inventory (BDI), the State- Trait Anxiety Inventory (STAI), the Short Form 36 (SF36) and peak oxygen consumption (pVO2). RESULTS: After the transplant there was a significant negative correlation between the BDI and most of subgroups on the SF36 (p<0.05). There were significant negative correlations found between the pVO2 and both the BDI and STAI-trait anxiety score (p<0.05). Statistically significant improvements were noted in all subgroups on the SF36 and all BDI scores after the transplant, in comparison to the pre-transplant period (p<0.05). CONCLUSIONS: The functional capacity of a person affects the state of their depression and anxiety. We recommend participation in a cardiac rehabilitation program in the early stages of transplantation and believe that the quality of life, which has been shown to be related to the functional capacity and psychological symptoms, would benefit from this program.

Pulmonary complications in heart transplant recipients.

BACKGROUND: Heart transplantation is an important therapeutic option for patients with end-stage disease, but is associated with major pulmonary complications. PATIENTS AND METHODS: We retrospectively reviewed the posttransplant follow-up of 34 orthotopic heart transplant recipients. RESULTS: Two of the 34 patients died of cardiac failure in the early postoperative period. Among the surviving patients, 10 (31.3%) developed pulmonary complications, all within the first 6 months: hospital-acquired bacterial pneumonia in five, fungal pneumonia in three, posttransplant lymphoproliferative disease in one, and community-acquired pneumonia in one patient. None of the patients developed transplantation-related malignancy. The overall mortality was 35.3%. Pneumonia-related mortality rate of 14.7% was due to early-onset nosocomial pneumonias, which were caused by bacterial and opportunistic microorganisms. Extrapulmonary causes of mortality were cardiac failure, meningitis, septicemia, and acute rejection. Cytomegalovirus antigenemia in the first month was associated with a poor prognosis. The frequency of pulmonary complications was higher among older patients and those who developed moderate rejection in the first month (P=.014 and P=.036, respectively). CONCLUSION: Pulmonary infections after heart transplantation occurred more frequently during the first 6 months posttransplantation, accounting for a significant portion of the posttransplantation mortality.

Primary cardiac lymphoma in a heart transplant recipient.

Posttransplantation lymphoproliferative disease (PTLD) is one of the most serious complications of chronic immunosuppression in transplant recipients. Involvement of the cardiac allograft or development of lymphoma in the heart is extremely rare. We report a primary cardiac lymphoma that developed about 14 months after the operation in a cardiac recipient. The patient presented with vague abdominal complaints. Multiorgan failure developed within a short period of time, and the patient died. The diagnosis of "diffuse large cell lymphoma of B cell type" was made on postmortem examination.