A rare case of takotsubo syndrome within the first day after heart transplantation.

A 39-year-old woman underwent heart transplantation (HTx) for advanced heart failure. The donor was a 36-year-old young woman without past medical history. The first day after HTx, T-waves changes were noted. Echocardiography revealed akinesia/dyskinesia of all basal segments of the two ventricles. Coronary catheterization plus biopsy were done 7 days later showing no coronary obstruction, no rejection and complete recovery of wall motion abnormalities on echocardiogram, suggesting biventricular inverted takotsubo syndrome (TTS). This is a case of TTS during the first day after HTx, with completely denervated heart but because of the inotropic drug support it still represents a target for catecholamine-induced cardiac dysfunction.

Validation of Cardiovascular Magnetic Resonance-Derived Equation for Predicted Left Ventricular Mass Using the UK Biobank Imaging Cohort: Tool for Donor-Recipient Size Matching.

BACKGROUND: Current guidance from International Society for Heart and Lung Transplantation recommends using body weight for donor-recipient size matching for heart transplantation. However, recent studies have shown that predicted heart mass, using body weight, height, age, and sex, may represent a better method of size matching. We aim to validate a cardiovascular magnetic resonance (CMR)-derived equation for predicted left ventricular mass (LVM) in a cohort of normal individuals in the United Kingdom. METHODS: This observational study was conducted in 5065 middle-aged (44-77 years old) UK Biobank participants who underwent CMR imaging in 2014 to 2015. Individuals with cancer diagnosis in the previous 12 months or history of cardiovascular disease were excluded. Predicted LVM was calculated based on participants' sex, height, and weight recorded at the time of imaging. Correlation analyses were performed between the predicted LVM and the LVM obtained from manual contouring of CMR cine images. The analysis included 3398 participants (age 61.5±7.5 years, 47.8% males). RESULTS: Predicted LVM was considerably higher than CMR-derived LVM (mean±SD of 138.8±28.9 g versus 86.3±20.9 g). However, there was a strong correlation between the 2 measurements (Spearman correlation coefficient 0.802, P<0.0001). CONCLUSIONS: Predicted LVM calculated using a CMR-derived equation that incorporates height, weight, and sex has a strong correlation with CMR LVM in large cohort of normal individuals in the United Kingdom. Our findings suggest that predicted heart mass equations may be a valid tool for donor-recipient size matching for heart transplantation in the United Kingdom.

Improved Outcomes of Heart Transplantation in Adults With Congenital Heart Disease Receiving Regionalized Care.

BACKGROUND: The number of adult congenital heart disease (CHD) patients undergoing heart transplantation is increasing rapidly. CHD patients have higher surgical risk at transplantation. High-volume adult CHD transplant centers may have better transplant outcomes. OBJECTIVES: This study aimed to evaluate the effect of center CHD transplant volume and expertise on transplant outcomes in CHD patients. METHODS: The authors studied heart transplantations in CHD patients age ≥18 years using the United Network of Organ Sharing (UNOS) database for the primary outcomes of waitlist mortality and post-transplant outcomes at 30 days and 1 year. Transplant centers were assessed by status as the highest CHD transplant volume center in a UNOS region versus all others, presence of Adult Congenital Heart Association accreditation, and adult versus pediatric hospital designation. RESULTS: Between January of 2000 and June of 2018, 1,746 adult CHD patients were listed for transplant; 1,006 (57.6%) of these underwent heart transplantation. After adjusting for age, sex, listing status, and inotrope requirement, waitlist mortality risk was lower at Adult Congenital Heart Association accredited centers (hazard ratio: 0.730; p = 0.020). Post-transplant 30-day mortality was lower at the highest volume CHD transplant center in each UNOS region (hazard ratio: 0.706; p = 0.014). CONCLUSIONS: Designated expertise in CHD care is associated with improved waitlist outcomes for CHD patients listed for transplantation. Post-transplant survival was improved at the highest volume regional center. These findings suggest a possible advantage of regionalization of CHD transplantation.

Benefits of the Modified Bicaval Anastomosis Technique for Orthotopic Heart Transplantation From a Size-Mismatched Marginal Donor.

BACKGROUND: Size-mismatched heart transplantation (HTx) is associated with a risk of stenosis of the caval anastomosis site or low cardiac output syndrome. We developed a modified bicaval anastomosis technique (mBCAT) that achieved an adjustable caval anastomosis to compensate for size mismatch. This study was performed to validate the rationale of the mBCAT for size-mismatched HTx.Methods and Results:This institutional consecutive series involved 106 patients who underwent HTx with the mBCAT during an 18-year period. The cohort was divided into 3 groups according to the donor-to-recipient body weight ratio: <0.8, undersized group (n=17); 0.8-1.3, size-matched group (n=68); and >1.3, oversized group (n=21); outcomes were compared. The undersized, size-matched, and oversized groups showed no significant differences in the rate of mild or worse echocardiographic tricuspid regurgitation at 1 month [1 (5.8%), 7 (10.2%), and 1 (4.8%), respectively; P=0.87] or the survival rate at 10 years [100%, 93.9%, and 100%, respectively; P=0.25]. The right heart catheter study revealed no pressure gradient across the orifices of both cavae in any patient. Additionally, the cardiac index immediately post-HTx was significantly low in the undersized group (P=0.008), but was similar to the other groups at 6 months post-HTx (P=0.16). CONCLUSIONS: The mBCAT prevented caval anastomosis-related complications in size-mismatched HTx and achieved excellent hemodynamics regardless of donor size.

Comparison of Renal Outcomes in Patients With Left Ventricular Assist Device and Heart Transplantation.

BACKGROUND: Renal function is a major consideration for orthotopic heart transplantation (OHT) and left ventricular assist device (LVAD) therapy. We compared serial changes in renal function and outcomes between patients who underwent OHT and LVAD therapy over 12 months. METHODS: Forty-five and 58 consecutive patients who underwent LVAD implantation (all bridge to transplant or candidacy) and OHT from April 2014 to November 2016 were included. Six of these patients were in both LVAD and OHT cohorts. Survival analysis was calculated using Kaplan Meier and log rank methods. Univariate analysis of data was performed using χ2, Mann-Whitney, Kruskal-Wallis, and Wilcoxon signed rank tests where appropriate. Comparisons of the renal function to baseline were conducted using generalized estimating equations. RESULTS: Renal function had a biphasic course among the LVAD cohort, increasing at 30 days but reducing at 6 and 12 months. Meanwhile, estimated glomerular filtration rate (eGFR) was seen to progressively decline among OHT recipients. Altogether, eGFR was significantly higher at 6 and 12 months among the LVAD cohort compared to OHT (68.3 vs 59.4, P = .046; 68.3 vs 50.4, P = .015). Compared to the baseline average, eGFR had risen among the LVAD patients (P = .031) but had decreased among the OHT group (P < .001) at 12 months. No significant difference in survival was seen at 1 year (84.4% vs 81.0%; P = .540) and 2 years (78.3% vs 78.8%, P = .687) between the cohorts. CONCLUSION: Despite poorer baseline renal function, LVAD therapy was associated with comparable survival and better renal outcomes compared to OHT at 12 months. Renal impairment may favor the use of LVAD therapy over OHT in the short term.

Aortobronchial Fistula Causing Recurrent Hemoptysis 21 Years Post-Heart Transplant.

Aortobronchial fistulae (ABF) are uncommon but potentially fatal anomalies. Patients may initially present with small volume hemoptysis, which can rapidly lead to massive hemoptysis and death if not diagnosed and intervened upon early. Diagnosis by imaging and bronchoscopy is not always conclusive; thus, a high index of suspicion is necessary to diagnose this life-threatening condition. Herein, we describe a case of a young man who had a late presentation of ABF 21 years following heart transplantation. This case illustrates the diagnostic and clinical challenge of ABF as a late sequela of cardiac transplantation and highlights the rarity of this anomaly.

Changes in Pulmonary Function in Patients With Advanced Heart Failure Listed for Heart Transplantation.

BACKGROUND: Pulmonary function tests (PFTs) are often impaired in patients with advanced heart failure. There is limited data about their impact on survival after heart transplantation (HT). We sought to assess the prevalence and type of PFT abnormalities in patients on HT waiting list and their impact on outcomes. METHODS: We performed a retrospective analysis of a prospective registry of consecutive patients undergoing HT between 2012 and 2018. Patients were classified into 4 groups according to pre-HT PFT results: 1. normal pattern: forced vital capacity (FVC) ≥ 80% and forced expiratory volume in 1 second (FEV1) to FVC ratio (FEV1/FVC) ≥ 0.7; 2. obstructive: FEV1/FVC < 0.7; 3. nonobstructive: FEV1/FVC ≥ 0.7 and FVC < 80% when total lung capacity value was not available; and 4. restrictive: FEV1/FVC ≥ 0.7 and total lung capacity < 80%. The prevalence of impaired carbon monoxide diffusing capacity corrected for hemoglobin < 80% and FEV1 < 70% was also analyzed. High-urgency HT patients and those referred from other centers without quantitative pulmonary evaluation were excluded. RESULTS: Among 123 patients who underwent HT, 83 patients with complete PFT were included. Median follow-up was 2.7 ± 1.9 years. Of these, 29 (34.9%) had an obstructive pattern, 20 (24.1%) a nonobstructive, 18 (21.7%) a restrictive, and 16 (19.3%) a normal pattern. Fifty-one (61.4%) patients had FEV1 < 70% and 58 (69.9%) a carbon monoxide diffusing capacity corrected for hemoglobin < 80%. There was a tendency to lower survival in all altered PFT groups compared with normal (P = .054) but not within the other groups. Patients with an impaired FEV1 had significantly higher mortality than patients with normal values (P = .008). Area under receiver operating characteristic curve for FEV1 was 0.73 (95% confidence interval [0.60-0.86]). A cutoff value of FEV1 (60.5) predicts mortality with 66% sensitivity and 64% specificity. CONCLUSIONS: PFT alterations have a very high prevalence on HT waiting list patients. Patients with impaired FEV1 had worse outcomes after heart transplantation.

Profiling of the plasma proteome across different stages of human heart failure.

Heart failure (HF) is a major public health problem characterized by inability of the heart to maintain sufficient output of blood. The systematic characterization of circulating proteins across different stages of HF may provide pathophysiological insights and identify therapeutic targets. Here we report application of aptamer-based proteomics to identify proteins associated with prospective HF incidence in a population-based cohort, implicating modulation of immunological, complement, coagulation, natriuretic and matrix remodeling pathways up to two decades prior to overt disease onset. We observe further divergence of these proteins from the general population in advanced HF, and regression after heart transplantation. By leveraging coronary sinus samples and transcriptomic tools, we describe likely cardiac and specific cellular origins for several of the proteins, including Nt-proBNP, thrombospondin-2, interleukin-18 receptor, gelsolin, and activated C5. Our findings provide a broad perspective on both cardiac and systemic factors associated with HF development.

Ambient Air Pollution and Mortality After Cardiac Transplantation.

BACKGROUND: Heart transplant recipients are at high risk for mortality, with traditional risk scores performing modestly in predicting post-transplant survival, underscoring the importance of as yet unidentified factors in determining prognosis. In this analysis, the association between PM2.5 exposure levels and survival after heart transplantation were investigated. OBJECTIVES: This study sought to study the association between PM2.5 exposure and mortality following heart transplantation. METHODS: On the basis of the zip code of residence, mortality data in patients who underwent heart transplantation (2004 to 2015) in the United Network for Organ Sharing (UNOS) database were linked with validated estimates of fine particulate matter concentrations (particles with diameter <2.5 µm [PM2.5]; 1 × 1-km grids) for each calendar year during which a UNOS cardiac transplant recipient was at risk for death. Cox proportional hazard models were used to estimate the relationship between exposure and overall mortality adjusting for recipient, donor, and neighborhood variables. RESULTS: A total of 21,800 patients with 86,713 patient-years of follow-up was included. Mean age at transplantation was 52.6 ± 12.6 years, 75% were male, 69% were white, and 39% had ischemic etiology of heart failure. Mean annual exposure to PM2.5 was 10.6 ± 2.3 µg/m3. At a median follow-up of 4.8 (95% confidence interval: 2.0 to 7.8) years, 5,208 patients (23.9%) had died. The estimated mortality hazard ratio, per 10 µg/m3 increment increase in annual PM2.5 exposure was 1.43 (95% confidence interval: 1.21 to 1.49). After adjusting for 30 recipient, donor, and neighborhood variables, the estimated mortality hazard ratio per 10 µg/m3 increment in annual exposure to PM2.5 was 1.26 (95% confidence interval: 1.11 to 1.43) relative increase in hazard of mortality. This association was consistent across subgroups. CONCLUSIONS: This study provides evidence linking air pollution with mortality after heart transplantation. These results suggest an important influence of a key environmental factor in outcomes following heart transplantation, and supports the need for further studies in this population.

Case report - coronary vasospasm in transplanted heart: a puzzling phenomenon.

BACKGROUND: Coronary artery spasm (CAS) is an underdiagnosed disease especially in heart transplant patients, and in those patients the etiology and pathophysiology remain largely unknown, although it has been associated with cardiac allograft vasculopathy or graft rejection. CASE PRESENTATION: We report the case of a heart-transplant patient whose cardiac graft experienced two coronary vasospasms: the first before transplantation, and the other at one-month of a postoperative course complicated by primary graft failure. CONCLUSION: Our case illustrates that a transplanted heart predisposed with coronary vasospasm may suffer from early relapse in the recipient despite of complete post-surgical autonomic denervation. Exacerbated endothelial dysfunction of the donor heart after transplant, with the addition of systemic factors in the recipient may be involved in the genesis of this puzzling phenomenon.

[Exploring the experience of living with a heart transplant: a systematic review of the literature]. / Explorando la experiencia de vivir con un trasplante cardíaco: una revisión sistemática de la literatura.

The focus of healthcare professionals is shifting from illness to health and the individual experience of each person. However, current health care continues to focus on the prevention and treatment of medical complications, leaving aside other important aspects of the experience of cardiac transplant patients. The aim of this systematic review of the literature was to explore how living with a transplanted heart affects their lives. We searched the databases Pubmed, Cinahl, Scielo, Scopus, Dialnet, Cuiden and PsyINFO, and specialized journals. Twenty-five articles were included for study. The analysis and interpretation of the results was based on the methodology by Dixon-Woods et al and by Evans. The results were grouped into seven categories: spiritual repercussions, psychological repercussions, social repercussions, relationship with the donor and the organ, repercussions in the physical environment and quality of life, coping strategies, and feelings towards the healthcare professionals. The results confirm the need for a change in the care given to cardiac transplant patients given that, although transplantation has been shown to improve the quality and quantity of life, it has multiple psychosocial implications that affect the well-being and day-to-day life of these patients.

A case report of a 40-year-old woman with endomyocardial fibrosis in a non-tropical area: from initial presentation to high urgent heart transplantation.

BACKGROUND: Endomyocardial fibrosis (EMF) represents the most common cause of restrictive cardiomyopathy worldwide. Despite a high prevalence in tropical regions, it occasionally occurs in patients who have never visited these areas. While researches have proposed various possible triggers for EMF, etiology and pathogenesis remain largely unknown. Diagnosis is based on patient history, heart failure symptoms, and echocardiographic signs of restrictive ventricular filling, atrioventricular valve regurgitation and frequently apical thrombus. Following is a case report of an Austrian patient with EMF who eventually had to undergo a heart transplant. This case report strives to promote awareness for this in non-tropical areas uncommon but nevertheless detrimental disease. CASE PRESENTATION: A 40-year-old woman was presented at our emergency department with chest pain and fever up to 38.1° Celsius. Plasma troponin-T levels and inflammatory markers were slightly elevated, but the echocardiogram was without pathological findings. The patient was hospitalized on the suspicion of acute myocarditis and discharged soon after improvement. Eight months later, she was presented again with chest pain and symptoms of heart failure. The echocardiogram showed normal systolic left ventricular (LV) function with LV wall thickening and severe restrictive mitral regurgitation as well as aortic and tricuspid regurgitation. Coronary angiogram was normal but right heart catheterization showed pulmonary hypertension due to left heart disease. Further diagnostic workup with cardiac magnetic resonance imaging revealed subendocardial late enhancement and apical thrombus formation in the left ventricle compatible with the diagnosis of EMF. A comprehensive diagnostic workup showed no evidence of infection, systemic immunologic or hematological disease, in particular hypereosinophilic syndrome. After a multidisciplinary consideration of several therapeutic options, the patient was listed for heart transplantation. On the waiting list, she deteriorated rapidly due to progressive heart failure and finally underwent a heart transplantation. Histological examination confirmed the diagnosis of EMF. Six years after her heart transplantation, the patient was presented in an excellent clinical condition. CONCLUSIONS: Even in non-tropical regions, the diagnosis of EMF should always be considered in restrictive cardiomyopathy. Knowledge of the distinct phenotype of EMF facilitates diagnosis, but comprehensive workup and therapeutic management remain challenging and require a multidisciplinary approach.

Explorando la experiencia de vivir con un trasplante cardíaco: una revisión sistemática de la literatura / Exploring the experience of living with a heart transplant: a systematic review of the literature

El enfoque de los profesionales de la salud está cambiando, pasando de centrarse en la enfermedad a orientarse hacia la salud y la experiencia individual de cada persona. Sin embargo, aunque esta perspectiva se considera relevante para los pacientes trasplantados cardíacos, la atención sanitaria actual se sigue centrando en la prevención y el tratamiento de las complicaciones médicas, dejando de lado otros aspectos importantes de su vivencia. El objetivo de esta revisión sistemática de la literatura fue explorar la experiencia de vivir con un corazón trasplantado y las implicaciones vitales que esto supone. Se realizó una búsqueda en las bases de datos Pubmed, Cinahl, Scielo, Scopus, Dialnet, Cuiden y PsyINFO, y en revistas especializadas y se incluyeron 25 artículos cuyo análisis e interpretación se basó en la metodología propuesta por Dixon-Woods y col y por Evans. Los resultados se agruparon en siete categorías: repercusiones espirituales, repercusiones psicológicas, repercusiones sociales, relación con el donante y el órgano, repercusiones en el ámbito físico y calidad de vida, estrategias de afrontamiento, y sentimientos hacia los profesionales. Los resultados confirman la necesidad de que haya un cambio en la atención que se presta a las personas trasplantadas cardíacas. Se ha visto que aunque el trasplante mejora la calidad y la cantidad de vida, tiene múltiples repercusiones psicosociales que afectan al bienestar y al día a día de estos pacientes

The focus of healthcare professionals is shifting from illness to health and the individual experience of each person. However, current health care continues to focus on the prevention and treatment of medical complications, leaving aside other important aspects of the experience of cardiac transplant patiens. The aim of this systematic review of the literature was to explore how living with a transplanted heart affects their lives. We searched the databases Pubmed, Cinahl, Scielo, Scopus, Dialnet, Cuiden and PsyINFO, and specialized journals. Twenty-five articles were included for study. The analysis and interpretation of the results was based on the methodology by Dixon-Woods et al and by Evans. The results were grouped into seven categories: spiritual repercussions, psychological repercussions, social repercussions, relationship with the donor and the organ, repercussions in the physical environment and quality of life, coping strategies, and feelings towards the healthcare professionals. The results confirm the need for a change in the care given to cardiac transplant patients given that, although transplantation has been shown to improve the quality and quantity of life, it has multiple psychosocial implications that affect the well-being and day-to-day life of these patients

Cost and Factors Associated With the Hospitalization of Patients Undergoing Heart Transplantation.

OBJECTIVES: The aim of the study was to describe the cost and factors associated with the hospitalization of patients undergoing heart transplantation. METHODS: A cross-sectional, descriptive study with a quantitative approach developed at an important heart transplant center in southern Brazil. Twenty patients who had undergone transplantation during the period 2007 to 2016 were included in the study. Central tendency measures and values presented as mean ± SD or median and quartiles were calculated. Multiple linear regression was performed to verify the variables that interfered with the cost. RESULTS: The cost of hospitalization of patients undergoing heart transplantation was $522,997.26 in Brazilian reals ($220,002.58 in US dollars). The Brazilian public health system was responsible for paying the hospital bill of all patients. Female sex, patients up to 40 years of age, and length of stay in the hospital units were variables that were related to the highest values for the hospital service. Clinical complications of the patients during the hospitalization period were also factors that were related to the greater length of stay in the hospitalization units, reflecting higher expenses for the health institution. CONCLUSIONS: There is a need for health managers to implement strategies that will minimize complications, such as health care-related infections, that can be prevented during hospitalization and to stimulate the allocation of resources in order to improve care and reduce hospital expenses.

Impact of Donor Origin on Survival After Orthotopic Heart Transplantation.

Heart transplantation is the definitive management for select patients with end-stage heart failure. Owing to an ongoing organ donor shortage, organs are sometimes allocated from distant locales. These organs may be perceived as less desirable because of donor risk factors and ischemic times. We compared survival after heart transplantation by donors originating from British Columbia (BC), other Canadian provinces, and the United States. This retrospective cohort analysis included all patients transplanted in BC between December 1, 1988, and October 21, 2014, and excluded those with missing data or retransplantation. Among 382 patients, 297 (77.7%) recipients and 238 (62.3%) donors were male. The median recipient age was 54.6 years (interquartile range, 46.0-61.0 years) and the median donor age was 33 years (interquartile range, 22-46 years). Overall 10-year survival was 62.1% (95% confidence interval, 56.3-67.4). There was no difference in 10-year survival when comparing donors from BC, other Canadian provinces, and the United States despite significantly lower median ischemic times in donors from BC. Donor location was not predictive of mortality after controlling for recipient age, donor age, and cold ischemic time. Donor origin did not impact 10-year survival after heart transplantation despite increased ischemic time, suggesting that distant donors result in similar outcomes in BC.

Pediatric Orthotopic Heart Transplantation.

Since the first pediatric orthotopic heart transplant was performed by Dr Adrian Krantowicz in 1967, just days after the first ever human transplant by Dr Christiaan Barnard, the technique for orthotopic heart transplantation has evolved from biatrial anastomosis to separate caval anastomoses, leaving the right atrium intact. In this video tutorial, we present our technique for standard orthotopic heart transplantation in children.