The effect of a donor's history of active substance on outcomes following orthotopic heart transplantation.

OBJECTIVE: To review the short-term and long-term outcomes of using heart donors with a history of substance abuse. METHODS: Retrospective chart review was performed of heart recipients over an 8-year span. Charts provided demographics, mechanisms of donor death, and history of substance abuse. Additionally, charts were quarried for post-operative echocardiography and coronary angiogram results, serologic tests, and survival. RESULTS: Between January 1997 and December 2005, 689 heart transplants were performed, 150 (21.8%) had a history positive for substance abuse. The mean donor age was 34.5 years (range 16-62 years); most common cause of death was traumatic head injury in 87 donors (58.0%). Most patients (76.0%) had a history of 1 ppd smoking for > or =5 years, 89 (59.3%) had a history of inhaled drug use, 75 (50.0%) alcohol abuse, and 12 (8.0%) intravenous drug use. At a mean follow-up of 8.3 days, 68 hearts (45.3%) had normal, 36 (24.0%) mild, 23 (15.3%) moderate, and 10 (6.7%) severe ventricular dysfunction by echocardiography. Furthermore, 110 hearts (73.3%) had normal coronaries, 20 (13.3%) had mild, and 2 (1.3%) had evidence of moderate coronary artery disease (CAD) on coronary angiogram at a mean follow-up of 9.8 months (range 0.1-43.7 months). All recipients who received organs from known hepatitis B, or C positive, donors converted to positive serologies. Overall post-transplant survival for the group was 89.8% at a mean follow up of 43.3 months (range 5.8-108.6 months). CONCLUSIONS: A history of donor substance abuse does not have a negative impact on overall survival, cardiac function, risk of transplant associated coronary artery disease (TCAD). In patients who receive organs from virus positive donors, the risk of viral conversion is high, but survival seems not to be influenced.

Impact of donor high-risk social behaviors on recipient survival in cardiac transplantation.

OBJECTIVE: To investigate the impact of cardiac donor participation in high-risk social behaviors (HRSBs) on recipient survival. METHODS: Retrospective chart review queried cardiac transplantations performed at our institution from August 1994 to November 2007 involving donors known to have engaged in HRSBs. Kaplan-Meier methodology was used to analyze survival rates, and a Cox proportional hazards regression was performed to determine the impact of donor HRSBs on survival. RESULTS: We identified 143 donors with social histories containing the following HRSBs: incarceration (n=69), unprofessional tattoos or piercings (n=44), alternative lifestyle practice (n=11), cocaine use (n=60), heroin smoking (n=6), marijuana use (n=79), oral narcotic abuse (n=20), and intravenous drug use (n=21). At the time of donation, viral screens detected 10 donors who were hepatitis B virus (HBV) positive, 11 donors who were hepatitis C virus (HCV) positive, and no donors who were positive for the HIV. One-year and 5-year survival were 92.2% and 84.4%, respectively. Cox regression analysis found only donor HCV infection to be associated with poorer recipient survival (P=0.14). CONCLUSION: Using cardiac allografts from high-risk donors who are serologically negative for viruses does not seem to impact recipient survival. There is a considerable risk for transmission of HBV and HCV when these are detected by pretransplant screens. However, if pretransplant screening does not discover donor HBV, HCV, or HIV infection, it is unlikely that subclinical disease transmission will occur.

The impact of CytoGam on cardiac transplant recipients with moderate hypogammaglobulinemia: a randomized single-center study.

BACKGROUND: We have previously shown that the preemptive use of cytomegalovirus (CMV) immunoglobulin (Ig) replacement (CytoGam) decreases the incidence of opportunistic infections in cardiac transplant recipients with severe hypogammaglobulinemia. However, the impact of Ig replacement in moderately hypogammaglobulinemic patients is unknown. METHODS: Periodic monitoring of the IgG levels was done in 300 heart transplant recipients. Moderate hypogammaglobulinemia (IgG, 350-500 mg/dl) developed in 56 patients (18.6%). Thirty-three patients declined randomization but agreed to have their IgG levels monitored. Twenty-three patients were randomized to placebo (n = 10) or CytoGam (n = 13) at 105 +/- 63 days after transplantation. RESULTS: The baseline characteristics were similar. A significant reduction in CMV infection was noted in the CytoGam Group compared with the Placebo Group (15.4% [2/13] vs 60% [6/10], p = .039). Among patients who declined randomization, CMV infection developed in 13 (39.4%) of 33, and 6 (46.1%) of the 13 progressed to severe hypogammaglobulinemia. A trend for reduction in the average episodes of > or =grade 2 rejection during the 6-month period after randomization was noted in the CytoGam group (0.4 +/- 0.6 vs 1.4 +/- 1.3, p = 0.065). CONCLUSIONS: The preemptive use of CytoGam decreases the incidence of CMV infection in patients with moderate hypogammaglobulinemia. A larger randomized study is needed to substantiate these results.