Heart retransplantation: the 25-year experience at a single institution.

BACKGROUND: The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford. METHODS: There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% +/- 8%, 33% +/- 8%, and 22% +/- 7%, respectively. RESULTS: This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% +/- 2%, 62% +/- 2%, 44% +/- 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% +/- 10% versus 33% +/- 16%), but the 5-year survival was similar in both groups (34% +/- 11% versus 33% +/- 16%). Since 1981, actuarial freedoms from infection and rejection were 22% +/- 8% and 41% +/- 9%, respectively, at 1 year, and 7% +/- 7% and 36% +/- 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I. CONCLUSIONS: We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.

Randomized, prospective assessment of bioprosthetic valve durability. Hancock versus Carpentier-Edwards valves.

BACKGROUND: Although the major limitation of porcine valves is their finite durability, no controlled clinical data exist regarding the relative durability of the two porcine bioprostheses implanted most commonly today, the Carpentier-Edwards (C-E) and Medtronic Hancock I (H) valves. METHODS AND RESULTS: To assess this question, 174 patients undergoing aortic (AVR) or mitral (MVR) valve replacement with a bioprosthesis between March 1980 and March 1982 were randomized to receive either a C-E or a H valve. There were 102 AVRs (54 C-E and 48 H) and 74 MVRs (39 C-E and 35 H). For both the AVR and MVR cohorts, the average patient age was 58 +/- 14 years (+/- SD). The male/female ratio was 2.2:1 for AVR and 0.57:1 for MVR. Clinical follow-up was undertaken periodically; the most recent follow-up closing interval was July through October 1992, and current follow-up was 96% complete. Cumulative follow-up totaled 1369 patient-years (mean, 7.7 +/- 3.6 years; median, 9.1 years; maximum, 12.0 years). The main focus of this analysis was bioprosthetic durability, using the AATS/STS guidelines defining "Structural Valve Deterioration" (SVD). Multivariate analysis revealed that (younger) age was the only significant (P = .024) independent predictor of SVD. Valve manufacturer (C-E versus H) and valve site (aortic versus mitral) did not emerge as significant independent risk factors for SVD. Actuarial rates (Cutler-Ederer) expressed as percent free of SVD (+/- SEM) at 10 years (n = number of patients remaining at risk) were 71 +/- 7% and 59 +/- 9% for the C-E (n = 26) and H (n = 17) groups, respectively, for the AVR cohort; for the MVR cohort, these estimates were 60 +/- 10% (n = 12) and 72 +/- 10% (n = 11), respectively, but these differences were not statistically significant (P = NS, Lee-Desu). CONCLUSIONS: After 10 years, there was no statistically significant difference in durability or other valve-related complications between the H and C-E aortic or mitral valves. Based on current information, the choice of a porcine bioprosthesis should be based on factors other than durability, including ease of implantation, hemodynamic performance, and cost.

Eight-year results of cyclosporine-treated patients with cardiac transplants.

To elucidate the long-term effects of cyclosporine, we retrospectively studied 310 consecutive patients who have undergone cardiac transplantation at our institution since December 1980 and in whom immunosuppression has been maintained with cyclosporine. The ages of recipients ranged from 1 month to 64 years and of donors from 1 month to 48 years. The actuarial survival rates for cyclosporine-treated patients were 80.7% at 1 year and 59.7% at 5 years and were significantly greater than those for previous patients not treated with cyclosporine (p less than 0.005). Their actuarial prevalence of rejection was 60.0% at 1 month and 86.9% at 1 year; 206 patients are living. The actuarial prevalence of lymphoma development was 4.6% at 5 years but has been significantly lower with the current immunosuppression protocol of lower doses of cyclosporine, and OKT3 in place of rabbit anti-thymocyte globulin (p less than 0.005). Infection remains the most common cause of death. Recipients less than 50 years of age had a significantly higher actuarial survival than older recipients (p less than 0.01). Male and female recipients had similar overall prevalence of survival and rejection, but men died of graft atherosclerosis significantly more frequently (p less than 0.005). Rehabilitation has been successful in 85% of patients surviving 1 year after transplantation. Of those surviving 1 year, 96.5% were in New York Heart Association class I. Thus the results of orthotopic cardiac transplantation have improved since the introduction of cyclosporine and have allowed measured liberalization of the criteria for recipient selection.

Cardiac transplantation in perspective for the future. Survival, complications, rehabilitation, and cost.

Two hundred twenty-seven cardiac transplant procedures have been performed in 206 patients from January, 1968, to April, 1981. Postoperative survival rates, calculated by the actuarial method for program years 1968 to 1973 (66 patients), are 44%, 33%, 27%, 21%, and 18% at 1, 2, 3, 4, and 5 years after transplantation, respectively. Postoperative survival rates for program years 1974 to 1981 (140 patients) are 63%, 55%, 51, 44%, and 39% at 1, 2, 3, 4, and 5 years after transplantation, respectively. This increase results primarily from improvement in survival achieved in the first 3 postoperative months (59% +/- 7%, 1968 to 1973, versus 80% +/- 40%, 1974 to 1980), reflecting improved patient management. Infection remains the primary cause of death following transplantation (76/131 patients, 58%), followed by acute rejection (24/181, 18.3%), graft arteriosclerosis (14/131, 10.7%), and malignancy (6/131, 4.6%). The development of graft arteriosclerosis has been examined in 85 one-year survivors studied by annual coronary arteriograms. Coronary lesions of varying severity have developed in 21 patients. HLA-A2 incompatibility was associated with a higher incidence of graft arteriosclerosis than was apparent for all other A locus incompatibilities (p less than 0.0003). Lymphoma has been shown to be associated with younger recipient age, a primary disease diagnosis of idiopathic cardiomyopathy, and retransplantation. One hundred six patients have survived at least 1 year after transplantation; 97% were in NYHA Class 1 at that time interval and 82% returned to employment or activity of choice. The longest survival time is new 11 years, 3 months. Cardiac transplantation can be considered "reasonable and therapeutic treatment to extend life" in selected individuals.

Therapeutic efficacy of intraaortic balloon pump counterpulsation. Analysis with concurrent "control" subjects.

During a 7-year period, intraaortic balloon pumping (IABP) was attempted in 319 cardiac surgical patients. The indications for IABP were stringent and consisted of unsuccessful discontinuation of cardiopulmonary bypass (39%), anticipated failure (40%) to wean from cardiopulmonary bypass, postoperative low cardiac output, or intractable ventricular tachyarrhythmias (15%). IABP support was successfully instituted in 280 patients and was unsuccessful in 39 patients ("controls"). These two groups were comparable except for an older mean age and a higher ejection fraction in controls. Operative mortality rates were 45% and 62% for IABP and control groups, respectively (p = 0.077). This difference was most evident in coronary artery bypass patients, in whom the decision to institute IABP counterpulsation was made intraoperatively before attempted discontinuation of cardiopulmonary bypass. Two years postoperatively the actuarial survival rate was 45 +/- 3% for the IABP group and 23 +/- 9% for the control group (p = 0.006). After exclusion of operative deaths, however, these survival rates were 81 +/- 3% and 60 +/- 20%, respectively (p = NS). The average hospital charge incurred by IABP patients was threefold greater than that of uncomplicated cardiac surgical procedures. We conclude that IABP counterpulsation is therapeutic for some cardiac surgical patients, but its benefits cannot be defined easily. The long-term survival rates for patients with advanced disease requiring IABP support perioperatively are poor and warrant continued development of more effective methods of mechanical circulatory assistance and heart replacement.

Two dimensional echocardiographic assessment of patients with bioprosthetic valves.

The clinical utility of two dimensional echocardiography in assessing bioprosthetic and left ventricular function was studied in 40 consecutive patients 1 week to 60 months after valve replacement surgery. These patients were referred to obtain normal baseline studies as well as to evaluate complications:suspected endocarditis, embolic phenomena and congestive heart failure of unknown cause. Independent M mode echocardiograms were also obtained in each patient. Confirmation of ultrasonic studies was by cardiac catheterization with angiography, surgery and pathologic study in 10 patients; cardiac catheterization with angiography alone in 7 patients; surgery and pathologic study in 3 patients; autopsy in 3 patients; blood cultures to confirm or exclude endocarditis in 10 patients; and confirmation on clinical grounds in 7 patients. Technically adequate two dimensional studies were recorded in 39 of 40 subjects. Two dimensional echocardiography accurately assessed 15 of 16 patients with an abnormal bioprosthetic valve and a normal left ventricle (1 of 16 patients had a false positive two dimensional echocardiogram); 8 of 8 patients suspected to have prosthetic valve or left ventricular dysfunction but who were normal; 7 of 7 patients with a normal prosthesis and an abnormal left ventricle; the one patient with an abnormal valve and left ventricle; and 7 of 7 clinically normal patients who were referred for baseline studies. In summary, the two-dimensional echocardiogram demonstrated a 97 percent diagnostic accuracy rate which was significantly greater than the 67 percent (P less than 0.001) for M mode echocardiography in the same group of patients. It is concluded that two dimensional echocardiography has excellent diagnostic accuracy in assessing bioprosthetic and left ventricular function and is superior to M mode echocardiography in evaluating patients after such valve replacement.