Pregnancy-related allograft rejection following heart transplant.

Current recommendations do not discourage pregnancy in stable, orthotopic heart transplant (OHT) recipients who are more than 1 year posttransplant, although a highly specialized level of care with a multidisciplinary team is recommended. These patients may incur significant risk to themselves, their allograft, and/or their fetuses. Recognition and treatment of posttransplant complications in pregnancy also may be difficult. Although the risk of recurrent pregnancies in patients with peripartum cardiomyopathy (PPCM) is well defined, the risk of pregnancy after a PPCM patient has undergone OHT is unknown. A case of severe allograft rejection in a woman with a history of PPCM who became pregnant nearly 3 years after OHT is presented and her subsequent management is described. The data available on pregnancy after transplant are based on case reports, registry data, and reviews. The decision to become pregnant should be preceded by an extensive discussion including the patient, her partner, her obstetrician, and the transplant team, reviewing potential risks to her health as well as to her allograft and the fetus. Providers should be clear that many questions pertaining to pregnancy after transplant remain unanswered, and the patient should be comfortable going forward in this situation.

Living with a total artificial heart: patients' perspectives.

BACKGROUND: Advances in mechanical circulatory support have reduced morbidity and mortality in end-stage heart failure. To date, there have been no published studies examining the psychosocial impact on patients who are supported with a total artificial heart (TAH-t). PURPOSE: The purpose of this study was to describe the lived experience of patients currently supported by the TAH-t awaiting transplant. METHODS: A qualitative method using Giorgi's modification of phenomenologic inquiry guided the investigation, which was conducted at a transplant center located in the mid-Atlantic region of the United States. A purposive sample was selected to reflect participants currently supported by the TAH-t. All participants (9 men, 1 woman; mean age, 48.2 years; nonischemic etiology, 80%) were in-patients on the progressive care unit at the time of the interview and had been supported for at least 30 days. The mean length of device therapy was 84.7 days (range, 33-245 days). FINDINGS: Hope for the future was the overarching theme. Subthemes included reflections, for better or for worse, the secret club, and coping and adaptation. The patients reflected on severity of illness, progress, and expressed optimism. For better or for worse described how symptoms improved but were offset by restrictions imposed by the technology. The secret club described the support provided to help deal with their life situation. Coping and adaptation suggested that the patients came to terms with and accepted their circumstances. CONCLUSIONS: The findings will help clinicians understand patients experiencing a life-changing situation and implications for psychosocial interventions.

Lifestyle and health status differ over time in long-term heart transplant recipients.

OBJECTIVE: To describe differences in lifestyle and health status across 5 post-transplant periods. METHODS: The sample consisted of 126 heart transplant recipients (87% men) grouped by time after transplantation: group 1, 12 to 24 months (n= 13); group 2, 25 to 48 months (n= 19); group 3, 49 to 72 months (n=24); group 4, 72 to 96 months (n=27); and group 5, > or =97 months (n=43). Data were obtained using demographic and health status evaluation forms and the Lifestyle Profile-II, which measures physical activity, nutrition, health responsibility, interpersonal relationships, stress management, and spiritual growth. RESULTS: Most often reported lifestyle attributes were spiritual growth and interpersonal relationships. Least often reported was physical activity. Pairwise comparisons revealed that groups 3 (chi2 = 16.4; SD = 4.8; P = .03) and 4 (chi2 = 16.6; SD= 5.8; P = .04) had lower physical activity than group 2 (chi2 = 21.3; SD = 5.2). Health status evaluation revealed that there were no group differences in systolic (P = .46) or diastolic (P = .77) blood pressure. Although creatinine was elevated, there were no group differences (P = .86). High-density lipoprotein was higher than 42 mg/dL in all groups, but there were differences across groups in low-density lipoprotein (P = .003). Groups 1 (chi2 = 139.2; SD = 38.5) and 2 (chi2 = 141.0; SD = 47.8) were different than group 5 (chi2 = 112.9; SD = 36.1; P = .05). There were group differences in cholesterol (P = .002), with lower levels in groups 4 (chi2 = 190.5; SD= 38.6) and 5 (chi2 = 186.3; SD = 37.7) as compared to group 2 (chi2 = 230.8; SD = 66.5). CONCLUSIONS: Identifying posttransplant periods in which healthy behaviors and health status may be vulnerable to decline is important for providing ongoing education and psychological support to transplant recipients who manage a complex regimen.

Living with pulmonary artery hypertension: patients' experiences.

BACKGROUND: Research on the outcomes of medical therapy in persons with pulmonary artery hypertension (PAH) has increased as new therapeutic options have emerged. Little investigation has been done on the impact of living with PAH despite inferences that quality of life (QOL) improves. PURPOSE: The purpose of this qualitative study was to describe patient experiences of living with PAH and identify factors that may have an impact on QOL. PARTICIPANTS: Participants (n = 11; 8 women, 3 men) were selected from among 42 adult patients, 40 to 72 years of age, followed in an outpatient setting at a tertiary care hospital. Multiple types of treatment modalities were represented including calcium channel blockers, endothelin-receptor antagonists, prostacyclin analog, and lung transplantation. METHODS: Semistructured interviews allowed participants to describe experiences living with PAH. Interviews were recorded on audiotape and transcribed verbatim. Analysis was conducted in accordance with Colaizzi's 7-step process for analysis of phenomenologic data. RESULTS: Two overarching themes emerged indicating that participants experience uncertainty associated with a variety of aspects of this illness but also learn to cope with this uncertainty and move on with their lives. IMPLICATIONS: Assisting patients to cope with the uncertainty associated with this chronic health problem is essential if patients are to successfully adjust to the demands of the illness and its treatment. Attention to the findings of this study should guide health care professionals in their efforts to improve QOL in this patient population.

Surveillance Endomyocardial Biopsy in the Modern Era Produces Low Diagnostic Yield for Cardiac Allograft Rejection.

BACKGROUND: The changing epidemiology of cardiac allograft rejection has prompted many to question the yield of surveillance endomyocardial biopsy (EMB) in heart transplantation (HT) patients. We sought to determine the yield of EMB in the modern era. METHODS: We evaluated 2597 EMBs in 182 consecutive HT patients who survived to their first EMB. The EMBs were categorized as asymptomatic or clinically driven and were compared based on era of antiproliferative therapy use at our center (early azathioprine era: 1990-2000 vs modern mycophenolate era: 2000-2011). RESULTS: In the modern era, patients had a higher prevalence of risk factors for developing rejection (≥ International Society of Heart and Lung Transplantation grade 2R); however, the frequency of rejection was decreased at all times (0-6 months: 60.2% vs 21.5%, P < 0.001, 6-12 months: 26.8% vs 1.8%, P < 0.001, 12-36 months: 32.3% vs 10.5%, P = 0.006). The yield of asymptomatic EMB decreased in the modern era between 0 and 6 months (10.9% vs 3.12%), 6 to 12 months (17% vs 0%), and years 2 to 3 (6.1% vs 1.5%). In the early era, the odds ratio of rejection during asymptomatic EMB compared to a clinically driven EMB was 0.47 (95% confidence interval, 0.31-0.71) and was decreased in the modern era (0.17 [0.07-0.42], P = 0.04). The probability of detecting rejection on asymptomatic EMB was significantly reduced in the modern era, even after adjustment for tacrolimus and induction therapy (1% vs 8%, P < 0.001). CONCLUSIONS: The clinical yield of surveillance EMB has decreased in the modern era. The EMB in asymptomatic patients longer than 6 months after HT warrants further scrutiny.

Lifestyle and quality of life in long-term cardiac transplant recipients.

BACKGROUND: The purposes of this study were to describe long-term (>1 year) cardiac transplant recipients' perceptions of barriers to health-promoting behaviors; ability to manage their health, health-promoting lifestyle, health status and quality of life (QOL); and determine predictors of QOL. METHODS: Data were collected from 93 recipients who completed a self-report questionnaire incorporating: (1). patient characteristics; (2). barriers to health promotion, perceived health competence and health-promoting lifestyle; (3). perceived health status; and (4). QOL. All instruments used had acceptable reliability and validity. Objective measures of health status were retrieved from medical records. Data were analyzed using descriptive and comparative statistics, measures of association and multiple regression. RESULTS: Recipients were uncertain about their ability to manage their health; felt that barriers sometimes interfered with engaging in health-promoting behaviors; and often included health-promoting behaviors in their lifestyle. They rated their health as good and were moderately satisfied with life. Predictors of better perceptions of QOL included less education, longer time since transplant, ischemic etiology of heart failure, fewer barriers, higher perceived health competence and a health-promoting lifestyle (R(2) = 0.51; F = 14.77; p = 0.001). CONCLUSIONS: The present results provide information regarding factors that contribute to perceptions of quality of life after cardiac transplantation, have implications for identifying patients at risk for poor QOL, and sensitize clinicians to the need for ongoing patient education.

Evidence for racial disparity in cardiac transplantation survival rates.

Studies show that survival rates of cardiac transplantation are lower for African American transplant recipients than for Caucasians. Due to similarities in terms of etiology, treatment modalities and responses to these modalities, the authors examine some potential variables for survival of cardiac transplantation that have been well documented in both the renal transplantation literature and the medically managed congestive heart failure literature. The authors also discuss access to care, socioeconomic factors and immunological differences in attempting to identify relevant factors for survival of cardiac transplantation.

Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support.

BACKGROUND: The psychosocial assessment of candidates for transplantation (PACT), developed to assess candidates for heart transplant, has not been routinely used to assess left ventricular assist device (LVAD) candidacy. We examined the efficacy of the PACT to assess psychosocial outcomes in LVAD patients. METHODS: We reviewed patients who received LVAD implants between June 2006 and April 2011 and retrospectively applied the PACT. We determined the accuracy of identifying social success with the PACT and revised domains to reflect criteria influencing social success for LVAD patients. RESULTS: Forty-eight patients (72% men, 44% non-white, 50.4 years old) were divided into high-scoring and low-scoring groups. Nine patients with low PACT scores were falsely categorized as high-risk, whereas 4 with high scores had poor social outcomes. The score had a high positive-predictive value (0.86) but low negative-predictive value (0.31). The PACT was revised (modified [m]PACT) to measure indicators, such as social support and understanding of care requirements, identified to more closely affect LVAD outcome. The mPACT exhibited improved accuracy. A reclassification table was developed, and the net reclassification index was 0.32. The percentage of patients incorrectly classified for social risk decreased from 27% with the PACT to 8% with the mPACT. Patients with higher mPACT scores had decreased 30-day readmission rates (26% vs 67%, p = 0.045) after device implantation. CONCLUSIONS: By emphasizing social support, psychologic health, lifestyle factors, and device understanding, the mPACT showed improved performance in risk-stratifying candidates for LVAD therapy. Prospective validation is warranted.