Cancer Incidence in Heart Transplant Recipients With Previous Neoplasia History.

Neoplasm history increases morbidity and mortality after solid organ transplantation and has disqualified patients from transplantation. Studies are needed to identify factors to be considered when deciding on the suitability of a patient with previous tumor for heart transplantation. A retrospective epidemiological study was conducted in heart transplant (HT) recipients (Spanish Post-Heart Transplant Tumor Registry) comparing the epidemiological data, immu-nosuppressive treatments and incidence of post-HT tumors between patients with previous malignant noncardiac tumor and with no previous tumor (NPT). The impact of previous tumor (PT) on overall survival (OS) was also assessed. A total of 4561 patients, 77 PT and 4484 NPT, were evaluated. The NPT group had a higher proportion of men than the PT group (p < 0.001). The incidence of post-HT tumors was 1.8 times greater in the PT group (95% confidence interval [CI] 1.2-2.6; p < 0.001), mainly due to the increased risk in patients with a previous hematologic tumor (rate ratio 2.3, 95% CI 1.3-4.0, p < 0.004). OS during the 10-year posttransplant period was significantly lower in the PT than the NPT group (p = 0.048) but similar when the analysis was conducted after a first post-HT tumor was diagnosed. In conclusion, a history of PT increases the incidence of post-HT tumors and should be taken into account when considering a patient for HT.

Health-related quality of life, social support, and caregiver burden between six and 120 months after heart transplantation: a Spanish multicenter cross-sectional study.

A multicenter cross-sectional study was conducted to determine the current heart transplant (HTx) outcomes in Spain. Clinical and functional status, health-related quality of life (HRQoL), social support, and caregiver burden were analyzed in 303 adult transplant recipients (77.9% males) living with one functioning graft. Mean age at time of HTx (SD) was 56.4 (11.4) years, and the reason for transplantation in all patients was congestive heart failure. All patients had received a first heart transplant 6 (± 1), 12 (± 2), 36 (± 6), 60 (± 10), or 120 (± 20) months previously. Participants completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), the EQ-5D, the Duke-UNC Functional Social Support Questionnaire, and the Zarit Caregiver Burden Scale. Reasonable HRQoL, social support, and caregiver burden levels were found at all time points, although a slight decrease in HRQoL was recorded at 120 months (p ≤ 0.033). Multivariate regression analyses showed that complications, comorbidities, and hospitalizations were associated with HRQoL (EQ-5D: 48.4% of explained variance, F4,164 = 38.46, p < 0.001; KCCQ overall summary score: 45.0%, F3,198 = 54.073, p < 0.001). Patient functional capabilities and complications affected caregiver burden (p < 0.05). In conclusion, HTx patients reported reasonable levels of HRQoL with low caregiver burden. Clinical variables related to these outcomes included functional status, complications, and number of admissions.

Risk factors associated with cytomegalovirus infection in heart transplant patients: a prospective, epidemiological study.

BACKGROUND: The objectives of this epidemiological, prospective study were to describe the characteristics of cytomegalovirus (CMV) infection in heart transplant (HT) recipients and to identify the variables that may influence the development of CMV viremia and CMV disease in these patients. METHODS: HT recipients ≥18 years of age (n=199) were included in the study. Variables studied included CMV serostatus, immunosuppressive treatment, and administration of anti-CMV prophylaxis. RESULTS: The mean age of the population was 52 years, and 84% were males. Immunosuppressive regimens were administered as induction therapy to 92.5% of patients; 88.5% of patients received calcineurin inhibitors as maintenance therapy. Anti-CMV treatment was given to 59% of 199 patients as prophylaxis (70%), preemptive therapy (10%), or to treat CMV infection (20%). Overall, 43% of patients had at least 1 positive viremia test. No patient with a high-risk serostatus (donor+/recipient-) receiving prophylaxis developed CMV syndrome, and only 2.5% of 199 patients developed CMV invasive disease. Multivariate analysis showed that having a positive donor CMV serostatus was associated with an increased risk of developing CMV viremia (P<0.012), while use of mammalian target of rapamycin (mTOR) inhibitors was associated with a decreased risk (P=0.005). CONCLUSIONS: In a population of HT recipients, the CMV infection rate was similar to that seen in previous studies, but the progression to overt CMV disease was very low. Having a CMV-positive donor was identified as an independent risk factor for developing CMV viremia, while the use of mTOR inhibitors was protective against viremia.

Outcomes of heart transplantation for cardiac amyloidosis: subanalysis of the spanish registry for heart transplantation.

Amyloidosis (Am), a systemic disease, has poor prognosis because of organ damage produced by protein deposition in the extracellular space. Although heart transplantation (HTx) is possible, donor availability concerns and high mortality make this approach controversial. The Spanish Registry for Heart Transplantation includes 25 Am patients (54 +/- 9 years): 13 with AL type, 2 with AA and 10 with TTR mutation. Fifteen patients (60%) died during follow-up (4.9 +/- 1.3 years): 9 AL-Am patients, both AA-Am patients and 4 with TTR-Am. HTx survival for Am patients was similar to patients without Am at 1 month but significantly worse at 5 years: 46% versus 78% (p < 0.02). Of 10 AL-Am patients undergoing successful HTx, 4 died of systemic Am. Stem cell transplantation was performed in 3 (1 died of acute rejection). Five of 10 patients with TTR-Am underwent liver transplant; 4 remained alive at the last follow-up. Findings include poor outcome for AL-Am patients despite HTx and better survival for TTR-Am patients if HTx is associated with liver transplantation. Given the shortage of donors and poor outcome for Am patients, we would recommend that HTx be reserved for patients without or with mild systemic Am and be supplemented by additional therapies as indicated.

[Pharmacogenetic analysis of the absorption kinetics of cyclosporine in a population of Spanish cardiac transplant patients]. / Análisis farmacogenético de la cinética de absorción de ciclosporina en una población española de pacientes trasplantados cardíacos.

OBJECTIVE: To determine how single nucleotide polymorphisms located on genes MDR1, CYP3A4 and CYP3A5 affect the absorption kinetics of cyclosporine in cardiac transplant patients. METHOD: We selected a sample of 30 adult patients having previously undergone a primary cardiac transplant and who had received cyclosporine as an immunosuppressant. During the first month after the transplant, we performed a pharmacokinetic study of each patient to determine values in the cyclosporine concentration area under the 12-hour curve, steady-state cyclosporine concentration, maximum cyclosporine concentration, and time to reach that concentration. Single nucleotide polymorphisms were genotyped in all patients: MDR1 3435C > T, CYP3A4-390A > G and CYP3A5 6986A > G. RESULTS: Being a carrier of the T-allele for polymorphism MDR1 3435C > T is associated with higher values in the cyclosporine concentration area under the 12-hour curve (p = 0.01) and in steady-state cyclosporine concentration (p = 0.05), compared with those from patients who do not carry that allele. DISCUSSION: Our results show that genotype differences in MDR1 3435C > T can explain part of the variability in cyclosporine absorption among individuals in the population of Spanish cardiac transplant recipients.

Malignancy after heart transplantation: incidence, prognosis and risk factors.

The Spanish Post-Heart-Transplant Tumour Registry comprises data on neoplasia following heart transplantation (HT) for all Spanish HT patients (1984-2003). This retrospective analysis of 3393 patients investigated the incidence and prognosis of neoplasia, and the influence of antiviral prophylaxis. About 50% of post-HT neoplasias were cutaneous, and 10% lymphomas. The cumulative incidence of skin cancers and other nonlymphoma cancers increased with age at HT and with time post-HT (from respectively 5.2 and 8.9 per 1000 person-years in the first year to 14.8 and 12.6 after 10 years), and was greater among men than women. None of these trends held for lymphomas. Induction therapy other than with IL2R-blockers generally increased the risk of neoplasia except when acyclovir was administered prophylactically during the first 3 months post-HT; prophylactic acyclovir halved the risk of lymphoma, regardless of other therapies. Institution of MMF during the first 3 months post-HT reduced the incidence of skin cancer independently of the effects of sex, age group, pre-HT smoking, use of tacrolimus in the first 3 months, induction treatment and antiviral treatment. Five-year survival rates after first tumor diagnosis were 74% for skin cancer, 20% for lymphoma and 32% for other tumors.

Soluble HLA-G in heart transplantation: their relationship to rejection episodes and immunosuppressive therapy.

The aims of this study were to quantify the level of soluble HLA-G in heart transplant patients, to determine the relationship between the sHLA-G levels and the appearance of acute rejection episodes, and to identify the influence of immunosuppressive therapy on sHLA-G levels. Analysis of sHLA-G, measured by enzyme-linked immunosorbent assay in the transplant patients, revealed the existence of two similarly sized groups of patients. One group displayed a significant increase (p < 0.001) in sHLA-G during the first month after transplantation while the other group maintained low levels of the molecule (0-30 ng/ml) throughout the study. The latter group displayed a high incidence of recurrent severe rejection. A significant increase (p < 0.01) in sHLA-G 2 hours after administration of immunosuppressive treatment (mycophenolate mofetil, cyclosporine A/FK506, corticoids) was found. These results suggest that sHLA-G participates in the induction of certain levels of immunological tolerance in these recipients.

sHLA-G levels in the monitoring of immunosuppressive therapy and rejection following heart transplantation.

The aim of this study was to further determine the immediate influence, over a 12-h period, after the initiation of daily immunosuppressive treatment on the serum levels of sHLA-G in heart transplant patients during the post-transplant period (1 month). It was found that there are two patterns of patients in term of the changes observed in their levels of sHLA-G in response to the immunosuppressive treatment. One group (group A) showed no changes on sHLA-G while the other group (group B) a significant rise in sHLA-G levels was observed at 2 to 4 h post dose. Interestingly, it was observed that the patients in group B have better prognosis of acceptance of the heart graft than those of group A. On the other hand it was found that the patients with high levels of sHLA-G (77.3+/-34.8 ng/ml) in pre-transplant sera have a better prognosis of acceptance of the heart graft than those with low sHLA-G levels (9.7+/-7.1 ng/ml). In conclusion, both the intensity of changes of sHLA-G levels induced by immunosuppression and basal levels in pre-transplant could be used in the monitoring of the immunosuppression as well as the heart transplant evolution.

Relationship between pharmacokinetic parameters of cyclosporin and the incidence of acute rejection after heart transplantation.

Despite two decades of use, there are limited data on the best way to monitor Cyclosporine (CsA) for heart transplantation. The aim of our study was to determine the relationships between pharmacokinetic parameters and clinical outcomes after heart transplantation and to evaluate the range of CsA trough levels provided the most effective protection against graft rejection. We retrospectively analyzed the clinical outcomes of all adult patients who received a heart transplant between January 1998 and February 2005. All had routine monitoring of CsA trough levels and scheduled endomyocardial biopsies. Rejection was defined as grade > or =3, based on International Society for Heart and Lung Transplantation (ISHLT) criteria. Follow-up period was 1 year. All patients were on CsA, corticosteroids, and azathioprine/mycophenolate mofetil with or without antilymphocyte induction (eight patients with basiliximab). Data were analyzed by unpaired Student t-test, Cox regression model, and ROC curve. Among 70 patients (60 men and 10 women) who entered the study, 34 (48.6%) had at least one acute rejection episode of grade > or =3 during the first posttransplant year. Mean CsA trough level (C(0)) measured at first week posttransplant was significantly lower in the rejection than the no-rejection group (125.17 +/- 56.9 ng/mL versus 169.33 +/- 48.27 ng/mL, P = .001). C(0) was the strongest predictor of acute graft rejection (P = .000, HR = .985.) The risk decreased by 1.5% for each unit increase of the C(0) value. ROC analysis showed that C(0) of 150 ng/mL provided the optimal cutoff. Patients with mean C(0) >150 ng/mL over the first week had less incidence of acute rejection than patients with levels <150 ng/mL (30.3% versus 64.9%) (P = .009, Cochran-Mantel-Haenszel test). In conclusion, our data suggest that in heart transplant patients it may be crucial to target early trough levels above 150 ng/mL during the first days postsurgery to avoid rejection.

Comparison of the effectiveness of lovastatin therapy for hypercholesterolemia after heart transplantation between patients with and without pretransplant atherosclerotic coronary artery disease.

With the aim of assessing the effectiveness and safety of lovastatin in patients with hypercholesterolemia after heart transplantation, as well as the potential differences in the lipid-lowering effect of lovastatin between patients with or without pretransplant coronary artery disease (CAD), we studied 63 heart transplant patients who had serum total cholesterol > 250 mg/dl in spite of dietary therapy. Mean age of subjects was 47 +/- 2 years. Triple-drug immunosuppressive therapy consisted of cyclosporine, azathioprine, and steroids. Thirty-nine patients (62%) had pretransplant CAD and 24 (38%) did not. Pretreatment serum lipid levels were: total cholesterol, 302 +/- 32 mg/dl; low-density lipoprotein (LDL) cholesterol, 201 +/- 35 mg/dl; high-density lipoprotein (HDL) cholesterol, 60 +/- 19 mg/dl; triglycerides, 205 +/- 86 mg/dl; and total/HDL cholesterol ratio, 5.4 +/- 1.6. Patients received 10 to 40 mg/day of lovastatin (mean dose 17 +/- 6) for 13 +/- 4 months. There were no serious adverse events. At 3 months, lovastatin decreased total cholesterol by 15% (p < 0.001), LDL cholesterol by 21% (p < 0.001), triglycerides by 17% (p < 0.05), and total/HDL cholesterol ratio by 17% (p < 0.001), and increased HDL cholesterol by 3% (NS). Although lovastatin was effective in both patients with pretransplant CAD and non-CAD, analysis of its effect in each subgroup (CAD and non-CAD) revealed that its lipid-lowering effect was higher for non-CAD patients (-20% vs -12% for total cholesterol, and -27% vs -17% for LDL cholesterol, both p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal balloon dilatation for discrete subaortic stenosis.

Seven patients, mean age 8 +/- 3.6 years, with clinical and hemodynamic diagnoses of discrete subaortic stenosis were treated by percutaneous transluminal balloon dilatation (PTBD) of the membrane during cardiac catheterization. One patient had an associated aortic coarctation that was first dilated. After PTBD left ventricular (LV) systolic pressure decreased significantly, from 181 +/- 25 to 139 +/- 11 mm Hg (p less than 0.005); peak gradient diminished from 65 +/- 18 to 12 +/- 9 mm Hg (p less than 0.001). Mild aortic regurgitation was present in 6 patients during basal conditions. After PTBD, the same degree of regurgitation was observed in all but 1 patient, in whom it disappeared. There were no major complications. Clinical observations after PTBD were consistent with hemodynamic findings. Precordial thrill always disappeared and the peak murmur became earlier in systole. In 2 patients the discrete subaortic stenosis was clearly visualized at 2-dimensional echocardiography as a fixed subvalvular structure throughout the cardiac cycle. After dilatation this was only identifiable at its implantation base; during contraction there was no fixed structure at the LV outflow tract. Four patients were hemodynamically reevaluated 6.7 +/- 1.7 months later and were found to have LV pressure relief and a degree of aortic regurgitation similar to those observed immediately after PTBD.

Abrupt homeostatic responses to transient intracardiac occlusion during balloon valvuloplasty.

The present study analyzes the hemodynamics of intracardiac occlusive periods during balloon mitral or aortic valvuloplasty and compares them with immediate plasma levels of atrial natriuretic factor (ANF), vasopressin and renin activity. Forty-nine patients were studied; 33 of them had mitral stenosis and 16 had aortic stenosis. The mean age was 52 +/- 17 years. During dilations pressures were monitored from the ascending aorta and left atrium. Plasma levels of ANF, vasopressin and renin were serially determined at baseline, after diagnostic procedures, within 15 to 30 seconds after the first 2 occlusive dilations, and 1 and 7 hours later. There were no significant changes in plasma renin throughout the study stages. ANF and vasopressin significantly increased after the dilations. These hormonal changes were related to the significant hemodynamic changes observed during intracardiac occlusion. The left atrial pressure correlated directly and significantly (r = 0.54, p less than 0.001) with plasma ANF levels throughout the conditions. On the other hand, the plasma vasopressin also correlated (r = 0.76, p less than 0.001) with systemic pressure in an exponential fashion. These findings show that abrupt releases of ANF and vasopressin occur immediately after intracardiac occlusive periods as a response to the acute and transient hemodynamic changes observed.

Clinical and hemodynamic predictors of survival in patients aged < 65 years with severe congestive heart failure secondary to ischemic or nonischemic dilated cardiomyopathy.

To identify which clinical or hemodynamic parameters predict survival in patients with end-stage heart failure due to dilated cardiomyopathy, 130 consecutive patients aged < 65 years (mean 46 +/- 13) assessed for heart transplantation from May 1986 to April 1991 were studied. Mean follow-up was 15 +/- 11 months. Left ventricular ejection fraction was 22 +/- 7%. Left ventricular end-diastolic pressure was 27 +/- 9 mm Hg, and cardiac index was 2.2 +/- 0.6 liter/min/m2. Symptom class was IV in 91% of patients and III in 9%. Etiology was ischemic in 40% of patients and idiopathic in 60%. After intensive medical therapy, heart transplantation was considered indicated in 53% of patients, contraindicated in 20% and not indicated in 27%. Transplantation was performed in 36% of patients during follow-up, and 35% died and 29% were alive without transplantation. A comparison, excluding patients with transplantation, was performed between those who were alive and had survived > or = 6 months after assessment, and those who died. On multivariate analysis, the following 3 parameters were independent predictors of prognosis: intravenous inotropic requirement (p < 0.001), maximal, tolerated captopril dose (p = 0.013) and systolic blood pressure (p = 0.003). When patients with transplantation were considered as deaths, stabilization on medical therapy also reached statistical significance (p = 0.009). Classic prognostic markers including ventricular arrhythmias, left ventricular end-diastolic pressure, cardiac index, amiodarone therapy and etiology were not associated with prognosis in this homogeneous population of severely ill patients.

Comparison of lovastatin and bezafibrate on lipoprotein(a) plasma levels in cardiac transplant recipients.

Our results suggest that bezafibrate may be useful in the treatment of high Lp(a) levels in heart transplant patients.

The activation antigen CD69 is selectively expressed on CD8+ endomyocardium infiltrating T lymphocytes in human rejecting heart allografts.

We analyzed the presence of T-cell subsets (CD4/CD8) and the activation markers CD25 and CD69 in the cellular infiltrates of endomyocardium biopsies taken from transplanted human hearts. The results indicate that CD25 was present within specimens mainly infiltrated by CD4+ cells. In contrast, CD69 was found in infiltrated biopsies by CD8+ cells, as determined by single immunofluorescence. Double immunoenzymatic staining was used to investigate the cellular distribution of the activation markers studied in some representative cases. Thus, CD25 was found on both CD4+ and CD8+ cells while CD69 molecule was selectively expressed on CD8+ T-cell subset. These results suggest that CD69 is a surface molecule relevant to the CD8+ cell-mediated graft rejection events of allografted human hearts.

Spontaneous clinical and hemodynamic improvement in patients on waiting list for heart transplantation.

Heart transplantation is currently the most effective therapy for patients with severe heart failure due to dilated cardiomyopathy, although long-term survival without transplantation has been described in a few patients. We have identified five patients with severe heart failure who experienced a significant clinical and hemodynamic improvement while they were waiting for heart transplantation. At initial assessment, all five patients were symptom-class 4; left ventricular end-diastolic pressure was 33 +/- 4 mm Hg, left ventricular ejection fraction was 0.20 +/- 0.01, left ventricular end-systolic volume was 130 +/- 3 ml/min/m2, and cardiac index was 2.1 +/- 0.1 L/min/m2. These patients showed a marked improvement at two to ten months after initial assessment, while they were waiting for a donor heart. After a follow-up of 10 to 31 months (mean follow-up, 20 months), the five patients were still alive and their clinical and hemodynamic condition remained stable. On the contrary, survival was less than 15 percent at six months for the remaining patients with indications for heart transplantation but in whom transplant could not be performed because of the existence of contraindications or lack of donors; all these patients were dead at 18 months after initial assessment. The five patients who developed spontaneous favorable outcome showed a trend to have higher serum sodium values, shorter symptomatic history, lesser need for intravenous inotropic support, and better response to medical therapy than the other patients. Our findings suggest that some patients with transplants could have experienced a sustained and spontaneous clinical and hemodynamic recovery with medical therapy alone, although it seems currently difficult to identify patients with this favorable outcome.

Heart transplantation in Spain: the Spanish National Registry of Heart Transplantation (1984-1992).

The first heart transplantation in Spain was performed in 1984. Since then, 950 patients had undergone heart transplantation in our country as of December 1992. Data from all these 950 patients have been reported to the Spanish National Registry of Heart Transplantation since its inception in 1989. Follow-up is complete for all patients. Mean age of recipients was 46 +/- 14 years; 86% were male patients. Almost 50% of all heart transplant procedures were performed in 1991 (232 patients, 6 per million persons) and 1992 (254 patients, 6.6 per million). Twelve centers have performed heart transplantations in Spain. Of the 950 procedures, 907 (95%) have been orthotopic, 6 (0.6%) heterotopic, 16 (1.7%) heart-lung transplantations, and 21 (2.7%) retransplantations. Mortality on waiting list was 8% in 1991 and 5.2% in 1992. Idiopathic (47%) and ischemic (37%) cardiomyopathy were the two main causes leading to transplantation. Mean recipient age has increased from 38 years in 1985 to 50 in 1992; 50% of all patients who underwent transplantation in 1992 were older than 50 years of age, with 11% older than 60 years of age. Actuarial survival was 74% at 1 year and 63% at 6 years, which is similar to that of the International Society for Heart and Lung Transplantation Registry. One-year survival increased from 61% for patients receiving transplants in 1985 to 77% for those who received transplants in 1992. One-month mortality decreased from 23% in 1985 to 12% in 1992.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of heart transplantation in recipients with active infection.

Although active infection in the recipient is generally considered to be an absolute contraindication for heart transplantation, seven of our first 104 transplant patients (6.7%) had active severe infection within the week before transplantation. Because of unstable clinical condition of these recipients, heart transplantation was performed when an adequate donor was offered, in spite of infection. Patients were managed with cyclosporine as the only immunosuppressive therapy during the first week after transplantation. Mortality rate and incidence of acute rejection were not different for these seven patients than for the remaining 97 patients.

A randomized study comparing deflazacort and prednisone in heart transplant patients.

Prednisone is widely used by most heart transplantation units despite its frequent side effects. Deflazacort, an oral synthetic steroid with fewer side effects, has been successfully used in patients after heart transplantation, but a prospective study comparing deflazacort and prednisone in transplant patients is lacking. We have carried out, in the last year, a prospective trial of deflazacort versus prednisone involving 35 consecutive heart transplant patients. Two of these patients died perioperatively (surgical mortality, 5.7%), and another two were excluded from the protocol because of diabetes mellitus in one patient and active infection before transplantation in the other patient. Thus 31 patients were enrolled in the 3-month study. All of them were treated with antithymocyte globulin, 10 mg/kg/day for 3 days after transplantation, azathioprine, and cyclosporine; patients were randomly assigned groups: 15 patients to receive deflazacort therapy, 1.5 mg/kg/day, and 16 patients to receive prednisone therapy, 1 mg/kg/day, starting the first day after transplantation. Steroids were rapidly tapered, reaching the maintenance dose at 2 to 3 weeks after transplantation (prednisone, 0.15 mg/kg/day; deflazacort, 0.25 mg/kg/day). Both groups were similar in terms of age, gender, ABO identity, serum cyclosporine levels, azathioprine dosage, and pretransplantation serum glucose and lipids levels. Seven endomyocardial biopsies were performed on each patient, at 1, 2, 3, 5, 7, 10, and 13 weeks after transplantation. Incidence of acute rejection was similar between prednisone and deflazacort groups; 33% of patients receiving prednisone therapy and 42% of patients receiving deflazacort therapy had one episode of 3A or higher rejection (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of heart transplantation on the natural history of patients with severe congestive heart failure.

In an attempt to study the influence of heart transplantation on the natural history of patients with severe congestive heart failure, we have reviewed our experience with 240 consecutive patients who were New York Heart Association class IV or III/IV, who had left ventricular ejection fraction less than 35%, who were younger than 65 years of age, and who were assessed for heart transplantation in our hospital since May 1986. Mean age was 47 +/- 12 years. Left ventricular ejection fraction was 20% +/- 6%. Eighty-seven percent were male. New York Heart Association class was IV in 88% and III/IV in 12%. The cause was ischemic heart disease in 35% of patients, valvular heart disease in 13% of patients, and primary dilated cardiomyopathy in 52% of patients. At initial assessment, heart transplantation was considered to be not indicated in 30% of patients, indicated in 51% of patients, and contraindicated in 19% of patients. During a follow-up of 13 +/- 13 months (2 to 64 months), 110 patients underwent transplantation (46%). Posttransplantation actuarial probability of survival was 70% at 3 years. Three-year probability of survival free from transplantation was significantly lower for patients older than 55 years of age (p < 0.05), for those with left ventricular ejection fraction less than 20% (p < 0.05), ischemic causes (p < 0.05), New York Heart Association class IV (p < 0.001), and indication/contraindication for transplantation (p < 0.001); no difference was noted for gender.(ABSTRACT TRUNCATED AT 250 WORDS)