Perioperative risk and long-term results of heart transplantation after previous cardiac operations.

BACKGROUND: In recent years, there has been an increasing proportion of candidates for heart transplantation who have sustained one or several previous cardiac operations. This study analyzes the perioperative management and the long-term survival of patients undergoing orthotopic heart transplantation as a redo operation and compares the results with those obtained in patients undergoing transplantation as the first cardiac operation. METHODS: From October 1985 to October 1994, 204 heart transplantations were performed in 202 patients. Thirty-eight transplantations were performed in patients who had undergone prior cardiac operations because of coronary artery disease (n = 21) and valvular disease (n = 8) as well as one or several palliative or corrective procedures because of complex congenital heart disease (n = 9). These 38 patients were compared in a case-control fashion with 76 patients who underwent orthotopic cardiac transplantation as a primary cardiac procedure during the same period and using similar techniques. The majority of preoperative variables (hemodynamics, inotropic support, liver and renal function, coagulation, and priority to transplantation) were comparable in the two groups of patients. Mean age was significantly younger in the group of patients with a previous operation (42.2 +/- 9.5 versus 50.1 +/- 7.3 years; p < 0.001). RESULTS: Except the problem of more fastidious hemostasis, which is nowadays under better control since aprotinin has been routinely administered, the results show no significant difference in term of perioperative risk (hospital mortality: 5.2% in study group versus 7.8% in the control group) and long-term outcome. The 1-year survival rate was 92.7% +/- 3.6% in the study group versus 90.8% +/- 3.6% in the control group, and the 5-year survival rate was 79.4% +/- 4.5% versus 74.8% +/- 7.5%, respectively. CONCLUSIONS: These results are very acceptable and confirm the fact that carefully selected candidates for transplantation are not exposed to a particularly high perioperative risk when a prior cardiac operation has been performed. The incidences of early and late rejection episodes as well as the numbers of postoperative infections are similar in the two groups. Although multiple prior procedures do constitute significant risk factors for perioperative morbidity and mortality in isolated lung and heart-lung transplantation, this is not the case in heart transplantation.

Should cardiac transplantation for congenital heart disease be delayed until adult age?

The number of pediatric heart transplantations for complex congenital heart disease has increased over the last years, but little experience has been reported in adolescent and adult populations. Between 1987 and 1992, 14 patients (mean age 33.2 years, range 14 to 51 years) were transplanted in our institution because of structural congenital heart disease (n = 9) or other rare disorders of the endomyocardial morphogenesis (n = 5). The main diagnosis included transposition of the great arteries, congenitally corrected transposition of the great vessels, left superior vena cava, tricuspid atresia with right ventricular hypoplasia, double outlet right ventricle with transposition, left ventricular sinusoidal malformation and right ventricular dysplasia. In several cases there were additional intracardiac malformations, including ventricular septum defect, atrial septum defect as well as different forms of pulmonary stenosis. Seven patients had undergone one or more palliative repairs that consisted of modified Blalock-Taussig shunts, Glenn's cavopulmonary anastomosis, Waterstone shunt, Blalock-Hanlon atrioseptectomy and Brock pulmonary valvotomy. Two patients had undergone Senning procedure for transposition of the great arteries. The donor cardiectomy was modified in order to include complete inflow and outflow tissue in the explant and transplantation could be performed without prosthetic material in all patients; deep hypothermic cardiac arrest was never necessary in this series. There was no early or late mortality after a mean follow-up of 37 months (range 4 to 74 months); postoperative echocardiography and cardiac catheterization demonstrated perfect anatomical and functional results in all patients. Adolescent and adult patients with complex congenital cardiac diseases can be transplanted with a very low perioperative risk, even after several prior operative procedures.(ABSTRACT TRUNCATED AT 250 WORDS)