Preoperative Right Heart Dysfunction and Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices.

Gastrointestinal bleeding (GIB) is a common cause of morbidity among patients supported by left ventricular assist devices (LVADs). The aim of this study was to identify if pre-LVAD right ventricular (RV) dysfunction is associated with risk of GIB after LVAD implantation. Of 398 patients implanted with LVADs between July 2008 and July 2016, 130 (33%) developed GIB at a median of 2.6 months following LVAD implantation. Arteriovenous malformations (AVMs) were found in 42 (34%) GIB patients. Patients with GIB were older and more likely to have hypertension, diabetes, and ischemic cardiomyopathy. On pre-LVAD echocardiography, GIB patients had increased RV diastolic dimension (4.7 ± 0.8 vs. 4.4 ± 0.9 cm, p = 0.02), a higher rate of greater than mild tricuspid valve (TV) regurgitation (73 [60%] vs. 120 [47%], p = 0.006), and underwent TV repair more often (38 [30%] vs. 43 [16%], p = 0.0006) during LVAD implantation. After multivariable adjustment, preoperative greater than mild RV enlargement (hazard ratio [HR] 2.32, 95% CI 1.12-5.03; p = 0.03), TV regurgitation (HR 1.83, CI 1.02-3.44; p = 0.01), and TV repair (HR 3.76, confidence interval [CI] 1.02-4.44; p = 0.01) remained associated with risk of GIB. This finding was driven by the AVM-GIB subgroup. Preoperative RV enlargement and TV regurgitation are associated with post-LVAD AVM-related GIB.

Clinical characteristics and outcomes of patients with severe left ventricular dysfunction undergoing cardiac MRI viability assessment prior to revascularization.

Coronary artery bypass grafting improves survival in patients with ischemic cardiomyopathy, however, these patients are at high risk for morbidity and mortality. The role of viability testing to guide revascularization in these patients is unclear. Cardiac magnetic resonance imaging (CMR) has not been studied adequately in this population despite being considered a reference standard for infarct imaging. We performed a multicenter retrospective analysis of patients (n = 154) with severe left ventricular systolic dysfunction [ejection fraction (EF) < 35%] on CMR who underwent CMR viability assessment prior to consideration for revascularization. Using the AHA16-segment model, percent total myocardial viability was determined depending on the degree of transmural scar thickness. Patients with or without revascularization had similar clinical characteristics and were prescribed similar medical therapy. Overall, 43% of patients (n = 66) experienced an adverse event during the median 3 years follow up. For the composite outcome (death, myocardial infarction, heart failure hospitalization, stroke, ventricular tachycardia) patients receiving revascularization were less likely to experience an adverse event compared to those without revascularization (HR 0.53, 95% CI 0.33-0.86, p = 0.01). Patients with > 50% viability on CMR had a 47% reduction in composite events when undergoing revascularization opposed to medical therapy alone (HR 0.53, p = 0.02) whereas patients with a viability < 50% were 2.7 times more likely to experience an adverse event (p = 0.01). CMR viability assessment may be an important tool in the shared decision-making process when considering revascularization options in patients with severe ischemic cardiomyopathy.

Impact of donor smoking history on post heart transplant outcomes: A propensity-matched analysis of ISHLT registry.

PURPOSE: Smoking is a major public health issue, and its effect on cardiovascular outcomes is well established. This study evaluates the impact of donor smoking on heart transplant (HT) outcomes. METHODS: HT recipients between January 1, 2005, and December 31, 2016, with known donor smoking status were queried from the International Society of Heart and Lung Transplantation (ISHLT) registry. The primary outcome was all-cause mortality, and secondary endpoints were graft failure, acute rejection, and cardiac allograft vasculopathy. We utilized propensity-score matching to identify cohorts of recipients with and without a history of donor smoking. Hazard ratios for post-transplant outcomes for the matched sample were estimated from separate Cox proportional hazard models. RESULTS: Of 26 390 patients in the cohort, 18.9% had history of donor smoking. Donors with history of smoking were older, predominantly male and had higher incidence of diabetes, hypertension, cocaine use, and "high-risk" status. In propensity-matched analysis, recipients with a history of donor smoking had increased risk of death (HR 1.11, 95% CI 1.03-1.20) and higher risk of graft failure (HR 1.11, 95% CI 1.03-1.20). CONCLUSION: Donor smoking was associated with increased mortality and higher incidence of graft failure following HT. Consideration of donor smoking history is warranted while evaluating donor hearts.

Elevated Heart Rate Following Heart Transplantation Is Associated With Increased Graft Vasculopathy and Mortality.

BACKGROUND: The effect of elevated heart rate (HR) on outcomes after heart transplantation (HT) has not been well established. The aim of this study was to assess predictors of elevated HR following HT and its impact on outcomes. METHODS AND RESULTS: We retrospectively evaluated 394 patients who underwent HT at 2 academic medical centers from 2005 to 2016. Patients were divided into 2 groups based on HR 1 year after HT: HR ≥95 beats/min (n = 162; 41%) and HR <95 beats/min (n = 232; 59%). Median follow-up time was 6.6 (interquartile range [IQR] 2.2-7.5) years. HR ≥95 beats/min 1 year after HT was associated with younger donor age, whereas HR <95 beats/min was associated with heavy donor alcohol use and African-American recipient race. Left ventricular (LV) end-diastolic dimension, mass, and ejection fraction were lower and E/E' higher in the HR ≥95 group at the time of the last follow up. HR ≥95 beats/min at 1 year after HT was independently associated with the development of cardiac allograft vasculopathy and increased mortality. CONCLUSIONS: HR ≥95 beats/min 1 year after HT is associated with a reduction in LV size and function, increased incidence of cardiac allograft vasculopathy, and reduced survival. Studies investigating the effect of medical HR reduction on post-HT outcomes are warranted.

Early immune biomarkers and intermediate-term outcomes after heart transplantation: Results of Clinical Trials in Organ Transplantation-18.

Clinical Trials in Organ Transplantation-18 (CTOT-18) is a follow-up analysis of the 200-subject multicenter heart transplant CTOT-05 cohort. CTOT-18 aimed to identify clinical, epidemiologic, and biologic markers associated with adverse clinical events past 1 year posttransplantation. We examined various candidate biomarkers including serum antibodies, angiogenic proteins, blood gene expression profiles, and T cell alloreactivity. The composite endpoint (CE) included death, retransplantation, coronary stent, myocardial infarction, and cardiac allograft vasculopathy. The mean follow-up was 4.5 ± SD 1.1 years. Subjects with serum anti-cardiac myosin (CM) antibody detected at transplantation and at 12 months had a higher risk of meeting the CE compared to those without anti-CM antibody (hazard ratio [HR] = 2.9, P = .046). Plasma VEGF-A and VEGF-C levels pretransplant were associated with CE (odds ratio [OR] = 13.24, P = .029; and OR = 0.13, P = .037, respectively). Early intravascular ultrasound findings or other candidate biomarkers were not associated with the study outcomes. In conclusion, anti-CM antibody and plasma levels of VEGF-A and VEGF-C were associated with an increased risk of adverse events. Although this multicenter report supports further evaluation of the mechanisms through which anti-CM antibody and plasma angiogenesis proteins lead to allograft injury, we could not identify additional markers of adverse events or potential novel therapeutic targets.

The effect of donor alcohol abuse on outcomes following heart transplantation.

BACKGROUND: Current guidelines recommend against the use of hearts from donors that abuse alcohol. We explored the effect of donor alcohol abuse (AA) on cardiac allograft function and outcomes in heart transplant (HTx) recipients. METHODS: Overall, 370 HTx recipients were divided into two groups: (a) the alcoholic donor group (AD, n = 58) and (b) the non-alcoholic donor group (NAD, n = 312). RESULTS: Recipients in the AD group had a slower heart rate (86 ± 13 vs 93 ± 13, P = 0.004) and an increased incidence of early atrial fibrillation (AF) (30% vs 11%, P = 0.003). Echocardiographic left ventricular mass was higher among alcoholic donors (171.7 ± 66.7 vs 151.6 ± 54.7, P = 0.02). This difference remained present 1 year following HTx (185 ± 43 vs 166 ± 42, P = 0.007). E/E' was higher in the AD group (9.5 ± 3.9 vs 8.4 ± 2.9, P = 0.04) and a larger number of AD recipients had a ventilatory equivalent for VCO2  > 34 (50% vs 31%, P = 0.04) on cardiopulmonary exercise test. There was no significant difference in rejection, cardiac allograft vasculopathy (CAV), or survival between the groups. CONCLUSIONS: Our data suggest that donor AA does not impact rejection, CAV, or intermediate-term survival, but may cause increased incidence of post-HTx AF and impaired cardiac allograft diastolic function.

The value of psychosocial factors in patient selection and outcomes after heart transplantation.

Heart transplantation remains the gold standard treatment for advanced heart failure, although its use is limited by donor organ availability. To ensure that the rare resource of a donor heart is allocated appropriately, the evaluation of the heart transplant candidates includes extensive medical and psychosocial assessments. These psychosocial factors are critically important to understand pre-heart transplant because it is known that psychosocial evaluation and psychosocial comorbidities have a strong association with post-heart transplant outcomes. The critical factors to assess are psychological functioning, adherence to medical recommendations, and social support. These factors are likely inter-related and have been shown to have an effect on the health-related quality of life and overall survival. Recently, new tools have been developed to standardize the evaluation process. In this review, we will discuss the tools available to assess psychosocial factors in the transplant candidate and discuss the role these factors have on post-heart transplant outcomes.

Incidence of fractures after cardiac and lung transplantation: a single center experience.

Osteoporotic fractures are well-known complications of organ transplantation. Fracture rates up to 35% have been previously reported following heart and lung transplantations. Our institutional pretransplant protocols include DXA scans, vitamin D screening, and appropriate antiresorptive therapy. We aimed to assess the incidence of fragility fractures following cardiac or lung transplantation. In a retrospective study 210 electronic medical records of patients who underwent LT (110 men, 100 women) and 105 HT (88 men, 17 women) between 2005 and 2010 were analyzed. Both clinical and radiographic fractures were recorded. DXA scans were obtained immediately after transplant. 17 out of 210 LT patients (8.0%) had fractures after transplantation and 9 out of 105 HT patients (8.6%) had fractures. The median time to the first fracture was 12 months and the mean time was 18 months for both LT and HT. In the HT recipients, the median femoral neck T score was statistically lower in the fracture group versus the nonfracture group. Similar results were seen in the LT patients. Conclusion. Our findings demonstrate a much lower incidence of fractures in heart and lung transplant recipients in comparison with earlier reports. Comprehensive bone care and early initiation of antiresorptive therapy are possible contributors to these improved outcomes.

Neurologic aspects of heart transplantation.

Cardiac transplantation remains the best treatment option for patients with end-stage, NYHA class IV heart failure who have failed conventional therapy. However, transplant rates have remained static largely due to limited organ donor supplies. Therefore, appropriate allocation of this precious resource is critical to maximize benefit, both at a patient level and at a societal level. Neurologic diseases, such as cerebrovascular disease and peripheral neuropathy, are prevalent in this patient population, as the major risk factors for heart disease place patients at risk for neurologic disease as well. Examples include hypertension, smoking, hypercholesterolemia, obesity, and diabetes. Pretransplant neurologic evaluation is very important to identify conditions that may limit survival after cardiac transplantation. In general, systemic diseases exacerbated by immunosuppression, conditions limiting ability to rehabilitate, and dementias are considered contraindications. Post-transplant neurologic complications are divided into central versus peripheral, and early versus late. The most common early complication is ischemic stroke. Other serious complications include hemorrhagic stroke, encephalopathy, and critical illness neuropathy. Over the long term, post-transplant immunosuppressive regimens are considered "a double edged sword." Although immunosuppressive medications are critical to preventing rejection and allograft dysfunction, they do have significant risk of morbidity and mortality associated with them, including neurologic side-effects. These include: (1) drug toxicities, such as lowering of seizure thresholds; (2) encephalopathy, such as posterior reversible encephalopathy syndrome (PRES); (3) infections; (4) malignancies, such as post-transplant lymphoproliferative disorder (PTLD). Many of the same considerations discussed in adult heart transplant recipients apply to pediatric heart transplant recipients as well. In children, seizures are the most common neurologic complication, although other neurologic complication rates are comparable.

Variations in institutional staffing and clinical practice are predictive of center-specific 1-year survival post-transplant.

BACKGROUND: The accuracy of various risk models to predict early post-transplant mortality is limited by the type, quality, and era of the data collected. Most models incorporate a large number of recipient-derived and donor-derived variables; however, other factors related to specific institutional practices likely influence early mortality. The goal of this study was to determine if the addition of institutional practice variables would improve the predictive accuracy of a recipient/donor risk model in a modern cohort of heart transplant recipients. METHODS: Between 1999 and 2007, 3,591 primary heart transplants were performed at the 26 institutions participating in the Cardiac Transplant Research Database. Multivariable regression analysis in the hazard domain was used to identify recipient, donor, and institutional practice variables that were predictive of 1-year mortality. The derived model was used to predict institutional outcomes and compare them with observed outcomes first without and then with the inclusion of the institutional practice variables. RESULTS: Eleven individual plus 2 interaction recipient variables and 2 individual plus 2 interaction donor variables were predictive of increased mortality. The addition of institutional practice variables to the model identified 4 variables associated with decreased mortality: greater number of transplant cardiologists, a thoracic surgery fellowship, a surgery or cardiology attending taking donor call, and routine surveillance for antibody-mediated rejection. By using a p-value > 0.10 as a robust measure of similarity, the addition of institutional practice variables increased the number of institutions with similar predicted vs. observed mortality from 18 of 26 institutions (69%) to 26 of 26 (100%), demonstrating improved predictive accuracy of the model. CONCLUSIONS: Multiple recipient and donor variables influence early survival but do not fully explain the difference in predicted and observed outcomes at the institutional level. Variations in staffing and clinical practice contribute to risk, and the addition of these variables to our risk model improved predictive accuracy.

Regulation of connective tissue growth factor gene expression and fibrosis in human heart failure.

BACKGROUND: Heart failure (HF) is associated with excessive extracellular matrix (ECM) deposition and abnormal ECM degradation leading to cardiac fibrosis. Connective tissue growth factor (CTGF) modulates ECM production during inflammatory tissue injury, but available data on CTGF gene expression in failing human heart and its response to mechanical unloading are limited. METHODS AND RESULTS: Left ventricle (LV) tissue from patients undergoing cardiac transplantation for ischemic (ICM; n = 20) and dilated (DCM; n = 20) cardiomyopathies and from nonfailing (NF; n = 20) donor hearts were examined. Paired samples (n = 15) from patients undergoing LV assist device (LVAD) implantation as "bridge to transplant" (34-1,145 days) also were analyzed. There was more interstitial fibrosis in both ICM and DCM compared with NF hearts. Hydroxyproline concentration was also significantly increased in DCM compared with NF samples. The expression of CTGF, transforming growth factor (TGF) ß1, collagen (COL) 1-α1, COL3-α1, matrix metalloproteinase (MMP) 2, and MMP9 mRNA in ICM and DCM were also significantly elevated compared with NF samples. Although TGF-ß1, CTGF, COL1-α1, and COL3-α1 mRNA levels were reduced by unloading, there was only a modest reduction in tissue fibrosis and no difference in protein-bound hydroxyproline concentration between pre- and post-LVAD tissue samples. The persistent fibrosis may be related to a concomitant reduction in MMP9 mRNA and protein levels following unloading. CONCLUSIONS: CTGF may be a key regulator of fibrosis during maladaptive remodeling and progression to HF. Although mechanical unloading normalizes most genotypic and functional abnormalities, its effect on ECM remodeling during HF is incomplete.

Factors associated with stress and coping at 5 and 10 years after heart transplantation.

BACKGROUND: Heart transplant-related stressors and coping are related to poor outcomes early after transplant. The purposes of our study were to (1) identify the most frequent and bothersome stressors and most used and effective coping strategies and (2) compare the most frequent and bothersome stresses and most used and effective coping styles between patients at 5 and 10 years after heart transplantation. We also examined differences in coping styles by patient characteristics and factors associated with frequency and intensity of stress at 5 and 10 years after heart transplantation. METHODS: This report is a secondary analysis of data from a prospective, multisite study of quality of life outcomes. Data are from separate cohorts of 199 patients at 5 years after transplant and 98 patients at 10 years. Patients completed the Heart Transplant Stressor Scale and Jalowiec Coping Scale. Statistical analyses included frequencies, measures of central tendency, t-tests, chi-square, and generalized linear models. RESULTS: At 5 and 10 years after heart transplantation, the most bothersome stressors were regarding work, school, and financial issues. Patients who were 10 years after transplant reported less stress, similar stress intensity, and less use and perceived effectiveness of negative coping than patients who were 5 years after transplant. Long-term after transplant, demographic characteristics, psychologic problems, negative coping, and clinical factors were related to stress frequency and/or intensity. CONCLUSIONS: Heart transplant-related stress occurs long-term after surgery. Types of transplant-related stress and factors related to stress confirm the importance of ongoing psychologic and clinical support after heart transplantation.

Left ventricular assist device-induced coagulation and platelet activation and effect of the current anticoagulant therapy regimen.

Left ventricular assist devices (LVADs) are mechanical pumps that enhance cardiac function in patients with heart failure. In all, 7 patients with an LVADs (1.8 international normalized ratio warfarin, 81 mg aspirin) were evaluated monthly for 3 months for platelet and coagulation activation (controls: 5 healthy adults and 5 patients having warfarin). Platelet works revealed greater inhibition of collagen (31.8% vs 7.9%; P = .004), arachidonate- (30.9% vs 8.2%; P = .001), and adenosine diphosphate- (10.9% vs 6.1%; P = .004)-induced platelet aggregation for LVADs. Thrombelastography (recalcified whole blood) showed inhibition of clot initiation time (R; 8.81 vs 6.02 min; P = .001) and stronger clot formation (maximum amplitude; 69.1 vs 64.9 mm; P = .016). Platelet function determined by plateletMapping and flow cytometry was within the normal range. The LVADs had increased ratio of von Willebrand Factor (vWF) antigen and vWF propeptide, indicating increased degradation of vWF (2.04 vs 1.44; P = .144). Coagulation and platelet activation caused by LVAD is suppressed by pharmacotherapy, yielding a profile similar to that of patients on warfarin alone.

Single photon emission computed tomography myocardial perfusion imaging to detect cardiac allograft vasculopathy.

AIMS: Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality in cardiac transplant recipients. This study evaluates the usefulness of single photon emission computed tomography (SPECT) and various SPECT-derived diastolic variables to detect CAV in heart transplant patients. METHODS AND RESULTS: A retrospective review of 141 SPECT studies with corresponding coronary angiograms within 12 months was performed on 99 transplant recipients. Diastolic function was assessed using computer-derived measures of peak filling rate (PFR), time to peak filling rate (TPFR), and mean first one-third filling rate (MFR/3). Angiography identified CAV in 53 of the 141 studies (38%). Of the 53, SPECT identified 7 with reversible myocardial defects (sensitivity 13%) and stress-induced electrocardiographic evidence of ischaemia was seen in one patient (sensitivity 2%). SPECT imaging was negative in 86 of the 88 negative coronary angiograms (specificity 98%). The positive predictive value and negative predictive value were 78 and 65%, respectively. If a more stringent definition of CAV was used (≥70% stenosis), the sensitivity and specificity were unchanged (14 and 98%, respectively). There was no statistical difference in diastolic variables between patients with or without angiographic evidence of CAV in regard to PFR (3.57 ± 1.14 vs. 3.18 ± 1.21 EDV/s, P = 0.90), TPFR (149 ± 32 vs. 153 ± 43 ms, P = 0.33), or MFR/3 (1.37 ± 0.43 vs. 1.27 ± 0.42 EDV/s, P = 0.94). CONCLUSION: Adenosine stress/rest technetium-99m tetrofosmin-gated SPECT is not a sensitive test for detection of CAV in heart transplant recipients. Diastolic dysfunction, as assessed by SPECT, was not shown to be associated with development of CAV.

Abdominal aortic aneurysms (AAA) post heart transplantation: a systematic review of literature.

Peripheral vascular disease is highly prevalent post heart transplantation (HTx). The prevalence of abdominal aortic aneurysms (AAA) post HTx ranges from 1.1-10%. We performed a Pub Med, EMBASE and Cochrane review search to identify articles on AAA post HTx. Data gathered from published data included: risk factors, progression of the aneurysm and clinical outcomes. Five studies were included in the systematic review. Baseline demographic data, clinical characteristics, data on AAA prevalence and characteristics, the treatment strategies and follow up were extracted from each of these studies. Our systematic review showed that the prevalence of AAA post HTx ranged from 2-10% in the retrospective studies and 6.5% in a single prospective study. Rupture rates during a follow up period ranged from 11-38% and during that time period the mean aneurysmal expansion rate ranged from 0.78±0.41 cm/yr to 1.2±0.4 cm/yr. Male gender, ischemic heart disease, corticosteroid use, smoking and improved hemodynamics and ejection fraction post HTx were reported as possible associated risk factors in the development of AAA. Open surgical management was the treatment of choice although endovascular treatment was used in a minority of patients. AAA is increasingly prevalent post HTx and may be associated with greater rupture and expansion rates. Meticulous follow up and further prospective clinical studies are warranted to determine risk factors, expansion rates and clinical outcomes.

Serine-910 phosphorylation of focal adhesion kinase is critical for sarcomere reorganization in cardiomyocyte hypertrophy.

AIMS: Tyrosine-phosphorylated focal adhesion kinase (FAK) is required for the hypertrophic response of cardiomyocytes to growth factors and mechanical load, but the role of FAK serine phosphorylation in this process is unknown. The aims of the present study were to characterize FAK serine phosphorylation in cultured neonatal rat ventricular myocytes (NRVM), analyse its functional significance during hypertrophic signalling, and examine its potential role in the pathogenesis of human dilated cardiomyopathy (DCM). METHODS AND RESULTS: Endothelin-1 (ET-1) and other hypertrophic factors induced a time- and dose-dependent increase in FAK-S910 phosphorylation. ET-1-induced FAK-S910 phosphorylation required ET(A)R-dependent activation of PKCδ and Src via parallel Raf-1 → MEK1/2 → ERK1/2 and MEK5 → ERK5 signalling pathways. Replication-deficient adenoviruses expressing wild-type (WT) FAK and a non-phosphorylatable, S910A-FAK mutant were then used to examine the functional significance of FAK-S910 phosphorylation. Unlike WT-FAK, S910A-FAK increased the half-life of GFP-tagged paxillin within costameres (as determined by total internal reflection fluorescence microscopy and fluorescence recovery after photobleaching) and increased the steady-state FAK-paxillin interaction (as determined by co-immunoprecipitation and western blotting). These alterations resulted in reduced NRVM sarcomere reorganization and cell spreading. Finally, we found that FAK was serine-phosphorylated at multiple sites in non-failing, human left ventricular tissue. FAK-S910 phosphorylation and ERK5 expression were dramatically reduced in patients undergoing heart transplantation for end-stage DCM. CONCLUSION: FAK undergoes S910 phosphorylation via PKCδ and Src-dependent pathways that are important for cell spreading and sarcomere reorganization. Reduced FAK-S910 phosphorylation may contribute to sarcomere disorganization in DCM.

Utility of screening computed tomography of chest, abdomen and pelvis in patients after heart transplantation.

INTRODUCTION: Malignancy is a late cause of mortality in heart transplant recipients. It is unknown if screening computed tomography scan would lead to early detection of such malignancies or serious vascular anomalies post heart transplantation. METHODS: This is a single center observational study of patients undergoing surveillance computed tomography of chest, abdomen and pelvis at least 5 years after transplantation. Abnormal findings, included pulmonary nodules, lymphadenopathy and intra-thoracic and intra-abdominal masses and vascular anomalies such as abdominal aortic aneurysm. The clinical follow up of each of these major abnormal findings is summarized. RESULTS: A total of 63 patients underwent computed tomography scan of chest, abdomen and pelvis at least 5 years after transplantation. Of these, 54 (86%) were male and 9 (14%) were female. Mean age was 52±9.2 years. Computed tomography revealed 1 lung cancer (squamous cell) only. Non specific pulmonary nodules were seen in 6 patients (9.5%). The most common incidental finding was abdominal aortic aneurysms (N=6 (9.5%)), which necessitated follow up computed tomography (N=5) or surgery (N=1). Mean time to detection of abdominal aortic aneurysms from transplantation was 14.6±4.2 years. Mean age at the time of detection of abdominal aortic aneurysms was 74.5±3.2 years. CONCLUSION: Screening computed tomography scan in patients 5 years from transplantation revealed only one malignancy but lead to increased detection of abdominal aortic aneurysms. Thus the utility is low in terms of detection of malignancy. Based on this study we do not recommend routine computed tomography post heart transplantation.

Incidence, risk factors, and clinical outcomes of atrial fibrillation and atrial flutter after heart transplantation.

Atrial fibrillation (AF) and atrial flutter (AFL) after heart transplantation (HT) has been associated with increased mortality. Diverse incidence rates have been reported to date, with no clear classification according to the time of onset of such arrhythmias. We determined the incidence of AF/AFL using the time of onset after HT and analyzed the associated risk factors and outcomes. We performed a retrospective study of 228 HT recipients (March 1996 to July 2007), including donor and recipient demographics, gender mismatch, ischemia time, surgical anastomosis, time of onset of AF/AFL, acute cellular rejection, left ventricular systolic function, and all-cause mortality. The mean age of the donors (81% men) was 30 +/- 12 years and of the recipients (78% men) was 53 +/- 11 years. AF/AFL occurred in 45 patients (20%): 24 (11%) in the first 30 days, 10 (4%) within the 31 days to 1 year, and 11 (5%) after 1 year. When the patients with AF/AFL were compared to those with sinus rhythm, the significant difference was the older mean age of the donors (p = 0.001) and the recipients (p = 0.02). The all-cause mortality rate was 43% for those with AF/AFL compared to 23% for those with sinus rhythm (hazard ratio 2.45; 95% confidence interval 1.2 to 4.8), mostly driven by the greater mortality in the later-onset AF/AFL group (>30 days after HT). In conclusion, AF and AFL have an incidence of 20% after HT and are associated with increased overall mortality compared to that in patients in sinus rhythm. AF/AFL is more common within the first 30 days of HT, with an overall incidence of 20%. Older donor and recipient age is a risk factor associated with AF/AFL.

Gemella morbillorum prosthetic valve endocarditis.

The authors describe a case of prosthetic valve infective endocarditis (IE) caused by Gemella morbillorum (GM), a gram-positive coccus that grows slowly in culture and occasionally causes a subacute to chronic form of IE. To the author's knowledge, this is the third case of GM prosthetic valve IE to be reported. Subacute to chronic IE caused by slow-growing organisms can be subtle in presentation and should be suspected in patients who have prosthetic valves presenting with worsening heart failure.

Symptom frequency and distress from 5 to 10 years after heart transplantation.

BACKGROUND: Patterns of symptom frequency and distress have not been examined long-term after heart transplantation, nor have predictors of long-term symptom frequency and distress. This report identified the most commonly reported and distressful symptoms long-term after transplantation, described patterns of symptom frequency and distress over time, and examined predictors of symptom frequency and distress at 5 and 10 years after heart transplantation. METHODS: The sample included 555 participants from a prospective, multisite, longitudinal study of quality of life outcomes. Patients were 78% male, 88% white, 79% married, and mean age of 54 years at time of heart transplantation. Data were collected using patient self-report and medical records review. Statistical analyses included descriptive statistics, Pearson correlations, t-tests, and generalized linear models. RESULTS: Significant predictors of lower symptom frequency after heart transplantation were not having psychological problems and not having cardiac allograft vasculopathy at 5 years, and not having psychological problems and not having infection at 10 years. Significant predictors of less symptom distress were having more than a high school education, having no psychological problems, and having gout at 5 years, and being married at 10 years. CONCLUSIONS: Symptom frequency is low and symptom distress is moderate long-term after heart transplantation. Significant relationships exist between both demographic and clinical variables and symptom frequency and distress. Identification of the most common and bothersome symptoms after heart transplantation provides clinicians with important information from which to develop a plan of care.