Fourth time cardiac retransplantation.

Beginning at age 11 years, our patient has had four heart transplants. Now, 26 years later at age 37, he is fully active. This case is presented to document a unique experience and to consider the difficult decision-making process and ethical issues of multiple cardiac retransplantation.

Experience with more than 100 total artificial heart implants.

OBJECTIVE: The SynCardia Total Artificial Heart (SynCardia Systems Inc, Tucson, Ariz) has been used as a bridge to cardiac transplantation in 930 patients worldwide and in 101 patients in our program. Our experience with SynCardia Total Artificial Heart implantation documents its indications, safety, and efficacy. METHODS: Data regarding preoperative condition, mortality, and morbidity have been reviewed and analyzed. RESULTS: From January 1993 to December 2009, 101 patients had bridge to transplant procedures with the SynCardia Total Artificial Heart. Ninety-one percent of cases were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, and the remaining 9% of cases were failing medical therapy on multiple inotropic medications. The mean support time was 87 days (median, 53 days; range, 1-441 days). Pump outputs during support were 7 to 9 L/min. Adverse events included strokes in 7.9% of cases and take-back for hemorrhage in 24.7% of cases. Survival to transplantation was 68.3%. Causes of death of 32 patients on device support included multiple organ failure (13), pulmonary failure (6), and neurologic injury (4). Survival after transplantation at 1, 5, and 10 years was 76.8%, 60.5%, and 41.2%, respectively. The longest-term survivor is currently alive 16.4 years postimplantation. CONCLUSIONS: These patients were not candidates for left ventricular assist device therapy and were expected to die. The SynCardia Total Artificial Heart offers a real alternative for survival with a reasonable complication rate in appropriate candidates who otherwise might have been assigned to hospice care.

Elective cardiac retransplantation: a viable option that can be repeated.

OBJECTIVE: Our hypothesis is that cardiac retransplantation is a viable option for selected recipients. Furthermore, in some patients multiple retransplantations are reasonable. METHODS: We studied 23 patients who had all received an elective second, third, or fourth cardiac transplant over a 25-year period. Comparisons were made with 792 primary transplantations. Subsequent retransplantations (third and fourth time) were elective and included in the evaluation. RESULTS: Twenty-three patients electively received a second, 4 a third, and 1 a fourth transplant for coronary vasculopathy or chronic graft failure. Sixteen (70%) patients were men, and 7 (30%) were women. Median survival in years for primary cardiac recipients was 10.7 years; for a second transplantation, median survival from the date of retransplantation was 9.3 years. Average age at the time of first transplantation was 47.8 years, and it was 44.3 years at the time of second transplantation. No significant difference was noted in Kaplan-Meier survival curves between patients undergoing primary transplantation and elective retransplantation. Survival at 1 year for patients undergoing a first transplantation was 88.8%, and it was 81.8% for patients undergoing retransplantation. Patient survival at 10 years was nearly identical for patients undergoing first-time transplantation and those undergoing retransplantation (58%). All 5 third- and fourth-time transplant recipients survived. CONCLUSIONS: Cardiac retransplantation is a reasonable option for elective recipients with coronary vasculopathy or chronic graft failure. Survival for groups undergoing primary transplantation and retransplantation is similar. Careful selection of this small group of cardiac recipients (3% of the total) might be the key to success.