Eosinophilic myocarditis: characteristics, diagnostics and outcomes of a rare condition.

Eosinophilic myocarditis is a rare and potentially fatal condition characterised by eosinophilic inflammatory infiltration of myocardium. We report seven consecutive cases of eosinophilic myocarditis at our centre and discuss the important characteristics, investigation and management of this disease.

Confocal Scanning Microscopy in Assessment of Cardiac Allograft Rejection--A Pilot Study.

Cardiac allograft rejection is typically diagnosed on the basis of hematoxylin and eosin (H&E) histology of endomyocardial biopsies. This diagnosis is made based on the degree of immune cell infiltrate and associated myocyte damage. However, considerable variability in rejection grading between pathologists can occur. Confocal microscopy provides high contrast and high resolution imaging that has the potential to provide detailed views of pathological features of allograft rejection. In this pilot study we sought to determine if confocal microscopy could be used to detect features of cardiac rejection. This was achieved by collection of additional sample at 30 biopsy procedures from 15 heart transplant patients. Routine pathological grading of H&E histology identified 5 gradings of 0R, 21 gradings of 1R, and 3 gradings of 2R. From these gradings, 3 samples for 0R, 9 samples for 1R, and 3 samples for 2R were imaged by confocal microscopy. This was achieved by fluorescently labeling sections with DAPI, wheat germ agglutinin, and phalloidin, to visualize the cell nuclei, cell border and extracellular matrix, and muscle cell actin, respectively. Labeling with these fluorescent markers was of high contrast. However, we did note variability in DAPI and phalloidin labeling of tissue sections. Confocal imaging of these labels revealed the following features at high resolution: perivascular and/or interstitial infiltrate, myocyte damage, and Quilty lesions. In particular increased detail of damaged myocytes reveals distortion in myofilament organization that could be exploited to distinguish between 1R and 2R grades. In conclusion, confocal microscopy provided high contrast and resolution imaging of cardiac biopsies that could be explored further to aid assessment of cardiac allograft rejection.

Outcomes of simultaneous heart-kidney and lung-kidney transplantations: the Australian and New Zealand experience.

BACKGROUND: Heart or lung transplantation alone in individuals with significant pre-existing renal impairment results in high mortality and morbidity. Simultaneous heart-kidney (SHK) or simultaneous lung-kidney (SLK) transplantation may be considered in patients with dual organ failure not suitable for single organ transplantation. AIM: We aimed to outline the Australian and New Zealand experience of SHK and SLK transplantations, focussing on patient characteristics and survival. METHODS: We analysed all SHK and SLK transplants performed in four centres across Australia and New Zealand between 1990 and 2014. RESULTS: Over the study period, 35 SHK and 3 SLK transplants were performed across 4 transplant centres. Mean age at transplantation for SHK transplants was 45 years, and for SLK transplant was 27 years. The most common aetiology of renal failure was glomerulonephritis. Most SHK transplant patients (77%) required renal replacement therapy prior to transplantation, with only one of the three patients undergoing SLK transplant, dialysis dependent. One-year survival for the cohort was 79%, which is lower than reported for single organ transplantation. However, 5- and 10-year survivals of 76% and 68%, respectively, were comparable. Isolated renal graft loss was seen in five patients, with only one patient successfully re-transplanted and the rest commencing dialysis. CONCLUSION: The Australian and New Zealand experience of SHK and SLK includes 38 patients with a high 1-year mortality, but excellent 5- and 10-year survivals. Based on this, it seems reasonable to continue to offer combined organ transplantation to select patients with dual organ failure.

The utility of a 'non-significant' coronary angiogram.

BACKGROUND: Coronary angiography is the gold standard for assessing coronary artery disease (CAD). In many patients with chest pain, no or mild CAD (< 50% stenosis) is found. It is uncertain whether this 'non-significant' result influences management and outcomes. We reviewed characteristics and outcomes in a contemporary cohort of chest pain referrals who had mild or absent CAD on coronary angiography. METHOD: All patients undergoing coronary angiography at Auckland City Hospital during July 2010-October 2011 were reviewed (n = 2983). Of these, 12.3% (n = 366) underwent coronary angiography for evaluation of chest pain and were found to have absent or mild CAD. These patients were followed up for 2.3 ± 0.6 years. RESULTS: Mean age was 60.0 ± 12.3 years, 56.1% were female. The ECG was abnormal in 55.0% of patients. Stress testing for inducible ischaemia was undertaken in 40.7% of patients and was abnormal in 57.7%. Following angiography, 43.2% had no changes to cardiac medications. Additional drug therapy (aspirin, statin, beta-blockers, ACE-inhibitor) was commenced in around 14.2-22.1% of cases. These drugs were discontinued in 4.1-8.2% of patients. Rates of major adverse cardiovascular events and readmissions with chest pain were 0.3% (1) and 1.9% (7) respectively at 30 days, and 1.9% (7) and 6.0% (22) at 1 year. CONCLUSION: Although even non-obstructive atheroma may justify medical therapy to limit disease progression, our findings may suggest that in these cases, invasive coronary angiography, may not lead to the patient/physician reassurance justified by historical data.

Return to work after heart transplantation: the New Zealand experience.

INTRODUCTION: Return to work and social re-integration following heart transplantation is a significant challenge for patients. The aim of this study is to provide a snapshot of the current employment status and factors associated with return to work in New Zealand recipients over the past decade. METHODS: Consecutive surviving patients who underwent heart transplantation in the 10 years from June 2001 to June 2011, alive in July 2012, were retrospectively identified. Details on demographics, employment before and after transplantation were obtained and recorded. RESULTS: A total of 87 patients were included, out of a total of 111 patients who underwent heart transplantation in the 10 year period from June 2001 (24 patients had died prior to July 2012). The median age of the study cohort was 52 years (range 15-75 years) and 19 were female. A total of 51 (58.6%) patients were in paid employment at the time of review. Of the 36 (41.4%) patients not in paid employment, 5 were students, 12 were retired and 10 were homemakers or not working through lifestyle choice. Two patients were unable to work for health reasons. Seven (8%) patients considered able to work were on an unemployment or invalid's benefit. Of the patients working prior to heart transplantation, 88.9% returned to work after a median of 8.5 months, and 70.6% remained on paid employment at a median follow-up of 77 months after transplantation. There was a statistically significant correlation between the time of stopping work prior to transplant and return to work after transplant (r = 0.497, P < .01). CONCLUSION: The current rate of paid employment in patients who underwent heart transplantation was similar to the overall employment rate in New Zealand. The most important predictor of returning to work was employment status prior to transplantation. Discussions regarding return to work early in the transplantation assessment process and actively assisting patients to seek employment after transplantation may improve employment rates.

Bone density in heart or lung transplant recipients--a longitudinal study.

BACKGROUND: Osteoporosis is prevalent among heart or lung transplant (HLT) candidates. Bone loss is common posttransplant, with an associated increase in fracture risk. There is a lack of consensus regarding optimal management of bone health in HLT recipients. We report bone health data in a cohort of HLT recipients before and after transplantation and make recommendations for management. METHODS: Patients over the age of 20 who had a heart or lung transplant between 2000 and 2011 were identified from the New Zealand HLT Service database, and demographic data, immunosuppressive regimens, bisphosphonate use, and serial bone mineral density (BMD) data were extracted. RESULTS: Pretransplant BMD was available in 52 heart and 72 lung transplant recipients; 30 and 42, respectively, also had posttransplant BMD data. Pretransplant osteopenia or osteoporosis prevalence were 23% and 8% for heart candidates and 36% and 31% for lung candidates. Posttransplant, BMD decreased significantly at the femoral neck but not at the lumbar spine in the first year, with subsequent stabilization particularly in the presence of bisphosphonate use. Pretransplant BMD was the major predictor for developing osteopenia or osteoporosis after transplantation. CONCLUSION: A significant proportion of HLT recipients have osteopenia or osteoporosis pretransplant, and this persists posttransplant. Pretransplant BMD is an important predictor of subsequent osteopenia or osteoporosis development, allowing risk stratification and targeted intervention.

Exploring parenthood in the New Zealand Heart Transplant Program.

Heart transplantation is an established treatment for end-stage cardiac disease. This study describes parenthood after heart transplantation in the New Zealand population. An analysis was performed of all heart recipients from the New Zealand program. Exclusion criteria were death within 3 months of transplantation or age <18 years at the time of the survey. Recipients (or next of kin if recipients deceased) were surveyed regarding family status at the time of transplantation and new parenthood after transplantation. A total of 145 of 199 eligible recipients completed the survey ∼12.2 years after transplant (119 male, 26 female). Before transplantation, 81% were in a permanent relationship; 72% had children. After transplantation, 19/45 recipients had 27 children (2 female recipients had 3 children), of whom 15 were planned. Complications occurred in 7/27 pregnancies (including one atrial septal defect requiring surgery). Two recipients died after the birth of their children (children aged 2.6 and 14.1 years). This study provides unique data relevant to both female and male recipients regarding new parenthood after heart transplantation and will promote more informed discussion with transplant recipients.

Progressive pulmonary hypertension post atrial septal defect device closure-early symptomatic improvement may not predict outcome.

BACKGROUND: For patients with an atrial septal defect and pulmonary hypertension it can be difficult to determine whether it is safe to intervene. With newer treatments for pulmonary hypertension and transcatheter techniques avoiding surgical stressors, it has been hoped that we can occlude previously inoperable defects safely. METHODS: We undertook a subgroup analysis of outcomes for patients with mean pulmonary artery pressure (PAp) ≥30mmHg from within our database of patients undergoing transcatheter ASD closure from 1997 to 2004. RESULTS: Data for 11 patients were reviewed. Mean age of the patients at intervention was 38 years (5-69 years). Eight patients have had symptomatic improvement with no evidence of progressive pulmonary hypertension. There was one death due to unrelated causes. Two patients have developed progressive pulmonary vascular disease with one death. CONCLUSIONS: Despite early symptomatic improvement, adverse outcomes may occur in patients with elevated pulmonary vascular resistance undergoing transcatheter ASD closure. Careful haemodynamic evaluation is vital. Modest elevation of pulmonary vascular resistance and the presence of left to right shunt (Qp:Qs>1.5:1) are reassuring.

Non-invasive model-based estimation of aortic pulse pressure using suprasystolic brachial pressure waveforms.

Elevated central arterial (aortic) blood pressure is related to increased risk of cardiovascular disease. Methods of non-invasively estimating this pressure would therefore be helpful in clinical practice. To achieve this goal, a physics-based model is derived to correlate the arterial pressure under a suprasystolic upper-arm cuff to the aortic pressure. The model assumptions are particularly applicable to the measurement method and result in a time-domain relation with two parameters, namely, the wave propagation transit time and the reflection coefficient at the cuff. Central pressures estimated by the model were derived from completely automatic, non-invasive measurement of brachial blood pressure and suprasystolic waveform and were compared to simultaneous invasive catheter measurements in 16 subjects. Systolic blood pressure agreement, mean (standard deviation) of difference was -1 (7)mmHg. Diastolic blood pressure agreement was 4 (4)mmHg. Correlation between estimated and actual central waveforms was greater than 90%. Individualization of model parameters did not significantly improve systolic and diastolic pressure agreement, but increased waveform correlation. Further research is necessary to confirm that more accurate brachial pressure measurement improves central pressure estimation.

Treatment of recurrent chest pain in a heart transplant recipient using spinal cord stimulation.

A patient presented with chest pain refractory to conventional medical therapy eight years after heart and renal transplantation. High-dose opioids provided limited relief and repeated hospitalisation was required. Angiography demonstrated severe cardiac allograft vasculopathy, unsuitable for percutaneous or surgical intervention. Reports of sympathetic re-innervation of the transplanted heart encouraged us to undertake a trial of spinal cord stimulation. This was successful so we proceeded to permanent implantation. The patient was weaned from opioids and after six months had needed no further hospital admissions. We recommend consideration of spinal cord stimulation in patients with features of angina pectoris following heart transplantation.

Percutaneous closure of patent foramen ovale.

AIM: To review the safety and efficacy of percutaneous closure of patent foramen ovale (PFO) in symptomatic patients without the use of general anaesthesia or echocardiographic guidance. METHOD: All patients accepted for percutaneous PFO closure by our service from August 2002 to August 2004 were included. Patient demographics and clinical information were obtained from clinical records and by telephone interview. Follow-up outcomes recorded were recurrence of systemic thromboembolism, residual shunt, and change in pattern of migraines. RESULTS: Forty consecutive adult patients, of whom 19 (48%) had an atrial septal aneurysm (ASA), underwent PFO closure using the Amplatzer occluder device with fluoroscopic guidance alone. Their mean age was 45 +/- 10 years (range 23-63 years) and 24 (60%) were male. The indications for closure were ischaemic stroke (n = 26), transient ischaemic attack (TIA) (n = 8), both stroke and TIA (n = 2), refractory hypoxia (n = 2), platypnoea-orthodeoxia (n = 1) and severe migraine with seizures (n = 1). Twenty patients suffered a single neurological event and 16 suffered >1 event, including six with only radiographic evidence of >1 event. Mean procedure time was 17.7 +/- 9.6 min and fluoroscopy time was 6.7 +/- 7.3 min. Implanted device sizes were 18 mm (n = 1), 25 mm (n = 37) and 35 mm (n = 2). In 33 patients, the procedure was performed as a day-case. No complications were encountered. No further neurological events occurred in 39 patients at a mean follow-up time of 11 +/- 7 months (3-25 months) nor was a significant shunt detected in the 34 who underwent follow-up echocardiography. CONCLUSIONS: Percutaneous closure of PFO with or without ASA, under local anaesthesia and without echocardiographic guidance, is a safe and effective procedure which can be performed as a day-case. This has now become our standard clinical practice.

Transcatheter closure of a complex postmyocardial infarction ventricular septal defect after surgical patch dehiscence.

Ventricular septal defect (VSD) complicating acute myocardial infarction is a rare but serious event carrying a high mortality. Residual shunting after emergency surgical repair is common, adversely affects prognosis and can necessitate reoperation. We describe the successful transcatheter VSD closure with the Amplatzer occluder in a 75-year old man after earlier emergency surgical repair of a VSD complicating an acute myocardial infarction. The technique and positioning of the device in a tortuous infero-apical VSD are described.

Transplant "twins": the experience of sharing transplanted thoracic organs from the same donor.

BACKGROUND: Many thoracic transplant recipients who receive organs from the same donor share facilities for 3 months, and are aware that they have received organs from the same donor. METHODS: A confidential questionnaire including open and closed questions assessed relationships between "twins" and the experience of having a twin. The Significant Others Scale assessed social support. Of 141 heart and 58 lung transplants, 25 pairs of transplant twins were identified. Questionnaires were sent to the 32 surviving twins. RESULTS: Twenty-six twins responded; 17 had received a heart and nine a lung. The 17 men and 9 women had a mean age of 51 years. Eighteen respondent's "twins" remained alive at the time of participation and eight had died. Sixty-six percent of the both- twin alive group and 43% of one-twin alive group felt they had a special bond with their twin, different from the other relationships that they have experienced. Fifty-six percent of the both-twin alive group and 43% of one-twin alive group felt having a twin enriched their transplant experience. Transplant twins rated social support last behind: the transplant support personnel; close family members; other transplant recipients; and good friends and general practitioners, both in levels of ideal and actual support. Transplant twins showed the largest discrepancy between levels of ideal and actual support than any other individual ranked. CONCLUSIONS: Being a transplant twin is a special experience that generally enriches the overall transplant experience but having a transplant twin, does not appear to enhance the amount of social support.

Planned pregnancy in a heart transplant recipient.

Solid organ transplantation often leads to the return of fertility in recipients. In females of childbearing age this can be accompanied by a desire to have children. The present paper discusses a planned pregnancy in a heart transplant recipient and outlines important -management issues. These principles of management can be applied to most solid organ transplant recipients.