Mediastinal radiation and adverse outcomes after heart transplantation.

Orthotopic heart transplantation (OHT) may represent the only treatment option for patients with end-stage cardiovascular disease due to mediastinal radiation therapy (MRT). The primary aim of this study was to evaluate the safety and efficacy of OHT in this patient population. We conducted a retrospective, single-center cohort study of patients with MRT-associated cardiovascular disease who underwent OHT between January 1987 and September 2008. Nine patients (3 men), aged 46 +/- 11 years at the time of their OHT, were identified. Time from MRT to OHT was 26 +/- 11 years. Lymphoma was the indication for MRT in all patients. Five patients had non-ischemic dilated cardiomyopathy, 2 had ischemic cardiomyopathy and 2 had constrictive pericarditis. Three patients expired in the peri-operative period, whereas another patient died 3 years post-transplant from lung carcinoma. Two additional patients developed a secondary malignancy post-transplant. Five patients are still alive at a mean follow-up of 10 +/- 8 years. Early survival rate is poor in patients who undergo OHT for MRT-associated end-stage cardiovascular disease. In addition, long-term follow-up shows an elevated incidence of malignancies. Our results raise concern about the safety and efficacy of performing OHT in patients with MRT-associated cardiovascular disease.

Higher rate of comorbidities after cardiac retransplantation contributes to decreased survival.

BACKGROUND: Cardiac retransplantation is the definitive treatment for allograft failure despite decreased long-term survival in these patients. The cause of the poorer outcomes in cardiac retransplant patients is unclear. METHODS: This study was a retrospective analysis of 859 adult cardiac transplant patients. Of these, 45 (5.7%) underwent cardiac retransplantation at 8.2 +/- 5.3 (mean +/- SD) years after the first transplant, primarily for severe transplant vasculopathy (n = 42). RESULTS: One-year survival for retransplant patients was significantly lower compared with de novo transplant patients (75% vs 87%; p < 0.003). Twenty-three patients died due to either malignancy (n = 8), infection (n = 6), rejection (n = 3), sudden death (n = 2), recurrent transplant coronary artery disease (n = 2) or post-operative bleeding (n = 1). CONCLUSION: Although cardiac retransplantation has immediate life-saving benefits, survival is lower compared with de novo cardiac transplantation due to higher rates of malignancy and infection.

Heart transplantation in human immunodeficiency virus-positive patients.

BACKGROUND: Human immunodeficiency virus (HIV) infection is widely considered a contraindication for cardiac transplantation. However, with the newer anti-retroviral drugs, the estimated 10-year survival after seroconversion is exceeds 90%. This case series describes the intermediate range outcome of HIV-positive cardiac transplant recipients. METHODS: A retrospective analysis of 1679 cardiac transplant patients was undertaken to identify HIV-positive recipients. RESULTS: Seven patients were identified. Five (4 men) were diagnosed with HIV before transplantation and 2 patients seroconverted after transplantation. Dilated cardiomyopathy was the indication for transplant in all patients. The 5 HIV recipients were aged 42 +/- 8 years, and time after HIV seroconversion averaged 9.5 years. All underwent cardiac transplantation as high-risk candidates. The CD4 count was 554 +/- 169 cells/microl, and viral load was undetectable in all patients at the time of transplantation. Two patients seroconverted to HIV-positive status at 1 and 7 years after transplant. No AIDS-defining illness was observed in any patient before or after transplant. Six patients received highly active anti-retroviral therapy. Viral load remained low in the presence of immunosuppression. All patients are alive with a follow-up from transplant of 57 +/- 78.9 months. CONCLUSION: Excellent intermediate term outcome is noted in carefully selected HIV-positive patients. No significant AIDS-related infections or complications occurred.

Neurocognitive assessments in advanced heart failure patients receiving continuous-flow left ventricular assist devices.

BACKGROUND: Neurocognitive (NC) changes in heart failure patients receiving left ventricular assist devices (LVADs) are not well understood. The purpose of this study was to document changes in the cognitive performance of patients with the continuous-flow HeartMate II LVAD as a bridge to transplant (BTT). METHODS: A NC protocol was used to evaluate patient performance at 1, 3 and 6 months after LVAD implantation at 11 centers. A total of 239 test sessions were completed in 93 patients including paired evaluations in 51 to 57 patients from 1 to 3 months, and in 20 to 28 patients with results from 1, 3 and 6 months. Five NC domains were assessed, including visual spatial perception, auditory and visual memory, executive functions, language and processing speed. RESULTS: There were statistically significant (p < 0.05), but limited improvements between 1, 3 and 6 months in NC domain performances as seen in visual memory, executive functions, visual spatial perception and processing speed. There were no significant declines in any neurocognitive test in any domain over these time periods. CONCLUSIONS: The cognitive performance of advanced heart failure patients remained stable or showed slight improvements from Month 1 to Month 6 of continuous-blood-flow support with the HeartMate II LVAD.