Heart donor management and expansion of current donor selection criteria.
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Adult↗
Biomedical subjects
U Livi
Publications and source records attributed to U Livi.
Clinical and hemodynamic evaluation of 21 mm and 23 mm Cryolife-O'Brien stentless bioprostheses implanted in the aortic position.
BACKGROUND: The aim of this study was to investigate early and mid-term results after aortic valve replacement with Cryolife-O'Brien stentless bioprosthesis, model 300. METHODS: Records of 59 patients who received a 21 or 23 mm (Group A) aortic Cryolife-O'Brien stentless valve were retrospectively reviewed and compared to 54 patients who received a valve > or = 25 mm (Group B). Group A patients were mainly female (p < 0.001), were older (p = 0.034), had dominant aortic stenosis (p = 0.011), and a smaller (p < 0.001) body surface area. Effective orifice area index was larger (p = 0.041) and left ventricular mass index higher (p = 0.024) in Group B. RESULTS: The actuarial survival at 5.5 years was 94.9 +/- 2.3% and 92.5 +/- 4.3% in Group A and B respectively (p = NS). The actuarial freedom from all events was 85.1 +/- 6.1% and 88.2 +/- 5.2% in Group A vs Group B respectively (p = NS). At late echocardiographic studies performed between 4 and 42 months (mean 27.3 +/- 6.1 months) postoperatively, peak and mean gradients decreased and effective orifice area index increased over the follow-up period (p = NS between groups). Left ventricular mass index decreased by 25% (p < 0.001) in Group A and by 20% (p < 0.001) in Group B from preoperatively and a further 13% (p = 0.034) and 8.5% (p = 0.004), respectively, from the early to the late study. No significant difference in left ventricular mass regression was noticed between groups (p = NS). CONCLUSIONS: The Cryolife-O'Brien porcine stentless bioprosthesis showed satisfactory mid-term results and may represent a good choice for patients with a small aortic annulus selected for a biological valve.
Aged↗
Extracorporeal photochemotherapy after cardiac transplantation: a new therapeutic approach to allograft rejection.
UNLABELLED: Photopheresis (ECP) is a new immunomodulatory therapy in which recipient lymphocytes are treated extracorporeally with 8-methoxypsoralen and ultraviolet light. The treatment seems to induce an inhibition of both humoral and cellular rejection after transplantation. OBJECTIVE: Since recurrent rejection (RR) continues to be a severe complication after heart transplantation (HTx) and the immunosuppressive regimes used for the treatment are often associated with increased morbidity and mortality, we investigated whether ECP could have a beneficial effect on the number and severity of rejection episodes. METHODS: Eleven HTX recipients (5 M and 6 F, mean age 48.5 yrs) with RR were enrolled in the study. ECP was performed at weekly intervals during the 1st month, at 2 week intervals during the 2nd and 3rd month, and then monthly for another 3 months. RESULTS: The fraction of biopsies (EMB) with a grade 0/1A rejection increased during ECP from 46% to 72% while the EMB showing a 3A/3B rejection decreased from 42% to 18%. It is also noteworthy that out of the 78 EMB performed during ECP only one showed a 3B rejection in comparison with 13 out of 110 EMB in the pre-ECP period. Six rejection relapses were observed in a total follow-up of 60 months, two of them occurring during the tapering of oral steroid. Four relapses were reversed by ECP, one by i.v. steroids and the last by methotrexate after the failure of both i.v. steroids and ECP. The mean doses of immunosuppressive drugs resulted lower after 6 months of ECP: steroids were reduced from 13 to 8.25 mg/day, cyclosporine from 375 to 285 mg/day, azathioprine from 55 to 35 mg/day. CONCLUSIONS: ECP is a well tolerated treatment. Its administration allows better RR control and significant reduction in immunosuppressive therapy.
Adult↗
Histologic findings in the conduction system after cardiac transplantation and correlation with electrocardiographic findings.
The study of the sinus node and the specialized atrioventricular junction by serial sections in cardiac transplantation revealed that acute rejection involving the conduction system was equally severe as the working myocardium, with the exception of the His bundle. During acute rejection, the sudden appearance of a first-degree atrioventricular block may suggest severe involvement of the conduction system with impending cardiac arrest.
Adult↗
Multicenter study on hepatitis C virus infection in patients with dilated cardiomyopathy. North Italy Transplant Program (NITP).
Preliminary epidemiological and histological studies from Japan suggested that hepatitis C virus (HCV) infection has a role in the development of dilated cardiomyopathy (DCM). This multicenter study was conducted to verify this hypothesis on a large cohort of Italian patients with end-stage heart failure. Antibodies to HCV were determined in the 752 consecutive patients (608 males and 144 females; age, 53 +/- 13 years) who entered the waiting list for cardiac transplantation from 1995 to 1997 at the six cardiac surgery centers participating in the North Italy Transplant program. Three hundred and nine patients (41%) had dilated, 9 (1%) restrictive, and 4 (0.5%) hypertrophic cardiomyopathy; 284 patients (38%) had ischemic, 65 (9%) valvular, and 22 (3%) congenital heart disease; 5 patients (0.5%) had primary pulmonary hypertension; 54 patients (7%) had other or nonspecified heart disease. Overall, 41 of 752 patients (5.4%) resulted anti-HCV-reactive. Serological evidence of HCV infection was found in 12 of 309 patients with DCM (3.9%; 95% CI, 1.7-6.0), and in 29 of 443 without DCM (6.5%; 95% CI, 4.2-8.8), without statistical difference (difference of prevalence rate: 2.6%; 95% CI, -4.9 to 5.8). In conclusion, HCV does not seem to have a primary role in the pathogenesis of DCM. However, since our findings are in disagreement with those obtained in smaller series of patients of other ethnicity, large studies from different countries should be conducted.
Aged↗
Enteroviral genome in native hearts may influence outcome of patients who undergo cardiac transplantation.
The Enterovirus may be the most common agent responsible for viral myocarditis and cardiomyopathy. Very little of the literature is available concerning the follow-up of patients who underwent transplantation with enteroviral positivity in native hearts. In the present study, 45 explanted hearts from patients who underwent orthotopic heart transplant at University of Padova were studied by reverse transcriptase (RT)-polymerase chain reaction (PCR): 27 patients had dilated cardiomyopathy (DC), 12 had ischemic cardiopathy (IC), 2 had valvular disease (VD), 2 had arrhythmogenic right ventricular cardiomyopathy (ARVC), 1 had giant cell myocarditis (GCM), and 1 had lymphocytic myocarditis (LM). Two sets of PCR primers from the highly conserved region of Enterovirus and Rhinovirus were used. Samples of both ventricles and septum were analyzed in every patients. The RT-PCR and nucleotide sequencing of amplicons were also performed on all post-transplantation follow-up biopsies in patients with Enterovirus positivity in the native heart. The viral genome was detectable in only 1 of 27 patients with DC (3%) and in 1 patient with LM. Nucleotide sequence analysis of the amplified product showed differences in nucleotide sequence of PCR samples compared with the sequence of the coxsackievirus B3 used in the current study. The patient with Enterovirus-positive DC showed a higher index of severe rejection (>3A) in the first 6 months, compared with the other patients tested. The patient with Enterovirus-positive LM died of disease recurrence 2 months after transplantation. The present study reveals a scarce presence of Enterovirus in the myocardium of patients with chronic myocardial disease. Because Enterovirus infection was predictive of a poor prognosis in these two patients, molecular studies are useful in excluding viral involvement in native hearts of transplanted patients.
Adolescent↗
Photopheresis for the prevention of rejection in cardiac transplantation. Photopheresis Transplantation Study Group.
BACKGROUND: Photopheresis is an immunoregulatory technique in which lymphocytes are reinfused after exposure to a photoactive compound (methoxsalen) and ultraviolet A light. We performed a preliminary study to assess the safety and efficacy of photopheresis in the prevention of acute rejection of cardiac allografts. METHODS: A total of 60 consecutive eligible recipients of primary cardiac transplants were randomly assigned to standard triple-drug immunosuppressive therapy (cyclosporine, azathioprine, and prednisone) alone or in conjunction with photopheresis. The photopheresis group received a total of 24 photopheresis treatments, each pair of treatments given on two consecutive days, during the first six months after transplantation. The regimen for maintenance immunosuppression, the definition and treatment of rejection episodes, the use of prophylactic antibiotics, and the schedule for cardiac biopsies were standardized among all 12 study centers. All the cardiac-biopsy samples were graded in a blinded manner at a central pathology laboratory. Plasma from the subgroup of 34 patients (57 percent) who were enrolled at the nine U.S. centers was analyzed by polymerase-chain-reaction amplification for cytomegalovirus DNA. RESULTS: After six months of follow-up, the mean (+/-SD) number of episodes of acute rejection per patient was 1.44+/-1.0 in the standard-therapy group, as compared with 0.91+/-1.0 in the photopheresis group (P=0.04). Significantly more patients in the photopheresis group had one rejection episode or none (27 of 33) than in the standard-therapy group (14 of 27), and significantly fewer patients in the photopheresis group had two or more rejection episodes (6 of 33) than in the standard-therapy group (13 of 27, P=0.02). There was no significant difference in the time to a first episode of rejection, the incidence of rejection associated with hemodynamic compromise, or survival at 6 and 12 months. Although there were no significant differences in the rates or types of infection, cytomegalovirus DNA was detected significantly less frequently in the photopheresis group than in the standard-therapy group (P=0.04). CONCLUSIONS: In this pilot study, the addition of photopheresis to triple-drug immunosuppressive therapy significantly decreased the risk of cardiac rejection without increasing the incidence of infection.
Combined Modality Therapy↗
Cyclosporine-based steroid-free therapy in pediatric heart transplantation: long-term results.
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Adolescent↗
Heart transplantation in patients with neoplastic disease.
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Adult↗
Cardiac transplantation in a Duchenne muscular dystrophy carrier.
We report here for the first time the case of a symptomatic DMD carrier, who had a heart transplant for a severe dilated cardiomyopathy. Dystrophin immunohistochemistry, western blot and analysis of X-chromosome inactivation on leucocytes, and skeletal and cardiac muscle biopsies on the explanted heart were performed. The patient was a heterozygote for exons 50-52 deletion in the dystrophin gene. The number of dystrophin-deficient fibres in the heart was much higher than in skeletal muscle. On the other hand, the explanted heart showed a non-skewed pattern of X-chromosome inactivation, as in leukocytes and skeletal muscle. The adverse cardiac course may be explained by the absence of regeneration among cardiomyocytes.
Adult↗
HIV infection in the first heart transplantation in Italy: fatal outcome. Case report.
A 46-year-old man with alcoholic dilated cardiomyopathy underwent heart transplantation on November 14, 1985. It was the first cardiac transplant in Italy and at that time no HIV antibody screening test was available in this country. The patient remained in good health for 6 years postoperatively, with only one episode of rejection (type 3A). In June 1992 he died of fulminant complications of AIDS and severe chronic rejection. Neither the patient nor the organ donor belonged to any of the known risk groups for HIV infection; a retrospective analysis revealed that perioperative blood transfusions had been the vectors of transmission.
AIDS-Related Opportunistic Infections↗
Autotransplantation procedure for giant left atrium repair.
BACKGROUND: Giant left atrium has been associated with bronchopulmonary and left ventricular compression [Kawazoe 1983]. CASE REPORT: We present a patient with severe congestive heart failure (CHF), respiratory insufficiency and a giant left atrium (GLA) following two previous mitral valve procedures and tricuspid valve annuloplasty in the distant past. Mitral prosthetic function and ventricular systolic function were felt to be normal leading to a tentative diagnosis of diastolic restriction from left ventricular compression and pericardial constriction. A pericardial decortication procedure through left thoracotomy was initially done but proved ineffective. Subsequently, full evidence of hemodynamic failure due to the giant left atrium and its respiratory complication was recognized and the patient underwent cardiac autotransplantation procedure [Kosak 1987], with the aim to reduce the left atrial dimensions to normal. CONCLUSIONS: Calcification of posterior left atrial wall prevented a completely satisfactory reduction of atrial size and the severity of ventricular adhesions from the previous pericardial procedure resulted in very long cardiopulmonary bypass time with severe bleeding complications. This case provides ample evidence that GLA can cause respiratory failure and needs to be surgically corrected.
Cardiac Catheterization↗
Impairment of fibrinolytic potential in long-term steroid treatment after heart transplantation.
Thrombotic complications constitute an important risk in transplant recipients, in whom a hypercoagulable state and hypofibrinolysis have been associated with immunosuppressive treatment, especially with cyclosporine. In no case have clotting and fibrinolytic abnormalities been correlated with steroid immunosuppression, even though steroids were always administered. Previous studies found a relationship between hypercorticism and hypofibrinolysis both in Cushing's disease and after renal transplantation. The aim of this investigation was to compare fibrinolytic potential using the venous occlusion test in two similar groups of heart transplant patients treated with or without steroids. Euglobulin lysis time, tissue-type plasminogen activator and plasminogen activator inhibitor-1 (PAI-1) activities, and antigens were determined before and after the venous occlusion test. A reduced fibrinolytic potential (significant prolongation of lysis time) due to a significant increase in PAI-1 activity and antigen levels was found in heart transplant patients treated with steroids, as compared with patients without steroid treatment and control subjects. The prevalence of reduced fibrinolytic potential was 69.2% (18 cases) in the steroid-treated group and 34.8% (8 cases) in the non-steroid-treated group. In every case, the impaired fibrinolytic potential was due to high basal PAI-1 levels. Our results are compatible with the presence of a hypofibrinolytic state secondary to long-term steroid treatment. In heart transplant recipients, steroid-induced hypofibrinolysis may constitute a further risk factor for thrombotic disease.
Adolescent↗
Morphologic spectrum of primary restrictive cardiomyopathy.
A restrictive hemodynamic profile with left ventricular (LV) end-diastolic volume < 100 ml/m2 and LV end-diastolic pressure > 18 mm Hg, in the absence of endomyocardial, pericardial, and specific cardiomyopathy, is a peculiar feature of primary restrictive cardiomyopathy. From 1985 to 1994, 7 hearts of patients who met the above hemodynamic criteria and underwent endomyocardial biopsy because of heart failure, were studied through gross (5 cardiectomies and 2 autopsies), histologic, and electron microscopic investigations. Ages ranged from 9 to 48 years (mean age 29 +/- 13). Four patients (57%) had a positive family history: 2 for hypertrophic and 2 for restrictive cardiomyopathy. Three patterns were identified in the 7 hearts: (1) pure restrictive form in 4 cases with mass/volume ratio 1.2 +/- 0.5 g/ml, ejection fraction 58 +/- 5%, LV end-diastolic volume 67.5 +/- 12.6 ml/m2, LV end-diastolic pressure 26.7 +/- 3.5 mm Hg; (2) hypertrophic-restrictive form in 2 cases with mass/volume ratio 1.5 +/- 0.07 g/ml, ejection fraction 62 +/- 1%, LV end-diastolic volume 69 +/- 10 ml/m2, LV end-diastolic pressure 30 +/- 7 mm Hg; and (3) mildly dilated restrictive form in 1 case with mass/volume ratio 0.9 g/ml, ejection fraction 25%, LV end-diastolic volume 98 ml/m2, LV end-diastolic pressure 40 mm Hg. Histology and electron microscopy disclosed myocardial and myofibrillar disarray and endoperimysial interstitial fibrosis in each pattern. The familial forms suggest the presence of a genetic abnormality. Primary restrictive cardiomyopathy may present with or without hypertrophy and shares similar microscopic pictures with hypertrophic cardiomyopathy. The 2 entities may represent a different phenotypic expression of the same genetic disease.
Adolescent↗
Impact of organ preservation techniques on outcome of cardiac transplantation in the era of donor pool expansion.
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Actuarial Analysis↗
[Indications for heart transplant: retrospective evaluation of criteria for selection of candidates].
INTRODUCTION: Heart transplantation (HT) is a largerly accepted therapy for patients with refractory congestive heart failure. However, lack of donors imposes a rigorous choice among candidates for transplantation. Aim of this study was to identify retrospectively determinants for the selection of recipients. METHODS: Between december 1985 and december 1993 500 patients were listed for HT at the Department of Cardiovascular Surgery of the Padua University. Among United Network for Organ Sharing (UNOS) status II patients, 42 transplanted (group I) and 38 died waiting for a donor (group II) were chosen. The following parameters were collected at the time of insertion into the waiting list: sex, blood group, diagnosis, age, body surface area, natriemia, renal function, hepatic function, presence of ventricular arrhythmias, use of ACE-inhibitors, cardiac index, mean pulmonary pressure, mean wedge pressure, mean arterial pressure, central venous pressure, pulmonary arteriolar resistances, left ventricular ejection fraction. Also the time on waiting list until a final event (transplantation or death) was considered. RESULTS: Comparing the two groups the diagnosis of dilated cardiomyopathy (59.4% group I vs 36.8% group II; p = 0.04) and ejection fraction (26.4 +/- 9.1% group I vs 22.2 +/- 8.0% group II; p = 0.03) were the only variables statistically different. Multivaried analysis evidenced some parameters as independent predictors for HT. In detail, being listed for HT for more than 6 months lowered the probability to receive a heart to 0.34, while waiting for more than 12 months increased it to 2.64. Mean arterial pressure higher than 75 mmHg increased the probability for HT to 2.87, while an increase in mean pulmonary pressure of 5 mmHg lowered the probability to 0.80. An increase in the cardiac index of 0.5 l/m1/m2 lowered the probability to 0.61. A blood group other than 0 increased the possibility to 3.60, the basal surface area higher than 1.78 m2 lowered it to 0.306 and an ejection fraction higher than 22% increased it to 3.94. CONCLUSIONS: We can conclude that parameters which predict the outcome of patients listed for HT were not only size matching, blood group and waiting time, but also ejection fraction, arterial pressure and diagnosis.
Adult↗
[Improvement of short-term prognosis in patients with refractory heart failure].
BACKGROUND: Prognosis of patients with severe heart failure is poor, despite improved results in medical therapy. Heart transplantation is the only treatment possible in end-stage heart failure. The aim of this study was to evaluate the variation in prognosis over the past six years in the patients admitted to Intensive Care Unit for heart failure in spite of optimal oral therapy. STUDY POPULATION AND METHOD: Between January 1990 and December 1995, 133 patients with heart failure were admitted to the Intensive Care Unit, despite the fact that they were on optimal oral therapy. All patients were in New York Heart Association (NYHA) functional class III to IV and required intravenous administration of sympathomimetic amines, in addition to standard heart failure treatment procedures. Cumulative survival at six months of patients observed between 1990-1992 (group A) was compared with the survival rate of patients observed from 1993 to 1995 (group B). RESULTS: Clinical and haemodynamic parameters were similar in groups A and B, but ACE-inhibitors were used more frequently in group B (75 vs 31% respectively, p < 0.05). During the follow-up period, heart transplantation was indicated in a similar percentage of patients (A 53% vs B 58%). However, mortality on the waiting list (58% group A vs 21% group B; p < 0.05) and the percentage of patients who underwent heart transplantation (41% group A vs 78% group B; p < 0.05) differed. Moreover, all patients in group A and 50% of group B were operated on as "status one" patients. The total six-month mortality rate decreased from 69% before 1992 to 48% thereafter (p < 0.05). CONCLUSION: The short-term prognosis of patients with refractory heart failure improved over time. In the latter period, ACE-inhibitors were used more frequently and the number of heart transplantations was greater. Nevertheless, our results do not allow us to identify the causes of the improved survival rate.
Adult↗
Immunosuppressive treatment in a heart transplantation candidate with antiphospholipid syndrome.
Dilated cardiomyopathy secondary to a devastating anterior myocardial infarction developed in a young patient with the antiphospholipid antibody syndrome. Due to severe left ventricular failure, heart transplantation was considered. To reduce antiphospholipid antibody titer, plasmapheresis followed by immunosuppressive treatment with cyclosporin and azathioprine were attempted in the pretransplant period. The antibody titer normalized after plasmapheresis, but then rose sharply despite immunosuppressive drugs. This case report underscores the failure of cyclosporin, a treatment not previously reported, to control autoimmunity in antiphospholipid syndrome. Moreover, progressive renal insufficiency can develop as a result of the long-term use of this drug.
Adult↗