ABO histo-blood group antigen expression on the graft endothelium long term after ABO-compatible, non-identical heart transplantation

We recently reported a complete change in the endothelial ABO histo-blood group phenotype of a cardiac allograft long term after B to O mismatched transplantation. In the context of the current controversy on graft recolonization with recipient endothelial cells and its importance in the development of immunological unresponsiveness, we monitored the expression of endothelial ABH histo-blood group antigens of 10 ABO-compatible, non-identical cardiac allografts over an observation period of at least 30 months. ABH antigens as well as markers for endothelial cells, erythrocytes and thrombocytes were investigated retrospectively by immunohistochemistry using monoclonal antibodies on sections of formalin-fixed, paraffin-embedded biopsies and were evaluated semi-quantitatively by microscopy. In contrast to our earlier finding of the change in the endothelial ABO histo-blood group phenotype long term after ABO- mismatched transplantation, we could not confirm this change in 10 compatible but non-identical cases.

Posttraumatic stress disorder after implantation of a mechanical assist device followed by heart transplantation: evaluation of patients and partners

AIM: We sought to investigate the prevalence of posttraumatic stress disorder, anxiety, and depression in patients and their partners after implantation of a mechanical assist device as a bridge to heart transplantation. METHODS: This was a retrospective assessment of 41 patients (age 46.3 +/- 12.0 years; male-female ratio, 38:3; time since transplantation, 55.3 +/- 34.2 months [range, 7-122 months) and 27 partners (male-female ratio 2:25) by standardized instruments (Impact of Event Scale, Hospital Anxiety and Depression Scale), in 2 University Heart Transplant Centers (Vienna, Austria, Munster, Germany). The duration of the support systems (MicroMed DeBakey-VAD in 17 patients, Novacor in 10, Thoratec in 8, TCI HeartMate in 5, and Berlin Heart Incor in 1 patient) ranged from 28 to 711 (176 +/- 146) days. RESULTS: None of the patients, but 23% of the partners (n = 6), met the criteria for posttraumatic stress disorder (Maercker cutoff >0). The Impact of Event Scale (IES) sum scales differed significantly between the 2 groups (21.2 +/- 15.1, mean +/- SD) for the patients versus 38.1 +/- 27.8 for the partners, respectively; P = .001). Two percent of the patients, but 19% of the partners, showed mild to moderate depression; 4% of patients, but 23% of their partners, reported mild to moderate anxiety. None of the results were significantly influenced by the time since transplantation, patient age, diagnoses, type of assist device, or indication for heart transplantation. CONCLUSIONS: Despite patients being much closer to a life threat, their partners experience significantly more psychologic distress even in the long run. Our findings highlight the need for attention to the supporting persons.

[Changes in partner relationship after organ transplantation: comparison between heart, liver, and kidney transplantation]

AIM: This study was conducted to delineate partnership-relation functioning over time and specifically matched to various organs such as heart, liver, and kidney. METHOD: Prospective, paralleled case-control-study including patients and their respective partners before and one year after organ transplantation in 23 heart-transplant recipients, 19 liver-transplant patients, and 16 kidney-transplant recipients. To assess partnership functioning, the FB-Z (family assessment measure) of Cierpka and Frevert was used. Statistics included descriptive methods, correlations, and analysis of variance including the items "organ" and "time". RESULTS: Heart-transplant recipients and their partners show significant better overall measures in their partnership ratings (sum-value) in comparison to liver or kidney patients and their partners. In all patient and partner groups, except in kidney-transplant recipients a significant deterioration over time is discernible in the subscales role performance and emotionality. In respect to the item "organ" significant differences were found in overall functioning and the subscale communication where heart-transplant recipients and their partners have significant better functioning compared to kidney or liver transplant patients. In kidney patients and their partners only communication changes to the better in the time course. CONCLUSION: In any organ transplantation the two sides of the coin are important to bear in mind, the one is the live-saving act of transplantation as such, the other is the important distress in the phase before but equally after the operation, mainly in the first year where patients and their respective partners have to be followed and treated even in respect to psychosocial and marital functioning.

Long-term effects of heart transplantation: the gap between physical performance and emotional well-being

The purpose of our study was to assess physical and emotional factors in heart transplant patients. A prospective design was used to compare patients' physical symptoms, emotional complaints, and restrictions at admission to the waiting list, immediately after, and 1 and 5 years after heart transplantation. Thirty-three patients were included (30 male, 3 female) in the study. Their mean age at admission was 48 +/- 10.2 years. Of these, 23 suffered from cardiomyopathy, 8 from coronary heart disease, and 2 from valvular insufficiency. At admission, the patients suffered from symptoms of cardiac insufficiency, and were restricted in sports, gardening, hobbies, sexual life, job, food-intake, and mobility. More than three-fourths rated their physical and emotional status as moderate to poor. Emotionally, they suffered from irritability, restlessness, depression, psychic lability, lowered drive, lack of social contact, low self-esteem, and anxiety. At the end of rehabilitation (4-8 weeks after the operation), all physical and emotional complaints, as well as restrictions had significantly decreased (p < 0.0001 to p < 0.001), except for trembling, numbness of hands/feet, and food-intake. One year postoperatively, patients reported even fewer physical complaints (p < 0.01). Three-fourths rated their physical and emotional status good or excellent. Five years postoperatively--in contrast to physical status, restrictions, and physical complaints--the emotional complaints had increased significantly (p < 0.0001). Patients reported excellent physical performance up to 5 years postoperatively. On the other hand, the study revealed that their emotional well-being had significantly deteriorated from 1 to 5 years postoperatively. Attention should, therefore, not only be paid to the good physical health of the survivors, but also to the worsening of their emotional status.

Patients benefit--partners suffer? The impact of heart transplantation on the partner relationship

Terminal heart disease affects not only the patient, but also members of the patient's family, and especially the spouse. The aim of this prospective study of 26 couples was to collect information about the impact of heart transplantation on the partner relationship. Data were collected from patients and spouses when the patients were placed on the waiting list for transplantation, 1 year postoperatively, and 5 years postoperatively. The Family Assessment Measure (FAM III), a self-report instrument that provides quantitative indices of family functioning on seven interacting dimensions, was used. In the course of the transplant process, both patients and spouses reported a significant deterioration in the partner relationship in general. While patients perceived only one clear-cut point of conflict communication about emotions - as crucial, the spouses reported a significant worsening in role performance, communication, emotional involvement, and values and norms. These changes were discernible 1 year after transplantation and persisted for at least 5 years. We conclude that heart transplantation has a significant negative impact on the partner relationship 1-5 years after transplantation. Consequently, more attention should be paid to all aspects of the partner relationship in a holistic approach to the treatment of heart transplant recipients and their partners.

[Knowledge, attitude and reservations of medical students about organ transplantation: results of a survey during the first year of study]

AIM: Establish a list of first year medical students' attitudes, doubts, and knowledge in the fields of organ transplantation and donation. METHOD: Anonymized questionnaire handed out to students during class lectures. RESULTS: 183 questionnaires were distributed and 117 returned (participation: 64%). The average age of the students was 21.6 +/- 2.7 years (range 18 to 38 years); the sample included 71 women (60.7%) and 48 men (39.3%). Only 2 students (2%) were not interested in the subject of organ donation. The students knew very little of the legal aspects of organ donation and 1/4 of them thought there was even a Federal law regarding organ transplantation. When asked if they knew whether a law existed in the Canton of Berne, 44% replied yes, but only 24 (20%) knew that this is contradictory. There was no gender difference in the answers to these question. From 57 students (48%) 246 individual comments on doubts and concerns were analyzed. In this respect, the students mainly questioned whether the donor was truly dead when donation took place (n = 48), if illegal transplantation could be eliminated (n = 44) and if transplantation was truly necessary (n = 43). Some also mentioned religious/ethical doubts (n = 42). In regard to organ donation by a living individual, 27 students were concerned about the health of this donor. 20 students had doubts regarding the pressure possibly applied by family members and friends and as many voiced doubts in regard to premature diagnosis of brain death of potential donors. Only 2 students were concerned about the post-mortem presentation. 45 students (48%) indicated discomfort with the donation of certain organs. They ranked the kidney as the first organ to donate, followed by the pancreas, heart, cornea, intestine, lung and liver. CONCLUSION: The interest in organ donation and transplantation is already strong in fist year medical students in the pre-clinical stage. However, differences from lay public are not readably detectable at this stage of medical training. Adequate information could influence future physicians in their mediatory role.

Progression of steroid-associated osteoporosis after heart transplantation

BACKGROUND: Osteoporosis has been recognized as an important side effect of long-term and of pulsed steroid application after heart transplantation. METHODS: In June 1989 a prospective clinical trial was started to study bone demineralization by quantitative computed tomographic scan. All patients received vitamin D and calcium. In group I (n = 30) synthetic calcitonin (40 Medical Research Council Standard Units subcutaneously per day was administered in 14-day cycles, whereas group II patients (n = 31) received a placebo preparation. Repeat trabecular and cortical quantitative computed tomographic scans of the thoracic (T12) and lumbar spine (L1, L2, L3) were obtained within 48 weeks after heart transplantation. RESULTS: Expressed as the means of T12, L1, L2, and L3, trabecular bone density decreased significantly from 100+/-24 to 79+/-29 mg/mL within 3 weeks after heart transplantation, followed by a further reduction to 67+/-29 mg/mL after 3 months in the calcitonin group. The values for cortical bone density decreased significantly from 229+/-37 to 202+/-40 mg/mL (calcitonin) 3 weeks after heart transplantation. Comparable results were obtained in the placebo group. In both groups bone density remained stable thereafter. Intergroup differences were not of statistical significance. CONCLUSIONS: In heart transplant recipients progressive trabecular bone demineralization is limited to the first 3 postoperative months. Thereafter, bone density remained stable. A positive effect of synthetic calcitonin in addition to prophylactic calcium and vitamin D application could not be proved by repeat quantitative computed tomography.

Valve reconstruction or replacement for long-term biopsy-induced tricuspid regurgitation following heart transplantation

Tricuspid regurgitation following heart transplantation can become a severe problem in a subset of patients, where medical therapy fails. Operative findings are described and results of subsequent results with surgical intervention including repair and replacement are analysed. Although follow-up is short, tricuspid replacement seems superior to reconstruction following heart transplantation. Best results are obtained, if replacement is performed, before right ventricular function deteriorates.

Treatment of recurrent rejection in heart transplantation: cytolytic therapy or bolus steroids?

OBJECTIVES: The treatment of recurrent rejection in heart transplant recipients has been a controversial issue for many years. The intent of this retrospective study was to perform a risk-benefit analysis between treatment strategies with bolus steroids only versus anti-thymocyte globulins (RATG; 1.5 mg/kg q 4 days). METHODS: Between 1986 and 1993, 69 of 425 patients (17 male, 52 female; mean age 44 +/- 11 years) who had more than one rejection/patient per month (rej/pt per mo) in the first 3 postoperative months were defined as recurrent rejectors. RESULTS: Repetitive methylprednisolone bolus therapy (70 mg/kg q 3 days) was given in 27 patients (group M; 1.4 +/- 0.2 rej/pt per mo) and RATG therapy for one of the rejection episodes of the 42 remaining patients (group A; 1.5 +/- 0.2 rej/pt per mo). The quality of triple drug immunosuppression in the two study groups was comparable. The rejection-free interval (RFI) following RATG treatment in group A was 21.6 +/- 10 days and 22 +/- 11 in group M. In group M, 3 of 27 patients (11%) had a rejection treatment-related infection (2 bacterial; 1 viral) versus 6 of the 42 patients of group A (14.2%; bacterial 1, viral 5). During postoperative months 3-24, 0.15 +/- 0.12 rej/pat per mo were observed in group M and 0.21 +/- 0.13 rej/pat per mo in group A (n.s.). In this 21-month period cytolytic therapy for rejection was initiated in 8 of the remaining 21 patients of group M (38%) and 15 of the remaining 37 patients of group A (40.5%). The absolute survival and the individual causes of death were not affected by the type of initial treatment of recurrent rejection. The actuarial freedom of graft atherosclerosis is comparable in the two groups with 78% in group A versus 79% in group M free of graft atherosclerosis at 3 years postoperatively. CONCLUSIONS: A comparison of cytolytic therapy versus repeated applications of bolus steroids for treatment of recurrent rejection reveals no significant difference in the long-term patient outcome with respect to the incidence of future rejection episodes and survival.

Tricuspid valve regurgitation attributable to endomyocardial biopsies and rejection in heart transplantation

In the present report the prevalence, severity, and risk factors of tricuspid valve regurgitation (TR) in 251 heart transplant recipients have been analyzed retrospectively. Tricuspid valve function was studied by color-flow Doppler echocardiogram and annual heart catheterization. The presence or severity of TR was graded on a scale from 0 (no TR) to 4 (severe). Additional postoperative data included rate of rejection, number of endomyocardial biopsies, incidence of transplant vasculopathy, and preoperative and postoperative hemodynamics. The incidence of grade 3 TR increases from 5% at 1 year to 50% at 4 years after transplantation. Multivariate analysis showed rate of rejection and donor heart weight to be significant risk factors. The ischemic intervals as well as the preoperative and postoperative pulmonary hemodynamics did not affect the severity or prevalence of TR. These results indicate that various factors appear to have an impact on the development of TR and that the prevalence might be lowered by a reduction of the number of biopsies performed and when possible, oversizing of donor hearts.