Ani C. Anyanwu

Assessment of quality of life in lung transplantation using a simple generic tool

BACKGROUND The EuroQol is a generic questionnaire developed to provide a simple method for assigning utility values to health. This study examines the applicability of the EuroQol to the measurement of quality of life in single, bilateral, and heart-lung transplantation. METHODS A cross sectional study was performed in 87 patients awaiting lung transplantation and in 255 transplant recipients attending follow up clinics in four transplant units. RESULTS In the waiting list group 61% reported extreme problems in at least one of the five EuroQol quality of life domains compared with 20% single lung recipients, 4% bilateral lung recipients, and 2% heart-lung recipients at 3 or more years after transplantation. The mean utility value of patients on the waiting list was 0.31. In comparison, utility values for recipients 3 years after transplantation were 0.61 for single, 0.82 for bilateral, and 0.87 for heart-lung transplants. The utility scores and health profiles of bilateral and heart-lung recipients were consistently superior to those of single lung recipients. Problems in all five domains were more frequent in single lung recipients. Subjective assessment with a visual analogue scale showed a similar trend. CONCLUSIONS The EuroQol is a simple method of deriving a single utility value for quality of life and is responsive to changes after lung transplantation. It is worth considering as a means of monitoring quality of life after transplantation and as an index of quality of survival in research studies in solid organ transplantation. These data suggest that quality of life after transplantation of one lung is inferior to that after transplantation of two lungs.

Determinants of outcome after heterotopic heart transplantation

BACKGROUND Donor availability is currently the major factor limiting the use of heart transplantation as a treatment for severe heart failure. Heterotopic heart transplantation may address this issue by allowing the use of smaller donor organs, which otherwise may not be used. METHODS We analyzed the outcome of 42 consecutive, adult heterotopic transplantations performed between 1993 and 1999 at our center and compared them with the 303 consecutive orthotopic transplants performed in adult patients during the same period. METHODS Univariate analysis showed a relative risk for death of 1.8 at 1 year after transplantation for the heterotopic group compared with the orthotopic transplantation group (p = 0.04). Multiple regression analysis using a proportional hazards model showed that donor-recipient size-mismatch, i.e., donor body surface area < or =75% of recipient body surface area (p = 0.0001), donor age (p = 0.0001), and use of a female donor (p = 0.04) were significant risk factors but heterotopic transplantation per se was not. A Kaplan-Meier survival analysis of heterotopic vs orthotopic transplantation showed that 30-day survival was 76% vs 87%. By 1 year, this was 59% vs 74%. At 3 years, the comparison was 56% vs 69%. Repeating this analysis after sub-dividing the heterotopic group into those size-matched vs size-mismatched, the 1-year survival was 81% vs 45%, respectively (p = 0.02). CONCLUSIONS Heterotopic transplantation using a size-matched graft resulted in similar survival to that seen after orthotopic transplantation during the same period. Heterotopic transplantation with an undersized graft resulted in significantly decreased survival.

Low incidence and severity of transplant-associated coronary artery disease in heart transplants from live donors

BACKGROUND Hearts transplanted from patients undergoing heart-lung transplantation (domino hearts) are unique because they have not been subjected to the deleterious effects of brain-stem death. This study examines the incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts. METHODS We retrospectively reviewed angiographic and clinical data from 97 patients who survived more than 1 year after domino heart transplantation at our hospital. Duration of follow-up ranged from 1 to 11 years after transplantation. The diagnosis of coronary artery disease was based on angiographic criteria. RESULTS At 1 year, freedom from angiographic coronary artery disease was 99% (70% confidence interval [CI], 97-100), at 5 years it was 83% (70% CI, 78-89), and at 10 years it was 77% (70% CI, 70-84). Donor age, cystic fibrosis in the donor, organ ischemia time during transplantation, and acute rejection after transplantation did not influence risk for the disease. We found an increased incidence of coronary disease in hearts from male donors compared with those from female donors: freedom from disease at 5 years was 72% (70% CI, 63-81) in men vs 93% (87-99) in women. Thirteen patients experienced coronary artery disease at a median of 3 years after transplantation; 4 patients died but most patients remained asymptomatic with angiographically mild disease at their last follow-up examination. CONCLUSIONS We found decreased incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts compared with that reported in recipients of cadaveric hearts. This data supports the continued practice of domino heart transplantation and also supports the hypothesis that brain death may contribute to the development of transplant coronary artery disease in recipients of hearts transplanted from cadaveric organ donors.

Cardiothoracic TransplantationAn economic evaluation of lung transplantation

Objective: This study was undertaken to determine the cost per quality-adjusted life-year gained with lung transplantation relative to medical treatment for end-stage lung disease in the United Kingdom. Methods: Patients on the transplant waiting list were used to represent medical treatment. Four-year national survival data were extrapolated to 15 years by means of parametric techniques. Quality-adjusted life-years were derived by means of utility scores obtained from a cross-section of patients. Resource consumption and costs were based on local and national sources. Costs and benefits were discounted at an annual rate of 6%. Results: Across a 15-year period lung transplantation yielded mean benefits (relative to medical treatment) of 2.1, 3.3, and 3.6 quality-adjusted life-years for single-lung, double-lung, and heart-lung transplantation, respectively. During the same period the mean cost of medical treatment was estimated at

Conversion to off-pump coronary bypass without increased morbidity or change in practice

73,564, compared with

Long-term results of cardiac transplantation from live donors: the domino heart transplant

176,640,

Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery

180,528, and

Patients' views of the consent process for adult cardiac surgery: questionnaire survey

178,387 for single-lung, double-lung, and heart-lung transplantation, respectively. The costs per quality-adjusted life-year gained were

Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life.

48,241 for single-lung,

Primary lung carcinoma after heart or lung transplantation: Management and outcome

32,803 for double-lung, and