Bieber Cp

IDIOPATHIC CARDIOMYOPATHY, AGE, AND SUPPRESSOR-CELL DYSFUNCTION AS RISK DETERMINANTS OF LYMPHOMA AFTER CARDIAC TRANSPLANTATION

A review of lymphomas developing in recipients of cardiac allografts has yielded significant risk factors. Frequency varied strikingly according to original cardiac disease: lymphoma developed in 6 of 37 patients with prior idiopathic cardiomyopathy (I.C.M.) but in one of 54 patients with prior coronary-artery disease (C.A.D.). All patients who developed lymphomas were aged under 40. Combination of both risk factors (I.C.M. and age less than 40) produces a sub-group with a highly significantly increased risk of lymphoma. I.C.M., but not C.A.D., is characterised by a defect in mitogen-induced mononuclear-cell suppressor activity. It is postulated that defective regulation in the immune systems of younger patients under chronic alloantigen stimulation may allow lymphoid proliferation to proceed to lymphoreticular malignancy. Immunosuppressive agents such as azathioprine may exert a co-oncogenic effect.

COMBINED HEART AND LUNG TRANSPLANTATION

Combined heart-lung transplantation has now been carried out in 27 patients at Stanford University Medical Center. All recipients had suffered from pulmonary hypertension, either primary or the result of Eisenmengers syndrome. The one-year survival has been approximately 70%. All survivors returned to normal activity, though later respiratory difficulty has been encountered in some of these patients and has required retransplantation in one. These late occurrences are likely the result of inadequate control of rejection. Heart and lung transplantation has been shown to be an effective therapy for otherwise progressively fatal pulmonary conditions, and, in the case of Eisenmengers syndrome, has presented a therapeutic avenue for the first time. The late complications encountered in some of these patients can probably be averted with increased experience.

Current management of cardiac transplant recipients.

Changes in the management of cardiac transplant recipients over the past 10 years have resulted in a substantial improvement in the outlook for survival. Imuran and prednisone remain the primary immunosuppressive agents, but rabbit antihuman thymocyte globulin is used initially and reinstituted during rejection. Endomyocardial biopsy has allowed more precise diagnosis and management of rejection, and more recently immunological monitoring has been introduced to provide more frequent assessment of the host immune response. Infection is the major cause of death, and its diagnosis and treatment is managed aggressively. Current survival figures justify the use of cardiac transplantation, by an experienced team, when other measures have been exhausted.