C. Murks

Isolated heart transplantation for familial transthyretin (TTR) V122I cardiac amyloidosis

Abstract Transthyretin (TTR) cardiac amyloidosis is characterized by deposition of either mutant or wild type TTR amyloid protein in the myocardium ultimately leading to progressive cardiomyopathy and heart failure. The most common TTR gene mutation that leads to TTR cardiac amyloidosis is the valine-to-isoleucine substitution at position 122 (V122I or Ile122). Currently, the only definitive treatment suggested for mutant TTR cardiac amyloidosis is the combined or sequential liver-heart transplantation in eligible patients, since liver is the source of TTR production. Here, we report a case of heterozygous Val122L mutated TTR-related cardiac amyloidosis treated with isolated heart transplantation with no recurrence of amyloid in the cardiac allograft and no systemic abnormalities 5 years after heart transplantation.

Adult cardiothoracic transplant nursing: An ISHLT consensus document on the current adult nursing practice in heart and lung transplantation

BACKGROUND The role of nurses in cardiothoracic transplantation has evolved over the last 25 years. Transplant nurses work in a variety of roles in collaboration with multidisciplinary teams to manage complex pre- and post-transplantation issues. There is lack of clarity and consistency regarding required qualifications to practice transplant nursing, delineation of roles and adequate levels of staffing. METHODS A consensus conference with workgroup sessions, consisting of 77 nurse participants with clinical experience in cardiothoracic transplantation, was arranged. This was followed by subsequent discussion with the ISHLT Nursing, Health Science and Allied Health Council. Evidence and expert opinions regarding key issues were reviewed. A modified nominal group technique was used to reach consensus. RESULTS Consensus reached included: (1) a minimum of 2 years nursing experience is required for transplant coordinators, nurse managers or advanced practice nurses; (2) a baccalaureate in nursing is the minimum education level required for a transplant coordinator; (3) transplant coordinator-specific certification is recommended; (4) nurse practitioners, clinical nurse specialists and nurse managers should hold at least a masters degree; and (5) strategies to retain transplant nurses include engaging donor call teams, mentoring programs, having flexible hours and offering career advancement support. Future research should focus on the relationships between staffing levels, nurse education and patient outcomes. CONCLUSIONS Delineation of roles and guidelines for education, certification, licensure and staffing levels of transplant nurses are needed to support all nurses working at the fullest extent of their education and licensure. This consensus document provides such recommendations and draws attention to areas for future research.

Cardiac toxoplasmosis after heart transplantation diagnosed by endomyocardial biopsy

We describe a case of cardiac toxoplasmosis diagnosed by routine endomyocardial biopsy in a patient with trimethoprim‐sulfamethoxazole (TMP‐SMX) intolerance on atovaquone prophylaxis. Data are not available on the efficacy of atovaquone as Toxoplasma gondii prophylaxis after heart transplantation. In heart transplant patients in whom TMP‐SMX is not an option, other strategies may be considered, including the addition of pyrimethamine to atovaquone.

Increase in short-term risk of rejection in heart transplant patients receiving granulocyte colony-stimulating factor

BACKGROUND Neutropenia is a significant adverse event after heart transplantation (HT) and increases infection risk. Granulocyte colony-stimulating factor (G-CSF) is commonly used in patients with neutropenia. In this work, we assessed the adverse effects of G-CSF treatment in the setting of a university hospital. METHODS Data on HT patients from January 2008 to July 2016 were reviewed. Patients who received G-CSF were identified and compared with patients without a history of therapy. Baseline characteristics, rejection episodes, and outcomes were collected. Data were analyzed by incidence rates, time to rejection and survival were analyzed using Kaplan-Meier curves, and odds ratios were generated using logistic regression analysis. RESULTS Two hundred twenty-two HT patients were studied and 40 (18%) received G-CSF for a total of 85 total neutropenic events (0.79 event/patient year). There were no differences in baseline characteristics between the groups. In the 3 months after G-CSF, the incidence rate of rejection was 0.067 event/month. In all other time periods considered free of G-CSF effect, the incidence rate was 0.011 event/month. This rate was similar to the overall incidence rate in the non-GCSF group, which was 0.010 event/month. There was a significant difference between the incidence rates in the G-CSF group at 0 to 3 months after G-CSF administration and the non-GCSF group (p = 0.04), but not for the other time periods (p = 0.5). Freedom from rejection in the 3 months after G-CSF administration was 87.5% compared with 97.5% in the non-GCSF group (p = 0.006). CONCLUSIONS G-CSF administration was found to be associated with significant short-term risk of rejection. This suggests the need for increased surveillance during this time period.

Interdisciplinary Pain Education: Moving From Discipline-Specific to Collaborative Practice

BACKGROUND Pain is a common symptom reported by hospitalized patients with cancer. Cancer pain management requires an interdisciplinary approach for quality patient care. Although the literature suggests that most cancer pain can be managed with available treatments, many patients continue to experience pain even with opioid prescriptions. Implementation of evidence-based guidelines, such as the National Comprehensive Cancer Networks guidelines for adult cancer pain, promotes collaboration across disciplines and enhances patient care. OBJECTIVES This article reports the development, implementation, and evaluation of an interdisciplinary pain education program, Oncology Provider Pain Training (OPPT), to improve clinician knowledge and promote collaborative practice. METHODS The Kirkpatrick Model was used to design the OPPT program. A multifaceted training approach was used to accommodate the various needs of potential participants. Interdisciplinary educational sessions were held during a one-month period. Knowledge gained, learner reaction, and satisfaction were evaluated using predetermined benchmarks one month following program completion. FINDINGS Satisfaction benchmarks for content, teaching materials, and presenter were met. Although the knowledge gained benchmark was not met, substantial progress toward achievement was made. Additional modifications include increasing discipline-specific content and focus on pain pathophysiology and addressing time constraints. Inconsistent technology adoption across disciplines may have a negative effect on interdisciplinary educational efforts.

Simultaneous multiple organ cardiac transplantation is a successful treatment for chronic multiorgan failure

are not fully understood, but immunological processes may play an important role. Platelets can act as inflammatory cells and activated platelets are suggested to contribute to the pathophysiology of native atherosclerosis. We sought to investigate whether: i) platelet activation is common in heart transplant recipients; ii) markers of increased platelet activity are related to the presence of CAV. At the annual coronary angiography, platelet analyses was performed in 41 consecutive heart transplant recipients (age 49.4 13.1; 5.5 3.5 years postoperatively). 41 ageand gender-matched healthy individuals served as controls. Platelet activation was assessed by the use of immunological surface markers of activation (CD63 and P-selectin) by flow cytometry, platelet content of CD40L, and soluble P-selectin. CD63 was significantly increased in patients compared to controls [4,0% (2.6 5.4) vs. 2.0% (1.3 3.4), p 0.003], with a similar trend for P-selectin [3.4% (1.5 5.8) vs. 2.5% (1.1 4.5), p 0.07]. Furthermore, patients had a significantly increased platelet pellet content of CD40L compared to controls [2.95 ng/mL (1.80 3.72) vs. 1.6 ng/mL (0.76 2.31), p 0.001] and also increased release of CD40L in stimulated platelets [1.19 ng/mL (0.64 1.76) vs. 0.49 (0.22 1.30), p 0.026]. Levels of soluble P-selectin in plateletpoor plasma were significantly increased in patients compared to controls [61.8 ng/mL (43.8 75.6) vs. 51.3 (33.6 62.3), p 0.009]. While only 9 patients had angiographic signs of CAV, no association was found between CAV and markers of platelet activation. Enhanced platelet activation is evident in heart transplant recipients, judged by recognized immunological markers of activation and flow cytometry. The relative contribution of platelet activation to development and progression of CAV warrants further investigation.