Claudio Goggi

Ten years of "extended" life: quality of life among heart transplantation survivors.

Background: Long-term quality of life (QOL) outcome in heart transplant recipients still remains uncertain. This study evaluates the health status and QOL of survivors with associated predictors 10 years after heart transplantation. Patients and Methods: A total of 276 patients who underwent heart transplantation in the Department of Cardiac Surgery, University of Pavia, between 1985 and 1992 were included in a cross-sectional study. Patients still alive 10 years after transplantation (n=122) were asked to complete the SF36 questionnaire and then received a full clinical examination. All QOL instruments that were used had acceptable reliability and validity. Descriptive statistics, Kaplan-Meier estimate, correlation coefficients, and general linear regression were used to analyze the data. Results: Survival rates 1, 5, and 10 years after transplantation were 87%, 77%, and 57%, respectively, and the average life expectancy was 9.16 years. The mental QOL of patients 10 years after heart transplantation was similar to that among the general population. The physical QOL was worse among patients when compared with the QOL of the general population, with predictors including older age, being married, the presence of complications, and impaired renal function. Conclusions: Heart transplantation ensures a relatively high QOL even 10 years after surgery. Predictors of a poor QOL were determined, which may help to identify those patients for whom a poor outcome is likely so treatment can be tailored accordingly.

Expression of natriuretic peptide in ventricular myocardium of failing human hearts and its correlation with the severity of clinical and hemodynamic impairment

Atrial natriuretic peptide (ANP) was immunohistochemically investigated in (1) right ventricular endomyocardial biopsy specimens from 87 apparently healthy donor hearts taken from victims of cerebral accidents; (2) 1 normal heart not suitable for transplantation (HBsAg carrier); (3) right ventricular endomyocardial biopsy specimens from 151 patients with dilated cardiomyopathy (DC); and (4) 57 explanted hearts, 26 with DC and 31 with ischemic heart disease. No ANP immunoreactivity was found in normal ventricles. Failing hearts showed ventricular positivity in 31% of the DC biopsy series, in 61% of the left ventricles, and in 30% of the right ventricles of the explanted heart series. An endoepicardial gradient was observed, because ANP positivity was greater and more extensive in the subendocardial layers. Ultrastructural studies were performed on biopsy specimens from 10 normal hearts and 132 DC biopsy samples. No ANP-storing granules were found in biopsy samples of normal ventricles, whereas ANP granules were seen in 15 of 132 (11.4%) DC cases. In parallel immunoblotting, investigation showed the same 13 kDa band protein in 1 normal atrium as well as in 8 failing atria and ventricles. ANP immunoreactivity was positively correlated with higher New York Heart Association functional classes as well as with higher left ventricular end-diastolic pressure (p less than 0.005), end-diastolic volume (p less than 0.005) and end-diastolic volume index (p less than 0.005). In conclusion, apparently healthy ventricles do not show ANP immunoreactivity, whereas failing ventricles do. ANP expression seems to be independent of the underlying disease, but positively related to the clinical status and the degree of left ventricular impairment and dilatation.

Return to work after thoracic organ transplantation in a clinically-stable population

To evaluate the rate of return to work after transplantation and its determinants in a clinically‐stable population of patients transplanted and followed‐up at a single institution in Italy.

Clodronate treatment of established bone loss in cardiac recipients: a randomized study.

Background. Bone loss has been reported as a complication after heart transplantation (HTx), and the increase in bone fractures is an effective problem. Treatment of osteoporosis has obtained mixed results. In this study we evaluate the effect of treatment with an oral bisphosphonate. Methods. Sixty-four patients with low mineral density 6 months after HTx were randomized as follows: Group A received oral clodronate (1600 mg/day in two divided doses), and Group B received placebo. Every patient was also treated with 2000 mg/day of oral calcium carbonate. Bone mineral density (BMD) was measured by dual energy x-ray absorptiometry at the lumbar spine, 1/3 and 1/10 of the distal nondominant forearm before and after 12 months of treatment. Laboratory tests were performed at 3, 6, and 12 months of treatment. Results. All patients demonstrated manifest bone loss 6 months after HTx compared with normal non-HTx controls (P =0.0001). After 1 year of clodronate therapy, BMD at the lumbar spine increased from 0.77±1.4 g/cm2 to 0.86 g/cm2 (P =0.02). Laboratory tests did not show any significant variation, except for the bone isoenzyme of alkaline phosphatase, which showed a significant decrease after 1 year of treatment. The incidence of new fractures was 9.3% in the placebo group and 0% in the clodronate group. Therapy was well tolerated without impact on graft function. Conclusions. One year of clodronate therapy induced a significant increase in BMD at the lumbar spine in our HTx patients. Treatment was well tolerated without onset of new bone fractures.

Expression of proliferating cell markers in normal and diseased human hearts

Proliferating cell nuclear antigen (PCNA) myocyte expression and histopathologic features related to its occurrence were investigated in normal and diseased hearts of adult humans using both immunohistochemical and Western blotting techniques. Ki67 Western blotting was also performed in the same samples used for PCNA blotting. Two hundred seventy-one endomyocardial biopsies, and 15 adult, 1 embryonic and 2 fetal hearts were studied. The biopsies were from normal donor hearts (n = 71), patients with cardiomyopathy and myocarditis (n = 64), and patients with transplantation with (n = 106) and without (n = 30) acute rejection of any grade. The 15 hearts were from 1 heart donor, and from patients with cardiomyopathy (n = 5), valvular heart disease (n = 2), ischemic heart disease (n = 4), amyloidosis (n = 1) and transplantation with acute rejection (n = 2). The PCNA labeling index was plotted against myocyte hypertrophy, inflammatory infiltrates and binucleation index. The PCNA labeling index ranged from 2 to 9% in embryonic and fetal hearts. PCNA was expressed by 1 to 2% of myocyte nuclei in 12% of normal heart biopsies, 1 to 5% of myocyte nuclei in 28% of cardiomyopathy and myocarditis biopsies, and by up to 8% of myocyte nuclei in 53% of biopsies of patients with transplantation, independently of the presence and degree of acute rejection. In the latter biopsies and in myocarditis, some inflammatory cells also showed PCNA expression. PCNA positive myocytes were both mono- and binucleated, and there was no correlation between binucleation and PCNA labeling indexes. Ki67 and PCNA blotting confirmed immunohistochemical results.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative Anemia and Exercise Tolerance After Cardiac Operations in Patients Without Transfusion: What Hemoglobin Level Is Acceptable?

BACKGROUND Restrictive transfusion strategies have been suggested for cardiac surgical patients, leading to various degrees of postoperative anemia. This study investigates the exercise tolerance during rehabilitation of cardiac surgical patients who did not receive transfusions, with respect to their level of postoperative anemia. METHODS This observational study started in January 2010 and ended in May 2010 in 2 rehabilitation hospitals and 2 large-volume cardiac surgical hospitals. The study population was 172 patients who did not receive transfusions during cardiac surgical operations with cardiopulmonary bypass and subsequently followed a rehabilitation program in 1 of the 2 rehabilitation hospitals. No patient received a transfusion during the rehabilitation hospital stay. Exercise tolerance was measured using the 6-minute walk test at admission and discharge from the rehabilitation hospital. The level of anemia at admission to the rehabilitation hospital was tested as an independent predictor of exercise tolerance within a model inclusive of other possible confounders. RESULTS Patients with values of hemoglobin less than 10 g/dL at admission to the rehabilitation institute had a significantly (p=0.007) worse performance on the 6-minute walk test than patients with higher values (258±106 vs 306±101 meters). This functional gap was completely recovered during a normal rehabilitation period. Other independent factors affecting exercise tolerance were age, sex, and albumin concentration. CONCLUSIONS Postoperative anemia with hemoglobin levels of 8 to 10 g/dL is well tolerated in patients who have not received a transfusion and induces only a transient impairment of exercise tolerance.

Successful treatment of aortic dissection after heterotopic heart transplantation

Heterotopic heart transplantation is a valid option when there is a large donor-recipient size mismatch. However, the presence of the diseased native heart can jeopardize the medium-term and long-term outcome. The problems stemming from this most commonly described in the literature are thromboembolism, angina, and arrhythmias. In this report, we describe the case of a type A aortic dissection in the native aorta that occurred 30 months after heterotopic heart transplantation and the surgical technique successfully applied for its repair. We also discuss some of the alternative techniques.

The 6-minute walking test and all-cause mortality in patients undergoing a post-cardiac surgery rehabilitation program

Background The 6-minute walking test (6mWT) is used to prescribe physical activity in cardiac surgery patients. The clinical value of a pre-discharge 6mWT and its association with outcome is not well defined. Design and methods We retrospectively analyzed data from 313 patients (age 66 ± 11 years, 23% females, left ventricular ejection fraction (LVEF) 52 ± 11%, Hb 10.5 ± 1.3 g/dl, serum albumin 3.9 ± 0.4 mg/dl) who were admitted to our rehabilitation institute following cardiac surgery. A 6mWT was performed at entry and at discharge and expressed as % of theoretical predicted values calculated on the basis of individual age, height, weight and sex. The endpoint was represented by all-cause mortality. The predictive value of 6mWT was tested in univariate and multivariate analysis. Results A pre-discharge 6mWT was completed by 284 out of 313 patients. Two patients died in hospital. During a median of 23 months, mortality was 9% (26/284) and 44% (12/27) (p < 0.0001) in patients who did or did not perform the pre-discharge 6mWT. The distance covered at the pre-discharge 6mWT as a continuous variable of % predicted values was a significant predictor of subsequent mortality (Hazard Ratio (HR) 0.97 (95% CI 0.96–0.99), p = 0.0019). After adjustment for all preselected covariates, the pre-discharge 6mWT (HR 0.97 (95% CI 0.95–0.99), p = 0.0038) and LVEF (HR 0.93 (95% CI 0.90–0.96), p < 0.0001) remained significantly associated with the outcome. Conclusions In recent cardiac surgery patients, the pre-discharge 6mWT is not only a valid measurement of the impact of cardiac rehabilitation but also provides outcome information offering the possibility to identify patients who may need more intensive follow-up.

Heart transplantation without informed consent: discussion of a case

AbstractObjective: To discuss informed consent to heart transplantation in the case of an intensive care unit (ICU) patient: relatives’ informed consent was refused by the patient himself whose cognitive ability appeared to be reasonable for the purpose. Setting: ICU of a university teaching hospital. Patient: a 62-year-old man who underwent myocardial revascularization had in the immediate post-operative hemodynamic instability, continuous serious arrhythmias, ventilatory support, fentanyl infusion. Heart transplantation could be the only chance for his survival. Intervention: heart transplantation. Results: despite patient’s refusal, we decided to hold the relative’s consent as valid, and transplantation was accordingly performed, to the subsequent satisfaction of the patient. Conclusions: Our decision was based on two beliefs: (1) the severity of the patient’s clinical condition may have impaired his cognitive abilities; (2) the very same conditions may mask impairment and certainly make reliable assessment of cognition and judgment impossible. This being so, the preservation of life assumes priority.

Chronic thromboembolic pulmonary hypertension: From transplantation to distal pulmonary endarterectomy

within the chest. For example, patients who have undergone Fontan palliation have only 1 atrioventricular valve, and a capacitance chamber must be constructed to adequately connect the TAH-t. Virtual implantation offers the ability to test several surgical approaches for device placement before the patient even enters the operating room. This study was limited by a single-center experience in a small patient cohort. In addition, the assessment by virtual implantation was retrospective, and no 50cc TAH-t device was actually implanted to confirm the predicted results of the virtual implantation because it was not available during the study. However, two 70cc TAH-t devices were placed successfully as predicted by virtual implantation. In conclusion, virtual compatibility testing allows device consideration for fit to be individualized and represents a movement away from using generalized assumptions about heart size, chest wall anatomy, and spatial relationships of cardiothoracic structures to determine fit. Disclosure statement