G.M. Mullen

Does heart transplantation confer additional benefit over medical therapy to patients who have waited >6 months for heart transplantation?

OBJECTIVES This study compared the survival of patients with heart failure who have waited > 6 months for heart transplantation with that patients who undergo heart transplantation after a similarly prolonged waiting period. BACKGROUND There are little data describing outcome in patients with severe heart failure who have waited for extended periods of time on the heart transplant waiting list. METHODS Sixty-three consecutive patients who spent > 6 months on the heart transplant waiting list were examined. Mean (+/- SD) age was 53 +/- 9 years, mean left ventricular ejection fraction was 19 +/- 6%, and all were taking digoxin and diuretic and vasodilator agents. Patients who underwent transplantation during the follow-up period were censored from the pretransplantation analysis, and their survival was examined as part of the posttransplantation phase of the study. RESULTS Of the 63 original patients examined, 25 underwent transplantation, 10 during inotropic or mechanical circulatory support. The pretransplantation mortality rate was 6% at 6 months after the 6-month milestone on the waiting list, 12% at 12 months and 22% at 18 months. The posttransplantation mortality rate was 5% at 6 months, 10% at 12 months and 24% at 18 months. There were no differences in survival at any time between the two phases of the study. CONCLUSIONS Survival of patients who have survived > 6 months on the heart transplant waiting list is generally good. Although heart transplantation did not appear to confer additional survival advantage over medical therapy, a large proportion of the patients who underwent transplantation were critically ill at the time of transplantation and would undoubtedly have died of progressive heart failure had they not undergone transplantation. We conclude that heart transplantation should still be considered a therapeutic alternative in patients with heart failure even after a prolonged waiting period on the heart transplant waiting list.

Prevention of osteoporosis in cardiac transplant recipients

Osteoporosis is a leading cause of pretransplant and posttransplant morbidity. The need for early detection by measuring bone mineral density, even before transplant, must be emphasized. Preventive measures are not comparable. The use of calcium and vitamin D supplements, although recommended, is inadequate for the prevention of bone loss and complications such as vertebral fractures. Bisphosphonates have been shown to attenuate the bone loss and reduce fractures associated with steroid-induced osteoporosis. Small studies in transplant recipients suggest similar results. Other preventive measures such as hormone replacement therapy are also helpful. There are limited data on the administration of nasal calcitonin in transplant recipients.

Diagnostic value and safety of endomyocardial biopsy in selected patients with heart failure

Abstract Background: The routine use of endomyocardial biopsy (EMB) as a diagnostic test in the evaluation of heart failure patients (HFP) is controversial and generally unadvisable because of low diagnostic yield and potential for significant procedural morbidity and mortality. Purpose: Therefore we reviewed our experience with EMB in a large and mostly referral HFP at our tertiary care center. Methods: We retrospectively reviewed 3419 EMB records from 3/1/97 to 2/28/02 and identified 78 (2.3%) HFP, who were screened and referred for EMB by the heart failure specialists. Pre-EMB clinical diagnosis included 55% dilated cardiomyopathy, 14% prior condition (amyloid, sarcoid, lupus), 7% probable myocarditis, 11% ischemia, 6% drug toxicity, 3% hypertrophic cardiomyopathy, 3% constrictive pericarditis, 1% restrictive cardiomyopathy. EMB samples were routinely submitted for light and electron microscopy, immunofluoresence, Congo red and iron staining. Results: There were 44 (56%) men and 34 (44%) women with mean age of 50.5±18.5 (13–81) years. EMB results were non-diagnostic in 57 (73.1%) and diagnostic in 21(26.9%). Diagnostic finding consisted of 8 (10.2%) amyloid, 5 (6.4%) drug toxicity, 4 (5.1%) myocarditis, 2 (2.6%) iron overload and 2 (2.6%) immunologic/lupus. In HFP undergoing EMB there were 2 (2.6%) of right ventricular perforations as the major procedural complication. In comparison in 3341 EMB performed routinely in heart transplant recipients there were 4 (0.12%) bleedings/hematoma, 3 (0.09%) life threatening arrhythmia, 3 (0.09%) carotid puncture and 1 (0.03%) right ventricular perforation. Conclusions: In HFP without established etiology for heart failure, EMB is of diagnostic value in 26.9% of cases. Contrary to prior concerns regarding the safety of the EMB in HFP this diagnostic test can be completed with low procedural morbidity and no mortality.