G. Tenderich

Risk Factor Analysis in Pediatric Heart Transplantation

BACKGROUND Steady assessment of risk factors will enable identification of patients at higher risk for post-transplant death, and may thus improve organ utilization and outcomes. In this study we aimed to identify the risk factors of mortality in pediatric heart transplantation. METHODS Between November 1989 and February 2004, there were 116 orthotopic heart transplantations performed in patients <18 years of age at our institution. RESULTS The 30-day mortality risk was 12% (dilated cardiomyopathy 7%, congenital heart disease 26%; univariate analysis: p = 0.023). The main cause of 30-day mortality was primary graft failure (36%). The late mortality rate was 31 per 1,000 person-years. The main causes of late mortality were acute rejection (44%) and cardiac allograft vasculopathy (26%). The 1-, 5-, 10- and 15-year survival rates were 85%, 77%, 65% and 53%, respectively. Male donor (odds ratio [OR] 6.33, 95% confidence interval [CI] 1.11 to 36.01) and cardiopulmonary bypass >210 minutes (OR 43.05, 95% CI 1.11 to 1,669) were risk factors for 30-day mortality. Risk factors for 1- and 5-year mortality were body weight ratio <0.8 (OR 40.36, 95% CI 3.04 to 536.47) and male donor (OR 3.36, 95% CI 1.05 to 10.75), respectively. Recipient age <1 year (OR 64.65, 95% CI 1.69 to 2,466.77) and donor-recipient body surface area mismatch of <0.9 (OR 10.58, 95% CI 1.03 to 108.25) were risk factors for 10-year mortality. CONCLUSIONS Pediatric heart transplantation can be performed with an expectation of excellent results. Certain risk factors suggest poorer outcomes.

Total artificial heart-implantation technique using the CardioWest or the Thoratec system

Total artificial heart is a safe and efficient bridge for patients with terminal congestive heart failure awaiting cardiac transplantation. The implantation of the CardioWest total artificial heart has become an accepted therapeutic option in critically ill patients who have irreversible biventricular failure and are candidates for cardiac transplantation. Because of anatomical limitations in smaller patients (women, adolescents) implantation of the CardioWest system might be impossible. In these cases we have implanted the paracorporeal Thoratec device in a modified technique as a total artificial heart.

Bosentan in pulmonary hypertension secondary to left heart failure

ABSTRACT Background: Pulmonary hypertension (PH) secondary to left ventricular failure not only predicts a poor clinical outcome, but also excludes patients from orthotopic heart transplantation (HTX). Recent clinical and laboratory findings indicate comparable pathophysiological mechanisms in PH secondary to left ventricular dysfunction and pulmonary arterial hypertension (PAH), a clinical situation in which endothelin (ET)-1 is an established key pathogenetic mediator. In addition to ET-1-mediated constriction and remodelling of the pulmonary vasculature, ET-1 further contributes to cardiac hypertrophy and aldosterone secretion in left heart failure (HF). Results: Initial results with the oral, dual ET receptor antagonist bosentan in patients with advanced left HF and secondary PH (presented herein as two case studies of patients with Class III and IV HF and a case series of 19 patients with PH secondary to left HF of different aetiologies) has shown promising results: cardiopulmonary haemodynamics improved significantly with a concomitant clinical stabilization. Conclusion: As illustrated by these initial results, bosentan may expand the therapeutic arsenal in PH secondary to left ventricular dysfunction and may not only help to bridge the time to HTX, but may also allow the improvement of cardiopulmonary haemodynamics and thus listing of patients that would be otherwise excluded from HTX.