H. Laks

Selecting oversized donor cardiac allografts for patients with pulmonary hypertension may be unnecessary.

INTRODUCTION There is a tendency to favor oversized donor hearts for heart transplant candidates affected by mild to moderate pulmonary hypertension (PHTN). We hypothesize that both undersized and oversized donor hearts fare equally well in this setting. METHODS A total of 107 cases from 2003 to 2008 were retrospectively reviewed and subsequently divided into those receiving organs from undersized donors (group 1: donor weight/recipient weight ≤ 0.90, n = 37) and oversized donors (group 2: donor weight/recipient weight ≥ 1.2, n = 70). PHTN was identified in the perioperative period in those patients with systolic pulmonary artery pressure (SPAP) ≥ 40 mm Hg. Endpoints of mortality and hemodynamic data were investigated. RESULTS Of 107 patients, 37 received undersized donor allografts, with a mean donor-to-recipient weight ratio of 0.8, and 70 received oversized donors allografts, with a mean donor-to-recipient ratio of 1.4. Perioperative PAH was diagnosed in 20 of the 37 (54%) patients from the undersized group (mean SPAP = 45.9 mm Hg) and 41 of 70 (59%) patients from the oversized group (mean SPAP = 46.5 mm Hg). There was no significant difference in right ventricular function at 1 week, 1 month, or 6 months. Left ventricular function was similar between both groups at 6 months (P = .22). The mean SPAP in the undersized group was 45.9, 33.4, 31.8, and 23.1 mm Hg at the perioperative, 1 week, 1 month, and 6 month time points, respectively. Corresponding mean SPAP for the oversized group was 46.5, 35.0, 29.4, and 26.1 mm Hg. The 1 month, 1 year, and 3 year survivals were similar in both groups. CONCLUSIONS Oversized and undersized donor hearts fared equally well in the setting of mild to moderate perioperative PAH. This in addition to the propensity for resolution of pulmonary hypertension over time suggests that the current practice of favoring oversized donor hearts for patients with pre-transplantation PAH may be unwarranted.

Bronchiolitis obliterans with organizing pneumonia: possible association with human herpes virus-7 infection after lung transplantation

transplant database of the centre was carried out. All single lung (SL), double lung (DL) and heart-lung block (HL) transplant patients who survived over 2 years post transplant were included in the study group. They were grouped as follows: A 5 D-/R(n5102), B 5 D-/R1 (n570), C 5 D1/R(n533) and E 5 D1/R1 (n592). The respective incidence of BOS in the different groups was 43.1%, 45.7%, 51.5% and 47.8% (p50.32). The 3-year BOS free survival was 65%, 56%, 58% and 67% respectively (p.0.05). In group A, the significant risk factors for developing BOS were three or more episodes of acute rejection (p50.02) and non-CMV pulmonary infection (p50.03). The mean number of acute rejection episodes per 100 patients days within the first six months were 1.28 (group A), 1.06 (group B), 0.50 (group C) and 1.11 (group E) [p,0.05]. Conclusion: Although CMV has been shown to be a risk factor for BOS, its absence did not preclude lung transplant patients from developing BOS. Moreover, absence of CMV was associated with an increase in the number of acute rejection episodes within the first transplant year. However, this could be accounted for by changes in frequency of acute rejection over time. Moreover, this may also reflect the non-uniformity of the pathological processes that are grouped as BOS.

Increased risk of CMV infection in heart transplant patients on mycophenolate mofetil

plantation (grp II, n58). Methods: Patients receiving HCV positive allografts between July 1994 to Dec. 1999 were reviewed. The HCV RNA level, seroconversion of anti-HCV antibody, hepatic enzymes, correlation of liver dysfunction and cause of death were examined. Survival and transplant coronary artery disease (TCAD) free rate were compared with age matched patients transplanted in the same period (n5 392). Results: The recipients consisted of 17 males and 1 female, with median age 54 yrs for grp I and 66 for grp II; 2 pts in grp II who were pretransplant HCV positive were also retransplants. Hospital mortality rate was 1/10 in grp I and 2/8 in grp II(total517 %), all from multiple organ failure. All survivors were HCV negative prior to transplant. At a median follow up of 26.5 months, 6/15 survivors (40 %) were infected with detectable viremia. Three(20 %) seroconverted after 1-13 months and two, one per grp, developed HCV related liver dysfunction. One from grp I developed fibrosing cholestatic hepatitis and expired. Actuarial 3 yr survival in those discharged is 56% and 84% for grp I and II. Freedom from rejection (.grade 3) was 40% for grp I and 100% for grp II. TCAD accounted for 2 late deaths in persistently seronegative but viremic pts in grp I and none in grp II. Overall 3-year TCAD free rate was 87% for the 15 patients discharged. Conclusions: (1) Under TDI, hepatitis C transmission using donor heart as the reservoir is moderate with seroconversion lower. (2) Limited use of such donors is justified in selected patients. (3) Seroconversion and risk for hepatic disease may be reduced by tailoring immunosuppression particularly if they are at low risk of rejection.

506 SURGICAL CREATION OF AUTOLOGOUS PERICARDIAL NEO-AORTIC SINUSES TO MANAGE SINUS OF VALSALVA PATHOLOGY.

Objective We sought to evaluate the efficacy of creating glutaraldehyde-tanned autologous pericardial neosinuses to repair (exclude) sinus of Valsalva aortic root pathology. Methods Over the last decade (1996-2005), 81 patients (mean age 46 ± 20 years) underwent aortic root repairs involving construction of neoaortic pericardial sinuses as a central feature. Sixty-seven (83%) patients were male. The etiology was congenital in 53% (43), including bicuspid aortic valve (30), ventricular septal defect (6), aortic coarctation (4), and connective tissue disorder in 15% (12), including Marfans syndrome (9). Fifty-eight patients had an ascending aorta aneurysm and five patients experienced Type I dissection. Sixty-six patients had significant aortic regurgitation (AR) and 24 patients had concomitant AR/AS. Seventy-six patients had an aneurysmal non-coronary sinus; 37 and 25 patients had affected right and left coronary sinuses, respectively. Three patients had sinus ruptures into the right ventricle. Surgical approaches included creation of pericardial neosinuses (NCS: 75, RCS: 38, LCS: 24); AV repair (10 pericardial leaflet extensions, 21 subcommissuroplasties); AV replacement (39); ascending aorta repair (14 Hemashield grafts, 54 Dacron mesh wraps), and concomitant mitral valve and tricuspid repairs in 11 and 4 patients, respectively. Results There was no early mortality (mean follow-up 23 ± 31 months). There was one death at 6.3 years due to complications following another cardiac operation. Nine patients required reoperation for recurrent AR and aneurysmal sinuses (6), and aortic aneurysms/dissections (3). The remaining patients demonstrated good AR (mean grade 1.3 ± 1.1; 3.2 ± 1.0 preoperatively) and aortic root statuses (mean diameter 34.3 ± 6.0 mm; 46.9 ± 12.3 mm preoperatively). Conclusions Creating neo-aortic sinuses with autologous pericardium offers a promising simple approach to repair sinus-related pathology solely or as adjunctive surgical intervention for multi-level disease in the aortic root and ascending aorta.

528 ARTERIAL SWITCH OPERATION IN INFANTS WITH ABNORMAL CORONARY PATTERNS: CLINICAL OUTCOMES.

Objective To determine the short- and midterm outcome of the arterial switch operation (ASO) in infants with normal and abnormal coronary artery patterns. Methods A retrospective analysis was conducted of the experience with the ASO at one institution over the span of 20 years from 1985 through 2005. Two hundred eight consecutive ASOs were performed by the same surgeon for transposition and double-outlet ventricle complexes. Of the 208 coronary artery patterns, 159 (76%) and 49 (24%) were normal and abnormal, respectively. These were classified into 4 groups: Type I (n = 159, 76%) had the typical dual arrangement (1AD, Cx; 2R), Type II (n = 26, 13%) had a dual system other than the typical, Type III (n = 11, 5%) had a single ostium coronary system, and Type IV (n = 12, 6%) included any pattern that had an intramural coronary course or commissural take-off. The primary end points were short- and long-term mortality. Results There was no difference at operation in weight, gender, preoperative inotropic support, presence of VSD and RVOTO between the normal and abnormal groups. There were a total of 16/208 deaths over 20 years (7.7%), with a mean follow-up time of 7.2 years (range 3 months to 19 years). There was no significant difference in the early mortality rate for the normal coronary patterns, 6 out of 159 (3.7%) and the abnormal coronary patterns, 3 out of 49 (6.1%) (p = .29). Similarly, there was no difference in late deaths in the normal, 4 (2.5%), and abnormal, 3 (6.1%), groups (p = .12). Conclusions The existence of abnormal coronary patterns is not a risk factor for early or late mortality after ASO. The impact on late ventricular function awaits determination.

233 HEMODYNAMIC COMPROMISE REJECTION PREDICTS FUTURE CARDIAC ALLOGRAFT VASCULOPATHY AND NONFATAL MAJOR ADVERSE CARDIAC EVENTS.

Hemodyanamic compromise rejection (HCR) has been reported to be between 5 and 20% in the cardiac transplantation population. There has been controversy as to whether this form of rejection leads to a higher incidence of cardiac allograft vasculopathy (CAV) and nonfatal major adverse cardiac events (nf-MACE, defined as acute myocardial infarction, congestive heart failure, percutaneous cardiac intervention, need for implantable cardiac defibrilator, cerebral vascular accident, peripheral vascular disease). In our program, HCR is defined as heart failure symptoms associated with left ventricular ejection fraction ≤ 40%, cardiac index ≤ 2.0 L/min/m2, and the need for inotropic support. Between January 1994 and December 2003, 487 heart transplants were performed at our institution. There were 86 episodes of HCR, 23 occurring less than 30 days (early HCR) and 63 occurring greater than 30 days (late HCR) after heart transplantation. Compared to those patients without HCR (control group), 5-year survival was significantly less in those patients with early HCR (early HCR 47.8% vs control 71.3%, p = .008). The incidence of nf-MACE and CAV was without difference between these two groups. However, more patients in the early HCR group died and did not have the opportunity to develop nf-MACE and CAV. For patients with late HCR, 5-year survival and nf-MACE was comparable compared to the control group. However, there was increased development of CAV at 5 years (33.3% vs 21.7% for control, p = .049). For early and late HCR combined, there was significantly more nf-MACE compared to the control group (12.8% vs 5.1%, p = .011). Conclusion HCR less than 30 days of transplant confers poor 5-year survival, and late HCR is associated with greater development of CAV at 5 years. Overall, HCR is associated with the development of nf-MACE. Modification of subsequent maintenance of immunosuppresion and/or careful monitoring need to be pursued in these patients in order to improve outcome.

408 AVERAGE FIRST-YEAR BRAIN NATRIURETIC PEPTIDE PREDICTS POOR OUTCOME AFTER HEART TRANSPLANTATION.

Elevated single BNP measurements after cardiac transplantation have been reported to predict cardiac rejection. The physiology behind elevated BNP may be due to volume overload, restrictive cardiac physiology, or rejection. It is not known what is the significance of persistently elevated BNP levels in the first year after heart transplantation. Methods We reviewed 107 heart transplant patients between July 2001 and November 2003 who had 2348 BNP blood samples obtained from the time of transplant. A mean first-year BNP level was obtained by averaging at least 4 blood samples (2 blood samples before and after the 6 month post-transplant period). Samples during allograft rejection, hemodialysis, and during the first 2 months (during which levels are known to be elevated) were excluded. The patients were divided into two groups: low BNP (n = 75, those with first-year mean BNP less than 140 ng/mL) and high BNP (n = 32, those with first-year mean BNP greater than 140 ng/mL). Results Compared to the low-BNP group, patients with high BNP had a significantly greater incidence of cardiac allograft vasculopathy (4% vs 22%), any hemodynamic compromising rejection (4% vs 31%), and mortality (1.4% vs 12%) (all comparisons p < .05) over an average follow-up of 28 months. There was no difference in mean echocardiographic ejection fraction between the two groups (LVEF 54.6% vs 52.2%, p = .08). Conclusion Persistently elevated BNP in the first year after heart transplant appears to be an early marker for poor outcome. Further studies into the management and actual cause of persistently elevated BNP following cardiac transplantation need to be performed.

109 SURGICAL CORRECTION OF ANEURYSMS OF THE SINUS OF VALSALVA IN THE 21ST CENTURY

Objective To evaluate contemporary management of sinus of Valsalva aneurysms. Methods We reviewed the medical records of all patients, since 2000, presenting to UCLA with rare sinus of Valsalva aneurysms. Seven patients (6 males, 1 female) were identified with a mean age of 22.2 yrs (range, 6 wks to 45 yrs). Their mode of presentation, diagnosis and operative management were evaluated and compared to historical controls. Results Forty-three percent (3/7) of cases presented unruptured. Patients with ruptured aneurysms presented with exercise intolerance, continuous murmurs and volume overload from left to right shunting. In every case, the aneurysm originated in the right coronary sinus, protruding or rupturing into the right ventricular outflow tract (RVOT) in 5, the right ventricle in 1 and the pulmonary artery in another. Color Doppler and 2-D echocardiography was the most common diagnostic tool (5), supplemented by cardiac catheterization (4) and transesophageal echocardiography (2). Predominant co-existing defects included VSD (6) and PFO (2). Four and one patient presented with important aortic and tricuspid regurgitation.Operative strategy required cardiopulmonary bypass and cardioplegia for myocardial protection. The aortic root was opened in all cases in addition to the communicating cardiac chambers and great vessels. Pericardium was used to repair the coronary sinus and obliterate the fistulous tract. Additional VSD closures (6), aortic valve repairs (4), PFO closures (2) and tricuspid valve repair (1) were performed. There was no patient mortality, residual shunting or valvular dysfunction. Conclusion Contemporary surgical repair of rare sinus of Valsalva aneurysms yields excellent outcomes.

106 THE FATE OF OLDER DONOR CARDIAC ALLOGRAFTS IN ADOLESCENT RECIPIENTS

Background We sought to test the hypothesis that older donor cardiac allografts in pediatric recipients had worse outcomes. Methods: Medical records of 207 consecutive heart transplants in 190 patients were reviewed. Donor allografts were divided into three groups by age. Analysis was limited to recipients between 10-21 yrs due to few children 0-9 yrs receiving grafts from donors ≥ 18 yrs of age. Recipients were stratified into low and high-risk categories, the latter bearing one or more of: CHD diagnosis, re-transplant, ventilator or mechanical circulatory assist dependency. Study endpoints were survival and freedom from rejection. Statistical analysis employed a Cox proportional hazards model with donor age 0-18 yrs as baseline. (Table) Results One and 3-yr actuarial survival for low-risk adolescents was 100 and 81%; and high-risk was 80 and 65%. One-year freedom from acute rejection for low-risk and high-risk patients was 58 and 78%. In the high-risk category alone, there was a trend towards lower 30-day mortality (0 vs. 17%, p=0.12) in Group 2. One year post-transplant, Group 2 had higher graft survival (96 vs. 66%, p=0.03) and a trend toward less rejection (87 vs. 68%, p=0.3). Freedom from the composite endpoint of graft failure, rejection, or death at 1 year was 35%, 85% and 58% for Groups 1, 2, and 3 respectively (p=0.01). Conclusion Adolescents had better outcomes with allografts from donors 18-36 yrs than less than 18 yrs. The results support use of older donor allografts in patients in their second decade of life given critical organ supply shortages.

257 THE INFLUENCE OF ADVERSE DONOR FACTORS ON OUTCOME OF PEDIATRIC HEART TRANSPLANTATION - THE MARGINAL DONOR ALLOGRAFT

Background We sought to examine the influence of various marginal donor criteria on pediatric heart transplantation outcome. Methods We reviewed the medical records of 191 pediatric heart transplants performed in 174 patients from 1984 through 2003 at our institution. Recipients were grouped into four (0, 1, 2, and ≥ 3 marginal factors) based on number of donor marginal criteria. A marginal donor allograft was defined by at least one of the following criteria: hx of cardiac arrest, LVEF≤50%, positive hepatitis B or C serology, dopamine ≥ 10 mcg/kg/min, gender mismatch (female donor), age ≥ 34 yr, allograft ischemia time ≥ 6 hours and donor-recipient weight ratio ≤ 0.8 ≥ 2. Study endpoints were actuarial survival and freedom from rejection. A Cox proportional hazards model was used for statistical analysis. (Table) Table Results: Conclusions Despite a trend in worse outcome the number of marginal donor criteria did not significantly impact the 1 and 3-year freedom from adverse events in pediatric heart transplantation justifying this strategy to increase the potential donor pool.