Koshal A

Troponin T and I are not reliable markers of cardiac transplant rejection

OBJECTIVEnHeart transplant recipients undergo a number of invasive endomyocardial biopsies to screen for rejection. Serum assays of troponin T and/or I may provide a less invasive alternative. The purpose of this study was to evaluate troponin T and I as markers of cardiac transplant rejection.nnnMETHODSnWe conducted a prospective analysis comparing troponin T and I levels to biopsy results in heart transplant recipients. Plasma was assayed for troponin T and I preoperatively, on the first 3 postoperative days, and with each subsequent biopsy.nnnRESULTSnTwenty-nine patients entered the study. A total of 173 biopsies were performed at a mean follow-up of 129+/-9 days (range: 12-564 days). There were two rejection episodes (> or = grade 3), one in each of two patients. There were no significant relationships between troponin T or I and biopsy-proven rejection (> or = grade 3; P=0.59 and 0.54, respectively). There were also no correlations between troponin T or I levels and biopsy grade (P=0.40 and 0.92, respectively). Troponin T and I levels peaked on postoperative day 1 and fell to baseline over long-term follow-up with no peak in serum markers associated with rejection episodes. Donor ischemic time was significantly correlated to troponin T on postoperative days 1-3 (r=0.58, P=0.005; r=0.61, P=0.004; and r=0.61, P=0.003, respectively).nnnCONCLUSIONSnTroponin T and I are not useful indicators of cardiac rejection, but do correlate with donor heart ischemic injury.

Coronary endarterectomy. An adjunct to coronary artery bypass grafting.

Manual coronary endarterectomy remains a valuable adjunct to coronary artery bypass grafting in selected patients. The authors discuss the indications for endarterectomy and present the results of several large series. Their technique of endarterectomy of the right and left coronary arteries is described.

Pretransplant diabetes, not donor age, predicts long-term outcomes in cardiac transplantation.

Abstractu2003 Background and Aim: Accepting donors of advanced age may increase the number of hearts available for transplantation. Objectives were to review the outcomes of using cardiac donors 50 years of age and older and to identify predictors of outcome at a single institution. Methods: A retrospective analysis of all adult cardiac transplants (n = 338) performed at our institution between 1988 and 2002 was conducted. Results: Of these, 284 patients received hearts from donors <50 years old and 54 received hearts from donors ≥50 years old. Recipients of hearts from older donors had a greater frequency of pretransplant diabetes (19% vs 33%), renal failure (16% vs 30%), and dialysis (3% vs 9%). There were no differences in ICU or postoperative length of stay, days ventilated, or early rejection episodes. Recipients of older donor hearts, however, had increased perioperative mortality (7% vs 17%; p = 0.03). Multivariate analysis identified older donors (OR 2.599; p = 0.03) and donor ischemia time (OR 1.006; p = 0.002) as significant predictors of perioperative mortality. Actuarial survival at 1 (87% vs 74%), 5 (76% vs 69%), and 10 (59% vs 58%) years was similar (p = 0.08) for the two groups. Separate multivariate analyses identified pretransplant diabetes as the sole predictor of long‐term survival (HR 1.659; p = 0.02) and transplant coronary disease (HR 2.486; p = 0.003). Conclusions: Despite increased perioperative mortality, donors ≥50 years old may be used with long‐term outcomes similar to those of younger donor hearts. This has potential to expand the donor pool. Pretransplant diabetes has a significant impact on long‐term outcomes in cardiac transplantation and requires further investigation.

Characteristics and Outcomes of Patients Bridged to Cardiac Transplantation on Centrifugal Ventricular Assist Devices: A Case Series of the Early Experience of One Canadian Transplant Centre

Background: Centrifugal ventricular assist devices (VADs) have been used successfully to bridge patients in cardiogenic shock to cardiac transplantation, though complications are frequent and often life-threatening. Purpose: To describe characteristics and examine outcomes of patients bridged to cardiac transplantation on centrifugal VADs. Methods: A retrospective health record review was conducted on all adults over a 12 year period (N=20) placed on centrifugal VADs with the intent to bridge to cardiac transplantation at a major Canadian transplant centre. Results: Complications of VAD support necessitated removal of 12 patients from the transplant list; seven (35%) survived to cardiac transplantation. Of the seven recipients, five survived to discharge and four remain alive and well. Conclusions: Bridging patients on centrifugal VADs to cardiac transplantation requires improvement, including maintaining patient stability during the period of early VAD institution, aggressively managing complications of VAD support, and consideration of long-term pulsatile devices. However, if patients survive to transplantation, good long-term outcomes are expected.