Vincenzo Tursi

Long-term decrease in subjective perceived efficacy of immunosuppressive treatment after heart transplantation

BACKGROUND Mild, long-term non-compliance with immunosuppressive treatment after organ transplantation is common, and can result in early mortality. One possible source of non-compliance is the belief that the treatment is ineffective or unnecessary. This study investigates patients perception of the efficacy of their immunosuppressive treatment in a sample of heart transplant patients. METHODS A questionnaire was given to 67 heart transplant recipients. The first part of the questionnaire addressed health-related behavior and attitude toward the immunosuppressive medication, using self-report questions. In the second part of the questionnaire, participants evaluated the perceived risk of rejection associated with non-compliant behaviors described in 8 scenarios. RESULTS The data from the self-report questions showed a mild level of behavioral non-compliance, increasing over time, and a mild level of medication non-compliance. One third of the medication non-compliant patients chose the inefficacy or non-necessity of the treatment as a main cause of non-compliance. The second part of the questionnaire showed that subjective perceived efficacy of the immunosuppressive treatment decreased over time. CONCLUSIONS Medication non-compliance is fostered by many factors. One of these is the belief that the treatment is ineffective or unnecessary. This belief increases over time, and could be the result of a non-clinical selective-attention bias.

Mid-term clinical outcomes in cardiac surgery of Jehovahʼs witnesses

Introduction Surgical treatment of Jehovahs witnesses is a special challenge for cardiac surgery. The purpose of this study was to evaluate perioperative management and mid-term clinical outcome of Jehovahs witnesses who underwent cardiac surgery. Methods Between January 1990 and June 2009, 34 Jehovahs witnesses (22 men, mean age 66 ± 8 years) underwent cardiac surgery. Surgical procedures included 17 coronary artery bypass grafts (CABG): 3 CABG and aortic valve replacements (AVR); 1 CABG and mitral valve plasty (MVP); 6 AVR; 1 subaortic membrane resection; 2 mitral valve replacements (MVR) and 2 MVP; 1 mitro-aortic valve replacement; and 1 cardiac foreign body removal. There were four urgent operations; 14 patients had NYHA class II–III. Sixteen patients received erythropoietin preoperatively. Preoperative haemoglobin (Hb) value was 14.2 ± 1.4 g/dl. Results Extracorporeal circulation time was 127 ± 66 min, aortic cross-clamping 84 ± 45 min. Haemoglobin value 24 h after surgery was 11.2 ± 1.7 g/dl, haematocrit 34.1 ± 5.2%. None required surgical reoperation for bleeding. Intensive care unit stay was 2.3 ± 4.3 days, hospital stay 12.3 ± 10.4 days; there was no hospital mortality. Postoperatively, erythropoietin was administered to 19 patients. Follow-up was completed in 100%. Reoperation was necessary 8 years later in one patient for mitral bioprosthesis degeneration; the patient died 8 months later. All other patients are alive 59 ± 60 months after surgery; actuarial survival is 100% and 80 ± 2% at 5 and 10 years, respectively. Conclusion In our limited experience, early and late surgical results of Jehovahs witnesses patients are satisfactory. Appropriate preoperative management, optimization of Hb values, intraoperative measures to reduce the risk of bleeding and total blood loss recovery are the goals to achieve these results.

Laparoscopic approach for urgent abdominal surgery in patients with left ventricular assist devices.

Despite the fact that the rate of surgical complications mainly related to the necessary anticoagulation has been reported to be significant in patients supported by ventricular assist devices (VADs) who underwent noncardiac surgery, we report two cases showing that adequate peri-operative management of medical therapy and utilization of mini-invasive surgical approaches (i.e. laparoscopy) may limit the risks of morbidity, especially when surgery is required on an urgent basis.

Does psychosocial compliance have an impact on long-term outcome after heart transplantation?†.

OBJECTIVES Since patient compliance following organ transplantation is considered a limiting factor for long-term outcome, psychosocial assessment is commonly employed to evaluate suitability for organ transplantation. We analysed the impact of psychosocial characteristics on long-term outcome after heart transplantation in our institution. METHODS The outcomes of 345 patients (82% male, mean age: 56 ± 11 years) who had undergone a heart transplant since 1999 were evaluated taking into consideration major clinical and psychosocial findings. The impact on survival of the psychological habitus, substance abuse, economic status, education level, presence of caregivers and distance from the hospital (Area 1: <100 km, Area 2: ≥100 and <500 km, Area 3: ≥500 km) were considered in an univariate and multivariate analysis. RESULTS Univariate analysis showed that only retired patients had an increased risk of mortality. In fact, survival at 1, 5 and 10 years in unemployed versus retired versus employed people was 94 ± 3% vs 91 ± 2% vs 88 ± 3%; 86 ± 5% vs 75 ± 3% vs 80 ± 5%; 72 ± 8% vs 57 ± 5% vs 76 ± 5%, respectively (P = 0.05). Unemployed and employed patients were younger than retired patients. In multivariate analysis, after correction of clinical data, no psychosocial characteristics were found to be risk factors for long-term mortality: psychological problems [hazard ratio (HR) = 0.87; 0.56-1.33]; smoking (HR = 0.96; 0.61-1.54); alcohol abuse (HR = 1.62; 0.73-3.61); absence of caregivers (HR = 0.9; 0.44-1.83); critical economical condition (HR = 1.12; 0.65-1.93); lower school degree (HR = 0.95; 0.60-1.51); unemployment (HR = 1.00; 0.58-1.73) and distance from hospital (HR = 1.12; 0.76-1.98). At the same time, no psychosocial factors were identified as risk factors for coronary allograft vasculopathy, acute rejection and infection. CONCLUSIONS The psychosocial factors analysed in our study seem to have no impact on patient outcome, and should not preclude candidates from listing for heart transplantation; on the other hand psychosocial assessment should be utilized to identify patients requiring more specific surveillance to obtain the best outcome.

Recipient age impact on outcome after cardiac transplantation: should it still be considered in organ allocation? †

OBJECTIVES Improvement of clinical results in heart transplantation (HTx) has favoured the expansion of indication criteria towards aged population. The impact of increasing recipient age is controversial and, owing to donor shortage, the debate still remains whether HTx is justified for older patients. We analysed age as a prognostic factor at long-term after HTx and if it should be a determinant in organ allocation. METHODS Data of 364 consecutive patients who underwent cardiac transplantation between 1999 and 2014 at the University Hospital of Udine were analysed. Patients were divided into three groups according to age (Group 1: 18-40, Group 2: 41-59, Group 3: ≥ 60 years) and survival and major complications were evaluated at long-term (mean follow-up 6.7 ± 4.5 years, range 1-15.7 years). RESULTS Preoperatively, renal failure (2.9, 16.1, 39.5%, P < 0.01) and cardiovascular factors such as diabetes (1.2, 17.1, 36.4%, P < 0.01), systemic hypertension (5.9, 31.5, 40.8%, P < 0.01) and dyslipidaemia (5.9, 40.3, 42.9%, P < 0.01) were more common in older patients (Group 3), as well as ischaemic cardiopathy (0, 42.6, 49.7%, P < 0.01). Donor age was lower in younger recipients (Group 1) (33 ± 15, 39 ± 14, 45 ± 14 years, P < 0.01). Older patients showed a worse long-term survival (hazard ratio 1.7; 1.1-2.5), also after adjusting for major cardiovascular risk factors, renal failure and donor age. In fact, 15-year survival was 100% in Group 1, while at 1, 5, 10 and 15 years survival was 88, 78, 69 and 56% in Group 2, and 87, 68, 49 and 43% in Group 3, respectively. Even major long-term complications were less frequent in younger patients in terms of neoplasms (P < 0.01), rehospitalizations (P < 0.01) and a tendency to higher freedom from other complications such as cytomegalovirus infections, renal failure and dialysis. CONCLUSIONS Our results showed a significantly different outcome according to recipient age, even when adjusted for major risk factors. Notably, patients younger than 40 years showed 100% long-term survival, and apparent lower rate of complications due to immunosuppression. Since 15-year survival in patients ≤40 years is twice that of patients ≥60 years, recipient age should be taken into account in organ allocation.

Atypical presentation of idiopathic granulomatous myocarditis mimicking idiopathic giant cell myocarditis: diagnostic, therapeutic and prognostic insights

Myocarditis is the cause of up to 8% of heart transplants [1]. Specific types of myocarditis as idiopathic giant cell myocarditis (IGCM) and cardiac sarcoidosis (or granulomatous myocarditis, GM) require different management because of the risk of recurrence after transplantation. IGCM and GM are sometimes grouped together, but recently there has been a distinction made between the two on clinical and pathological bases [2]. We describe a case with a clinical course mimicking IGCM, but with histopathological findings of GM in the explanted heart. A 39-year-old man was referred for cardiac transplantation in September 2004 for severely dilated cardiomyopathy with refractory heart failure. In 1987 he was treated successfully with mesalazine for ulcerative proctocolitis. Cardiac examination, in 2002, showed no pathological findings. In May 2004, the patient began complaining of asthenia, fatigue and ankle edema with paresthesia of the arms; in June, congestive heart failure was diagnosed because of severely dilated cardiomyopathy with depressed ejection fraction (EF, 20%) and a small amount of pericardial fluid. The coronary arteries were normal. Electrocardiogram (ECG) showed sinus rhythm with low voltage in all leads and incomplete right bundle branch block. He was treated with angiotensin converting enzyme (ACE) inhibitors, diuretics, betablockers and spironolactone. Episodes of sustained ventricular tachycardia were treated with an implantable cardioverter defibrillator, resynchronization therapy, and amiodarone. Laboratory exams showed elevated creatinine phosphokinase (CPK), elevated hepatic markers and lymphocytopenia T. A muscle biopsy excluded peripheral myopathy. The clinical situation deteriorated rapidly and he was transplanted in October 2004. The explanted heart weighted 350 g; the ventricles were dilated; the ventricular walls were 12 mm thick on the left and 7 mm on the right. The myocardium appeared diffusely marbled and multiple irregular greyish-white areas were noted on both the ventricular walls and interventricular septum. The papillary muscles, chordae tendinae, orifices, ostia, valves and coronary vessels were unremarkable. Sections taken from the ventricular walls, septum and atria showed myocyte necrosis, inflammatory cell infiltration comprising lymphocytes, histiocytes, some eosinophils and some giant cells. The inflammatory infiltrates formed noncaseating granulomas with rare giant cells surrounded by B and T (CD8 lymphocytes). The same histopathological pattern was observed in the right ventricle and atria. The histopathology was consistent with GM with features of lymphocytic and histiocytic myocarditis (Fig. 1). The immediate post-operative course was uneventful and the patient was started on standard immunosuppressive therapy with cyclosporin, mycofenolate and corticosteroids. Echocardiograms performed on day one and five after transplant were within normal limits, although the patient was beginning to develop hypotension and oliguria. Endomyocardial biopsy on the sixth day was grade 0. The symptoms worsened and the patient was treated with infusions of furosemide, dopamine and dobutamine, and pulsed, supplemental high-dose intravenous prednisolone along with the standard immunosuppressive maintenance regimen. The next day the patient had to be intubated, ventilated and started on noradrenaline because of