The University of California at Los Angeles heart transplantation experience.
ABSTRACT During the past 20 years, the number of older patients undergoing heart transplantation has steadily increased as a result of expanding indications for this procedure. At UCLA, 1,046 adult heart transplant procedures were performed from 1984-2004. Actuarial one-, 3-, 5-year survival rates for all recipients are 83%, 76%, and 72%, respectively. Our patients were grouped into 2 eras: those transplanted between 1984-1993 and those between 1994-2004. The current era, incorporating those patients transplanted between 1994-2004, may be defined by the introduction of pravastatin in 1994, which we have reported to benefit heart transplant patients. There were 403 adult heart transplant recipients in the pre-1994 era and 643 adult recipients in the current era. Additionally, patients were then grouped by age into those aged 18-61 years and those older than age 61 years. In the current era, there was less rejection and cardiac allograft vasculopathy (CAV) with improved survival and comparable survival in younger versus older patients. Although cellular rejection has decreased over the 1990's decade, we have reported that the incidence of noncellular or humoral rejection in our cardiac transplant recipients has remained unchanged despite improved immunosuppressive therapies. Thus, there appears to be a need for newer immunosuppressive agents to treat humoral rejection effectively. CAV is one of the major factors limiting long-term survival in heart transplant patients. Early CAV can be detected by intravascular ultrasound (IVUS), which is a new technology that detects intimal thickening in the donor coronary arteries. We demonstrated in the multicenter IVUS validation study that the progression of IVUS-defined intimal thickening > or = 0.5 mm in the first year after heart transplantation appears to be a reliable surrogate marker for subsequent mortality, nonfatal major adverse cardiac events, and the development of angiographic CAV through 5 years follow-up. The limitation on the number of transplants performed has been the number of donor organs available. We began the alternate list at our program in 1992, which is designed to match those patients excluded for regular heart transplant listing (mostly older patients) to marginal donor hearts which are unused. We have demonstrated that the alternate list patients who have undergone heart transplant have satisfactory outcomes. This has allowed expansion of the donor pool and offered heart transplantation to those patients who would not routinely have an opportunity for this life extending procedure.
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ABSTRACT: We compared the interobserver reproducibility of the 1990 and 2004 International Society for Heart and Lung Transplantation (ISHLT) grading system for cardiac rejection. The 2004 ISHLT grading system for cardiac allograft rejection did not improve reproducibility partly due to pathologists' disagreement in diagnosing Grades 1B/1R and 3A/2R rejection. To achieve better reproducibility, better criteria for defining 1B/1R vs. 3A/2R rejection and markers of myocyte injury are needed.Cardiovascular pathology: the official journal of the Society for Cardiovascular Pathology 08/2008; 18(4):198-204. DOI:10.1016/j.carpath.2008.05.003 · 2.34 Impact Factor
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ABSTRACT: The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation. The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7. Survival in the standard transplant group, defined as non-high-risk patients who received nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001). Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.The Annals of thoracic surgery 05/2009; 87(4):1066-70; discussion 1071. DOI:10.1016/j.athoracsur.2008.12.020 · 3.65 Impact Factor
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ABSTRACT: The lung allocation score (LAS) was initiated in May 2005 to allocate lungs based on medical urgency and posttransplant survival. The purpose of this study was to determine if there is an association between an elevated LAS at the time of transplantation and increased postoperative morbidity and mortality. The United Network for Organ Sharing provided de-identified patient-level data. Analysis included lung transplant recipients aged >or= 12 years who received transplants between April 5, 2006, and December 31, 2007 (n = 3,836). Recipients were stratified into three groups: LAS < 50 (n = 3,161, 83.87%), LAS 50 to 75 (n = 411, 10.9%), and LAS >or= 75 (n = 197, 5.23%), referred to as low LAS (LLAS), intermediate LAS (ILAS), and high LAS (HLAS), respectively. The primary outcome was posttransplant graft survival at 1 year. Secondary outcomes included length of stay and in-hospital complications. HLAS recipients had significantly worse actuarial survival at 90 days and 1 year compared with LLAS recipients. When transplant recipients were stratified by disease etiology, a trend of decreased survival with elevated LAS was observed across all major causes of lung transplant. HLAS recipients were more likely to require dialysis or to have infections compared with LLAS recipients (P < .001). In addition, length of stay was higher in the HLAS group when compared with the LLAS group (P < .001). HLAS is associated with decreased survival and increased complications during the transplant hospitalization. Whereas the LAS has improved organ allocation through decreased waiting list deaths and waiting list times, lower survival and higher morbidity among HLAS recipients suggests that continued review of LAS scoring is needed to ensure optimal long-term transplant survival.Chest 10/2009; 137(3):651-7. DOI:10.1378/chest.09-0319 · 7.13 Impact Factor