H Y Yu

Publications (55)72.17 Total impact

• Article: Endomyocardial biopsy in heart transplantation: schedule or event?

  N-H Chi, N-K Chou, C-I Tsao, S-C Huang, I-H Wu, H-Y Yu, Y-S Chen, S-S Wang
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  ABSTRACT: Endomyocardial biopsy is the gold standard to identify rejection after heart transplantation. Due to its invasiveness, discomfort, and difficult vascular access, some patients are not willing to accept routine scheduled biopsies years after heart transplantation. The purpose of this study was to identify whether there was a difference in outcomes among the scheduled versus event biopsy groups. We studied 411 patients who underwent heart transplantation from 1987 to 2011, reviewing biopsy results and pathology reports. There were 363 patients who followed the scheduled biopsy protocol, and 48 patients who were assigned to the event biopsy group. We extracted data on biopsy results, rejection episodes, rejection types, and survival time. The 2481 reviewed biopsies over 24 years, showed most rejection episodes (86.4%) to occur within 2 years after heart transplantation. The rejection incidence was low (2.1%) at 3 years after transplantation. The major reason for an event biopsy was poor vascular access, such as tiny central vein or congenital disease without a suitable central vein. Event biopsy group patients were younger than schedule biopsy patients (19.7 years old vs 47.6 years old; P < .05). The 10-year survival rates were 64% among the event versus 53% among the scheduled biopsy group (P = .029). The 10-year rates of freedom from rejection were similar. The rejection rate was low after 3 years; episodes occurred within 2 years. Although the long-term survival in the event group was better, they had a younger man age. The rejection and freedom from rejection rates were similar. As the rejection rate was low at 3 years after transplantation, we suggest that the event principle could be applied for biopsy at 3 years after heart transplantation.
  Transplantation Proceedings 05/2012; 44(4):894-6. · 1.00 Impact Factor
• Article: Steroid pulse therapy combined with plasmapheresis for clinically compromised patients after heart transplantation.

  H-W Chou, N-H Chi, M-H Lin, N-K Chou, C-I Tsao, H-Y Yu, Y-S Chen, S-S Wang
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  ABSTRACT: The most serious complication after heart transplantation is allograft dysfunction. Patients presenting with compromised hemodynamics show a high incidence of mortality. The most common reason for allograft dysfunction is rejection. We have employed steroid pulse therapy combined with plasmapheresis for hemodynamically compromised patients after heart transplantation. Steroid pulse therapy and plasmapheresis were performed on 35 patients who underwent orthotopic heart transplantation for graft dysfunction. Thus treatment rescued ventricular function and improved the ejection fraction in 77% of patients, among who ever 71.4% showed improved New York Heart Association (NYHA) functional class. Steroid pulse therapy combined with plasmapheresis improved the cardiac contractility and NYHA functional class of most heart transplant recipients with graft dysfunction.
  Transplantation Proceedings 05/2012; 44(4):900-2. · 1.00 Impact Factor
• Article: Isolated cardiac sarcoidosis in heart transplantation.

  T-I Chang, N-H Chi, N-K Chou, C-I Tsao, H-Y Yu, Y-S Chen, S-S Wang
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  ABSTRACT: Heart transplantation is the ultimate treatment for end-stage heart failure. Cardiac sarcoidosis has rarely been reported in heart transplantation worldwide. Their long-term prognosis after heart transplantation is unknown. Herein we have presented clinical and pathological observations among heart transplantation patients with isolated cardiac sarcoidosis. From 1987 to 2011, we performed 411 heart transplantations including five patients retrospectively reviewed due to the presence of sarcoidosis and giant-cell cardiomyopathy in the recipient heart. Among the heart transplantations from 2003 to 2011, the four male and one female patients were ages 31 to 40 years. None of them had extra-cardiac sarcoidosis. All five subjects presented with dilated cardiomyopathy with patent coronary arteries. The commonest clinical presentations were atrioventricular block, ventricular arrhythmia, electrocardiographic findings of ST elevations, and poor left ventricular ejection fractions (17%-23%). All patients survived without allograft heart failure to date with the longest survivor at 8 years postoperatively. No recurrence of sarcoidosis has been observed clinically or among the post-heart transplantation endomyocardial biopsies. Heart transplantation is a useful treatment for isolated cardiac sarcoidosis patients suffering end-stage heart failure. Often the diagnosis is difficult to establish before heart transplantation despite endomyocardial biopsy. No recurrence of sarcoidosis was observed among the allografted hearts.
  Transplantation Proceedings 05/2012; 44(4):903-6. · 1.00 Impact Factor
• Article: Extracorporeal membrane oxygenation and Thoratec pneumatic ventricular assist devices as double bridge to heart transplantation.

  N-K Chou, J-M Luo, N-H Chi, I-H Wu, S-C Huang, Y-S Chen, H-Y Yu, C-I Tsao, W-J Ko, S-H Chu, S-S Wang
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  ABSTRACT: Ventricular assist devices have benefited patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experiment of HTx using extracorporeal membrane oxygenation (ECMO) with Thoratec pneumatic ventricular assist device (TpVAD). From May 1996 to June 2011, among 410 patients who underwent HTx 23 required mechanical circulatory support (MCS) with implantation of the TpVAD and 15 (65%) of them received grafts. The 23 patients included 4 female and 19 male patients of age range 10 to 80 years. Eighteen (78%) of them needed ECMO before TpVAD implantation. Twelve (67%) were implanted with a TpVAD double bridge to HTx. The demand for MCS among patients with acute hemodynamic collapse has led to major improvements in the existing systems such as ECMO with double bridge to TpVAD. We used ECMO as a rescue procedure for acute hemodynamic deterioration. However, during ECMO support, left ventricular afterload increased. If prolonged support is required, TpVAD might be required: 15 (65%) of patients supported by ECMO with TpVAD needed to a wait a suitable donor. We recommend the application of ECMO for short-term support (within 1 week), and TpVAD as a bridge for medium- or long-term support.
  Transplantation Proceedings 05/2012; 44(4):878-80. · 1.00 Impact Factor
• Article: The influence of the organ allocation policy on a patient's chances of undergoing heart transplantation and the posttransplantation survival rate.

  C-I Tsao, N-K Chou, N-H Chi, S-C Chen, W-J Ko, H-Y Yu, Y-S Chen, S-S Wang
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  ABSTRACT: The Taiwan Organ Registry and Sharing Center (TORSC) was established by the Department of Health on June 6, 2002. According to the organ allocation policy, the computer-based organ-matching program began on April 1, 2005. In order to encourage organ donations, "donor hospitals" were given the highest priority. On October 1, 2010, the TORSC implemented a new allocation policy allowing highest priority to the most critically ill patients listed as 1A status. The aim of this study was to investigate the influence of the allocation policy on the likelihood of undergoing a heart transplantation (HTx) as well as the survival after the procedure. Based on the timeline of changes in the organ allocation policy, the patients were divided into three groups: "individual decision," "donor hospital first," and "urgency status first." We observed the waiting time of status 1A patients to decrease and their chance to receive a donor heart increase but their survival rate after HTx to decrease. Further research is needed to define the optimal organ allocation policy.
  Transplantation Proceedings 05/2012; 44(4):881-2. · 1.00 Impact Factor
• Article: The outcome of heart transplantation in hepatitis C-positive recipients.

  M-H Lin, N-K Chou, N-H Chi, Y-S Chen, H-Y Yu, S-C Huang, W-J Ko, H-W Chou, S-S Wang
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  ABSTRACT: Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes. Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease. Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30-63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients (P = .59). There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease.
  Transplantation Proceedings 05/2012; 44(4):890-3. · 1.00 Impact Factor
• Article: Cardiac allograft vasculopathy compared by intravascular ultrasound sonography: everolimus to mycophenolate mofetil--one single-center experience.

  N-K Chou, C-F Jan, N-H Chi, C-M Lee, I-H Wu, S-C Huang, Y-S Chen, H-Y Yu, C-I Tsao, W-J Ko, S-H Chu, S-S Wang
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  ABSTRACT: Cardiac allograft vasculopathy (CAV) remains one of the leading causes of late graft failure and death. Cyclosporine microemulsion Neoral (CsA) had been used in heart transplantation (HTx) recipients. Meanwhile, Everolimus (EVL; Certican, Norvatis Pharmaceuticals; Basel, Switzerland) or mycophenolate mofetil (MMF) have been combined with CsA for maintenance treatment. We compared atherosclerosis in HTx patients showing CAV by intravascular ultrasound (IVUS) in two groups: the CE who received CsA, EVL, and steroid versus the CM group, who received CsA, MMF, and steroid. We explored IVUS parameters such as plaque thickness (PT), lumen circumference (LC), media adventitial circumference, lumen diameter (LD), and media adventitial diameter to characterize the atherosclerosis among CE versus CM groups. In this study, both the CE and CM groups showed increased plaque thickening in the first year posttransplantation (P < .05). However, MMF significantly reduced LC and LD (P < .05) Upon multivariate linear regression analysis, the CE group seemed to show less effect on the maximal difference in PT between 2 and 12 months after adjusting for age at transplantation and gender (P < .05). There was no acute clinical adverse event of CAV reported in either both group during the follow-up. The atherosclerosis of CAV revealed by LC, LDmax, and LDmin was significantly less among patients treated with CE than CM. These results suggested that everolimus-treated patients showed benefits compared with MMF-treated subjects as extrapolated from these IVUS data.
  Transplantation Proceedings 05/2012; 44(4):897-9. · 1.00 Impact Factor
• Article: Clinical experience of tacrolimus with everolimus in heart transplantation.

  S-S Wang, N-K Chou, N-H Chi, S-C Huang, I-H Wu, C-H Wang, H-Y Yu, Y-S Chen, C-I Tsao, W-J Ko, C-T Shun
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  ABSTRACT: Tacrolimus (Tac) in combination with mycophenolate mofetil is widely used after heart transplantation (HT). Everolimus (EVR), a new potent proliferation signal inhibitor can be used with a carcineurin inhibitor to reduce the occurrence of rejection. The purpose of this study was to evaluate the efficacy and safety of Tac combined with EVR in de novo HT. From January 2009 to April 2011, 33/62 patients who underwent HT were prescribed Tac and EVR as de novo immunosuppression. The main exclusion criteria were poor kidney function (serum creatinine > 2.8 mg/dL), panel-reactive antibodies > 25%, donors > 60 years old, or cold ischemia time > 6 hours. All patients received Tac (C0 blood level 5-10 ng/mL during the first 6 months, then 3-5 ng/mL), EVR (C0 target 3-8 ng/mL), and corticosteroids. After transplantation, routine examinations included echocardiogram and protocol endomyocardial biopsy. There was no operative mortality. The 1- and 3-year actuarial survivals were 95.74% ± 3.49%. One patient who had undergone coronary artery bypass grafting previously and received intra-aortic balloon pumping and extracorporeal membrane oxygenator-assisted cardiopulmonary resuscitation before HT died of Aspergillus septicemia 58 days after HT. No biopsy-proven acute rejection > grade 2R or acute rejection associated with hemodynamic compromise was observed. Hyperlipemia was noted in 16 cases (48.5%), hypertension in 11 (33.3% 5%), and diabetes mellitus in 12 (36.4%). No other severe adverse events were noted. Concentration-controlled EVR (C0 target 3-8 ng/mL) in combination with Tac achieved good efficacy and safety. The 1- and 3-year actuarial survivals were 95.74% ± 3.49%.
  Transplantation Proceedings 05/2012; 44(4):907-9. · 1.00 Impact Factor
• Article: Heart retransplantation for pediatric primary allograft failure.

  J M Luo, N K Chou, Y S Chen, S C Huang, N H Chi, H Y Yu, W J Ko, S S Wang
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  ABSTRACT: Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. When the transplanted heart fails, retransplantation is suggested and herein we have presented the prognosis of these pediatric cases. From March 1987 to March 2011, we performed 404 heart transplantations including 45 pediatric patients, 6 (13.3%) of whom experienced graft failure requiring retransplantation. Only four of the six patients (66.7%) had a chance for retransplantation. Six of 45 pediatric heart transplant patients (13.3%) experienced graft failure requiring retransplantation. Four of them (66.7%) underwent retransplantation. Only one of the four died due to severe postoperative sepsis with acute respiratory distress. The other three patients recovered well and remain alive with no neurological sequelae; all are in New York Heart Association functional classification I at present. Pediatric post-heart graft failure require expectations retransplantation, which shows a good prognosis.
  Transplantation Proceedings 05/2012; 44(4):913-4. · 1.00 Impact Factor
• Article: Twenty-four year single-center experience of hepatitis B virus infection in heart transplantation.

  Y C Chen, M K Chuang, N K Chou, N H Chi, I H Wu, Y S Chen, H Y Yu, S C Huang, C H Wang, C I Tsao, W J Ko, S S Wang
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  ABSTRACT: Hepatitis B virus (HBV) infection is hyperendemic in Taiwan. We have reported the outcome of (1) recipients with hepatitis B surface antigen (HBsAg)-positive; HBsAg-negative recipients who receive donor hearts from HBsAg-positive donors; and treatment with lamivudine of hepatitis B flare-ups after heart transplantation, using case numbers that range from 100 to 200. From July 1987 to May 2011, all 412 orthotopic heart transplant recipients and donors underwent routine preoperative screening for hepatitis B virus markers and liver function parameters. Lamivudine was prescribed prophylactically for recipients with elevated serum enzyme levels or an HBV DNA virus load before transplantation, or when there was evidence of hepatitis B flare-up after transplantation. Postoperative HBV markers and liver function parameters were collected over a mean follow-up time of 7.8 years. Thirty-four recipients were HBsAg-positive before heart transplantation, and 23 experiencing HBV reactivation upon follow-up requiring lamivudine treatment. Clinical responses were achieved in all of them: 15 were complete and two, slow partial responses. Twenty-six recipients with an HBV naïve status at the time of heart transplantation, and three patients received donor hearts from an HBsAg-positive donor under perioperative hepatitis B immunoglobulin prophylaxis. HBV infection was successfully prevented in two patients, but the other one contracted HBV hepatitis, which was successfully treated with lamivudine. HBV reactivation after the heart transplantation was common but usually well controlled with lamivudine treatment. Although posttransplantation liver function deteriorated for a period, there was no HBV infection-related morbidity or mortality. Perioperative hepatitis B immunoglobulin prophylaxis can successfully prevent HBV naïve recipients from infection in some cases, but HBsAg-positive donors should only be considered in high risk situations.
  Transplantation Proceedings 05/2012; 44(4):910-2. · 1.00 Impact Factor
• Article: End-stage renal disease after orthotopic heart transplantation: a single-institute experience.

  Y C Chen, N K Chou, R B Hsu, N H Chi, I H Wu, Y S Chen, H Y Yu, S C Huang, C H Wang, C I Tsao, W J Ko, S S Wang
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  ABSTRACT: Orthotopic heart transplantation is the treatment of choice for end-stage heart failure, and calcineurin inhibitor agents allow for better allograft survival. However, pretransplantation low cardiac output status and posttransplantation immunosuppressants contribute toward deterioration of renal function. From 1987 to 2008, 350 patients underwent orthotopic heart transplantation in our hospital. Most of them received anti-thymocyte globulin (ATG) as the induction immunosuppressant. The introduction of mycophenolate mofetil (MMF) reduced the maintenance level of cyclosporine. The 26 patients who developed end-stage renal disease required dialysis. We reviewed the patient characteristics, including pretransplantation status, immunosuppressant regimens and drug levels, time and type of dialysis, and mortality rate. The mean age of these 26 patients was 53 years. Three patients underwent peritoneal dialysis. The overall 1-year survival rate was 96%, and the 5-year survival rate was 80%. The duration from heart transplantation to chronic dialysis correlated with the presence of a pretransplantation diagnosis of diabetes (P<.05) and an elevated pretransplantation blood creatinine level (P=.01), but there was no significant effect of the initial level of cyclosporine. In addition, the pretransplantation blood creatinine level was also related to the necessity of immediate postoperative hemodialysis (P=.01). There was no significant risk factor in relation to mortality. Regardless of modification of immunosuppressant regimens and initial drug levels, pretransplantation kidney function played an important inverse role in the duration from transplantation to dialysis: the higher the pretransplantation blood creatinine, the shorter the duration. While awaiting a heart transplant, more effort should be spent on protecting renal function to avoid early chronic dialysis.
  Transplantation Proceedings 04/2010; 42(3):948-51. · 1.00 Impact Factor
• Article: Fungal infection in heart transplant recipients with severe sepsis: single-center experience.

  N K Chou, N H Chi, I W Wu, S C Huang, Y S Chen, H Y Yu, C I Tsao, W J Ko, H Y Sun, S C Chang, S H Chu, S S Wang
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  ABSTRACT: The objective of this study was to describe in heart transplant recipients severe sepsis due to fungal infection, which is associated with high mortality. This was a retrospective study including 366 patients who underwent heart transplantation from 1987 to 2009 in whom severe sepsis due to fungal infection developed, with multiple-organ failure. Sepsis was diagnosed on the basis of a positive culture for the infective agent, such as Cryptococcus, Aspergillus, Candida, or Nocardia, from an appropriate source such as blood, wound, or sputum. In 10 patients, severe sepsis due to fungal infection was treated temporally by reducing or sparing immunosuppression; 7 of these patients survived after intensive care. Only 1 patient required pulsed therapy because of an acute rejection episode. Early diagnosis with aggressive diagnostic techniques and use of combination therapy must be considered to reduce the risk of death in heart transplant recipients with fungal infection.
  Transplantation Proceedings 04/2010; 42(3):952-4. · 1.00 Impact Factor
• Article: Pediatric heart transplantation bridged with ventricular assist devices.

  J-M Luo, N-K Chou, N-H Chi, Y-S Chen, H-Y Yu, C-H Wang, W-J Ko, C-I Tsao, C-D Sun, S-S Wang
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  ABSTRACT: Heart transplantation (HTx) is indicated in children with end-stage heart failure or complex inoperable congenital defects. Because of the shortage of pediatric donor hearts, various bridge techniques have been used in pediatric patients to prolong patient survival until a suitable heart becomes available. We reviewed medical records of several pediatric patients in whom bridging with ventricular assist devices was used. All of the patients survived HTx, and are alive and well with no neurologic sequelae. They are NYHA functional class I. Thus, morbidity and mortality were acceptable in this high-risk group of pediatric patients with a ventricular assist device bridging to HTx.
  Transplantation Proceedings 04/2010; 42(3):913-5. · 1.00 Impact Factor
• Article: Outcome in children bridged and nonbridged to cardiac transplantation.

  M H Lin, N K Chou, Y S Chen, N H Chi, W J Ko, H Y Yu, S C Huang, N T Wu, J K Wang, M H Wu, S S Wang
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  ABSTRACT: Heart transplantation (HTx) in children with end-stage heart disease has become an accepted treatment option. To evaluate our results of pediatric cardiac transplantation with vs without bridge methods. The study included 31 patients (34 transplantations) younger than 18 years who underwent orthotopic HTx between March 1995 and December 2008. Ten patients were girls, and 21 were boys. Preoperative diagnoses included cardiomyopathy (n=20), congenital heart disease (n=7), hypertrophic cardiomyopathy (n=2), restrictive cardiomyopathy (n=1), and ischemic cardiomyopathy (n=1). Mean (SD) ischemia time was 185 (72) minutes. Thirty-day mortality was 6%, and was due to primary graft failure (n=2). Overall follow-up was 4.36 (3.93) years. Eleven patients underwent bridge techniques before HTx, and 11 patients required perioperative extracorporeal membrane oxygenation or ventricular assist device support. In the group that received extracorporeal membrane oxygenation, 8 patients (73%) were successfully weaned and discharged with excellent functional class. There were no differences in operative mortality, functional class, survival, rejection, and infection rates between the bridged and nonbridged groups. Overall actuarial 1- and 5-year survival rates were 93% and 83%, respectively. All survivors had good functional class. Our findings demonstrate satisfactory medium-term outcome of HTx in selected pediatric patients with end-stage heart disease. Using bridge methods in children at high risk can increase the opportunity to receive a donor heart. These bridge methods achieve similar postoperative outcomes.
  Transplantation Proceedings 04/2010; 42(3):916-9. · 1.00 Impact Factor
• Article: Extracoporeal membrane oxygenation hybrid with Thoratec ventricular-assist devices as double bridge to heart transplantation.

  N K Chou, N H Chi, I W Wu, S C Huang, Y S Chen, H Y Yu, C I Tsao, W J Ko, S H Chu, S S Wang
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  ABSTRACT: Ventricular-assist devices (VADs) have benefitted patients with end-stage heart failure as a bridge to heart transplantation (HTx). Herein, we describe our experience with HTx in the presence of extracorporeal membrane oxygenation (ECMO) together with the Thoratec VAD (Thoratec Corp, Pleasanton, California). From May 1996 to June 2009, mechanical circulatory support with the Thoratec VAD was provided in 20 patients. Before implantation of the VAD, circulation in 17 patients was maintained using ECMO. Although 350 patients underwent HTx during that period, only 13 patients (65%) received suitable donor organs for orthotopic HTx. The 20 patients ranged in age from 10 to 80 years; 3 were female, and 17 were male; and 17 (85%) required ECMO before VAD implantation. In 11 of 17 patients (65%), the VAD was implanted as a double bridge to HTx. The demand for mechanical circulatory support in patients with acute hemodynamic collapse has led to major improvements in clinically available systems such as ECMO as a double bridge to VAD implantation. We use ECMO as a rescue procedure in patients with acute hemodynamic deterioration. However, during ECMO support, left ventricular afterload increases. If prolonged support is necessary, a VAD may be required. We observed that 65% of patients who received support from an ECMO hybridized with the Thoratec VAD could wait for a suitable donor for HTx. We recommend use of ECMO for short-term support (<1 week) and the Thoratec VAD for medium- or long-term support as a bridge to HTx.
  Transplantation Proceedings 04/2010; 42(3):920-2. · 1.00 Impact Factor
• Article: Heart transplantation in patients with amyloidosis.

  J-M Luo, N-K Chou, N-H Chi, Y-S Chen, H-Y Yu, C-H Wang, W-J Ko, C-I Tsao, C-D Sun, S-S Wang
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  ABSTRACT: Cardiac transplantation is currently the only established surgical approach to the treatment of refractory heart failure. Heart transplantation because of amyloid cardiomyopathy continues to generate controversy because of donor shortage and concerns about disease recurrence in the allograft. We reviewed the medical records for all patients who underwent heart transplantation at our institution from 1987 to 2007, and found that 4 patients were diagnosed as having amyloid cardiomyopathy after pathologic examination of the excised hearts. No operative mortality was noted; however, all of the patients died of sepsis after transplantation. Because of the poor results, we do not recommended performing transplantation in patients with amyloidosis. Preoperative surveys and evaluation for amyloidosis must be emphasized in patients with hypertrophic cardiomyopathy.
  Transplantation Proceedings 04/2010; 42(3):927-9. · 1.00 Impact Factor
• Article: Can cyclosporine blood level be reduced to half after heart transplantation?

  S-S Wang, N-K Chou, N-H Chi, S-C Huang, I-H Wu, C-H Wang, H-Y Yu, Y-S Chen, C-I Tsao, W-J Ko, C-T Shun
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  ABSTRACT: Cyclosporine (CsA) is widely used after heart transplantation. The purpose of this prospective randomized study was to evaluate the safety and efficacy of reduction of CsA blood level to one-half of the traditional blood concentration under a regimen of everolimus (EVL), CsA, and steroid. This prospective, 6 month, randomized, open-label study included adult (aged 18 to 65 years) recipients of a primary heart transplant with serum creatinine<or=2.8 mg/dL. Among 52 patients who underwent heart transplantation from December 2004 to March 2006 we excluded those who were hepatitis B or C carriers, who were recipients of organs from donors>60 years old, had cold ischemia time>6 hours, or had plasma renin activity>or=25%. All patients received CsA (C2 blood level 1000-1400 ng/mL), EVL (C0 target 3-8 ng/mL), and corticosteroids to day 60, before random entry into one of 2 groups: SE (C2 blood level from days 60-149=800-1200 ng/mL, and days 150-180 C2=600-1000 ng/mL), or RE group with CsA reduced by one-half after 3 months (days 90-149 C2=400-600 ng/mL, and from days 150-180 C2=300-500 ng/mL). The 25 recipients eligible for this study included 13 patients in the SE and 12 in the RE group. There was no operative mortality in either group. No death or graft loss was noted within 6-months in either group. Mean serum creatinine at month 6 tended to be lower in the RE cohort (1.23+/-0.44 mg/dL versus 1.55+/-0.85 mg/dL; P=.093). Biopsy-proven acute rejection>or=grade 3A was observed in only 1 patient (7.7%), who was in the SE group. There were no acute rejection episodes associated with hemodynamic compromise. The incidences of adverse events in each group were similar. Concentration-controlled EVL (C0 target 3-8 ng/mL) in combination with reduced CsA exposure of one-half the usual concentration achieved good efficacy and safety over 6 months. The renal function at 6 months among the RE group showed a trend toward improvement, suggesting a benefit of halving the target CsA blood level after heart transplantation.
  Transplantation Proceedings 04/2010; 42(3):930-3. · 1.00 Impact Factor
• Article: Combined sirolimus-calcineurin inhibitor immunosuppressive therapy in simultaneous heart and kidney transplantation: a retrospective analysis of a single hospital's experience.

  K H Hsu, N K Chou, M K Tsai, N H Chi, Y S Chen, H Y Yu, C H Wang, W J Ko, C I Tsao, P H Lee, S S Wang
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  ABSTRACT: Simultaneous heart and kidney transplantation (SHKT) has become an accepted therapeutic option for patients with end-stage heart failure associated with end-stage renal disease. The immunosuppressive therapy is usually based upon a heart transplantation protocol using a calcineurin inhibitor (CNI). Sirolimus (SRL) is a potent nonnephrotoxic immunosuppressant with antiproliferative activity in nonimmune cells. Its use has recently been reported to show less nephrotoxicity among both heart and kidney transplants. However, the data for the SHKT are limited. We retrospectively examined the causes of 5 patients who received combined SRL-CNI immunosuppressive therapy with reduced CNI doses from 2003 to 2009. There was no mortality during follow-up. Two of the 3 patients who received a conversion regimen recovered renal function. One who suffered severe proteinuria after transplantation proceeded to hemodialysis at 3 years after conversion. Both of the patients who received the combined regimen de novo remained stable regarding their renal function. Cardiac function was stable in these patients; there was neither allograft rejection nor allograft coronary vasculopathy. We observed that patients without dyslipidemia or hyperuricemia before SHKT were less likely to develop these disorders under the combined regimen. Early medical intervention after close follow-up of lipid and uric acid values by dose adjustments resulted in a stable status of our patients.
  Transplantation Proceedings 04/2010; 42(3):934-7. · 1.00 Impact Factor
• Article: The survival of heart transplant recipients using cyclosporine and everolimus is not inferior to that using cyclosporine and mycophenolate.

  S-S Wang, N-K Chou, N-H Chi, S-C Huang, I-H Wu, C-H Wang, H-Y Yu, Y-S Chen, C-I Tsao, W-J Ko, C-T Shun
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  ABSTRACT: Heart transplantation has become the best available therapy for patients with refractory end-stage heart failure. Cyclosporine (CsA) and mycophenolate mofetil (MMF) are the 2 FDA-approved drugs to prevent posttransplant acute rejection episodes. The purpose of this study was to evaluate the result of heart transplantation treated with CsA and everolimus (EVL), compared with that of patients treated with CsA and MMF. From 2000 to 2009 heart transplantation was performed in 239 patients among whom we enrolled 93 patients with a serum creatinine values<or=2.8 mg/dL after informed written consents. The 2 arms were a CE group, who received EVL (n=46) CsA, and steroid (n=46), and a CM group who received MMF, CsA, and steroid (n=47). There was no operative mortality in either groups. The 1- and 5-year survivals of the CE group were 97.67+/-2.22% and 80.23+/-6.87%, versus the CM group, 97.72+/-2.17% and 79.38+/-7.62%, respectively. There was significant difference between the 2 groups. Survival after heart transplantation under EVL or MMF plus CsA and steroid was good. The survival of patients under the regimen of EVL, CsA and, steroid was not inferior to that of subjects prescribed MMF, CsA and steroid up to 5 years.
  Transplantation Proceedings 04/2010; 42(3):938-9. · 1.00 Impact Factor
• Article: Extracoporeal membrane oxygenation to rescue cardiopulmonary failure after heart transplantation: a single-center experience.

  N K Chou, N H Chi, I W Wu, S C Huang, Y S Chen, H Y Yu, C I Tsao, W J Ko, S H Chu, S S Wang
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  ABSTRACT: Extracorporeal membrane oxygenation (ECMO) can provide excellent mechanical circulatory support (MCS). Some case reports use ECMO to rescue heart transplantation (HTx) recipients with posttransplant cardiopulmonary failure. Herein reported a series of use of ECMO to rescue HTx recipients with refractory cardiopulmonary failure have during the posttransplant period. The causes of cardiopulmonary failure were right ventricular failure, primary graft failure, acute rejection, or sepsis. A retrospective review of 366 consecutive HTx recipients revealed 40 cases of cardiopulmonary failure requiring ECMO rescue in the posttransplant period. There were 14 patients diagnosed as right ventricular cardiopulmonary failure; 7 primary graft failure with a stunned donors myocardium, 8 as acute cellular or humoral rejection, and 11 as sepsis with positive blood cultures. ECMO-related variables were evaluated for association with mortality. The HTx recipients included 35 males and 5 females with overall median age of 42.3 years (range, 0.48-65.22). The weaning rate was 72.5% (29/40) and survival, 52.5% (21/40). ECMO provided temporary MCS rescuing some HTx recipients with posttransplant cardiopulmonary failure. None of the patients receiving ECMO support for >4 days survived.
  Transplantation Proceedings 04/2010; 42(3):943-5. · 1.00 Impact Factor