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Pharmacological Research, Vol . 26, Supplement 2, 1992
HEART AND HEART-LUNG TRANSPLANTATION : THE PRESENT SITUATION M . Vigano', L .Martinelli, G .Minzioni, C .Goggi, T .Ragni M . Rinaldi, C . Pederzolli, N . Pederzolli, A . D'Armini Department of Cardiothoracic Surgery - IRCCS S .Matteo Hospital, University of Pavia, Italy Key-words : Heart and lung transplantation, Renal failure . Heart transplantation has become during this decade a well established therapeutical option in the treatment of end-stage heart disease . This success was mainly due to the great improvements in the fields of immunosuppression and diagnosis and treatment of infection and rejection . The Registry of the International Society for Heart and Lung Transplantation, collecting data from more than 200 centers all over the world, reports 16 .687 heart transplantation up to the end of 1990 1 . It also shows an increase in the number of Centers performing this operation (from 17 in 1980 to 216 in 1990) . The number of transplants per year has sharply increased until 1986 and than has stabilized around 2500 - 2800 cases per year . A further expansion is precluded by the natural limitation of donors number . The age range of the patients varies from neonatal age to the seventh decade, with a median of 51 years . The majority of this population are males (83%) and the most common indications are dilated cadiomyopathy (51%) and ischemic cardiomyopathy (41%) . Hospital mortality has constantly dicreased to the present 10%, while the actuarial survival has reached 70% at 5 years . The Italian Program of heart transplantation started in November 1985 in 8 centers (5 in the North and 3 in the South), with two Organ Sharing Centers : NITp (Nord Italia Transplant program) and SIT (Sud Italia Transplant) . Subsequentely further 5 centers have been authorized to heart transplantation by the Ministry of Health . Up to the end of 1990, 822 heart transplantations have been performed, 687 of which in NITp area, with an actuarial survival of 82% at 3 years . While the distribution of the recipient is uniform throughout the country, the majority of donors are coming from the north of Italy . Heart and lung transplantation has entered the clinical practice in 1982 and up to 1990, 1025 cases are reported to the International Registry, with a survival rate of 59% at 1 year, this data being expression of a younger and more complex activity' . From November 1985 to September 1991, 235 heart transplantations, 227 orthotopic and 8 heterotopic, have been performed at our Institution, which represents about 25 % of the national activity, with an actuarial survival of 82% at 5 years . If we consider the group of patients affected by dilated cardiomyophaty the 5-year survival is 92 %, compared
1043-6618/92/26110016-02/$03 .00/0
© 1992 The Italian Pharmacological Society
Pharmacological Research, Vol. 26, Supplement 2, 1992
to 73 % of the ischemic group (p < 0 .05) . This finding is probably expression of the fact that ischemic disease has a systemic involvement and tends to progress after transplantation, decreasing life expectancy in this group . Seven patients underwent retransplantation, 5 under emergency (4 because acute rejection and 1 because graft failure) and 2 electively because of chronic rejection . There was a 40% mortality in the emergency group due to the preoperative poor general conditions . One of the major concerns in the follow-up of these patients appears to be the long term effects of cyclosporine administration . We studied the effect of cyclosporine in a sub-group of 92 patients with at least 36 months of follow-up (mean follow-up = 56 months) . The creatinine serum level rose from 1 .32 +/- 0 .5 pre-operatively to 2 .17 +/- 2 .0 at 5 years (p = 0 .07) . Despite this negative trend, the decrease in kidney function was not correlated with levels of creatinine before transplantation nor with cyclosporine serum levels post- transplantation or with age . This suggests that the baseline renal function is more strictly related to circulatory failure and is therefore partially reversible and that the subsequent deterioration of renal function has a multi-factorial ethiology . In January 1991 we started the program of Heart and Lung Transplantation, with 7 cases performed up to date 2 . Two patients died (28 %), one at 2 months because of cerebral ischemic damage due to cardiac arrest at induction of anesthesia and one at 5 months because of multi-organ failure . The remaining 5 patients are alive and well after an average follow-up of 6 months . These results, although preliminary, appear to be very encouraging especially considering the good quality of life that these, once bed-bridden and terminal patients, presently enjoy . In conclusion, the efficacy of heart transplantation in the treatment of end-stage cardiac disease is absolutely well established, with very good long term results . Accurate follow-up is needed to control and minimize clinical problems such as rejection, infection, hypertension and renal failure . Heart and lung transplantation is a promising therapeutical option in the treatment of vascular and/or parenchymal pulmonary diseases . It still carries an higher early and late mortality, due to the massive surgical trauma and the vulnerability of transplanted lungs to infection and rejection . REFERENCES 1) Kriett JM, Kaye MP : The Registry of the International Society of Heart and Lung Transplantation : eight official report - 1991 . J Heart Transplant 1991, 10 :491-498 . 2) Vigano' M, Martinelli L, Volpato G, Rinaldi M, Pederzolli C, D'Armini A, Cremaschi P : Trapianto cuore-polmoni indicazioni e primi risultati . Cardiologia 1991, 835-842 .
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Pharmacological Research, Vol . 26, Supplement 2, 1992
HEART AND HEART-LUNG TRANSPLANTATION : THE PRESENT SITUATION M . Vigano', L .Martinelli, G .Minzioni, C .Goggi, T .Ragni M . Rinaldi, C . Pederzolli, N . Pederzolli, A . D'Armini Department of Cardiothoracic Surgery - IRCCS S .Matteo Hospital, University of Pavia, Italy Key-words : Heart and lung transplantation, Renal failure . Heart transplantation has become during this decade a well established therapeutical option in the treatment of end-stage heart disease . This success was mainly due to the great improvements in the fields of immunosuppression and diagnosis and treatment of infection and rejection . The Registry of the International Society for Heart and Lung Transplantation, collecting data from more than 200 centers all over the world, reports 16 .687 heart transplantation up to the end of 1990 1 . It also shows an increase in the number of Centers performing this operation (from 17 in 1980 to 216 in 1990) . The number of transplants per year has sharply increased until 1986 and than has stabilized around 2500 - 2800 cases per year . A further expansion is precluded by the natural limitation of donors number . The age range of the patients varies from neonatal age to the seventh decade, with a median of 51 years . The majority of this population are males (83%) and the most common indications are dilated cadiomyopathy (51%) and ischemic cardiomyopathy (41%) . Hospital mortality has constantly dicreased to the present 10%, while the actuarial survival has reached 70% at 5 years . The Italian Program of heart transplantation started in November 1985 in 8 centers (5 in the North and 3 in the South), with two Organ Sharing Centers : NITp (Nord Italia Transplant program) and SIT (Sud Italia Transplant) . Subsequentely further 5 centers have been authorized to heart transplantation by the Ministry of Health . Up to the end of 1990, 822 heart transplantations have been performed, 687 of which in NITp area, with an actuarial survival of 82% at 3 years . While the distribution of the recipient is uniform throughout the country, the majority of donors are coming from the north of Italy . Heart and lung transplantation has entered the clinical practice in 1982 and up to 1990, 1025 cases are reported to the International Registry, with a survival rate of 59% at 1 year, this data being expression of a younger and more complex activity' . From November 1985 to September 1991, 235 heart transplantations, 227 orthotopic and 8 heterotopic, have been performed at our Institution, which represents about 25 % of the national activity, with an actuarial survival of 82% at 5 years . If we consider the group of patients affected by dilated cardiomyophaty the 5-year survival is 92 %, compared
1043-6618/92/26110016-02/$03 .00/0
© 1992 The Italian Pharmacological Society
Pharmacological Research, Vol. 26, Supplement 2, 1992
to 73 % of the ischemic group (p < 0 .05) . This finding is probably expression of the fact that ischemic disease has a systemic involvement and tends to progress after transplantation, decreasing life expectancy in this group . Seven patients underwent retransplantation, 5 under emergency (4 because acute rejection and 1 because graft failure) and 2 electively because of chronic rejection . There was a 40% mortality in the emergency group due to the preoperative poor general conditions . One of the major concerns in the follow-up of these patients appears to be the long term effects of cyclosporine administration . We studied the effect of cyclosporine in a sub-group of 92 patients with at least 36 months of follow-up (mean follow-up = 56 months) . The creatinine serum level rose from 1 .32 +/- 0 .5 pre-operatively to 2 .17 +/- 2 .0 at 5 years (p = 0 .07) . Despite this negative trend, the decrease in kidney function was not correlated with levels of creatinine before transplantation nor with cyclosporine serum levels post- transplantation or with age . This suggests that the baseline renal function is more strictly related to circulatory failure and is therefore partially reversible and that the subsequent deterioration of renal function has a multi-factorial ethiology . In January 1991 we started the program of Heart and Lung Transplantation, with 7 cases performed up to date 2 . Two patients died (28 %), one at 2 months because of cerebral ischemic damage due to cardiac arrest at induction of anesthesia and one at 5 months because of multi-organ failure . The remaining 5 patients are alive and well after an average follow-up of 6 months . These results, although preliminary, appear to be very encouraging especially considering the good quality of life that these, once bed-bridden and terminal patients, presently enjoy . In conclusion, the efficacy of heart transplantation in the treatment of end-stage cardiac disease is absolutely well established, with very good long term results . Accurate follow-up is needed to control and minimize clinical problems such as rejection, infection, hypertension and renal failure . Heart and lung transplantation is a promising therapeutical option in the treatment of vascular and/or parenchymal pulmonary diseases . It still carries an higher early and late mortality, due to the massive surgical trauma and the vulnerability of transplanted lungs to infection and rejection . REFERENCES 1) Kriett JM, Kaye MP : The Registry of the International Society of Heart and Lung Transplantation : eight official report - 1991 . J Heart Transplant 1991, 10 :491-498 . 2) Vigano' M, Martinelli L, Volpato G, Rinaldi M, Pederzolli C, D'Armini A, Cremaschi P : Trapianto cuore-polmoni indicazioni e primi risultati . Cardiologia 1991, 835-842 .
17
