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Retransplantation-never too old for one?
S72
Abstracts
strategy for risk assesment of donor lungs with typical and atypical mycobacterium using nested primer PCR of mycobacterial strain variants, surveillance bronchoscopy with biopsy and gene expression analysis, and application of BAL lymphocyte phenotyping. 88 RETRANSPLANTATION-NEVER TOO OLD FOR ONE? J.K. Patel,1 B.T. Oeser,1 S. Go,1 B.J. Rivera,1 M.L. Plesa,1 J.D. Moriguchi,1 J.A. Kobashigawa,1 1University of California at Los Angeles, Los Angeles, CA Outcomes following repeat cardiac transplantation have generally been worse than for primary transplantation, especially when performed within the first year of primary transplantation. Retransplantation (Re-Tx) is controversial due to limited donor supply and significant mortality for those awaiting primary cardiac transplantation. Recipient age at Re-Tx may affect outcomes but its effect has not been studied. The impact of more recent advances in transplant therapies on Re-Tx has also not been determined. Methods: All cardiac Re-Tx performed at a single institution were studied. Patients retransplanted ⬍1yr following primary transplant were excluded. 50/51 Re-Tx patients were transplanted after 1991. Kaplan-Meier survival analysis was performed for 2 groups (patients ⬍50 yrs and ⬎50 yrs) at the time of Re-Tx. To assess the impact of era, Re-Tx survival was also compared prior to and after 1998. Results: 48 patients met inclusion criteria. Mean age of the younger group (N ⫽ 22) was 37.9 yrs (⫾9.7 yrs SD; range 19 – 48) and of the older group (N ⫽ 29) was 59.0 yrs (⫾4.7 yrs SD; range 50 – 67). 5-yr survival was comparable in patients ⬍ 50 yrs at time of Re-Tx (77.8%) and for patients ⬎50yrs (66.7%; p ⫽ 0.84 log rank). There was a trend towards more biopsy-proven rejection (ⱖ 3A) in the younger age group (40.0% vs 24%; p ⫽ 0.20) and more transplant vasculopathy (defined as any lesion ⬎30% stenosis) in the older age group (30.4% vs 20.7%; p ⫽ 0.24). Younger patients had significantly higher creatinine at time of Re-Tx, a known risk factor for adverse transplantation outcome (2.5 vs 1.8; p ⫽ 0.009). 5-yr survival for Re-Tx post 1998 was numerically better than those before 1998 (71.4% vs 40.7%; p ⫽ 0.48). Conclusion: Older patients have a comparable outcome to younger patients following Re-Tx, although younger patients generally have higher creatinine at Re-Tx, which likely reflects a sicker population. More recent 5-yr survival following Re-Tx may be approaching survival following primary transplantation (UNOS data). Recent advances in transplantation may have contributed to improved outcomes. Further studies are needed. 89 INTRAVASCULAR ULTRASOUND FINDINGS 10 YEARS AFTER HEART TRANSPLANTATION J. Segovia,1 L. Alonso-Pulpo ´ n,1 J. Jime´nez-Mazuecos,1 B. Fuertes,1 2 F. Alfonso, R.A. Herna ´ ndez-Antolı´n,2 J. Escaned,2 C. Ban ˜ uelos,2 M. Sabate´,2 C. Macaya,2 1Cardiac Transplant Unit, C. Puerta de Hierro, Madrid, Madrid, Spain; 2Interventional Cardiology Dept., Hosp. Clı´nico, Madrid, Madrid, Spain Background: The prevalence of graft vessel disease (GVD) after heart transplantation (HTx) is said to increase 10% with each year of follow-up. However, there are no systematic studies in cohorts with long-term follow-up. Methods: An intravascular ultrasound (IVUS) study was electively performed 10 years after HTx, except in recipients previously diagnosed of GVD in symptom-driven cardiac catheterisation. Cardiac failure, typical angina and low left ventricular ejection fraction (LVEF) were considered major symptoms of GVD. We defined angiographic
The Journal of Heart and Lung Transplantation February 2004
GVD as the presence of ⬎50% stenosis in a primary coronary artery, and ultrasound GVD as an score ⬎8 points in a scale ranging from 0 to 10 points. Results: From a series of 181 consecutive HTx performed before Dec/1993 and surviving more than 1 year, 20 (11%) died before 10 years of follow-up due to GVD. Other 39 patients were studied with IVUS before 10 years because of symtoms (in order of frequency: dyspnea, abnormal EKG, syncope, low LVEF, heart failure and angina). Of them, 15 (39%) had angiographic GVD, 13 (33%) had GVD only detectable by IVUS, and 11 (28%) did not have significant GVD. In other 53 patients, elective IVUS was performed at 10 years: 11 (21%) had angiographic GVD, 18 (34%) had GVD detectable by IVUS, and 24 (45%) did not show GVD. Thus, at 10 years follow-up, 11% of the patients had died due to GVD, the prevalence of symptomatic disease was 19% (35/181), the prevalence of angiographic disease was 41% (46/112), and ultrasound disease was present in 69% (77/112). The proportion of angiographic GVD among patients with major symptoms was 85%, 25% among recipients with minor symptoms and 20% in asymptomatic patients. Conclusion: In the long-term follow-up, severe GVD is somewhat less prevalent than expected. Elective catheterization with IVUS detects a significant number of asymptomatic cases. Major symptoms are reliable markers of the presence of advanced GVD, while minor symptoms have no diagnostic value. 90 QUANTIFYING HEALTH STATUS AND FUNCTIONAL OUTCOMES FOLLOWING LUNG TRANSPLANT J.M. L’Abbe,1 M. Loadman Joyce,1 M.J. Bentley,1 D.C. Lien,1 1 Transplant Services, University of Alberta Hospital, Edmonton, AB, Canada With the growth in lung transplantation and improved actuarial survival rates, there is increased emphasis on quality of life and functional outcomes to demonstrate efficacy. We quantified the health status of lung transplant candidates and recipients enrolled between January 2000 and June 2002. Measurements of general and disease-specific health were recorded pre-operatively and at 3, 6 and 12 month intervals following transplant and annually thereafter. Health related quality of life indicators included the Chronic Respiratory Questionnaire, SF-36 Health Survey, Beck Depression Inventory and an open-ended inquiry regarding patient satisfaction with health. In addition, Six-Minute Walk Test distance (6MWT), Borg Rating of Perceived Exertion (RPE) and pulmonary function tests (PFT) are recorded. 94 recipients who were at least one year post-transplant were reviewed. Diagnostic groups included COPD/emphysema (54%), cystic fibrosis (18%), pulmonary fibrosis (14%) and other lung diseases (14%). Nonparametric tests for multiple related samples revealed significant improvements in PFT’s and in general and disease-specific health measures (p ⬍ 0.001). Functional mobility as demonstrated by 6MWT and Borg RPE increased significantly following transplant (p ⬍ 0.001). The SF-36 domains of physical functioning, general health and vitality improved post-operatively at all time intervals with results continuing to trend upwards from 3 to 12 months (p ⬍ 0.001). Similarly, dyspnea and fatigue were reduced and patients reported greater self-efficacy. These improvement were maintained across the post-operative time intervals. Mood and emotional status were within norms for a community-based population and did not change significantly across the study period. The analysis demonstrates measurable and significant health benefits in the early post-operative phase and their sustainability over time. These results suggest that health status and functional outcomes can be quantified and contribute to the body of evidence supporting the efficacy of lung transplantation.
Abstracts
strategy for risk assesment of donor lungs with typical and atypical mycobacterium using nested primer PCR of mycobacterial strain variants, surveillance bronchoscopy with biopsy and gene expression analysis, and application of BAL lymphocyte phenotyping. 88 RETRANSPLANTATION-NEVER TOO OLD FOR ONE? J.K. Patel,1 B.T. Oeser,1 S. Go,1 B.J. Rivera,1 M.L. Plesa,1 J.D. Moriguchi,1 J.A. Kobashigawa,1 1University of California at Los Angeles, Los Angeles, CA Outcomes following repeat cardiac transplantation have generally been worse than for primary transplantation, especially when performed within the first year of primary transplantation. Retransplantation (Re-Tx) is controversial due to limited donor supply and significant mortality for those awaiting primary cardiac transplantation. Recipient age at Re-Tx may affect outcomes but its effect has not been studied. The impact of more recent advances in transplant therapies on Re-Tx has also not been determined. Methods: All cardiac Re-Tx performed at a single institution were studied. Patients retransplanted ⬍1yr following primary transplant were excluded. 50/51 Re-Tx patients were transplanted after 1991. Kaplan-Meier survival analysis was performed for 2 groups (patients ⬍50 yrs and ⬎50 yrs) at the time of Re-Tx. To assess the impact of era, Re-Tx survival was also compared prior to and after 1998. Results: 48 patients met inclusion criteria. Mean age of the younger group (N ⫽ 22) was 37.9 yrs (⫾9.7 yrs SD; range 19 – 48) and of the older group (N ⫽ 29) was 59.0 yrs (⫾4.7 yrs SD; range 50 – 67). 5-yr survival was comparable in patients ⬍ 50 yrs at time of Re-Tx (77.8%) and for patients ⬎50yrs (66.7%; p ⫽ 0.84 log rank). There was a trend towards more biopsy-proven rejection (ⱖ 3A) in the younger age group (40.0% vs 24%; p ⫽ 0.20) and more transplant vasculopathy (defined as any lesion ⬎30% stenosis) in the older age group (30.4% vs 20.7%; p ⫽ 0.24). Younger patients had significantly higher creatinine at time of Re-Tx, a known risk factor for adverse transplantation outcome (2.5 vs 1.8; p ⫽ 0.009). 5-yr survival for Re-Tx post 1998 was numerically better than those before 1998 (71.4% vs 40.7%; p ⫽ 0.48). Conclusion: Older patients have a comparable outcome to younger patients following Re-Tx, although younger patients generally have higher creatinine at Re-Tx, which likely reflects a sicker population. More recent 5-yr survival following Re-Tx may be approaching survival following primary transplantation (UNOS data). Recent advances in transplantation may have contributed to improved outcomes. Further studies are needed. 89 INTRAVASCULAR ULTRASOUND FINDINGS 10 YEARS AFTER HEART TRANSPLANTATION J. Segovia,1 L. Alonso-Pulpo ´ n,1 J. Jime´nez-Mazuecos,1 B. Fuertes,1 2 F. Alfonso, R.A. Herna ´ ndez-Antolı´n,2 J. Escaned,2 C. Ban ˜ uelos,2 M. Sabate´,2 C. Macaya,2 1Cardiac Transplant Unit, C. Puerta de Hierro, Madrid, Madrid, Spain; 2Interventional Cardiology Dept., Hosp. Clı´nico, Madrid, Madrid, Spain Background: The prevalence of graft vessel disease (GVD) after heart transplantation (HTx) is said to increase 10% with each year of follow-up. However, there are no systematic studies in cohorts with long-term follow-up. Methods: An intravascular ultrasound (IVUS) study was electively performed 10 years after HTx, except in recipients previously diagnosed of GVD in symptom-driven cardiac catheterisation. Cardiac failure, typical angina and low left ventricular ejection fraction (LVEF) were considered major symptoms of GVD. We defined angiographic
The Journal of Heart and Lung Transplantation February 2004
GVD as the presence of ⬎50% stenosis in a primary coronary artery, and ultrasound GVD as an score ⬎8 points in a scale ranging from 0 to 10 points. Results: From a series of 181 consecutive HTx performed before Dec/1993 and surviving more than 1 year, 20 (11%) died before 10 years of follow-up due to GVD. Other 39 patients were studied with IVUS before 10 years because of symtoms (in order of frequency: dyspnea, abnormal EKG, syncope, low LVEF, heart failure and angina). Of them, 15 (39%) had angiographic GVD, 13 (33%) had GVD only detectable by IVUS, and 11 (28%) did not have significant GVD. In other 53 patients, elective IVUS was performed at 10 years: 11 (21%) had angiographic GVD, 18 (34%) had GVD detectable by IVUS, and 24 (45%) did not show GVD. Thus, at 10 years follow-up, 11% of the patients had died due to GVD, the prevalence of symptomatic disease was 19% (35/181), the prevalence of angiographic disease was 41% (46/112), and ultrasound disease was present in 69% (77/112). The proportion of angiographic GVD among patients with major symptoms was 85%, 25% among recipients with minor symptoms and 20% in asymptomatic patients. Conclusion: In the long-term follow-up, severe GVD is somewhat less prevalent than expected. Elective catheterization with IVUS detects a significant number of asymptomatic cases. Major symptoms are reliable markers of the presence of advanced GVD, while minor symptoms have no diagnostic value. 90 QUANTIFYING HEALTH STATUS AND FUNCTIONAL OUTCOMES FOLLOWING LUNG TRANSPLANT J.M. L’Abbe,1 M. Loadman Joyce,1 M.J. Bentley,1 D.C. Lien,1 1 Transplant Services, University of Alberta Hospital, Edmonton, AB, Canada With the growth in lung transplantation and improved actuarial survival rates, there is increased emphasis on quality of life and functional outcomes to demonstrate efficacy. We quantified the health status of lung transplant candidates and recipients enrolled between January 2000 and June 2002. Measurements of general and disease-specific health were recorded pre-operatively and at 3, 6 and 12 month intervals following transplant and annually thereafter. Health related quality of life indicators included the Chronic Respiratory Questionnaire, SF-36 Health Survey, Beck Depression Inventory and an open-ended inquiry regarding patient satisfaction with health. In addition, Six-Minute Walk Test distance (6MWT), Borg Rating of Perceived Exertion (RPE) and pulmonary function tests (PFT) are recorded. 94 recipients who were at least one year post-transplant were reviewed. Diagnostic groups included COPD/emphysema (54%), cystic fibrosis (18%), pulmonary fibrosis (14%) and other lung diseases (14%). Nonparametric tests for multiple related samples revealed significant improvements in PFT’s and in general and disease-specific health measures (p ⬍ 0.001). Functional mobility as demonstrated by 6MWT and Borg RPE increased significantly following transplant (p ⬍ 0.001). The SF-36 domains of physical functioning, general health and vitality improved post-operatively at all time intervals with results continuing to trend upwards from 3 to 12 months (p ⬍ 0.001). Similarly, dyspnea and fatigue were reduced and patients reported greater self-efficacy. These improvement were maintained across the post-operative time intervals. Mood and emotional status were within norms for a community-based population and did not change significantly across the study period. The analysis demonstrates measurable and significant health benefits in the early post-operative phase and their sustainability over time. These results suggest that health status and functional outcomes can be quantified and contribute to the body of evidence supporting the efficacy of lung transplantation.