- Email: [email protected]
One year experience of thoratec ventricular assist device programme bridging to transplant at royal perth hospital
Heart,
Lung
and Circulation
2000; 9
48th Annual
CARDIAC TRANSPLANTATION IN NEW ZEALAND MAORI AND POLYNESIAN PATIENTS. R. D’Costa’. P.N. Ruwrok. H.A Coverdale. T.M. Aanew. H. Gibbs, D. Reddv. D.A. Havdock. A.R. Kerr. Departments of Cardiology and Cardiothoracic Surgery, Green Lane Hospital, Auckland, New Zealand. Introduction. Data on the outcome of cardiac transplantation (CTX) according to ethnic background is limited. New Zealand has the largest Maori and Polynesian (MP) population in the world and likely the largest CTX experience in this race. Patients and Methods. A retrospective analysis of the 104 patients (pts), 79 European (E), 23 MP and 2 Asian, who underwent CTX at Green Lane Hospital from the beginning of the programme in 1987 to mid 1999, with respect to race stated by the pt at the time of hospital registration, demographic profile, indication for CTX and outcome, was performed. Results. Number Age (years)
mean Range 1
Male gender Blood group
0
A B AB Mean weight (kg) NYHA Class IV Aetiology heart disease lschaemic DCM
Valvular Congenital Rheumatic Survival 1 year 5 year
P 23 38.3 4-56 19 (83%) 5 (22%) 15 (65%) 2 (9%) 1(4%) 79.6 20 (87%)
E 79 42.7 12-59 68 (86%) 45 (57%) 20 (35%) 6 (8%) 0 68.0 50 (63%)
4 (17%)
28 (25%) 44 (56%) 3 (4%) 4 (5%) 0 07% 73%
13 (57%) 1 (4%) 0 5 (22%) 83% 76%
0 value n.s.
ns.
0.001 0.001 0.056
Scientific
Meeting
of CSANZ
A16’
ANALYSIS OF THE ASSOCIATION OF CARDIAC TRANSPLANT BIOPSY FEATURES WITH THE DEVELOPMENT OF CHRONIC ALLOGRAFT DYSFUNCTION. S&&&lev AN’. EepD M. Maguird,
P. Dow Nl& Monash Department of Medicine, Heart Transplant Service, Anatomical Pathology, Alfred Hospital, Prabran,Vic A prospective longitudinal study was performed on biopsies from patients receiving a heart transplant at the Alfred Hospital. Biopsies were performed weekly for 6 weeks, fortnightly to 3 months, monthly to 6 months and every 2 months to 1 year. Left ventricular ejection fraction (LVEF) was assessed regularly by radionuclide gated blood pool scannmg. Chronic dysfunction (CD), defined as a reduchon in LVEF of >lO% from the LVEF at 6 months, was evident in 18 of 66 patients. Four of these patients had angiographic evidence of chronic allografi vasculopathy (CAV) and one had CAV at 1 year with normal LVEF at 6 months. The number of rejection episodes >3A was not associated with CD (7.3% vs 7.71% of biopsies in patients with and without CD respectively). Age was not a risk factor (P=O.56). In a subset of biopsies rejection grade was significantly correlated with CD45, CD45RA, CD45R0, CD3, CD8, CD14, CD20, CD25 leucocytes and adhesion molecules. No significant differences were observed between patients with and without CD, although possible trends were identified for CD25 (p=O.14) and CD14 @=0.12). TGFP,, PDGFA, PDGFB and PDGFRP mRNA were quantified by competitive RT-PCR. No significant association was evident with rejection grade or CD, though trends in CD vs no CD were seen for TGFP @=0.2), PDGFB (u=O.l) and PDGFRB (11=0.26). ’ = cells/nun*: 2 = copies/w RNA CD Yes
cD25”
CD14’ 415+38
i.tiFpl’ 13.4i3.8
’ PDGFB2
PDGFR~’
-
3000+912 16591503 No 6*2 300*29 7.1io.9 2594*790 1287+327 The observed tr&nds implicate T cell activation, 6onocyte/macrophage Infiltration and increased growth factor expression m the development of CD. Analysis of additional biopsies is under way to confirm these trends.
0.001 n.s.
lli5
Conclusions. MP pts differed from E pts with respecl to cause of end-stage heart failure, body weight and blood group. Survival following CTX was similar in both groups.
ONE YEAR EXPERLENCE OF THORATEC VENTRICULAR DEVICE PROGRAMME BRIDGING TO TRANSPLANT AT 9 PERTH HOSPITAL LG. 0 Dnscoll. R m
C.A.Wood. M. Loven Western Australia.
Cardiac Transplant
ASSIST ROYAL
Unit, Royal Perth Hospital,
* Perth,
Despite the success of orthotoplc heart transplantation, donor shortage, geographical isolation of W.A. and increased waiting times remain significant problems. Mechanical circulatory support used as a bridge to cardiac transplantation is now a firmly established treatment modality. The Thoratec TLC II VAD can be applied for univentricular or bwentricular support. This paper outlines the clinical outcomes, in terms of the complications associated with long term VAD support, morbidity/mortality, sepsis and embolus, and the cost benefit related to the estabhshment of a community based VAD programme. Method: Prior to the insertion of a Thoratec LVAD all patients were managed utilizing inotropic and IABP therapy. Mean age was 34 years (21-5Oyrs), 4 male and 1 female. Aetiologies included; ischaemic, dilated and post partum cardiomyopathy. A Patients discharged with the Thoratec VAD completed competency baaed mining and provided 24 hour support from a nominated carer. Results: The total number of days on LVAD support was 479 days (0 +/- 290). 2 patients were successfully bridged to cardiac transplantation, 1 after 290 days supporI and 1 after 11 days support. A thiid patient remains supported at home awaiting transplantation. 2 patients died within 24 hours of VAD insertion, due to pulmonary embolus and cardiac failure of unknown aetiology. Post VAD inpatient complications have included temporal lobe infarct and sepsis. 2 patients have been managed in the community accounting for 26% (125/479) of the total days on VAD support, representing a significant cost saving Average bed day cost $690 (Metropolitian Health Service Board Annual Report 1997/1998). To date there have been no major complications associated with managing these patients in the community. Conclusion: Thoratec VAD support in the community is an acceptable method of bridging patients to cardiac transplantanon offering an improved quality of hfe for the patient, full mobilization and a significant cost saving related to decreased muatient admissions.
Background:
IMMUNOTHERAPY PROLIFERATIVE TRANSPLANTATION
IN DISEASE
POST-TRANSPLANT FOLLOWING HEART
RR. Mom Lung Transplant Unit, Prince Charles Institute of Me&al Research, Brisbane.
Hospital,
LYMPHOAND LUNG
A.J. Galbra&. Heart Brisbane, Queensland
Post-transplant lymphoproliferative disease (PTLPD) 1s a complication of organ transplantation which can carry a poor prognosis, and for which present therapy is unsatisfactory. The genome of the Epstem-Barr (EB) virus is Identifiable in 90% of samples of PTLPD tissue. We treated two patients with PTLPD with a new form of immunotherapy, which targets the EB virus. In this technique, polyclonal lymphocytes cytotoxlc to the EB virus are produced by co-culhvating donor mononuclear cells with Irradiated EBV virus transformed lymphoblastoid cell lines. This process is repeated through a number of cycles m the presence of interleukin 2 (IL 2) until a satisfactory population of lymphocytes relatively specific for EBV epitopes is obtained. These cells are then injected into the patient. Patient one had undergone lung transplantation. Six months later he presented with monwlonal disease m a clinically advanced form with extensive invasion of the lungs, liver and bowel. He received two treatment cycles with cultured lymphocytes, but then died of a pulmonary haemorrhage. Autopsy showed complete resolution of liver and bowel lesions and extensive lysis of the lung tumour, which had invaded the pulmonary vasculature. Patient two underwent cardiac transplantation. She has developed multIfocal, monoclonal PTLPD in subcutaneous tissue four years after transplantation. Following adoptive immunotherapy, CT and clinical assessment has documented significant tumour regression. Adoptive immunotherapy 1s a promising technique, which merits further investigation.
Lung
and Circulation
2000; 9
48th Annual
CARDIAC TRANSPLANTATION IN NEW ZEALAND MAORI AND POLYNESIAN PATIENTS. R. D’Costa’. P.N. Ruwrok. H.A Coverdale. T.M. Aanew. H. Gibbs, D. Reddv. D.A. Havdock. A.R. Kerr. Departments of Cardiology and Cardiothoracic Surgery, Green Lane Hospital, Auckland, New Zealand. Introduction. Data on the outcome of cardiac transplantation (CTX) according to ethnic background is limited. New Zealand has the largest Maori and Polynesian (MP) population in the world and likely the largest CTX experience in this race. Patients and Methods. A retrospective analysis of the 104 patients (pts), 79 European (E), 23 MP and 2 Asian, who underwent CTX at Green Lane Hospital from the beginning of the programme in 1987 to mid 1999, with respect to race stated by the pt at the time of hospital registration, demographic profile, indication for CTX and outcome, was performed. Results. Number Age (years)
mean Range 1
Male gender Blood group
0
A B AB Mean weight (kg) NYHA Class IV Aetiology heart disease lschaemic DCM
Valvular Congenital Rheumatic Survival 1 year 5 year
P 23 38.3 4-56 19 (83%) 5 (22%) 15 (65%) 2 (9%) 1(4%) 79.6 20 (87%)
E 79 42.7 12-59 68 (86%) 45 (57%) 20 (35%) 6 (8%) 0 68.0 50 (63%)
4 (17%)
28 (25%) 44 (56%) 3 (4%) 4 (5%) 0 07% 73%
13 (57%) 1 (4%) 0 5 (22%) 83% 76%
0 value n.s.
ns.
0.001 0.001 0.056
Scientific
Meeting
of CSANZ
A16’
ANALYSIS OF THE ASSOCIATION OF CARDIAC TRANSPLANT BIOPSY FEATURES WITH THE DEVELOPMENT OF CHRONIC ALLOGRAFT DYSFUNCTION. S&&&lev AN’. EepD M. Maguird,
P. Dow Nl& Monash Department of Medicine, Heart Transplant Service, Anatomical Pathology, Alfred Hospital, Prabran,Vic A prospective longitudinal study was performed on biopsies from patients receiving a heart transplant at the Alfred Hospital. Biopsies were performed weekly for 6 weeks, fortnightly to 3 months, monthly to 6 months and every 2 months to 1 year. Left ventricular ejection fraction (LVEF) was assessed regularly by radionuclide gated blood pool scannmg. Chronic dysfunction (CD), defined as a reduchon in LVEF of >lO% from the LVEF at 6 months, was evident in 18 of 66 patients. Four of these patients had angiographic evidence of chronic allografi vasculopathy (CAV) and one had CAV at 1 year with normal LVEF at 6 months. The number of rejection episodes >3A was not associated with CD (7.3% vs 7.71% of biopsies in patients with and without CD respectively). Age was not a risk factor (P=O.56). In a subset of biopsies rejection grade was significantly correlated with CD45, CD45RA, CD45R0, CD3, CD8, CD14, CD20, CD25 leucocytes and adhesion molecules. No significant differences were observed between patients with and without CD, although possible trends were identified for CD25 (p=O.14) and CD14 @=0.12). TGFP,, PDGFA, PDGFB and PDGFRP mRNA were quantified by competitive RT-PCR. No significant association was evident with rejection grade or CD, though trends in CD vs no CD were seen for TGFP @=0.2), PDGFB (u=O.l) and PDGFRB (11=0.26). ’ = cells/nun*: 2 = copies/w RNA CD Yes
cD25”
CD14’ 415+38
i.tiFpl’ 13.4i3.8
’ PDGFB2
PDGFR~’
-
3000+912 16591503 No 6*2 300*29 7.1io.9 2594*790 1287+327 The observed tr&nds implicate T cell activation, 6onocyte/macrophage Infiltration and increased growth factor expression m the development of CD. Analysis of additional biopsies is under way to confirm these trends.
0.001 n.s.
lli5
Conclusions. MP pts differed from E pts with respecl to cause of end-stage heart failure, body weight and blood group. Survival following CTX was similar in both groups.
ONE YEAR EXPERLENCE OF THORATEC VENTRICULAR DEVICE PROGRAMME BRIDGING TO TRANSPLANT AT 9 PERTH HOSPITAL LG. 0 Dnscoll. R m
C.A.Wood. M. Loven Western Australia.
Cardiac Transplant
ASSIST ROYAL
Unit, Royal Perth Hospital,
* Perth,
Despite the success of orthotoplc heart transplantation, donor shortage, geographical isolation of W.A. and increased waiting times remain significant problems. Mechanical circulatory support used as a bridge to cardiac transplantation is now a firmly established treatment modality. The Thoratec TLC II VAD can be applied for univentricular or bwentricular support. This paper outlines the clinical outcomes, in terms of the complications associated with long term VAD support, morbidity/mortality, sepsis and embolus, and the cost benefit related to the estabhshment of a community based VAD programme. Method: Prior to the insertion of a Thoratec LVAD all patients were managed utilizing inotropic and IABP therapy. Mean age was 34 years (21-5Oyrs), 4 male and 1 female. Aetiologies included; ischaemic, dilated and post partum cardiomyopathy. A Patients discharged with the Thoratec VAD completed competency baaed mining and provided 24 hour support from a nominated carer. Results: The total number of days on LVAD support was 479 days (0 +/- 290). 2 patients were successfully bridged to cardiac transplantation, 1 after 290 days supporI and 1 after 11 days support. A thiid patient remains supported at home awaiting transplantation. 2 patients died within 24 hours of VAD insertion, due to pulmonary embolus and cardiac failure of unknown aetiology. Post VAD inpatient complications have included temporal lobe infarct and sepsis. 2 patients have been managed in the community accounting for 26% (125/479) of the total days on VAD support, representing a significant cost saving Average bed day cost $690 (Metropolitian Health Service Board Annual Report 1997/1998). To date there have been no major complications associated with managing these patients in the community. Conclusion: Thoratec VAD support in the community is an acceptable method of bridging patients to cardiac transplantanon offering an improved quality of hfe for the patient, full mobilization and a significant cost saving related to decreased muatient admissions.
Background:
IMMUNOTHERAPY PROLIFERATIVE TRANSPLANTATION
IN DISEASE
POST-TRANSPLANT FOLLOWING HEART
RR. Mom Lung Transplant Unit, Prince Charles Institute of Me&al Research, Brisbane.
Hospital,
LYMPHOAND LUNG
A.J. Galbra&. Heart Brisbane, Queensland
Post-transplant lymphoproliferative disease (PTLPD) 1s a complication of organ transplantation which can carry a poor prognosis, and for which present therapy is unsatisfactory. The genome of the Epstem-Barr (EB) virus is Identifiable in 90% of samples of PTLPD tissue. We treated two patients with PTLPD with a new form of immunotherapy, which targets the EB virus. In this technique, polyclonal lymphocytes cytotoxlc to the EB virus are produced by co-culhvating donor mononuclear cells with Irradiated EBV virus transformed lymphoblastoid cell lines. This process is repeated through a number of cycles m the presence of interleukin 2 (IL 2) until a satisfactory population of lymphocytes relatively specific for EBV epitopes is obtained. These cells are then injected into the patient. Patient one had undergone lung transplantation. Six months later he presented with monwlonal disease m a clinically advanced form with extensive invasion of the lungs, liver and bowel. He received two treatment cycles with cultured lymphocytes, but then died of a pulmonary haemorrhage. Autopsy showed complete resolution of liver and bowel lesions and extensive lysis of the lung tumour, which had invaded the pulmonary vasculature. Patient two underwent cardiac transplantation. She has developed multIfocal, monoclonal PTLPD in subcutaneous tissue four years after transplantation. Following adoptive immunotherapy, CT and clinical assessment has documented significant tumour regression. Adoptive immunotherapy 1s a promising technique, which merits further investigation.