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Routine angiography post cardiac transplantation: what value?
The Journal of Heart and Lung Transplantation Volume 23, Number 2S
85 HAS NEWER THERAPIES IMPROVED THE SURVIVAL OF CARDIAC DEATH DUE TO TRANSPLANT CORONARY ARTERY DISEASE? S.-Z. Gao,1 B. Cantin,1 M. Perlroth,1 S. Hunt,1 J. Schroeder,1 1 Cardiology, Stanford University School of Medicine, Stanford, CA Background: Coronary artery disease (CAD) is a major cause of death in heart transplant (Tx) recipients. New treatments have improved survival due to better control of rejection and infection post-Tx . The role of the newer therapies on the mortality of TxCAD has not been documented. Methods: 575 adults underwent Tx between 11/1980-12/1997 at Stanford. Based on treatment, patients were divided into 3 cohorts. 1: received cyclosporine, prednisone, azathioprine (n ⫽ 190, 11/80 – 6/ 86). 2: same as 1, plus gradual introduction of calcium channel blockers (CCB), OKT3 and ganciclovir (n ⫽ 263, 7/86 –12/93). 3: same as 2 plus gradual introduction of statin, mycophenolate mofetil (MMF) and tacrolimus (TCR) (n ⫽ 122, 1/94 –12/97). Life table analysis was used to compare mortality between cohorts. Follow-up was to 5 years post-Tx. Results: Freedom from cardiac death at 1, 3 and 5 years post-Tx was 100%, 92% and 82% in group 1; 99%, 95% and 92% in group 2; 99%, 97% and 95% in group 3 respectively p ⫽ 0.004 (Fig. 1). Cardiac death free survival was not different between cohort 2 and 3, but it was significantly lower in cohort 1 compare to cohort 2 p ⫽ 0.01 and cohort 3 p ⫽ 0.004. Conclusion: Improved survival from cardiac death in Tx recipients since 1986 was not further enhanced by addition of MMF, TCR and statins.
Abstracts
S71
recent follow-up visit. Data is presented as mean plus/minus standard deviation. Results: Between the two groups there were no significant differences in patient characteristics and survival.
Recipient sex (M/F) Recipient age (years) Statin (%) Prednisone (%) Cyclosporine (%) Tacrolimus (%) MMF (%) Azathioprine (%) Systolic blood pressure (mmHg) Creatinine (mol/L) Microalbuminuria (mg/L) LDL (mmol/L) HDL (mmol/L) LVEF (%) # rejections during first year # rejections after first year
Group I (n ⴝ 167)
Group II (n ⴝ 79)
139/28 47.2 ⫾ 11.3 50 28 96 4 13 30 130 ⫾ 23 198 ⫾ 139 309 ⫾ 568 3.0 ⫾ 1.0 1.2 ⫾ 4 53 ⫾ 12 .48 ⫾ 1.16 .12 ⫾ .43
69/10 45.3 ⫾ 12.7 35 39 95 2 7 37 133 ⫾ 24 206 ⫾ 137 552 ⫾ 756 3.0 ⫾ 9 1.2 ⫾ 6 55 ⫾ 8 .10 ⫾ .37 .07 ⫾ .26
p value
0.2595
0.4266 .7274 .1493 .9491 .7049 .5458 .0403 .4780
Conclusion: Patient outcomes are similar, whether or not routine coronary angiography is performed. The most vital role of follow-up is careful monitoring of medications, blood work, and patients’ symptoms as well as psychological support rather than invasive procedures. While routine coronary angiography permits documentation of coronary artery disease, at this time there are no specific therapies to alter the course. Patients require aggressive management of risk factors. Coronary angiography has a limited prophylactic value in long-term follow-up. 87 EPIDEMIOLOGY AND CLINICAL IMPLICATIONS OF ATYPICAL MYCOBACTERIAL INFECTIONS IN CADAVERIC LUNG TRANSPLANTS: THE ROLE OF SURVEILLANCE BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE PHENOTYPE C. Hoopes,1 A.F. Luetkemeyer,1 D. Jablons,1 T. Hall,1 T. Weaver,1 J. Golden,1 1Thoracic Surgery, University of California San Francisco, San Francisco, CA
86 ROUTINE ANGIOGRAPHY POST CARDIAC TRANSPLANTATION: WHAT VALUE? M.A.J. Rockx,1 P.W. Pflugfelder,1 W.J. Kostuk,1 1Cardiology, London Health Sciences Centre-University Campus, London, ON, Canada Background: Long-term survival has become the norm for cardiac transplant recipients. The question arises of which investigations are required routinely in follow-up. Selective coronary angiography is one such test obtained on a biannual basis. We have reviewed the value of this intervention on patient outcomes (morbidity and mortality). Methods: 505 consecutive heart transplants were performed at a single centre from 1981 to 2003. Of 246 who have survived greater than five years, 167 (Group I) had coronary angiography every two years while 79 (Group II) did not. Results were taken from the most
The role of surveillance bronchoscopy and the clinical significance of atypical mycobacterial species in bronchoalveolar lavage (BAL) fluid collected on surveillance bronchoscopy are both subjects of active clinical debate. Because of two deaths from atypical Mycobacterium abcessans in lung transplant recipients with no clinical or CT scan evidence of active mycobacterial infection we have reviewed the prevalence and clinical characteristics of both donors and recipients with atypical mycobacterial cultures on surveillance BAL. Forty three percent of patients (44 of 103) were BAL culture positive for atypical mycobacterium with Mycobacterium gordonii being the predominant species (30% or 31 of 103 patients). Nine of these gordonii patients were culture positive for a second atypical species. Ten patients grew Mycobacterium avium, six patients grew Fortuitum cheloneae, three patients M. abcessans, and two patients M. kansasii. PCR analysis of strain variants demonstrates no geographic pattern of origin or focal epidemiological source. Lymphocyte phenotypes of infected patients were frequently characterized by low natural killer cell ratios (⬍ 2%) but this pattern is neither predictive nor consistent. The incidenceand prevalence of atypical mycobacteria is higher in our patient population than previously reported as is the incidence of Mycobacterium tuberculosis. Whether this reflects the high incidence of regional donor procurements from patients born in areas of endemic TB (20%), specifics of donor organ selection, institution specific patterns of immunosuppression and antibiotic therapy, or increased use of surveillance bronchoscopy is unclear. Here we present a prospective
85 HAS NEWER THERAPIES IMPROVED THE SURVIVAL OF CARDIAC DEATH DUE TO TRANSPLANT CORONARY ARTERY DISEASE? S.-Z. Gao,1 B. Cantin,1 M. Perlroth,1 S. Hunt,1 J. Schroeder,1 1 Cardiology, Stanford University School of Medicine, Stanford, CA Background: Coronary artery disease (CAD) is a major cause of death in heart transplant (Tx) recipients. New treatments have improved survival due to better control of rejection and infection post-Tx . The role of the newer therapies on the mortality of TxCAD has not been documented. Methods: 575 adults underwent Tx between 11/1980-12/1997 at Stanford. Based on treatment, patients were divided into 3 cohorts. 1: received cyclosporine, prednisone, azathioprine (n ⫽ 190, 11/80 – 6/ 86). 2: same as 1, plus gradual introduction of calcium channel blockers (CCB), OKT3 and ganciclovir (n ⫽ 263, 7/86 –12/93). 3: same as 2 plus gradual introduction of statin, mycophenolate mofetil (MMF) and tacrolimus (TCR) (n ⫽ 122, 1/94 –12/97). Life table analysis was used to compare mortality between cohorts. Follow-up was to 5 years post-Tx. Results: Freedom from cardiac death at 1, 3 and 5 years post-Tx was 100%, 92% and 82% in group 1; 99%, 95% and 92% in group 2; 99%, 97% and 95% in group 3 respectively p ⫽ 0.004 (Fig. 1). Cardiac death free survival was not different between cohort 2 and 3, but it was significantly lower in cohort 1 compare to cohort 2 p ⫽ 0.01 and cohort 3 p ⫽ 0.004. Conclusion: Improved survival from cardiac death in Tx recipients since 1986 was not further enhanced by addition of MMF, TCR and statins.
Abstracts
S71
recent follow-up visit. Data is presented as mean plus/minus standard deviation. Results: Between the two groups there were no significant differences in patient characteristics and survival.
Recipient sex (M/F) Recipient age (years) Statin (%) Prednisone (%) Cyclosporine (%) Tacrolimus (%) MMF (%) Azathioprine (%) Systolic blood pressure (mmHg) Creatinine (mol/L) Microalbuminuria (mg/L) LDL (mmol/L) HDL (mmol/L) LVEF (%) # rejections during first year # rejections after first year
Group I (n ⴝ 167)
Group II (n ⴝ 79)
139/28 47.2 ⫾ 11.3 50 28 96 4 13 30 130 ⫾ 23 198 ⫾ 139 309 ⫾ 568 3.0 ⫾ 1.0 1.2 ⫾ 4 53 ⫾ 12 .48 ⫾ 1.16 .12 ⫾ .43
69/10 45.3 ⫾ 12.7 35 39 95 2 7 37 133 ⫾ 24 206 ⫾ 137 552 ⫾ 756 3.0 ⫾ 9 1.2 ⫾ 6 55 ⫾ 8 .10 ⫾ .37 .07 ⫾ .26
p value
0.2595
0.4266 .7274 .1493 .9491 .7049 .5458 .0403 .4780
Conclusion: Patient outcomes are similar, whether or not routine coronary angiography is performed. The most vital role of follow-up is careful monitoring of medications, blood work, and patients’ symptoms as well as psychological support rather than invasive procedures. While routine coronary angiography permits documentation of coronary artery disease, at this time there are no specific therapies to alter the course. Patients require aggressive management of risk factors. Coronary angiography has a limited prophylactic value in long-term follow-up. 87 EPIDEMIOLOGY AND CLINICAL IMPLICATIONS OF ATYPICAL MYCOBACTERIAL INFECTIONS IN CADAVERIC LUNG TRANSPLANTS: THE ROLE OF SURVEILLANCE BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE PHENOTYPE C. Hoopes,1 A.F. Luetkemeyer,1 D. Jablons,1 T. Hall,1 T. Weaver,1 J. Golden,1 1Thoracic Surgery, University of California San Francisco, San Francisco, CA
86 ROUTINE ANGIOGRAPHY POST CARDIAC TRANSPLANTATION: WHAT VALUE? M.A.J. Rockx,1 P.W. Pflugfelder,1 W.J. Kostuk,1 1Cardiology, London Health Sciences Centre-University Campus, London, ON, Canada Background: Long-term survival has become the norm for cardiac transplant recipients. The question arises of which investigations are required routinely in follow-up. Selective coronary angiography is one such test obtained on a biannual basis. We have reviewed the value of this intervention on patient outcomes (morbidity and mortality). Methods: 505 consecutive heart transplants were performed at a single centre from 1981 to 2003. Of 246 who have survived greater than five years, 167 (Group I) had coronary angiography every two years while 79 (Group II) did not. Results were taken from the most
The role of surveillance bronchoscopy and the clinical significance of atypical mycobacterial species in bronchoalveolar lavage (BAL) fluid collected on surveillance bronchoscopy are both subjects of active clinical debate. Because of two deaths from atypical Mycobacterium abcessans in lung transplant recipients with no clinical or CT scan evidence of active mycobacterial infection we have reviewed the prevalence and clinical characteristics of both donors and recipients with atypical mycobacterial cultures on surveillance BAL. Forty three percent of patients (44 of 103) were BAL culture positive for atypical mycobacterium with Mycobacterium gordonii being the predominant species (30% or 31 of 103 patients). Nine of these gordonii patients were culture positive for a second atypical species. Ten patients grew Mycobacterium avium, six patients grew Fortuitum cheloneae, three patients M. abcessans, and two patients M. kansasii. PCR analysis of strain variants demonstrates no geographic pattern of origin or focal epidemiological source. Lymphocyte phenotypes of infected patients were frequently characterized by low natural killer cell ratios (⬍ 2%) but this pattern is neither predictive nor consistent. The incidenceand prevalence of atypical mycobacteria is higher in our patient population than previously reported as is the incidence of Mycobacterium tuberculosis. Whether this reflects the high incidence of regional donor procurements from patients born in areas of endemic TB (20%), specifics of donor organ selection, institution specific patterns of immunosuppression and antibiotic therapy, or increased use of surveillance bronchoscopy is unclear. Here we present a prospective