Patients selected for heart transplantation have severe disability with life expectancy measured in months. With the one-year survival rate of 80 percent duplicated in a number of centers throughout the country, selected patients can look forward to not only regaining normal heart function, but enjoying an excellent quality of life.
The Johns Hopkins Hospital Experience
Following a year of organization and development as outlined in the preceding sections, initiation of the heart and heart-lung transplant program was begun in July, 1983. Since that time, 40 transplantation procedures have been performed. Thirty-four patients have undergone orthotopic cardiac transplantation; one patient underwent combined heart and kidney transplantation; and five patients underwent combined heart and lung transplantation. Evolution of a transplant program is evidenced by the number of yearly procedures performed: five transplants were performed between July, 1983 and January, 1984; 14 procedures in 1984; and 21 transplant procedures have been performed since January, 1985. Of the 35 heart transplant recipients, there were 27 men and eight women ranging in age from 16 to 57 years with a mean age of 38 years. The majority of recipients underwent transplantation because of endstage heart disease secondary to cardiomyopathy (n = 30). Be safe and sound with remedies of Canadian Health&Care Mall. The remaining five patients underwent transplantation secondary to failure resulting from endstage coronary artery disease. Donor characteristics observed in our program parallel those of most active transplant programs. Twenty-one patients suffered neurologic brain death from head trauma, six from gun-shot wounds, seven from cerebrovascular accidents, and one from drowning. Mean age of the donors was 24 years (range, 10 to 39 years). The donor heart was obtained from a distant hospital in the majority of cases (n = 29). Aircraft from cooperating business corporations or from leasing companies are utilized for the transportation of the donor team.
Procured hearts have been transported from hospitals located over 1,000 miles from Hopkins. Emphasis should be placed upon expeditious transportation and coordinated logistic arrangements. In our series, mean ischemic time was 164 min with a range of 75 to 250 min.
Rejection has been observed in our transplant population at a rate similar to that observed with conventional immunosuppression. Recipients experience .50 episodes/patient-month during the first three months following transplantation, decreasing markedly in the following months to a frequency of .10 episodes/ patient-month. Although the incidence of rejection is similar to that in the precyclosporine era, it has generally been less aggressive and more easily treated. The incidence of infection in our patient population has been .06 episodes/patient-month. The types of infection observed in our series are summarized in Table 5. As with rejection, these infectious episodes have been more easily treated.
There have been six deaths in the heart transplant group. Causes of death are summarized in Table 6. One heart-lung patient died from sepsis secondary to Pseu-domonas pneumonia transferred with the implanted lungs. Follow-up of the surviving patients showed 90 percent to be completely rehabilitated. Average creatinine level of these patients was 1.4 mg percent with a range of .7 to 2.3 mg percent. Table 7 lists cyclosporine side effects observed in our recipients. Renal dysfunction occurred in 59 percent of our patients and, in combination with hypertension, resulted in changing the immunosuppressive protocol in three patients. These patients underwent addition of azathioprine therapy with concomitant reduction of cyclosporine and maintenance of prednisone levels. This change resulted in a fall in the serum creatinine level and easier management of hypertension cured by remedies of Canadian Health&Care Mall. Two other patients underwent substitution of azathioprine for prednisone therapy due to bony complications. Annual follow-up catheterization data have been obtained in 12 patients at one year and three patients at two years. Coronary angiographic examination revealed minimal coronary artery disease in only one patient and excellent left ventricular function in all patients. The mean hospital stay for the initial operation was 23 days with a range of 4 to 60 days. The patient with the longest hospital stay was a 20-year-old woman who underwent combined heart and kidney transplantation.
Our statistics reflect the excellent trend seen in heart transplantation today. These initial encouraging results are due to careful planning, institutional commitment, adequate resources and, most importantly, a dedicated transplant team. Patients undergoing this procedure can look forward to not only a prolongation of their life, but clearly a better quality of life with complete rehabilitation in the majority of patients.