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We present a clinical case of an ischemic stroke in a young man, 37 years in the setting of severe cardiac pathology (coronary heart disease, repeated myocardial infarctions with a cardiomyopathy and progressing chronic heart failure). This patient had an orthotopic heart transplantation. In a month we observed an intense violation of cerebral blood circulation, the diagnosis was established: an ischemic stroke in the right carotid pool with formation of the advanced area of ischemia in the right frontotemporal and subcortical area. Total condition was complicated with cerebral edema and dislocation syndrome.In the course of diagnostic search this patient demonstrated genetically caused thrombophilic predisposition in the form of gene-mutation of the blood coagulating factor – plasminogen activator inhibitor (PAI - heterozygote), a glycoprotein Ia (ITAG 2 heterozygote), F7 heterozygote; the genetic polymorphism associated with violation of a folate cycle - MTHFR 1298 heterozygote, MTR heterozygote. The revealed mutations in heterozygous state genes with predisposition to thrombophilic complications can serve as a background for disorders in anti-coagulation and coagulation system which can appear at identification the factors starting the mechanism of its development. In a case with this patient, we speak about a secondary thrombophilia as a reason of an ischemic stroke in the setting of cardiac pathology, repeated myocardial infarctions, orthotopic heart transplantation, obesity. All above-mentioned factors allowed to administer reasonable pathogenetically justified antiagregant and anticoagulant therapy, folic acid drugs, group B vitamins for a purpose of secondary prevention of thrombotic complications.

The mortality rate reaches 50% in the patients with a terminal cardiac failure within one year after it is diagnosed. Orthotopic cardiac transplantation is a radical method to solve this problem and enhance life quality of such patients. Even 10 years ago this surgery and the most important post-transplantation management could be performed only by leading research centers. Currently, given the improvement and accessibility of cardiac surgery, anesthesiology, intensive care, cardiology, and immunology, this type of surgery and post-transplantation management have been mastered by multi-specialty regional centers. The latter improves the accessibility of high tech care for people residing in the periphery.

Aim. Evaluation of prognostic significance of the parameters of cardiopulmonary exercise test in life quality improvement for the post-cardiac transplantation patients.Material and methods. Into the study, 40 patients included, with severe chronic heart failure (CHF), included in the waiting list for cardiac transplantation. Before and after orthotopic heart transplantation (OHT), clinical status was evaluated, cardiopulmonary exercise testing parameters (CET) and life quality by SF-36.Results. After OHT the significant life quality improvement noted, by the scale “Physical health” from 36 (32-45) points before surgery to 52 (49-55) points (p

Aim. To identify new predictors of heart transplant rejection by using speckle-tracking echocardiography technique. Materials and methods. 117 recipients were included into research. The follow-up period in S.V. Ochapovsky Region Clinical Hospital No 1 was from March 2010 to April 2015. The groups were allocated based on results of the retrospective analysis of biopsies: group 1 (n = 68), recipients without signs of cellular and humoral rejection (AMR0 ACR0); group 2 (n = 28), recipients with ACR1; group 3 (n = 16), patients with ACR2; group 4 (n = 5), patients with chronic rejection. The analysis of the results was carried out with endomyocardial biopsy, coronary angiography, transthoracic echocardiography (TTE), tissue Doppler imaging, speckle-tracking echocardiography. Results. Early complications include infections and rejection of heart transplant. Cellular rejection is diagnosed in 70% of cases, humoral rejection in 30% of cases. The disease of coronary arteries is a kind of late complications. It was diagnosed in 13.7%. Fraction rejection sensitivity was 63%, specificity was 97% in recipients with ACR1 while carrying out TTE for the purpose of identification of early diagnostic criterion of rejection; recipients with ACR2 had 75% and 96%, respectively. While carrying out PW sensitivity and specificity Е/А in recipients with ACR1 were 83% and 53%, respectively; recipients with ACR2 had 85% and 52%, respectively. While carrying out PW-TDI sensitivity and specificity Е in recipients with ACR1 were 83% and 58%, respectively; recipients with ACR2 had 88% and 60%, respectively. The assessment of myocardial deformation of the left ventricle is as follows: global peak systolic strain in recipients without rejection (GLPS LV) – (–17.54 ± 3.71%), р = 0.0012; recipients with (ACR1, AMR1) had GLPS LV (–10.52 ± 1.8%), p = 0.0012; recipients with ACR2 had (–6.44 ± 1.8%), p = 0.002; recipients with chronic rejection had (–9.43 ± 1.8%), p = 0.002. The STE GLPS LV parameter (–10.52 ± 1.8%), p = 0.0012, which estimates longitudinal function of myocardium can be considered as early diagnostic criterion of myocardium rejection. The correlation coefficient between CD 3, CD 20, CD 68 and parameter GLPS LV% for groups ACR1-ACR2 was 0.54, 0.86 and 0.26, respectively. Conclusions. The parameters of deformation and cardiac mechanics being estimated by means of speckle-tracking echocardiography can be used as diagnostic monitoring of recipients with rejection of heart transplant.

Aim. Donor organ injury during cold preservation before transplantation negatively impacts graft survival. The current study was to examine available evidences for the efficacy of different cold storage solutions that are used to preserve donor hearts in vitro prior to orthotopic transplantation.Material and methods. A systematic search of full-length articles published from 1980 to August 2012 was performed in PubMed and Google Scholar. Detailed searches were also made for availability of any sourceware for histopathology images of endomyocardial biopsies of stored hearts.Results. Not even a single controlled trial has been published relating to this topic. However, we assessed all available literature pertaining to this topic, and performed original, simple yet innovative analyses using ImageJ, a Java based image analyses program, to show the tremendous power to objectively examine the efficacy of the storage solution. Our analysis suggest that ImageJ may be conveniently used to obtain evidences (or lack of it) of ischemic injury of donor hearts during cold storage.Conclusions. Even the UNOS database does not provide histopathological evidences of cardiac biopsies of orthotopically transplanted hearts. We, however, make the case of the need for image analyses and making availability of images to allow establishing evidence of the usefulness of these storage solutions. We recommend obtaining endomyocardial biopsy prior to orthotopic transplantation and create a registry of H&E stained slides. This is the only step that will direct us towards evidence based care of such highly critical patients who need the equally challenging surgical intervention of cardiac transplantation.

The transplanted heart is characterized physiologically by autonomic denervation, chronotropic incompetence, intermittent episodes of allograft rejection, and frequently by diastolic dysfunction. Sinus node dysfunction resulting in bradycardia is common in the early postoperative period following standard orthotopic cardiac transplantation. Bradycardia tends to remit spontaneously but there are no factors that accurately identify patients who will need long-term pacing. Patients in whom bradycardia persists beyond the second postoperative week despite treatment with theophylline require permanent pacemaker implantation. It has been observed that chronotropic incompetence and diastolic dysfunction are important determinants of exercise capacity following heart transplantation. Pacing that restores chronotropic competence improves exercise capacity, confirming the importance of impaired heart rate response. As in other settings, pacing that preserves atrioventricular (AV) synchrony results in increased cardiac output. For these reasons when pacing is necessary we recommend the DDDR mode (AAIR if intact AV nodal conduction is present) so that the 30%-50% of patients who remain pacemaker-dependent long-term obtain maximal benefit from their transplant. [ABSTRACT FROM AUTHOR]

Accelerated coronary artery disease following cardiac transplantation remains an important obstacle to long-term survival and the correct management strategy remains unclear. This observational, prospective study was designed to examine the feasibility of using percutaneous transluminal coronary angioplasty (PTCA) in the treatment of post-transplant coronary disease. Thirteen consecutive patients were selected from the total population of 276 transplant recipients who underwent routine coronary angiography between 1987 and 1990. Selection of patients was on angiographic criteria alone and PTCA was performed to all accessible stenoses with more than 80% luminal narrowing. PTCA was performed using standard angioplasty equipment and procedure as considered appropriate for the individual lesion. A successful PTCA was defined as more than 30% reduction in luminal narrowing and a residual narrowing of less than 50%. Restenosis was defined as a loss of 50% or more of the gain achieved at the time of successful PTCA or more than a 30% increase in narrowing at the site of stenosis. A total of 31 lesions were dilated in this group and a successful result was achieved in 29 of these (93%) and in 12 of the 13 patients. The one patient with failed PTCA underwent later successful coronary artery bypass grafting to complete revascularization. Four of the 13 patients have had two angioplasty procedures, two for restenosis and two for disease progression in other sites. One patient died 15 months after the initial PTCA and remaining 12 were asymptomatic with good exercise tolerance and ventricular function at a mean of 19 months (range 1–39 months) following first PTCA. Thus, PTCA can be considered a feasible form of treatment for significant single and multiple vessel disease in selected cardiac transplant recipients. Further study is required to assess the effect of this early intervention on long-term mortality. [ABSTRACT FROM PUBLISHER]

A 35-year-old man developed giant cell myocarditis resulting in severe congestive cardiac failure. He needed urgent orthotopic cardiac transplantation despite maximal doses of inotropes and augmentation with an intra-aortic balloon pump. The patient presented with rhythm disturbances and echocardiographically diminished ventricular function at subsequent follow-up. Biopsies then taken revealed recurrence of myocarditis in the transplanted heart. Investigations revealed no obvious cause for the myocardialgranulomas nor any evidence of systemic granulomatous disease. The patient received, in addition to maintenance cyclosporin A and azathioprine, high doses of corticosteroids which resulted in complete resolution of the inflammatory process and no recurrence has been detected to date. This case shows that giant cell myocarditis can recur in the transplanted heart despite routine immunosuppression with azathioprine and cylcosporin A and that additional treatment with high dose corticosteroids is effective in causing regression of the inflammatory process. [ABSTRACT FROM PUBLISHER]

Abstract: We describe a patient with idiopathic giant cell myocarditis who underwent orthotopic cardiac transplantation. On triple immunosuppressive therapy including prednisone, cyclosporine and mycophenolate, the patient has not had recurrence of idiopathic giant cell myocarditis in the transplanted heart in 48 months of follow-up. [Copyright &y& Elsevier]