Search

This article describes four years' experience with heart transplantation using conventional immunosuppression. Twenty of 32 patients are alive. The one-year survival rates were 75% (1979), 67% (1980), and 75% (1981). Actuarial survival rates for operative survivors were 70% at one year, 60% at two years, and 51% at three years. Patients in the 50- to 55-year age group have survived as well as younger recipients. Rejection resulted in six deaths, infection in three, donor heart failure in two, and multiple organ failure in one. There were 1.5 acute rejections per patient and one infection per patient in the first three posttransplant months. Postoperative hospital stay averaged 62 days and cost a total of $58,351.

In the past, psychological problems associated with HTx have not been well documented. We have identified six stages of psychological adjustment associated with the initial hospitalization and eight problem areas that develop after the initial hospitalization. Our approach has been to utilize psychiatric services for the initial evaluation and for intervention on an individual basis. This approach was extended in June, 1983, to include a family members support group, and we are now planning a support group for the HTx patients. The data from our multicenter survey indicates that other centers in the United States and England have had similar experience with their HTx recipients. The approach has been a "traditional" one, and there are no support groups like the ones we created at this time, although several centers are in the planning stages of this type of therapy. This inquiry represents the first attempt to address the psychological problems associated with HTx. It is a first step in learning to treat these patients as a whole. However, many issues remain unaddressed because the methods of this investigation were subjective. The patient population has yet to be studied intensely to identify how it perceives its own problems, and how those problems evolve during prolonged survival, one to five years after HTx. Are these latter problems the same as those experienced during that first post-operative year? Lastly, if other centers organize support groups, it would be useful to form a network that would allow a patient to attend the group closest to his home when he leaves the HTx center.

This study was designed to identify the determinants of postoperative work status among 47 heart transplantation patients at the University of Arizona Medical Center and to focus attention on those actions or policies that increase the probability that a patient will return to work within 6 months after transplantation. Issues regarding work status, disability, and early retirement have become increasingly salient. Case study methods were employed to assign each of the patients to one of four categories, which together form a typology of postoperative work status. Analysis of the patients identified four major variables of work status: age, length of disability before transplantation, control over working conditions including job redefinition/discrimination, and type of health insurance including cost of medication. Although these variables are interdependent, each also has an independent effect on postoperative outcome. The study concludes that although age and length of disability before transplantation cannot be directly affected, both control over working conditions and types of insurance are amenable to intervention.

Between March 29, 1979, and March 1, 1985, 62 heart transplants were done in 61 patients at the University Medical Center, University of Arizona. There were two treatment groups with nearly equal numbers in each; conventional immunosuppression (1979 to 1982) and cyclosporine (1982 to the present). Comparison of actuarial survival, number of rejection episodes, number of fatal rejection episodes, number of infections, and number of "other complications" failed to reveal any significant difference between the two groups. The cyclosporine-treated patients had a documented increase in blood urea nitrogen and serum creatinine accompanied by an increase in diastolic blood pressure. The length of hospital stay of the cyclosporine group was approximately one half of that of the conventionally treated patients, and they required fewer rehospitalizations. The cost for initial hospitalization was not significantly different between the two groups. Therefore, in 1979 dollars, the cost for cyclosporine-treated patients has decreased. This difference in cost was only minimally diminished by the difference in expenditure for outpatient pharmaceuticals, which was four times higher in the cyclosporine group. We believe that cyclosporine is a potent immunosuppressive agent but that it has toxic, possibly irreversible effects on the kidney. In view of the minimal differences that we were able to demonstrate in survival rejection and infection, it seems prudent to reduce or modify present doses of cyclosporine in an attempt to avoid irreversible renal damage.

From March 1, 1979, to March 1, 1985, the University of Arizona received 223 cardiac donor referrals. Sixty-two were accepted: 15 local, 23 regional (less than 370 km or 200 nautical miles), and 24 distant (370 to 1556 km or 200 to 840 nautical miles). Thirty-eight donor deaths were due to motor vehicle accidents, 10 to gunshot wounds, 6 to cerebral disease, and 8 to other closed-head lesions. The mean time from injury to brain death was 65 +/- 5 hours (+/- standard error of the mean [SEM]) and from brain death to organ donation, 12 +/- 3 hours. The mean ischemic time for the donor hearts ranged from 30 to 233 minutes (mean +/- SEM, 128 +/- 7 minutes). Fifty patients, otherwise acceptable, were refused as cardiac donors because an ABO-compatible recipient was not available. Two regionally procured hearts failed at operation, 1 because of unrecognized donor sepsis and 1 from a patient on large-dose inotropic support. Although there was no difference in myocardial function, median survival with follow-up through June 30, 1985, of patients receiving locally, regionally, and distantly procured organs was 59 months, 18 months, and 21 months, respectively. Cumulative proportion 1-year survival was 93%, 56%, and 61%, respectively. The 2-year survival was 85% for patients given locally procured hearts, 43% for those with regionally procured hearts, and 38% for those with a heart from a distant donor. Survival curves showed significantly longer survival for locally procured organs than regionally or distantly procured organs (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)