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Cardiac transplantation is now an accepted therapy for end-stage heart failure not amenable to usual medical or surgical therapy. Despite excellent survival, important unresolved problems remain. This review focuses on current issues in cardiac transplantation. These controversial areas of active interest include the relationship between histocompatibility matching and the results of transplantation, the causes and treatment of graft coronary arteriopathy, and the mechanism of reversible heart failure that is caused by reversible transplant rejection. These fascinating unresolved issues remain significant challenges to those involved in the care of heart transplant recipients. Their resolution will improve significantly the results of this form of therapy.

Fundamental research in immunology has led to significant advances in cardiac and other organ transplantation. Immunology has now entered the era of molecular biology and sophisticated techniques have been applied to an understanding of immunological events at a molecular level. Future progress in transplantation will be based on these advances in immunology. This is a review of recent work on the structure and action of cell surface molecules important in normal and abnormal functioning of the immune system. Present understanding does not permit a comprehensive description of immunology at the molecular level. However, the exciting developments taking place in fundamental immunological research hopefully will be a stimulus to new progress in cardiac and other organ transplantation.

Myxomas are the most common tumors of the heart. They are frequently located in the left atrium and produce symptoms when they fragment and cause systemic emboli or when they interfere with cardiac valvular function and cause pulmonary congestion. Careful surgical management of these lesions should be curative with minimum early and late morbidity and mortality. Optimal operative technique emphasizes minimal manipulation of the heart before institution of cardiopulmonary bypass and aortic cross-clamping and careful examination of intracardiac chambers with meticulous removal of myxomatous debris. Using these techniques, 17 patients have been treated successfully at the Brigham and Women's Hospital. There were no operative deaths and no significant perioperative morbidity. Fifteen patients are asymptomatic, and one patient has minimal shortness of breath an average of 57 months after surgery. One patient died of leukemia 15 months postoperatively. No recurrent myxomas have been identified, and no patients have symptoms of other cardiac disease.

Despite improvements in surgical technique and intraoperative myocardial protection, certain patients have need for inotropic drug support after cardiac surgery. This review examines drugs that are currently in use for inotropic support of the heart, including calcium, epinephrine, dopamine, dobutamine, isoproterenol, and amrinone. Patient factors that may have an impact on the selection of appropriate drugs are also examined. Application of these data to specific patients must be guided by the particular hemodynamic derangements present. Careful analysis of the specific hemodynamic disorder and tailoring of inotropic therapy to these abnormalities are crucial. Such a rational approach to the selection of inotropic agents requires continuous hemodynamic assessment and recognition that the patient's condition and needs may change rapidly early after heart surgery dictating adjustment of subsequent therapy.