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Abstract: Purpose: This project sought to compare Chinese heart transplant (HT) recipients'' psychospiritual needs during the preoperative (PS) and the postoperative predischarge stage (PDS). Methods: Thirty HT recipients from two leading medical centers in Taiwan were recruited for this research. Data collected by face-to-face interview were analyzed by content analysis. Results: The patients'' ages ranged from 23 to 45 years (mean [M] ± standard deviation [SD] = 28.5 ± 4.1); 90% were married. The subjects'' cardiac disease history ranged from 4.2 to 12.3 years (M ± SD = 8.2 ± 2.3). The waiting time list for HT ranged from 1.2 to 6.4 years (M ± SD = 3.1 ± 2.6). The subjects had the following six psychospiritual concerns: death (PS), unfulfilled family responsibilities (PS and PDS), unaccomplished personal life goals (PS and PDS), poor body image (PDS), loss of significant others'' support and love (PDS), and discrimination by others (PDS). The following seven needs of help were reported: comforting the fear of failure in heart transplantation (PS and PDS), meeting unfulfilled family responsibilities (PS and PDS), accomplishing personal life goal (PS and PDS), religious support (PS and PDS), establishing confidence in body image (PDS), establishing positive relationship with significant others (PS and PDS), and preparation for dying with dignity when necessary (PS and PDS). Conclusion: The in-depth investigation on Chinese HT recipients'' psychospiritual needs was first compared in PDS and PS. More distress and needs were found in PDS than PS. These findings were attributed by the dilemma of pursuing prospective future versus taking the risk of loss of life, valuing families'' and health professionals'' support system, and expecting grief and dying with dignity. Health professionals are encouraged to understand and provide stage-specific support to help them meet psycho-spiritual needs. [Copyright &y& Elsevier]

Abstract: Simultaneous heart and kidney transplantation (SHKT) is feasible for combined cardiac and renal failure. Herein we reviewed our 10-year experience in SHKT. Six patients underwent SHKT from June 1995 to December 2004. Their ages ranged from 13 to 63 years old with a mean of 45.5 ± 15.8 years. They were all men except one girl, who was the youngest (aged 13) who suffered from dilated cardiomyopathy with congestive heart failure and chronic renal failure due to systemic lupus erythromatosus. Because of aggravating heart failure, she changed from hemodialysis to peritoneal dialysis. Because of intractable heart failure, she underwent SHKT from a 24-year-old female donor. All received hemodialysis before SHKT. The indications for heart transplantation included dilated cardiomyopathy (n = 3), ischemic cardiomyopathy (n = 1), cardiac allograft vasculopathy (n = 1), and cardiac allograft failure (n = 1). The immunosuppressive protocol and rejection surveillance were these employed for heart transplantation. No operative mortality was noted in this study. The 1-year and 5-year survival rates were the same, 83%. The 10-year survival rate was 55%. No cardiac or renal allograft rejection was noted. No renal allograft loss was noted. There were two late mortalities: the one, who underwent redo heart transplantation for coronary artery vasculopathy died of cardiac allograft failure 1 year after SHKT. The other patient died of massive ischemic necrosis of the intestine at 6 years after SHKT. Our experience showed that SHKT had good short- and long-term results without increasing immunosuppressive doses. End-stage failure of either the heart or the kidney did not preclude heart plus kidney transplantation. [Copyright &y& Elsevier]

Abstract: Background: Heart transplantation (HTx) in children with end-stage heart disease has become an accepted treatment option. Objective: To evaluate our results of pediatric cardiac transplantation with vs without bridge methods. Patients and Methods: The study included 31 patients (34 transplantations) younger than 18 years who underwent orthotopic HTx between March 1995 and December 2008. Ten patients were girls, and 21 were boys. Preoperative diagnoses included cardiomyopathy (n = 20), congenital heart disease (n = 7), hypertrophic cardiomyopathy (n = 2), restrictive cardiomyopathy (n = 1), and ischemic cardiomyopathy (n = 1). Mean (SD) ischemia time was 185 (72) minutes. Thirty-day mortality was 6%, and was due to primary graft failure (n = 2). Overall follow-up was 4.36 (3.93) years. Eleven patients underwent bridge techniques before HTx, and 11 patients required perioperative extracorporeal membrane oxygenation or ventricular assist device support. Results: In the group that received extracorporeal membrane oxygenation, 8 patients (73%) were successfully weaned and discharged with excellent functional class. There were no differences in operative mortality, functional class, survival, rejection, and infection rates between the bridged and nonbridged groups. Overall actuarial 1- and 5-year survival rates were 93% and 83%, respectively. All survivors had good functional class. Conclusion: Our findings demonstrate satisfactory medium-term outcome of HTx in selected pediatric patients with end-stage heart disease. Using bridge methods in children at high risk can increase the opportunity to receive a donor heart. These bridge methods achieve similar postoperative outcomes. [Copyright &y& Elsevier]

Abstract: Patients receive methylprednisolone pulse therapy (MPT) when acute cardiac rejection occurs. Although the regimen is generally safe and effective, severe complications occasionally develop. From 1997 to 2007, there were 210 cardiac transplantation procedures performed at our hospital. Among these patients, there were 23 episodes of acute rejection treated with MPT, 10 mg/kg/d. Two patients in our series had cardiac arrest within 36 hours after initiating the therapy. Endomyocardial biopsy specimens showed International Society for Heart Transplantation grade 1B allograft rejection in both cases. Emergent intubation and cardiopulmonary resuscitation were performed. Venoarterial extracorporeal membrane oxygenation (ECMO) was used to rescue the patients. The cardiac function in both patients recovered gradually. Left ventricular ejection fraction increased from 16.2% to 47% in one patient and from 27% to 30% in the other patient. One patient was successfully weaned from ECMO after 2 days of support. The other patient was discharged against medical advice because of hypoxia-related brain death after 3 days. Both patients had a history of tachyarrhythmias before initiation of MPT. Although the relationship between mechanisms of cardiac arrest and MPT is uncertain, the risk of cardiac arrest cannot be overlooked when initiating MPT, especially in patients with a history of tachyarrhythmia. Meanwhile, ECMO can serve as a rescue method if cardiac arrest occurs. [Copyright &y& Elsevier]

Abstract: Ventricular assist devices (VAD) have benefitted patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experience with HTx after an extracorporeal membrane oxygenation (ECMO) hybrid with various ventricular assist devices (VAD). From May 1996 to December 2003, mechanical circulatory support with a Biopump VAD was performed in eight patients, HeartMate left VAD in eight patients, and Thoratec VAD in eight patients. Before VAD implantation, 19 patients maintained their circulation with ECMO. Half of the 24 patients were implanted with VAD to await a suitable donor for HTx. We observed that half of the patients supported by ECMO hybrid with various VAD awaited a suitable donor for HTx. In our experience, we recommend the application of ECMO for short-term support within 1 week and the Biopump VAD, Thoractec VAD, or HeartMate VAD for medium-term or long-term support as a bridge to HTx. [Copyright &y& Elsevier]

Abstract: Introduction: This study determined the accuracy of a limited sampling strategy to predict the 12-hour cyclosporine neoral (CsA) area-under-the-curve (AUC) to provide a practical method for more accurate therapeutic drug monitoring (TDM) of CsA in Chinese heart transplant recipients. Methods: Blood samples were collected at 0 (before the dose), and 0.5, 1, 2, 3, 4, 6, 8, 10, as well as 12 hours after CsA oral administration in 13 de novo heart recipients receiving oral CsA bidafter rabbit antithymoglobulin sequential immuno-induction. Pharmacokinetics were analyzed for the first dose (PK-1) and the steady state dose (PK-2, 1 month after transplantation). The limited sampling strategies included single-point, 2-point, and 3-point prediction of AUC using multiple linear regression analyses. Results: Comparing the AUC/mg dose, PK-1 was much lower than PK-2 (25.2 ± 11.4 ng.h/mg.mL vs 45.4 ± 12.9 ng.h/mg.mL; P = .0005 using paired t test). The correlations of each single-point blood level of PK-1 with the AUC were lower than those of the corresponding sampling time in PK-2. In the PK-2 study, C4 had the best correlation (r2 = 0.732; P = .00) as a single-point to predict AUC, but the 2-point C2 + C12 had a higher correlation (r2 = 0.937; P = .00). Among the 3-point combinations, C2 + C4 + C12 showen the best prediction (r2 = 0.982; P = .00) of the AUC in PK-2. Conclusion: The bioavailability of CsA was lower in PK-1 than in PK-2. At steady state, we recommand C2 + C12 to predict AUC because it is accurate and not labor-intensive. [Copyright &y& Elsevier]

Abstract: We investigated the short- and long-term results after heart retransplantation in terms of different causes of heart allograft failure. We sought to establish the data of heart retransplantation in Chinese compared with Western counterparts due to differences in heart allograft vasculopathy. From March 1995 to May 2005, eight heart transplantation recipients with allograft failure underwent retransplantation. Heart allograft failure was due to coronary vasculopathy (CAV) in six patients (75%) and acute rejection in two patients (25%). The mean interval to retransplantation was 32 to 84 months (mean 54.3 months). There were five patients who survived after heart retransplantation for CAV and no patient survived after an earlier diagnosis of acute rejection. Heart retransplantation is a feasible method with acceptable long-term survival rate for heart allograft failure. After careful pretransplant evaluation, retransplantation is acceptable. The survival after retransplantation for CAV is notably great than that after acute rejection. Heart retransplantation is the only way for patients who have cardiac allograft failure to achieve long-term survival. [Copyright &y& Elsevier]

Abstract: This study described an analysis of severe sepsis among heart transplantation recipients who were treated by sparing all immunosuppressants. Sepsis leading to multiple organ failure (MOF) in heart transplantation has a high mortality. This retrospective study of 190 patients who underwent heart transplantation from 1993 to 2004 included 12 who had severe sepsis with MOF who were treated by sparing all immunosuppressants. Half of them survived after sparing all immunosuppressants with intensive endomyocardial biopsy. Only one case needed pulse therapy for an acute rejection episode. The most common bacterial infectious episodes were caused by methicillin-resistant Staphylococcus aureus (n = 3). All sepsis episodes occurred in the first month after heart transplantation except in one case, which occurred 6 years after heart transplantation. There was a 50% survival rate of heart transplantation recipients who experienced MOF due to severe sepsis and were treated by sparing all immunosuppressants under a program of intensive endomyocardial biopsy. [Copyright &y& Elsevier]

Abstract: This study was designed to compare the chance of heart transplantation (HTx) and survival among patients in different UNOS statuses in Taiwan. Methods and results: From 1996 to 2002, among 203 patients on the heart transplant waiting list, 127 patients had undergone HTx up to December 2002 with 71 dead while waiting, and 5 still alive without transplantation. This study included those 198 patients who had either undergone HTx or who died. At the time of registry, 40 patients were at status IA, 57 at IB, and 101 at II. Nineteen (47.5%) of 40 status IA patients underwent HTx with a mean waiting time of 92 ± 116 days and median waiting time of 35 days. The 1-month survival was 84%, and 1-year survival was 58%. Seven (64.9%) of 57 status IB patients underwent HTx with a mean waiting time of 85 ± 100 days and a median waiting time of 40 days. Both 1-month and 1-year survivals were 92%. Seventy-one (70.3%) patients among 101 status II patients underwent HTx. Their mean waiting time was 134 ± 135 days and median waiting time was 86 days. Their 1-month survival was 95%, and 1-year survival was 85%. Conclusion: Although UNOS status IA patients had a shorter waiting time, their chance to undergo HTx was lower than those in either status IB or status II. The UNOS status IA heart-waiting patients showed lower posttransplant 1-month and 1-year survival rates. [Copyright &y& Elsevier]

Abstract: This study compares the pharmacokinetics of tacrolimus (TAC) and cyclosporine Neoral (CsA) in cardiac transplant recipients. Methods: Twenty-six de novo cardiac recipients were prospectively and randomly assigned to receive oral TAC- or CsA-based regimens after 5 to 6 days of rabbit antithymocyte globulin induction. Blood samples were collected at 0 (before the dose) and 0.5, 1, 2, 3, 4, 6, 8, 10, as well as 12 hours after drug administration. The pharmacokinetics of the first dose (PK-1) and at steady state (PK-S, 1 month after transplantation) were analyzed. Results: Comparing the AUC per milligram dose, there was no significant difference between PK-1 and PK-S among TAC (46.0 ± 24.3 ng.h/mg.mL versus 69.0 ± 43.9 ng.h/mg.mL, P = .15 by paired t-test), but a significant difference in CsA (25.2 ± 11.4 ng.h/mg.mL versus 45.4 ± 12.9 ng.h/mg.mL, P = .0005 by paired t-test). This means better TAC absorption in the early post–heart transplant period. Using a single-point blood level to predict AUC, TAC showed a significantly higher correlation than CsA at all corresponding sampling times. Besides, C12 in both PK-1 and PK-S of TAC displayed good correlations to the AUC (r2 = .895, P = .00 in PK-1 and r2 = .81, P = .00 in PK-S). The TAC trough level was accurate enough to predict the AUC. Conclusion: The pharmacokinetic profile of TAC is more reliable than that of CsA in the early post–heart transplant period. A high correlation of trough blood levels with AUC omits the requirement for a multiple sampling strategy to more accurately measure AUC as is needed with CsA. [Copyright &y& Elsevier]

Abstract: Introduction: This study compared the efficacy and safety of a tacrolimus (TAC)–based with a cyclosporine (CsA)microemulsion–based immunosuppressive regimen in primary cardiac transplantation. Methods: Heart recipients were randomly assigned to receive either TAC or CsA regimen after sequential induction with rabbit anti-thymoglobulin. Endomyocardial biopsies were performed at weeks 1, 2, 3, and 4 and months 2, 3, and 6. Results: Among 21 adult patients (TAC, 11; CsA, 10) in this study, patient survival rates were 100% in both groups at the end of 6 months. One patient (9%) in the TAC group experienced acute rejection (ISHLT≥ 1B) versus 6 patients (60%) in the CsA group (P = .02). The effects on hematology, biochemistry, cytomegalovirusinfection, and hemodynamics were similar in both groups except for better lipid profiles in the TAC group. There were no significant differences in severe adverse events. Conclusion: The TAC-based regimen had a lower risk of acute rejection compared with CsA in heart transplant recipients. The safety profiles were similar in both groups. Therefore, TAC is an alternative to CsA as a primary maintenance immunosuppressant in heart transplantation. [Copyright &y& Elsevier]