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Abstract: Introduction: This project examined heart transplant (HT) recipients'' perspectives of (a) the changes in their working competence (WC), status for job resumption and related factors at 1- to 2-year, 2- to 3-year, and 3- to 4-year stages; and (b) impacts of HT on interpersonal relationships (IPR). Method: We used a between-method triangulation (including qualitative and quantitative data) design. Quantitative data were collected using the Vertical Visual Analogue Scale and Taiwan''s version of the World Health Organization Health-Related Quality-of-Life (HRQoL) questionnaire. Six qualitative semistructured questions were further applied to explore social and environmental domains. Results: The Fifty subjects (86% males and 14% females) had an age range from 20 to 70 years old (mean, 47.68 years). Their post-HT time ranged from 1 to 4.1 years with 42%, 42%, and 16% at 1- to 2-, 2- to 3-, or 3- to 4-years post-HT, respectively. Within 6 months, 10% of administration or restaurant staff, and police resumed their jobs. At 6 to 12 months, 8% of administration, quality control, and design and planning staff resumed their jobs. At 12 months, 14% of educators, insurance personnel, managers, informatics engineers, and ironworkers resumed their jobs. Hindering factors to returning to work included (a) physical (ie, lack of energy, second heart attack, recurrence of rejection, physical discomforts of dizziness, memory lapses/lack of concentration or bone pain from osteoporosis); (b) psychological (ie, lack of confidence, worries about discrimination, being different, maladaptation); and (c) environmental (inadequate job opportunities due to poor socioeconomic conditions). Additionally, 34% reported worse IPR after HT due to diet limitations, slower pacing, less contacts with friends, and changes in personality. Reflections on both the meaning and value of life caused 10% to report better IPR with a better personality and positive mindset. By the end of the first postoperative year, the mean score of HRQoL in the preoperative extracorporeal membrane oxygenation (ECMO) group was similar to the non-preoperative ECMO group; the mean scores of WC and physical functions for the preoperative ECMO group were even higher than the non-preoperative ECMO group. Meanwhile, the mean scores of HRQoL and WC were higher in the Clinical Trail Plan (CTP) group than non-CTP groups across the three stages. As such, the use of preoperative ECMO and CTP groups are suggested to be both clinically and significantly associated with HTs recovery in heath status, positive HRQoL, and job resumption in the society. Finally, HRQoL and related domains of physical, psychological, social, and environmental health were stable at 12 months post-HT, with no significant change between 1- to 2-, 2- to 3-, and 3- to 4-years post-HT. [Copyright &y& Elsevier]

Abstract: Objective: To compare changes in overall health-related quality of life (HRQoL), working competence, and physical functions in heart transplant (HTx) recipients with vs without preoperative extracorporeal membrane oxygenation (ECMO) at 3 crucial stages post-HTx: 1 and 6 months and 1 year. Patients and Methods: This between-method triangulation study included qualitative and quantitative data for patients recruited from a medical center with 2200 beds. Quantitative data were obtained using a vertical visual analog scale and the Taiwan version of the World Health Organization Quality of Life Questionnaire. Six semistructured qualitative questions were added to further explore factors that influence changes in Social domains of HRQoL between the 4 groups across recovery stages. Results: The 50 patients (86% men and 14% women) ranged in age from 20 to 70 years (mean age, 47.68 years). Time post-HTx ranged from 1 year to 4 years and 1 month, and 16% had received preoperative ECMO therapy. Mean (SD) HRQoL, working competence, and physical functions improved from 54.76 (24.44), 31.8 (26.53), and 80.00 (33.67), respectively, at 1 month post-HTx (r = .48) to 65.76 (20.24), 50.90 (25.23), and 96.80 (11.05) at 6 months (r = .52) and 74.40 (13.65), 64.30 (21.48), and 98.8 (7.80) at 12 months (r = .44), with moderately significant differences. Compared with the non-ECMO group, the preoperative ECMO group perceived lower (stage 1), similar (stage 2), and higher (stage 3) working competence. Thirty-two percent of recipients resumed stable jobs across the 3 stages (10%, 8%, and 14%, respectively), and reported higher working competence and physical functions compared with other patients (68%) (P < .001). Recipients with stable marriages (P = .046), higher educational achievement level (P = .004), and stable jobs (P = .001) reported greater overall HRQoL across the 3 stages. Conclusion: Heart transplant recipients reported higher overall HRQoL, working competence, and physical functions across the 3 recovery stages during 12 months post-HTX. Three major influencing factors identified included stable marriage, higher educational achievement level, and stable job status. [Copyright &y& Elsevier]

Abstract: Aims: The aim of this project was to identify the dark-recovery experiences (DRE) that adult heart transplant recipients (AHTRs) perceived as causing the most suffering after heart transplantation (HT). In artition, we sought to explore the stage-specific difficulties, coping strategies, and helpers for transplant recipients DRE in Taiwan. Methods: A qualitative design was employed using a sample group of patients with DRE. Retrospective data collected by face-to-face in-depth interviews were subjected to content analysis. Results: A total of 20 AHTRs (16 men, 4 women) participated in this research. Their ages ranged from 32–70 years (mean, 46.95 years). Their post-HT timeframe ranged from 3 months–2.10 years. The subjects reported DRE the across preoperative intensive care unit (ICU), postoperative floor unit, and even after the hospital discharge stages. Four major difficulties during DRE were reported: (1) becoming a burden for families (all stages); (2) unfamiliar with medical protocols, environment, and policy (ICU stage); (3) mental and physical discomforts caused by the invasive examinations and unstable health condition (post-ICU to postdischarge stages); and (4) sense of uncertainty about health progression and quality of life in the future (post-ICU to postdischarge stages). Four coping strategies were used for DRE: (1) asking religious support (all stages); (2) changing mindsets and taking positive attitudes to live with difficulties (ICU to postdischarge stages); (3) setting goals for health maintenance and recovery (post-ICU to postdischarge stages); and (4) planning to look for an appropriate job in the future (postdischarge stages). Families and religious persons were cited as helpers (all stages), as well as health professionals (ICU to postdischarge stages), other AHTRs (post-ICU to postdischarge stages), and the social welfare systems (postdischarge stages). Conclusion: DRE, coping strategies, and related helpers in Taiwan were systematically explored in this project. With this information, the transplantation team will be empowered to provide better care for AHTRs during their most vulnerable time. [Copyright &y& Elsevier]

Abstract: Patients with hepatitis B virus (HBV) infection have a higher morbidity and mortality after heart transplantation (HT). HBV infection is endemic in Taiwan. We studied the effect of lamivudine treatment of HBV infection after HT. From July 1987 to July 2005, 252 patients underwent HT. All recipients and donors underwent routine screening of hepatitis B surface antigen (HBsAg), hepatitis B e antigen, antibody to hepatitis B surface antigen, antibody to hepatitis B core antigen, antibody to hepatitis B e antigen, and an alanine aminotransferase (ALT) level before HT. When ALT was two times greater than the upper limit of normal or serum bilirubin was higher than 3 mg/dL in HBsAg-positive patients, HBV-DNA were checked by a branched DNA assay or polymerase chain reaction. When HVB-DNA was greater than 100,000 copies/mL, lamivudine (100 mg per day) was prescribed indefinitely. There were 14 patients under lamivudine treatment after HT, among whom, none suffered severe adverse reactions from lamivudine. Four patients died: one due to end-stage cirrhosis while awaiting liver transplantation at 14 months after HT. Two died of sudden death at 54 months and 138 months after HT. Another died of diffuse B cell lymphoma at 62 months after HT. All the survivors have normal ALT and undetectable HBV-DNA after lamivudine treatment. But the YMDD mutant was detected in two patients. With successful treatment of HBV infection in HT, it is not necessary to exclude HBV infection patients from HT. [Copyright &y& Elsevier]

Abstract: Background: The aims of this project were to explore the factors contributing to poor sleep quality at 1 to 3 years after heart transplantation (post-HT), and to explore economic problems and social support for HT recipients (HTRs). Methods: This study used a cross-sectional retrospective triangulation approach combining qualitative and quantitative research method designs. Quantitative data included data from the visual analog scale and the Taiwanese version of the World Health Organization Quality of Life questionnaire. Qualitative data were derived from questions that explored physiological, psychological, and economic factors contributing to poor sleep quality postprocedure for HTRs. Results: Sixty-four subjects (81% male, 19% female) participated in this research. Their ages ranged from 20 to 70 (M = 46.88 ± 12.12) years old. Their post-HT timeframe ranged from 1 to 4.10 years; 33% received preoperative extracorporeal membrane oxygenation support. Sleeping disturbances were reported by 72.7% of subjects after HT. Poor sleeping quality at 2 to 3 years post-HT (P = .028) was a complaint, and was worse than at 1 to 2 years post-HT (P = .008). Six physiological (62.5%) and 3 psychological (37.5%) contributing factors were further identified in qualitative interviews. Physiological factors were the major causes affecting their sleep quality 2 to 3 years after HT, whereas psychological factors arose from various family roles, responsibilities, and economic-related pressures. Conclusions: Medical teams should find the causes that lead to sleep disturbances and use the findings to improve HTR sleep quality. When the family financial status is affected, these teams should offer assistance and suggestions for patients who are unable to work due to post-HT physical decline. Establishing and providing good family support systems or patient support groups may allow patients to obtain physical, psychological, and spiritual comfort. [Copyright &y& Elsevier]

Abstract: Orthotopic heart transplantation is the treatment of choice for end-stage heart failure, and calcineurin inhibitor agents allow for better allograft survival. However, pretransplantation low cardiac output status and posttransplantation immunosuppressants contribute toward deterioration of renal function. From 1987 to 2008, 350 patients underwent orthotopic heart transplantation in our hospital. Most of them received anti-thymocyte globulin (ATG) as the induction immunosuppressant. The introduction of mycophenolate mofetil (MMF) reduced the maintenance level of cyclosporine. The 26 patients who developed end-stage renal disease required dialysis. We reviewed the patient characteristics, including pretransplantation status, immunosuppressant regimens and drug levels, time and type of dialysis, and mortality rate. The mean age of these 26 patients was 53 years. Three patients underwent peritoneal dialysis. The overall 1-year survival rate was 96%, and the 5-year survival rate was 80%. The duration from heart transplantation to chronic dialysis correlated with the presence of a pretransplantation diagnosis of diabetes (P < .05) and an elevated pretransplantation blood creatinine level (P = .01), but there was no significant effect of the initial level of cyclosporine. In addition, the pretransplantation blood creatinine level was also related to the necessity of immediate postoperative hemodialysis (P = .01). There was no significant risk factor in relation to mortality. Regardless of modification of immunosuppressant regimens and initial drug levels, pretransplantation kidney function played an important inverse role in the duration from transplantation to dialysis: the higher the pretransplantation blood creatinine, the shorter the duration. While awaiting a heart transplant, more effort should be spent on protecting renal function to avoid early chronic dialysis. [Copyright &y& Elsevier]

Abstract: Simultaneous heart and kidney transplantation (SHKT) has become an accepted therapeutic option for patients with end-stage heart failure associated with end-stage renal disease. The immunosuppressive therapy is usually based upon a heart transplantation protocol using a calcineurin inhibitor (CNI). Sirolimus (SRL) is a potent nonnephrotoxic immunosuppressant with antiproliferative activity in nonimmune cells. Its use has recently been reported to show less nephrotoxicity among both heart and kidney transplants. However, the data for the SHKT are limited. We retrospectively examined the causes of 5 patients who received combined SRL-CNI immunosuppressive therapy with reduced CNI doses from 2003 to 2009. There was no mortality during follow-up. Two of the 3 patients who received a conversion regimen recovered renal function. One who suffered severe proteinuria after transplantation proceeded to hemodialysis at 3 years after conversion. Both of the patients who received the combined regimen de novo remained stable regarding their renal function. Cardiac function was stable in these patients; there was neither allograft rejection nor allograft coronary vasculopathy. We observed that patients without dyslipidemia or hyperuricemia before SHKT were less likely to develop these disorders under the combined regimen. Early medical intervention after close follow-up of lipid and uric acid values by dose adjustments resulted in a stable status of our patients. [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: The objective of this study was to describe in heart transplant recipients severe sepsis due to fungal infection, which is associated with high mortality. This was a retrospective study including 366 patients who underwent heart transplantation from 1987 to 2009 in whom severe sepsis due to fungal infection developed, with multiple-organ failure. Sepsis was diagnosed on the basis of a positive culture for the infective agent, such as Cryptococcus, Aspergillus, Candida, or Nocardia, from an appropriate source such as blood, wound, or sputum. In 10 patients, severe sepsis due to fungal infection was treated temporally by reducing or sparing immunosuppression; 7 of these patients survived after intensive care. Only 1 patient required pulsed therapy because of an acute rejection episode. Early diagnosis with aggressive diagnostic techniques and use of combination therapy must be considered to reduce the risk of death in heart transplant recipients with fungal infection. [Copyright &y& Elsevier]

Abstract: Extracorporeal membrane oxygenation (ECMO) can provide excellent mechanical circulatory support (MCS). Some case reports use ECMO to rescue heart transplantation (HTx) recipients with posttransplant cardiopulmonary failure. Herein reported a series of use of ECMO to rescue HTx recipients with refractory cardiopulmonary failure have during the posttransplant period. The causes of cardiopulmonary failure were right ventricular failure, primary graft failure, acute rejection, or sepsis. A retrospective review of 366 consecutive HTx recipients revealed 40 cases of cardiopulmonary failure requiring ECMO rescue in the posttransplant period. There were 14 patients diagnosed as right ventricular cardiopulmonary failure; 7 primary graft failure with a stunned donors myocardium, 8 as acute cellular or humoral rejection, and 11 as sepsis with positive blood cultures. ECMO-related variables were evaluated for association with mortality. The HTx recipients included 35 males and 5 females with overall median age of 42.3 years (range, 0.48–65.22). The weaning rate was 72.5% (29/40) and survival, 52.5% (21/40). ECMO provided temporary MCS rescuing some HTx recipients with posttransplant cardiopulmonary failure. None of the patients receiving ECMO support for >4 days survived. [Copyright &y& Elsevier]

Abstract: Ventricular-assist devices (VADs) have benefitted patients with end-stage heart failure as a bridge to heart transplantation (HTx). Herein, we describe our experience with HTx in the presence of extracorporeal membrane oxygenation (ECMO) together with the Thoratec VAD (Thoratec Corp, Pleasanton, California). From May 1996 to June 2009, mechanical circulatory support with the Thoratec VAD was provided in 20 patients. Before implantation of the VAD, circulation in 17 patients was maintained using ECMO. Although 350 patients underwent HTx during that period, only 13 patients (65%) received suitable donor organs for orthotopic HTx. The 20 patients ranged in age from 10 to 80 years; 3 were female, and 17 were male; and 17 (85%) required ECMO before VAD implantation. In 11 of 17 patients (65%), the VAD was implanted as a double bridge to HTx. The demand for mechanical circulatory support in patients with acute hemodynamic collapse has led to major improvements in clinically available systems such as ECMO as a double bridge to VAD implantation. We use ECMO as a rescue procedure in patients with acute hemodynamic deterioration. However, during ECMO support, left ventricular afterload increases. If prolonged support is necessary, a VAD may be required. We observed that 65% of patients who received support from an ECMO hybridized with the Thoratec VAD could wait for a suitable donor for HTx. We recommend use of ECMO for short-term support (<1 week) and the Thoratec VAD for medium- or long-term support as a bridge to HTx. [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]