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Renal function after heart transplantation (HTx) typically follows a biphasic pattern and an initial decay within 1 to 2 years. Trajectory of renal function after HTx is less reported, especially in Asia. The aims of this cohort study were to describe the changes in HTx recipients' serum creatinine and estimated glomerular filtration rate (eGFR) levels 5 years following HTx in Taiwan., Methods: We retrospectively reviewed 5 years of 440 consecutive adult patients (≥ 18 years) who underwent first HTx from June 1987 to December 2014 at the National Taiwan University Hospital., Results: Among 422 participants, they received induction therapy consisting of intravenous rabbit antithymocyte globulin. Here, we illustrated the trends over the years by dividing the subjects into 2 groups based on their immunosuppressive regimen of transplantation (1987-2002 and 2003-2014) The pretransplantation median serum creatinine concentration level was 1.2 mg/dL, rose to 1.4 mg/dL at 3 months after surgery, and remained steady over 5 years after HTx. Pretransplant median eGFR was 67 mL/min/1.73 m 2 .The median serum creatinine concentration level and eGFR at baseline were all significantly difference than pretransplantation (P > .05). This result has showed that an initial steep decline within 3 months after transplant remained stable 5 years after HTx., Conclusion: As renal function deteriorates after HTx, we observed a steep decline in serum creatinine level and glomerular filtration rate within the 3 months after HTx, followed by a slow rate of deterioration over the following months. We found a time-related progressive deterioration in renal function during the 5 years after HTx., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: An oversized cardiac allograft may have a negative impact on survival outcomes according to previous studies; however, due to the shortage of pediatric donor hearts, the use of oversized cardiac allografts is sometimes inevitable. In this study, we reported the survival outcomes of pediatric patients in relation with the donor-recipient weight ratio., Methods: Twenty-eight children, aged 3 months to 17 years, with dilated cardiomyopathy underwent primary cardiac transplantation at the National Taiwan University Hospital between 1995 and 2012. We analyzed these patients according to the donor-recipient weight ratio: group 1 (n = 19) with donor-recipient weight ratio <2.5 (median 1.1, interquartile range 1.0-1.6), and group 2 (n = 9) with donor-recipient weight ratio ≥2.5 (median 3.0, inter-quartile range 2.87-3.5)., Results: The 30-day survival rate was 100% for both group 1 and group 2 (P = 1). The survival rates for group 1 and group 2 were 95% vs 100% at 1 year, 84% vs 89% at 5 years, and 73% vs 61% at 10 years. The median survival was 14.4 years vs 12.9 years (P = .6313)., Conclusion: In this cohort, the use of oversized cardiac allograft in pediatric patients for dilated cardiomyopathy did not have a negative effect on short-term and long-term survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We report a heart transplantation in a patient with no heart. A 60-year-old man suffered from severe infective endocarditis, and due to extensive involvement of the myocardium, only minimal myocardium was left after debridement of the necrotic myocardium and aortic annulus. We finally excised the entire heart to eradicate the infection source and employed 2 extracorporeal membrane oxygenations for full life support. The infection was controlled with strong antibiotics. The patient underwent successful heart transplantation 16 days following the excision and the patient fully recovered without any complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Acute fulminant myocarditis with intractable cardiogenic shock is a fatal condition; its only therapeutic option is mechanical circulatory support. The use of mechanical circulatory support, either extracorporeal membrane oxygenation (ECMO) or a ventricular assist device (VAD), serves as a bridge to recovery or as a bridge to transplantation., Objectives: The aim of this research was to advance our understanding of the outcome of heart transplantation under mechanical support for acute myocarditis. Two groups of patients were compared: those recovered without undergoing transplantation and those who underwent transplantation., Methods: We reviewed 134 patients experiencing acute myocarditis who required mechanical circulatory support (including ECMO and/or VAD) in our institute between 1994 and 2014. Demographic data, clinical characteristics, support duration, and outcome of individuals were retrospectively analyzed., Results: Patients taking part in this study were aged from 1 month to 70 years, with an average age of 28 years. The transplantation-free survival rate in adults was 54%. A total of 6 adult patients receive a heart transplant under ECMO/left VAD; 2 of these patients died of uncontrolled sepsis after the heart transplantation. The duration of mechanical support ranged from 10 to 130 days (average, 41 days)., Conclusions: Mechanical circulatory support in patients with acute myocarditis proved to be effective. Approximately one half of all adult patients in this study experienced myocardium recovery under mechanical support, with only 5% undergoing a successful heart transplantation. In terms of patients who survived after heart transplantation, the mid-term and long-term outcomes are favorable., (Copyright © 2016. Published by Elsevier Inc.)

Background: Fontan failure (FF) occurs rarely. In patients with Fontan failure, heart transplantation is believed to be the most effective therapy. We review our experience in heart transplantations after the Fontan operation., Methods: From July 1987 to December 2014, 4 of 513 patients underwent orthotopic heart transplantation (OHT). Among them, 4 were due to FF. We reviewed these 4 cases via retrospective chart review. Clinical history, laboratory data, surgical technique, perioperative variables, and outcomes of long-term follow-up are presented herein. The primary outcomes were hospital mortality, 1-year-survival rate, and 4-year-survival rate. The secondary outcome is the improvement in patients with protein-losing enteropathy., Results: The hospital mortality rate was 0% in the 4 FF patients receiving OHT. No surgically related hemorrhage or infection was observed. The 1-year-survival rate was 100% (n = 4) and the 4-year-survival rate 50% (n = 2). One patient died of posttransplantation lymphoproliferative disorder. Hypoalbuminemia improved in 1 of 3 patients 4 months after OHT., Conclusions: Despite technical challenges, heart transplantation can be performed successfully in patients with Fontan operation. However, protein-losing enteropathy might not be resolved quickly after heart transplantation., (Copyright © 2016. Published by Elsevier Inc.)

Background: Malignancy is the leading cause of death in Taiwan. The risk of malignancy is higher in heart transplant recipients than in the general population. We reviewed the malignancy incidence among the patients who underwent heart transplantation (HT) at the National Taiwan University Hospital (NTUH) during the past 28 years. We found that the incidence of malignancy is low in Taiwan and that the pattern of malignancy is different from that in the Western population., Methods: From July 1987 to March 2015, 518 patients underwent HT at NTUH. Forty-four patients who died within 1 month after transplantation were excluded from this study. Thus, a total of 476 patients were enrolled in this study. There were 393 male and 83 female patients, with a mean age of 45 years at transplantation. The major indications for HT were dilated cardiomyopathy (52%) and ischemic cardiomyopathy (33%). After HT, all patients received triple immunosuppressive therapy, including a calcineurin inhibitor (cyclosporine or tacrolimus), cell-cycle inhibitor (azathioprine, mycophenolate mofetil, or everolimus), and steroid. After 1995, induction with rabbit anti-human thymocyte globulin was routinely performed. Survival was estimated by means of the Kaplan-Meier method., Results: Twenty-seven patients without pre-transplantation malignancy developed malignancies after HT. The median survival time (MST) of these 27 HT patients was 76.8 months. After malignancy was diagnosed, the overall MST was 20.7 months. The 3- and 5-year overall survival rates were 44% and 27%, respectively. Twenty-one patients (77.8%) died, 10 of them because of cancer. The most common malignancy was non-Hodgkin lymphoma (n = 6), followed by skin cancer (including 2 keratoacanthomas, 2 squamous cell carcinomas, and 1 basal cell carcinoma; n = 5) and lung squamous cell carcinoma (n = 3). The univariate analysis identified cancer stage (P = .044) and comorbidity (P = .002) as factors associated with poor malignancy survival. In the multivariate analysis, comorbidity was an independent prognostic factor for greater risk of death because of post-transplantation malignancy (P = .002)., Conclusions: In Taiwan, the risk of malignancy after HT is low (5.7%), as is the incidence of skin cancer. The most common malignancy was non-Hodgkin lymphoma, followed by skin cancer and lung cancer. Comorbidity was an independent factor for overall survival in cancer patients who previously underwent HT., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: With advances in immunosuppressive therapy, heart transplantation is currently recommended as the only established surgical treatment for refractory heart failure. However, chronic immunosuppression increases the risk for malignancy. Everolimus (EVR) is a potent mammalian target of rapamycin inhibitor that is used after transplantation and to treat advanced malignancies, as we have done in Taiwan after heart transplantation since 2004. Mycophenolate mofetil (MMF) and EVR are frequently used as cell-cycle inhibitors to optimize post-transplantation outcomes., Methods: We retrospectively analyzed the characteristics and outcomes of 454 patients who received either MMF (n = 232) or EVR (n = 222) after heart transplantation at the National Taiwan University Hospital from March 1, 1990, to March 1, 2015. Patient characteristics and Kaplan-Meier survival curves were compared between groups., Results: During a median follow-up of 69.2 months, malignancy was diagnosed in 27 patients receiving MMF (n = 23) or EVR (n = 4). There was a significant difference in malignancy risk between groups (9.91% vs 1.80%, P = .001). The most common malignancies were non-Hodgkin lymphoma, skin cancers, and lung squamous cell carcinoma. The 2-year overall survival after malignancy was 50% in the EVR group and 47% in the MMF group (P = .745)., Conclusions: EVR treatment after heart transplant is associated with a lower risk of malignancy than is MMF treatment. The 2-year survival rate after malignancy was similar between EVR and MMF groups., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Transplantation and immunosuppressive drugs are major limitations to the success of pregnancy. In 1988, the first pregnancy after a heart transplant was reported, which has given female recipients the hope to give birth. During pregnancy, physiologic changes with increased blood volume and hemodilution may influence blood drug level., Case Report: We reported our experience in monitoring on immunosuppressive drugs for 2 cases. Both of them underwent heart transplantation in 2006 and were 34 and 37 years old at time of pregnancy. For both cases, we frequently monitored the blood level and increased the dosage of immunosuppressive drugs accordingly. Both cases had uneventful pregnancy and delivery to healthy babies at the National Taiwan University Hospital in Taiwan. Their postpartum courses were uneventful as well., Conclusions: We advocate adjusting the immunosuppressive dosage according to the blood level before pregnancy., (Copyright © 2016. Published by Elsevier Inc.)

Purpose: The purpose of this study was to investigate ocular manifestations of patients undergoing heart transplantations., Method: We retrospectively reviewed the clinical data of 311 patients who underwent orthotropic heart transplantations from January 1989 to December 2007, including the demographic data, general conditions, medications, as well as the basic ophthalmic examinations, ophthalmic diagnosis, and management., Results: Of the 311 heart transplant recipients, common diagnoses included cataract (96 cases; 30.87%), dry eye syndrome (24 cases; 7.72%), allergic conjunctivitis (78 cases; 25.08%), and glaucoma (19 cases; 6.11%). The patients after heart transplantation had much lower incidences of severe opportunistic infections than patients undergoing the same procedure one decade ago. However, autoimmune-related endocrinopathy such as diabetes and Graves' disease became more prevalent. Diabetes-related complications were unexpectedly frequent, including nonproliferative diabetic retinopathy (6 cases; 1.93%), proliferative diabetic retinopathy (6 cases; 1.93%), retinal vein occlusion (6 cases; 1.93%), and neovascular glaucoma (4 cases; 1.29%). The occurrence of cataract formation and steroid glaucoma was often due to post-transplantation steroid use., Conclusion: Ophthalmologists and cardiac surgeons should collaborate and perform regular ophthalmic examinations, especially for those who have new-onset diabetes and difficulty tapering off steroids., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: In addition to having a lipid-lowering effect, statins also have an anti-inflammatory effect that may reduce allograft dysfunction by preventing cardiac allograft vasculopathy (CAV) and play an immunomodulatory role. We studied the effect of statins on cardiac allograft survival at the National Taiwan University Hospital (NTUH)., Materials and Methods: We retrospectively reviewed the patients undergoing heart transplantation at NTUH in the last 6 years. After transplantation, all patients received biochemical monitoring every month and echocardiographic examination regularly at NTUH. Protocol biopsy was performed in all except 18 pediatric patients. All patients received immunosuppressants, including tacrolimus or cyclosporine, everolimus or mycophenolate acid, and prednisolone. They were divided into statin and nonstatin groups according to whether or not a statin was taken., Results: At NTUH, from 2007 to 2012, 168 heart transplantations were performed. The ages of the patients ranged from 6 to 74 years old with male predominance. The etiology was mainly dilated cardiomyopathy (52.4%) and ischemic cardiomyopathy (39.3%), including 7 retransplantations from severe CAV with heart failure. Twenty-three patients (17%) suffered from acute rejection. The overall 1-year actuarial survival rate was 86% ± 2% and the 5-year survival rate was 79% ± 3%. Seventy-eight patients (57.4%) took statins and the statin group has a better 5-year survival rate and freedom from cardiac death survival rate (P < .01)., Conclusion: Our study showed that the use of statins after transplantation was associated with better survival., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Although primary graft failure (PGF) after heart transplantation is a feared complication, most reports have come from Western countries. We analyzed the incidence in our hospital and tried to determine the predictive risk factors for PGF that require mechanical circulatory support or high dosage of inotropic agents after heart transplantation. We observed the long-term prognosis of patients successfully surviving PGF., Methods: For this retrospective review, 447 patients undergoing heart transplantation between January 1990 and January 2013 were enrolled in our study. We compared the clinical data between patients with PGF and without PGF. The risk factors associated with PGF were analyzed, and the long-term survival curve was analyzed using a Kaplan-Meier analysis., Results: The incidence of PGF in our study was 36.2% (162 patients) and the overall PGF-related mortality rate was 17% (30 day in-hospital mortality). Independent risk factors for PGF included preoperative recipient hypoalbuminemia, high central venous pressure, United Network for Organ Sharing (UNOS) status 1A, dependence on inotropic agents, ventilator, intra-aortic balloon pump (IABP), and extracorporeal membrane oxygenation (ECMO), and longer ischemic time. Patients with PGF had poorer long-term survival than patients without PGF; the 1-year survival rate was 40% versus 76% (P < .01). The rate of weaning from ECMO for PGF was 46% (12 of 26 patients) and they have similar 1-year survival rates as non-EGF patients., Conclusions: Several recipient and donor variables significantly influenced the PGF after heart transplantation. The mortality rate was higher in patients with PGF. However, patients who survived PGF have similar mid-term and long-term survival as patients without PGF., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Over the past decade, antibody-mediated rejection (AMR) continues to be recognized as one of the major obstacles in cardiac transplantation, yet its clinical outcome has been reported only in small series studies. This investigation reviews our experience in treating 11 patients with AMR after heart transplantation., Methods: We retrospectively analyzed a total of 11 patients who underwent cardiac transplantation from 2004 to 2012 at a single medical institute. The diagnosis of AMR was made according to criteria set by the International Society for Heart and Lung Transplantation (ISHLT) 2011 working formulation., Results: The average age among the 11 patients was 50.4 ± 16.9 years. The overall mortality rate was 54.5%. Five patients (45.4%) developed hemodynamic compromise in an average of 5 days after transplantation, presenting with sudden onset of fatal arrhythmia (n = 4; 80%) and immediate heart failure (n = 1; 20%). All 5 patients underwent immediate resuscitation and extracorporeal membrane oxygenation (ECMO) support, and 3 patients died (60%); in contrast, the other 6 patients suffered from progressively worsening cardiac function during long-term follow-up. Three patients (50%) died in this group., Conclusions: Clinical presentation of AMR varies. Long-term postoperative follow-up in the form of endomyocardial biopsy is recommended with immunohistochemistry C4d staining, with the anticipation of the possibility of future recurrence., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Six-minute walk test (6MWT) is an important measure to assess the exercise capacity of cardiac patients. This study aimed to evaluate the correlations of 6MWT with findings of cardiopulmonary exercise testing (CPET), health-related quality of life (HRQoL), and obesity among heart transplantation recipients (HTR) at least 1 year after transplantation., Method: Clinically stable HTR were recruited for this study from the National Taiwan University Hospital, Taipei, Taiwan. The 6MWT was performed by a physical therapist following the American Thoracic Society standard. Each subject underwent a symptom-limited CPET to evaluate cardiorespiratory fitness and bioelectrical impendence analysis for determination of body composition. The HRQoL of study subjects was evaluated by the Medical Outcomes Trust 36-item health survey (SF-36)., Results: The study subjects included 43 HTR (age: 47.8±11.1 years; 37 men, 6 women) at 4.8±3.2 years after transplantation. The 6MWT distance was 539±108 m (89.9±18.2% of the predicted value). The peak oxygen uptake was 19.3±4.7 mL/kg/min. The body composition analysis showed body fat percentage 25.2±7.9%, body mass index 26.5±4.8, and waist circumference 94.8±13.3 cm. The 6MWT distance was significantly positively correlated with peak oxygen uptake, peak heart rate, peak work rate, and peak systolic blood pressure during CPET, and significantly negatively correlated with body fat percentage, body mass index, and waist circumference. The 6MWT distance was also significantly positively correlated with SF-36 HRQoL parameters including general health perception and standardized physical component scale. The peak HR during CPET and standardized physical component scale was significantly correlated with 6MWT distance in multivariate analysis., Conclusions: Our findings indicate that 6MWT is a simple and useful measure to assess the exercise capacity of clinically stable HTR. The 6MWT distance is positively correlated with HRQoL and negatively correlated with obesity among HTR. The prognostic significance of 6MWT for HTR requires further investigation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: We reviewed the national results of heart transplantation in Taiwan., Methods: From July 1987 to December 2012, 1354 patients underwent heart transplantation in 18 qualified heart centers in Taiwan. The transplantation volume and survival rate were reviewed., Results: The median age of recipients was 49 years at surgery, with 37% in the International Society for Heart and Lung Transplantation (ISHLT)-1A, 30% in ISHLT-1B, and 32% in ISHLT-2. The allograft 1-, 3-, 5-, and 10-year survival rates were 78%, 68%, 61%, and 47%, respectively. Mostly difficult recipients were bridged by extracorporeal membrane oxygenation (ECMO) instead of ventricular assist device (VAD)., Conclusion: The results of heart transplantation in Taiwan are comparable with ISHLT world results. In Taiwan, we use more ECMO than VAD for mechanical circulatory support to bridge critical recipients to heart transplantation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: There are limited options for mechanical circulatory support to treat end-stage heart failure in pediatric patients. Although extracorporeal membrane oxygenation is commonly used in infants and children, ventricular assist devices (VAD) provide a longer duration of support with fewer complications before recovery or as a bridge to heart transplantation (HTx), as described herein., Methods: This retrospective chart review of eight patients transplanted from April 2008 to December 2011, after left ventricular assist device (LVAD) implantation due to end-stage heart failure. Their mean age was 12 years (9-15 y) and mean body weight, 48 kg (20-78). All were New York Heart Association functional class IV with mean left ventricular ejection fractions less than 15%., Results: The six patients (75%) received HTx after a mean LVAD support duration of 43.2 days; 2 (25%) died before a suitable heart became available. Their mean duration of LVAD support was 30 days. There were 4 (50%) who experienced clinically evident thromboembolic events: 3 (37.5%) cerebrovascular with 1 mortality and 1 (12.5%) as acute limb ischemia. Transient hemodialysis was performed in 4 (50%). Bloodstream infection identified in 6 (75%) was controlled with intravenous antibiotics. Driveline infection identified in 4 (50%) was treated successfully with local wound dressing changes and intravenous antibiotics. One 9-year-old boy died of rejection at 16 months after transplantation., Conclusions: Because of the organ shortage, pediatric patients have a low chance to undergo HTx. VAD provides long-term support for children with end-stage heart failure before a suitable heart becomes available. A thromboembolic event remains a major complication influencing their survival., (Copyright © 2012. Published by Elsevier Inc.)

Background: Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes., Methods: Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease., Results: Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30-63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients (P = .59)., Conclusions: There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease., (Copyright © 2012. Published by Elsevier Inc.)

Purpose: Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. When the transplanted heart fails, retransplantation is suggested and herein we have presented the prognosis of these pediatric cases., Materials and Methods: From March 1987 to March 2011, we performed 404 heart transplantations including 45 pediatric patients, 6 (13.3%) of whom experienced graft failure requiring retransplantation. Only four of the six patients (66.7%) had a chance for retransplantation., Results: Six of 45 pediatric heart transplant patients (13.3%) experienced graft failure requiring retransplantation. Four of them (66.7%) underwent retransplantation. Only one of the four died due to severe postoperative sepsis with acute respiratory distress. The other three patients recovered well and remain alive with no neurological sequelae; all are in New York Heart Association functional classification I at present., Conclusion: Pediatric post-heart graft failure require expectations retransplantation, which shows a good prognosis., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The Taiwan Organ Registry and Sharing Center (TORSC) was established by the Department of Health on June 6, 2002. According to the organ allocation policy, the computer-based organ-matching program began on April 1, 2005. In order to encourage organ donations, "donor hospitals" were given the highest priority. On October 1, 2010, the TORSC implemented a new allocation policy allowing highest priority to the most critically ill patients listed as 1A status. The aim of this study was to investigate the influence of the allocation policy on the likelihood of undergoing a heart transplantation (HTx) as well as the survival after the procedure. Based on the timeline of changes in the organ allocation policy, the patients were divided into three groups: "individual decision," "donor hospital first," and "urgency status first." We observed the waiting time of status 1A patients to decrease and their chance to receive a donor heart increase but their survival rate after HTx to decrease. Further research is needed to define the optimal organ allocation policy., (Copyright © 2012. Published by Elsevier Inc.)

Background: Endomyocardial biopsy is the gold standard to identify rejection after heart transplantation. Due to its invasiveness, discomfort, and difficult vascular access, some patients are not willing to accept routine scheduled biopsies years after heart transplantation. The purpose of this study was to identify whether there was a difference in outcomes among the scheduled versus event biopsy groups., Methods: We studied 411 patients who underwent heart transplantation from 1987 to 2011, reviewing biopsy results and pathology reports. There were 363 patients who followed the scheduled biopsy protocol, and 48 patients who were assigned to the event biopsy group. We extracted data on biopsy results, rejection episodes, rejection types, and survival time., Results: The 2481 reviewed biopsies over 24 years, showed most rejection episodes (86.4%) to occur within 2 years after heart transplantation. The rejection incidence was low (2.1%) at 3 years after transplantation. The major reason for an event biopsy was poor vascular access, such as tiny central vein or congenital disease without a suitable central vein. Event biopsy group patients were younger than schedule biopsy patients (19.7 years old vs 47.6 years old; P < .05). The 10-year survival rates were 64% among the event versus 53% among the scheduled biopsy group (P = .029). The 10-year rates of freedom from rejection were similar., Conclusions: The rejection rate was low after 3 years; episodes occurred within 2 years. Although the long-term survival in the event group was better, they had a younger man age. The rejection and freedom from rejection rates were similar. As the rejection rate was low at 3 years after transplantation, we suggest that the event principle could be applied for biopsy at 3 years after heart transplantation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Heart transplantation is the ultimate treatment for end-stage heart failure. Cardiac sarcoidosis has rarely been reported in heart transplantation worldwide. Their long-term prognosis after heart transplantation is unknown. Herein we have presented clinical and pathological observations among heart transplantation patients with isolated cardiac sarcoidosis., Methods: From 1987 to 2011, we performed 411 heart transplantations including five patients retrospectively reviewed due to the presence of sarcoidosis and giant-cell cardiomyopathy in the recipient heart., Results: Among the heart transplantations from 2003 to 2011, the four male and one female patients were ages 31 to 40 years. None of them had extra-cardiac sarcoidosis. All five subjects presented with dilated cardiomyopathy with patent coronary arteries. The commonest clinical presentations were atrioventricular block, ventricular arrhythmia, electrocardiographic findings of ST elevations, and poor left ventricular ejection fractions (17%-23%). All patients survived without allograft heart failure to date with the longest survivor at 8 years postoperatively. No recurrence of sarcoidosis has been observed clinically or among the post-heart transplantation endomyocardial biopsies., Conclusion: Heart transplantation is a useful treatment for isolated cardiac sarcoidosis patients suffering end-stage heart failure. Often the diagnosis is difficult to establish before heart transplantation despite endomyocardial biopsy. No recurrence of sarcoidosis was observed among the allografted hearts., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Ventricular assist devices have benefited patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experiment of HTx using extracorporeal membrane oxygenation (ECMO) with Thoratec pneumatic ventricular assist device (TpVAD)., Methods: From May 1996 to June 2011, among 410 patients who underwent HTx 23 required mechanical circulatory support (MCS) with implantation of the TpVAD and 15 (65%) of them received grafts., Results: The 23 patients included 4 female and 19 male patients of age range 10 to 80 years. Eighteen (78%) of them needed ECMO before TpVAD implantation. Twelve (67%) were implanted with a TpVAD double bridge to HTx. The demand for MCS among patients with acute hemodynamic collapse has led to major improvements in the existing systems such as ECMO with double bridge to TpVAD., Conclusion: We used ECMO as a rescue procedure for acute hemodynamic deterioration. However, during ECMO support, left ventricular afterload increased. If prolonged support is required, TpVAD might be required: 15 (65%) of patients supported by ECMO with TpVAD needed to a wait a suitable donor. We recommend the application of ECMO for short-term support (within 1 week), and TpVAD as a bridge for medium- or long-term support., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The most serious complication after heart transplantation is allograft dysfunction. Patients presenting with compromised hemodynamics show a high incidence of mortality. The most common reason for allograft dysfunction is rejection. We have employed steroid pulse therapy combined with plasmapheresis for hemodynamically compromised patients after heart transplantation., Methods and Results: Steroid pulse therapy and plasmapheresis were performed on 35 patients who underwent orthotopic heart transplantation for graft dysfunction. Thus treatment rescued ventricular function and improved the ejection fraction in 77% of patients, among who ever 71.4% showed improved New York Heart Association (NYHA) functional class., Conclusions: Steroid pulse therapy combined with plasmapheresis improved the cardiac contractility and NYHA functional class of most heart transplant recipients with graft dysfunction., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Unlabelled: Cardiac allograft vasculopathy (CAV) remains one of the leading causes of late graft failure and death. Cyclosporine microemulsion Neoral (CsA) had been used in heart transplantation (HTx) recipients. Meanwhile, Everolimus (EVL; Certican, Norvatis Pharmaceuticals; Basel, Switzerland) or mycophenolate mofetil (MMF) have been combined with CsA for maintenance treatment. We compared atherosclerosis in HTx patients showing CAV by intravascular ultrasound (IVUS) in two groups: the CE who received CsA, EVL, and steroid versus the CM group, who received CsA, MMF, and steroid., Materials and Methods: We explored IVUS parameters such as plaque thickness (PT), lumen circumference (LC), media adventitial circumference, lumen diameter (LD), and media adventitial diameter to characterize the atherosclerosis among CE versus CM groups., Results: In this study, both the CE and CM groups showed increased plaque thickening in the first year posttransplantation (P < .05). However, MMF significantly reduced LC and LD (P < .05) Upon multivariate linear regression analysis, the CE group seemed to show less effect on the maximal difference in PT between 2 and 12 months after adjusting for age at transplantation and gender (P < .05). There was no acute clinical adverse event of CAV reported in either both group during the follow-up. The atherosclerosis of CAV revealed by LC, LDmax, and LDmin was significantly less among patients treated with CE than CM., Conclusion: These results suggested that everolimus-treated patients showed benefits compared with MMF-treated subjects as extrapolated from these IVUS data., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Hepatitis B virus (HBV) infection is hyperendemic in Taiwan. We have reported the outcome of (1) recipients with hepatitis B surface antigen (HBsAg)-positive; HBsAg-negative recipients who receive donor hearts from HBsAg-positive donors; and treatment with lamivudine of hepatitis B flare-ups after heart transplantation, using case numbers that range from 100 to 200., Methods: From July 1987 to May 2011, all 412 orthotopic heart transplant recipients and donors underwent routine preoperative screening for hepatitis B virus markers and liver function parameters. Lamivudine was prescribed prophylactically for recipients with elevated serum enzyme levels or an HBV DNA virus load before transplantation, or when there was evidence of hepatitis B flare-up after transplantation. Postoperative HBV markers and liver function parameters were collected over a mean follow-up time of 7.8 years., Results: Thirty-four recipients were HBsAg-positive before heart transplantation, and 23 experiencing HBV reactivation upon follow-up requiring lamivudine treatment. Clinical responses were achieved in all of them: 15 were complete and two, slow partial responses. Twenty-six recipients with an HBV naïve status at the time of heart transplantation, and three patients received donor hearts from an HBsAg-positive donor under perioperative hepatitis B immunoglobulin prophylaxis. HBV infection was successfully prevented in two patients, but the other one contracted HBV hepatitis, which was successfully treated with lamivudine., Conclusions: HBV reactivation after the heart transplantation was common but usually well controlled with lamivudine treatment. Although posttransplantation liver function deteriorated for a period, there was no HBV infection-related morbidity or mortality. Perioperative hepatitis B immunoglobulin prophylaxis can successfully prevent HBV naïve recipients from infection in some cases, but HBsAg-positive donors should only be considered in high risk situations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

Introduction: Heart transplantation has become the best available therapy for patients with refractory end-stage heart failure. Cyclosporine (CsA) and mycophenolate mofetil (MMF) are the 2 FDA-approved drugs to prevent posttransplant acute rejection episodes. The purpose of this study was to evaluate the result of heart transplantation treated with CsA and everolimus (EVL), compared with that of patients treated with CsA and MMF., Materials and Methods: From 2000 to 2009 heart transplantation was performed in 239 patients among whom we enrolled 93 patients with a serum creatinine values

Background: Cyclosporine (CsA) is widely used after heart transplantation. The purpose of this prospective randomized study was to evaluate the safety and efficacy of reduction of CsA blood level to one-half of the traditional blood concentration under a regimen of everolimus (EVL), CsA, and steroid., Materials and Methods: This prospective, 6 month, randomized, open-label study included adult (aged 18 to 65 years) recipients of a primary heart transplant with serum creatinine60 years old, had cold ischemia time>6 hours, or had plasma renin activity>or=25%. All patients received CsA (C2 blood level 1000-1400 ng/mL), EVL (C0 target 3-8 ng/mL), and corticosteroids to day 60, before random entry into one of 2 groups: SE (C2 blood level from days 60-149=800-1200 ng/mL, and days 150-180 C2=600-1000 ng/mL), or RE group with CsA reduced by one-half after 3 months (days 90-149 C2=400-600 ng/mL, and from days 150-180 C2=300-500 ng/mL)., Results: The 25 recipients eligible for this study included 13 patients in the SE and 12 in the RE group. There was no operative mortality in either group. No death or graft loss was noted within 6-months in either group. Mean serum creatinine at month 6 tended to be lower in the RE cohort (1.23+/-0.44 mg/dL versus 1.55+/-0.85 mg/dL; P=.093). Biopsy-proven acute rejection>or=grade 3A was observed in only 1 patient (7.7%), who was in the SE group. There were no acute rejection episodes associated with hemodynamic compromise. The incidences of adverse events in each group were similar., Conclusions: Concentration-controlled EVL (C0 target 3-8 ng/mL) in combination with reduced CsA exposure of one-half the usual concentration achieved good efficacy and safety over 6 months. The renal function at 6 months among the RE group showed a trend toward improvement, suggesting a benefit of halving the target CsA blood level after heart transplantation., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Introduction: Survival in patients with refractory heart failure greatly improves after heart transplantation (HTx)., Objective: To evaluate the rate of unplanned readmission within the first year post-HTx and the causes of such readmission., Patients and Methods: From January 2005 to June 2008, the 112 patients who underwent HTx were regularly followed up at our hospital. A protocol biopsy was performed every week during the first month, then every 3 months during the first year. Any unplanned readmission was discussed in detail in a transplantation meeting. Data were collected from review of medical records., Results: The rate of unplanned readmission was 19.3% in 2005, 21.5% in 2006, 22.2% in 2007, and 20.3% in 2008. Infection was the primary cause leading to unplanned readmission in 2005 (51.5%), 2006 (42.9%), and 2008 (30.7%). Rejection was the primary cause leading to readmission in 2007 (40%). Other causes included fluid retention, pericardial effusion, anemia, and systemic diseases., Conclusion: To reduce unplanned readmissions and to promote quality of life and long-term survival, health professionals must meticulously monitor the adverse effects of treatments including immunosuppression agents and concomitantly used medications., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

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 (c) 2010 Elsevier Inc. All rights reserved.)

Heart transplantation (HTx) is indicated in children with end-stage heart failure or complex inoperable congenital defects. Because of the shortage of pediatric donor hearts, various bridge techniques have been used in pediatric patients to prolong patient survival until a suitable heart becomes available. We reviewed medical records of several pediatric patients in whom bridging with ventricular assist devices was used. All of the patients survived HTx, and are alive and well with no neurologic sequelae. They are NYHA functional class I. Thus, morbidity and mortality were acceptable in this high-risk group of pediatric patients with a ventricular assist device bridging to HTx., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Cardiac transplantation is currently the only established surgical approach to the treatment of refractory heart failure. Heart transplantation because of amyloid cardiomyopathy continues to generate controversy because of donor shortage and concerns about disease recurrence in the allograft. We reviewed the medical records for all patients who underwent heart transplantation at our institution from 1987 to 2007, and found that 4 patients were diagnosed as having amyloid cardiomyopathy after pathologic examination of the excised hearts. No operative mortality was noted; however, all of the patients died of sepsis after transplantation. Because of the poor results, we do not recommended performing transplantation in patients with amyloidosis. Preoperative surveys and evaluation for amyloidosis must be emphasized in patients with hypertrophic cardiomyopathy., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: In this study, we examined whether cyclosporine was effective when combined with everolimus in clinical heart transplantation (HT)., Patients and Methods: From August 2004 to July 2007, 108 adult patients underwent primary HT. The main exclusion criteria were: donors > 60 years; cold ischemia times > 6 hours; recipients of multiorgan transplantation or a previous transplantation; and panel-reactive antibodies > or = 25%. The cyclosporine plus everolimus regimen (group CE, n = 32) was suggested first; upon refusal or if the recipient or donor was positive for hepatitis B surface antigen or PCR + hepatitis C infection, then patient was randomly assigned to success cyclosporine plus mycophenolate mofetil (MMF; group CM, n = 24) or tacrolimus plus MMF (group TM, n = 25). All patients underwent similar operative procedures and postoperative care with protocol endomyocardial biopsies., Results: No 30-day mortality was noted in any group. The efficacy failure rates were 3%, 25%, and 16% in groups CE, CM, and TM, respectively (P = .04 between groups CE and CM). The 1-year survivals were 96.7% +/- 18.1%, 89.7% +/- 29.8%, and 81.0% +/- 35.5% for groups CE, CM, and TM, respectively (P = .04 between groups CE and TM). The 3-year survival rates were 91.9% +/- 28.3%, 79.8% +/- 46.0%, and 81.0% +/- 35.5% in groups CE, CM, and TM, respectively., Conclusions: The 3 immunosuppressive regimens offered good efficacy after HT. The cyclosporine plus everolimus regimen showed a significantly better result with less efficacy failure (compared with cyclosporine plus MMF: 3% vs 25%) and better 1-year survival compared with tacrolimus plus MMF: 96.7% vs 81.0%.

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.

With improved immunosuppressive regimens, transplantation techniques, and postoperative care, heart transplantation (HTx) has been established as a definite therapy for end-stage heart disease. Because of a donor shortage, we have accepted marginal individuals. In this study, we identified donor-related factors influencing survival after HTx by retrospective analysis of recipient data after primary HTx from February 2002 to December 2006. The Cox regression model was used to examine the effects of the following variables on survival of 112 heart transplant recipients: demographic data of gender, age, body weight, donor-recipient body weight ratio; history of smoking, alcohol drinking, diabetes mellitus, hypertension, hepatitis B surface antigen, anti-hepatitis C virus antibody; donor condication before transplantation including catecholamine doses, hypotension, cardiopulmonary resuscitation, creatine MB isoenzyme of creatine kinase (CK-MB), tropinin I, and cold ischemic time of the allograft. Catecholamines and smoking showed significant influences on HTx survival. In our series, the percentage of donors receiving inotropic support before donation was 88% (n = 99), and the percentage of donors with a history of smoking was 25% (n = 28). There was no influence of donor status of diabetes, hypertension, or hepatitis B or C infection on postoperative survival. Our results showed that inotropic support of and a history of smoking by the donor were significant factors influencing posttransplant survival.

This study retrospectively investigated the outcomes of cardiac transplantation in a single medical center in Taiwan. From February 1997 to December 2005, 214 orthotopic cardiac transplantations were performed in our institution. Cumulative survival rates were compared by gender, waiting status, blood type, ischemia time, donor gender, age, and cause of brain death. The cumulative survival rates were significant different among recipient waiting status (P = .0026), blood type (P = .0376), and donor age > 40 years (P = .0260). The others parameters seem to not be different from the cumulative survival rate. There was a strong association between donors > 40 years old and increased postoperative mortality. The age of a marginal donor seemed to be > 40 years in this study.

We describe a case of complex congenital heart disease treated using balloon septostomy, pulmonary artery banding. Blalock-Taussig shunt, and cardiac resynchronization therapy; however, heart failure developed. A bicaval anastomosis was used to relieve superior vena cava (SVC) obstruction despite possible anastomotic stenosis. The postoperative course was uneventful and the patient recovered rapidly. Thus, we recommend bicaval anastomosis using a longer donor SVC concomitantly performed during heart transplantation to relieve both heart failure and SVC obstruction in pediatric patients.

The incidence of tuberculosis is slightly higher among heart transplantation cases than in the general population in Taiwan. Tuberculosis shows a high mortality rate ranging from 22% to 31% in transplant recipients. From October 1987 to October 2007, we performed 315 heart transplantations. Clinical records were reviewed for demographic data, clinical presentation, treatment, and outcome. Tuberculosis was diagnosed by cultures of any body sample in association with compatible symptoms and signs. Mortality was related to tuberculosis if there was evidence of active tuberculosis at the time of death and no other etiology accounted for death. Ten patients who had received heart transplants were diagnosed as tuberculosis. There were seven pulmonary lesions and seven extrapulmonary lesions. Treatment consisted of isoniazid, rifampin, ethambutol, pyrazinamide, streptomycin, ciprofloxacin, and levofloxacin. Seven patients completed the antituberculosis treatment: the median treatment duration was 1 year. Three patients developed hepatitis. There was no tuberculosis-related mortality. Ten out of a total of 315 patients (3.17%) represented a tuberculosis rate higher than that reported for the general Taiwan population (67/100,000). This high mortality of infection may be completely treated by a combination of at least three drugs except pyrzinamide because of side effects and tolerance.

Mediastinitis is a life-threatening complication among patients undergoing cardiac transplantation. There are conservative and aggressive surgical treatments. From October 1987 to October 2007, we reviewed the clinical records of 315 heart transplantations for those four cases with severe mediastinis needing surgical treatment for demographic data, clinical presentation, treatment, and outcome. Conservative therapy, such as sternal debridement without muscle flap closure and closed local irrigation with drainage, was performed in two cases. The other two patients needed aggressive surgical treatment with muscle flap or omental flap performed. Only one transplant recipient with severe mediastinis had undergone previous sternotomy before cardiac transplantation. The organisms were methicillin-resistant Staphylococcus aureus in three and Aspergillus fumigatus in one case. The one subject who received conservative therapy without a flap died. The other two with muscle flap and omental flap survived. Cardiac recipients survived if there was aggressive surgical treatment for severe mediastinitis. Meanwhile, we recommend prolonged aggressive antibiotic therapy and reduced immunotherapy.

Because of a shortage of deceased donors, more than one-third of patients die during the waiting period for transplantation. This study was conducted to analyze the influence of gender on survival after heart transplantation. We retrospectively reviewed the recipients after primary orthotopic heart transplantation. According to gender, patients were divided into four groups: male donor to male recipient, male donor to female recipient, female donor to male recipient, and female donor to female recipient. Kaplan-Meier survival curves were plotted with log-rank tests. Cox regression analysis with dummy variables were used to examine the effects of donor gender, recipient gender, and donor-recipient gender combinations on survival after heart transplantation. The data did not show any significant effect of donor gender, recipient gender, or donor-recipient gender combinations on patient survival, using the methods of log-rank test and Cox regression with dummy variables. Based on our results, we concluded that gender was not an important factor in organ allocation.

After clinical heart transplantation (HT), it is crucial to use appropriate immunosuppressive agents to prevent rejection. The use of basiliximab or rabbit anti-thymocyte globulin (RATG) for induction therapy has significantly reduced the incidence of acute rejection episodes after kidney transplantation. In this study we sought to examine the effects of basiliximab after HT. From June 2006 to July 2007, we performed 43 HT including patients 18-65 years old undergoing primary HT who were included in this study of basiliximab induction (20 mg intravenous [iv] on days 0 and 4). Cyclosporine and everolimus were given with basiliximab induction. All others received RATG induction (1.5-2.5 mg/kg iv infusion on days 0, 1, and 2) followed by cyclosporine or tacrolimus combined with mycophenolate mofetil. All patients underwent the same operative procedure, steroid-tapering protocol, and postoperative care with protocol endomyocardial biopsy. Basiliximab was well-tolerated and easy to use. There was only 1 operative mortality; the patient died of sepsis due to Enterobacter cloacae. All others survived the operation and are alive and in good health with a 2-year survival rate of 92.86%. No severe adverse events were noted during the first postoperative month. No acute rejection > or = grade 2R or rejection associated with hemodynamic compromise was noted during the whole course. Basiliximab as induction immunosuppressant was simple, safe, and effective after HT.

Cryptococcosis is a rare infection with high mortality in patients who have undergone heart transplantation (HT). In this study, we report four cases of the disease selected from our 328 HT cases (1.22%) between 1987 and 2007. The purpose of this study was to review risk factors for cryptococcosis after HT. Three of the four patients were men. The mean time from HT to diagnosis was 8.5 months (range, 3-17 months). Cryptococcosis was subcutaneous in one patient, systemic in one, and meningeal in two. One patient died. The Antifungal regimens included intravenous amphotericin B (amBisone) and oral fluconazole (Diflucan). Patients with diabetes mellitus or renal insufficiency, are hepatitis B carriers, have undergone repeat HT, or are receivings steroid therapy are susceptible to cryptococcosis. The recommend anticryptococcal therapy is amphotericin B, followed by oral fluconazole for at least 6 months. Early diagnosis with aggressive diagnostic techniques and a combination of therapies must be considered to reduce the risk of death in HT recipients with cryptococcosis.

Objective: The objective of this study was to report our experience of treating acute humoral rejection with plasmapheresis in heart transplant (HT) recipients., Patients and Methods: From May 1996 to December 2005, 238 HTs were performed using therapy with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and prednisolone as well as induction treatment with rabbit anti-human thymocyte globulin. Endomyocardial biopsy for rejection surveillance was performed weekly for the first month, monthly for 3 months, yearly after the first year, and whenever rejection was suspected. Immunofluorescence studies with IgG, IgM, C3, C4, C1q, and HLA-DR were performed routinely on the first month biopsy. After a 2-year trial, immunofluorescence studies were not performed routinely, because no significant findings were observed; thus they were performed only when clinical deterioration, unstable hemodynamic status, or suspicion of rejection occurred on routine echocardiographic examinations. Plasmapheresis with fresh frozen plasma exchanging twice the blood volume of the patients was performed for 5 days. Rescue immunosuppression with methylprednisolone (1 g/d) was delivered for 3 days and the immunosuppressants changed, but no intravenous immunoglobulin was prescribed., Results: Twelve patients suffered biopsy-proven acute humoral rejection at 3 days to 32 months after HT (mean, 9.4 months). Immunofluorescence studies showed positive HLA-DR in 7 patients; IgG in 4 patients; IgM in 1 patient; C3 in 4 patients; C4 in 1 patient; and C1q in 1 patient. One patient who was 3 months after HT showed only C1q positive but was treated with extracorporeal membrane oxygenation and intra-aortic balloon pumping support and died 1-month after plasmapheresis. Another patient who deteriorated on the 3rd postoperative day and died 3 days after plasmapheresis was considered to have vascular rejection by interstitial edema, vacuolated endothelial cells and no pathognomonic clinical features, although there was no positive immunofluorescence result. All other subjects were discharged from the hospital, although 3 required mechanical support during plasmapheresis. Hypotension with hypocalcemia was frequently noted during plasmapheresis. The 1-year survival rate was 75% +/- 11%, and 5-year survival rate, 51% +/- 15%., Conclusion: Plasmapheresis with concurrent rescue immunosuppression was an effective treatment for acute humoral rejection in HT even with unstable hemodynamics.

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.

Heart transplantation (HTx) is a treatment for end-stage heart failure or a complex or inoperable congenital defect. The long-term survival and the adequate donor to recipient body weight (D/R BW) ratio remain to be determined. From March 1995 to May 2004, 14 children (6 months-16 years of age) underwent HTx due to underlying diseases of idiopathic dilated cardiomyopathy (n = 10; 71.4%), congenital heart disease (n = 3; 21.4%), and Kawasaki disease (n = 1; 7.1%). Donor-recipient body weight ratio ranged from 0.89 to 3.9. Big heart syndrome was present in one patient when D/R BW ratio was more than 3. Actuarial survival was 92.9% at 5 years after transplantation. Only the one patient who had Kawasaki disease died due to early primary graft failure. HTx is a feasible method with good long-term survival rates for end-stage heart failure or for complex or inoperable congenital defects. After careful pretransplant evaluation, a high D/R BW ratio (more than 3) is acceptable.

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.

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 erythematosus. 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.