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Factors associated with long-term survival following cardiac transplantation/Kalp nakli sonrasi uzun donem sagkalimi etkileyen faktorler.

ABSTRACT

Objective: By improving short and long-term survivals, cardiac transplantation would be a more realistic curative treatment modality. The aim of this study was to evaluate factors associated with the long-term survival following cardiac transplantations in our center.

Methods: Forty-four patients were operated on cardiac transplantation between 1989 and November 2006. The study was designed in a retrospective manner and all data were collected from hospital records. Our study population consisted of 16 patients (Group A) who survived >1 month, but died <2 years after cardiac transplantation and 17 patients (Group B) who survived more than 2 years. All patients had triple immunosuppressive therapy (cyclosporine, azathioprine, corticosteroid). Statistical analyses were performed using Fischer's exact and Mann Whitney U tests, and multivariate regression analysis. Survival was analyzed using Cox proportional hazard regression analysis.

Results: Group B patients had lower pre-transplant creatinine levels (0.93 [+ or -] 0.28 mg/dl vs. 1.16 [+ or -] 0.21 mg/dl, p=0.033) younger donor age (24.5 [+ or -] 6.3 years vs. 30.1 [+ or -] 8.1 years, p=0.017) and more male donors (82.3% vs. 50%, p=0.05) as compared with Group A patients. The perioperative and follow-up analysis showed that patients with long-term survival had shorter ischemic time (141.5 [+ or -] 33.2 min vs.182.5 [+ or -] 49.2 min, p=0.007), aortic cross clamp time (65.9 [+ or -] 10.2 min vs. 83.6 [+ or -] 7.9 min, p<0.001), less amount of blood transfusion (3.4 [+ or -] 1.6 units vs. 5.0 [+ or -] 1.5 units, p=0.01), better NYHA status after operation (1 [+ or -] 0 vs. 1.63 [+ or -] 0.72, p=0.014) and less frequent acute rejection episodes (11.8% vs. 68.8%, p<0.001) than those with short-term survival after operation. Cox proportional hazard regression analysis showed higher preoperative creatinine level (HR=42.6, 95% CI 4.67-388.21, p=0.001), acute rejection (HR=4.45, 95% 1.44-13.77, p=0.01), early postoperative functional status (HR=4.84, 95% CI 1.9-12.27, p=0.001) and unsatisfactory rejection surveillance protocol in the first 6 months after transplantation (HR=0.2, 95% CI 0.07-0.67, p=0.008) were prominent factors associated with the long-term survival.

Conclusion: The availability of the donor hearts from younger male donors with the shortest ischemic times is identified as the most significant factor improving long-term survival. The main strategy in cardiac transplantation should be shortening ischemic times and applying strict postoperative follow-up. (Anadolu Kardiyol Derg 2008,& 360-6)

Key words: Cardiac transplantation, rejection, ischemic time, survival analysis

OZET

Amag: Gunumuzde kisa ve uzun donem sag kalimda elde edilen gelismeler sonrasinda kalp nakli daha tercih edilebilir kuratif bir tedavi yontemi olmustur. Bu calismanin amaci, klinigimizin gerceklestirdigi kalp nakli girisimlerinin uzun donem sonuclarini irdelemektir.

Yontemler: Kirk dort hasta 1989 ile Kasim 2006 arasinda kalp nakli ameliyatina alindi. Bu calisma retrospektif olarak dizayn edilmis olup, hastalara ait veriler hastane kayitlarindan to planmistir. Bu calismaya ameliyat tarihi uzerinden en az 2 yil gecen 33 hasta dahil edildi. Hastalar 2 gruba ayrildi: Grup A'da kalp naklinden sonra en az 1 ay yasamis, fakat 2 sene icinde kaybedilmis 16 hasta yer almaktayken, Grup B'de 2 seneden fazla yasayan 17 hasta yer almaktaydi. Tum hastalar uclu immunospressif (siklosporin, azatioprin, kortikosteroid) tedavi gordu. Istatistiksel analiz Fischer ve Mann Whitney U testleri, ve coklu regresyon analizleri ile yapildi. Sagkalim Cox oransal hazard regresyon analiz ile incelendi.

Bulgular: Grup B hastalari Grup A'ya gore daha dusuk pre-transplant kreatinin seviyesine (0.93 [+ or -] 0.28 mg/dl karsin 1.16 [+ or -] 0.21 mg/dl, p=0.033), daha genc yasta vericiye (24.5 [+ or -] 6.3 yil karsin 30.1 [+ or -] 8.1 yil, p=0.017) ve daha fazla erkek donore (%82.3 karsin %50, p=0.05) sahipti. Perioperatif ve takip analizlerine gore uzun sagkalima sahip hastalar daha kisa surede kaybedilen gruba nazaran daha kisa iskemik (141.5 [+ or -] 33.2 dak karsin 182.5 [+ or -] 49.2 dak, p=0.007) ve aortik kros klemp (65.9 [+ or -] 10.2 dak karsin 83.6 [+ or -] 7.9 dak, p<0.001) surelerine, daha az kan urunu kullanimina (3.4 [+ or -] 1.6 uniteye karsin 5.0 [+ or -] 1.5 unite, p=0.01), transplantasyondan sonra daha iyi fonksiyonel kapasiteye (NYHA 1 [+ or -] 0 karsin 1.63 [+ or -] 0.72, p=0.014) ve daha az akut rejesiyon ataklarina (%11.8 karsin %68.8, p<0.001) sahipti. Cox oransal hazard regresyon analizi yuksek preoperatif kreatinin seviyesini (HR=42.6, %95 GA 4.67-388.21, p=0.001), akut rejeksiyonu (HR=4.45, %95GA 1.44-13.77, p=0.01), erken postoperatif fonksiyonel kapasiteyi (HR=4.84, %95GA 1.912.27, p=0.001;) ve postoperatif ilk 6 aydaki yetersiz rejeksiyon takibini (HR=0.2, %95 GA 0.07-0.67, p=0.008) uzun donem sag kalimi olumsuz etkileyen faktorler olarak ortaya koydu.

Sonuc: Uzun donem sag kalimi etkileyen en onemli faktor, genc erkek donorlerden alinan kalbin ek kisa iskemik surede nakledilmesidir. Kalp nakli programlarinda uygulanmasi gereken en onemli strateji iskemik surenin en aza indirilmesi ve siki postoperatif takibin uygulanmasidir. (Anadolu Kardiyol Derg 2008; 8: 360-6)

Anahtar kelimeler: Kalp nakli, rejeksiyon, iskemik sure, sag kalim analizi

Introduction

Cardiac transplantation is a proven treatment modality for end stage heart failure in experienced centers with comparable clinical outcomes (1). The success of cardiac transplantation is evaluated by the early-mid-long term surveillance results and quality of life. Improvements gained over 35 years of cardiac transplantation have decreased early mortality (three months) because of graft failure, infection or rejection dramatically. However, the success of cardiac transplantation is determined by long-term survival. In some detailed studies, it has been shown that long-term survival following cardiac transplantation is correlated with preoperative and postoperative factors in both the donor and recipient (2, 3). Recent trends show increasing time on waiting lists, more frequent emergency transplantations, more usage of donor hearts with longer ischemic times and those with increasing inotropic support (4-6). Although these risky procedures for cardiac transplantation are widely accepted, more detailed studies are needed to evaluate factors influencing early and late mortality following cardiac transplantation. Given these circumstances, we aimed to investigate factors affecting long-term survival in a single center experience.

Methods

Between 1989 and November 2006, forty-four patients underwent cardiac transplantation at our center. The study was designed in a retrospective manner and all data were collected from hospital records. Investigating risk factors associated with long-term survival, we grouped patients who survived more than 24 months or died earlier. The first reason was the first longest survivor-recipient in Turkey died at the end of his second year. The second, we used Shumway technique for orthotopic cardiac transplantation until 1989 (7), but after 2002 we have preferred the bicaval technique and the longest survivor with this method was in his third year during this study. The third, most recipients died in their second postoperative year. Our study population consisted of 16 patients (Group A) who survived >1 month, but died < two years after cardiac transplantation and 17 patients (Group B) who survived more than two years. Remaining 11 patients were excluded from the study since 8 of them are still alive but have not filled the 24 months period. Two patients died in their first month, possibly due to early graft failure and the last one underwent heterotopic cardiac transplantation.

All patients had triple immunosuppressive therapy (cyclosporine, azathioprine, corticosteroid). Endomyocardial biopsy (7), cytoimmunologic monitoring (8), echocardiography (9) and pace electrocardiography (10) are the techniques that we have used for follow-up and rejection surveillance. Endomyocardial biopsy and echocardiography were used to identify acute rejection, and we performed coronary angiography and, echocardiography when a recipient was hospitalized because of heart failure and chronic rejection. The standardized grading system for the pathologic diagnosis of rejection in cardiac biopsies and its revision were used to address a uniform description and grading scheme for acute cardiac rejection (11).

Pre-transplant clinical and demographic variables, peroperative and follow-up data including long-term complications are collected prospectively and recorded in our center's computer based data bank. We have investigated our study groups by evaluating this data bank retrospectively.

Statistical Analyses

All data were analyzed by using SPSS for Windows version 13.0 software (Chicago, IL, USA). Data are shown as mean [+ or -] standard deviation (min-max) values. Univariate and multivariate analyses were used to assess risk factors as independent predictors of late mortality. Cox proportional hazard regression analysis was used to assess risk factors as independent predictors of patient survival. Categorical data between groups were compared with Fischer's exact test, while continuous and discrete data were analyzed with Mann Whitney U-test. All variables significant at the p<0.1 level in the univariate analysis were included into Cox proportional hazard regression test. Statistical significance was determined with p<0.05 values.

Results

Preoperative Findings

Demographic variables and follow-up periods for both groups are shown in Table 1. More patients in Group A needed more inotropic support. In Group B patients, younger age and male gender were more prominent. Preoperative creatinine levels were lower in Group B (p=0.033) Although patients in Group B had poorer NYHA preoperative status, they had better long-term survival. Comparison for preoperative risk factors and echocardiographic data are shown in Table 2. When groups were compared according to the echocardiographic data, no significant difference was determined except mitral insufficiency (p=0.041).

Per- and Postoperative Findings

Comparisons of peroperative and postoperative findings for both groups are shown in Table 3. When ischemic times between groups were compared, we observed significant differences. Cold ischemic and aortic cross clamp (ACC) times were longer in Group A than in Group B (p=0.007 and p<0.001, respectively). The need for inotropic support and prostaglandin 12 after operation were more prominent in Group A as compared with Group B (p=0.014 and p=0.031, respectively). We also observed more sinus node dysfunction in Group A (p=0.004). In the intensive care unit, less blood products were transfused to Group B patients (p=0.01).

Late Period Complications

Late Mortality

One patient in Group A died because of the right ventricular rupture and acute tamponade following cardiac biopsy for rejection surveillance. Four patients died because of infections. Six patients in Group A died in their first year because of acute cellular rejection. Four patients in Group B died following rehospitalization with the diagnosis of chronic rejection, supported by echocardiographic evidence of segmental wall movement impairment and decreasing in ejection fraction. Mortality causes in groups are given in Table 4.

Chronic Rejection

Eleven patients in Group A and two patients in Group B had severe rejection in their first year. Six patients in Group A died from acute rejection and 3 patients died from chronic rejection. In Group B, mortality was observed in 7 patients due to chronic rejection. Late mortality due to ventricular fibrillation was thought to be a cause for chronic rejection. In Group B, 12 patients had new onset segmental wall motion abnormality on echocardiography in the first year after the transplantation.

Infection

Ten patients in Group A and 3 patients in Group B had severe infection. Four patients in Group A died because of infection due to Enterobacter sepsis, gram-negative sepsis, Neisseria pneumonia and Klebsiella pneumonia. The remaining patients were cured following appropriate antibiotic treatment and were discharged.

Risk Factors Associated with Long-term Survival

Survival curves of all patients are shown in Figure 1. The longest follow-up time was 98 months and 66% of our patients (n=22) had survived more then one year, 33% (n=11) had completed their third years following the transplantation.

Univariate analysis showed that advanced donor age and female donor, higher preoperative creatinine level, prolonged ischemic and aortic cross-clamp time, postoperative blood products transfusion, early postoperative NYHA status, rejection episode type and frequency were found to be significant factors associated with long-term survival (Table 5). Cox proportional hazard regression analysis showed higher preoperative creatinine level, acute rejection, early postoperative functional status and unsatisfactory rejection surveillance protocol in the first 6 months after transplantation were prominent factors associated with the long-term survival (Table 6, Fig. 2).

[FIGURE 1 OMITTED]

Discussion

Many investigators have described various risk factors affecting survival after cardiac transplantation. There are differences in risk factors between different studies. Defining risk factors help to anticipate problems in recipients after cardiac transplantation, and to provide appropriate and early treatment of complications. Defining risk factors also provide appropriate procurement and matching strategy of donor hearts. Matching donors with appropriate recipients serve to improve long-term survival, and decreases mortality and morbidity for high-risk recipient and donors. We found significant differences between two groups.

Donor age and allograft coronary artery disease

Multicenter data define advanced donor age as a prominent risk factor for poor survival (3, 12). In our study, mean donor age was found to be significantly lower in the long-term group (p = 0.017). Although antigenic sensitivity causes negative results in younger recipients, we have not observed a difference for age distribution in our study groups. Literature data suggest advanced age as a prominent risk factor for increased allograft coronary artery disease (13). In our study, we observed more allograft coronary artery disease in long-term survival group. Since 69% of patients in short-term survival group had died in their first year, it was not possible to compare two groups for allograft coronary artery disease.

Obesity

Obesity becomes a significant risk factor for the general population when accompanied by hypertension, dyslipidemia, diabetes and coronary artery disease. This is also observed in most of transplant patients. Many investigators have declined that obesity and hyperlipidemia may be related to allograft coronary artery disease and possibly unsatisfactory immunosuppression (14, 15). Grady et al. (16) declined that pretransplant obesity increased mortality without increasing the risk of acute rejection and allograft coronary artery disease. In contrast to the literature, we observed that the recipients in the long-term group were more obese when compared to the recipients in the short-term group. We did not observe a difference in complications related to obesity between two groups. Most of the patients in our study were not morbidly obese and therefore possibly did not face significant complications from obesity. Only two patients in Group B and one patient in Group A had new onset diabetes that needed oral anti-diabetic treatment.

[FIGURE 2 OMITTED]

Gender

In some studies, male gender was associated with short-term survival, and this was thought to be due to ischemic cardiomyopathy (17, 18). Ischemic cardiomyopathy etiology can cause the development of allograft coronary artery disease. Young age and male gender can be prominent factors for long-term survival. In one study, male donor and female recipient combination was declared to be a cause for increased rejection in the first year and the reason for this was thought as an increased immune response in women or dimension discrepancy (19). Lietz et al. (20) pointed out higher acute rejection incidence in female recipients in the first 6 months and declared early mortality (< 6 months) caused by infection. Allograft coronary artery disease is more seldom in female patients during the first postoperative year (17). In our study, there were four females in Group B and one in Group A. Although we did not find a significant difference in gender between our recipients (p = 0.17), we found more female donor hearts in the short-term survival group (p = 0.05).

Time in Waiting List

Although we have not found waiting time as a risk factor for the long-term survival, there are relevant data for prolonged time in waiting lists which as a significant risk factor for early mortality (17,18) Improved therapies for heart failure increase the waiting time without causing secondary organ damage. In this study, we observed that the patients in the long-term survival group spent more time on waiting lists with longer symptom duration. Beyond these facts, there was no difference between groups before transplantation in terms of functional status criteria. Longer times in waiting lists did not cause significant organ dysfunction in Group B patients preoperatively. Patients in Group B had been involved to the waiting list earlier with elective criteria's for transplantation.

Rejection

We observed at least one rejection episode in 10 patients in Group A and we lost 69% of patients in their first year because of acute cellular rejection and early graft failure. In Group B, only three patients had an acute rejection episode. When considering two years period as a cut-off point for the long-term survival, rejection itself is a terminal point other than a risk factor.

Infection

We observed more infectious events in Group A (p = 0.007). Three of the eight patients died because of infection in the early period. Incidence of more infectious events was found as a risk factor for increased mortality itself. Infection is a serious issue in these immunosuppressed patients although proper antibiotics are used. Infection control is very important for the long time survival.

Ischemic Times

Prolonged ischemic time, which can be a cause of graft failure itself, is thought to be a prominent risk factor for survival. Ischemic times can be shortened with the success of improving organizations in donor organ transportation. Donor cold ischemic and recipient operation ischemic times were statistically different between groups. In Group B, shorter overall ischemic times were observed. In Group A, donor cold ischemic time was longer because of the difficulties in transportation of donor hearts. Prolonged ischemic times in donor hearts by causing early graft failure manifest clinically with prolonged inotropic needs and sinus node dysfunction. Both of these negative consequences were observed more in short-term survival group (69%). Cold ischemic time on an average was 4 hours in Group A and 3 hours in Group B. Better results would be accomplished if total ischemic time could be reduced to less than 3 hours. Intraregional organ sharing would be the best option other than interregional transfers of donor hearts. Cardiac recipient transfer to that region should be considered as a second best option to avoid prolonged ischemic times.

Quality Standards of Life after Transplantation

The main reason for early death after transplantation was the lower standards of home-life of our patients. The end stage cardiac failure is observed mostly in patients with lower social and economical level. After transplantation they must be followed very closely and carefully in Turkey. They have to be informed about their post-transplant life, exercise capacity, sexual behavior, infection risk and work area. We observed if the recipients were careful with health, work and medication, than they had longer high-quality life with longer survival. If we worry that recipients can not continue their high-quality life, we hold them in the hospital and give them a special room and work.

Limitations

The patient number was low, quite enough to compare both groups. May be, it would be better if we could perform angiographic evaluation in all patients including early deaths.

Conclusion

By improving short and long-term survivals, cardiac transplantation would be more beneficial treatment modality. Towards this goal, the availability of the donor hearts from younger male donors with the shortest ischemic time would be the best factor in improving long-term survival. The main strategy in cardiac transplantation should be shorten ischemic times and enforce strict postoperative surveillance and follow-up protocols

This paper was presented at the 25th Meeting of the Society of Cardiac Surgeons, Pamplona, Spain, 21-23 June 2007 and 19h Annual Meeting of Asian Society of Cardiovascular Surgery, Beijing, China, 17-20 May 2007

References

(1.) Hunt SA. Current status of cardiac transplantation. JAMA 1998; 280:1692-8.

(2.) DeCampli WM, Luikart H, Hunt S, Stinson EB. Characteristics of patients surviving more than ten years after cardiac transplantation. J Thorac Cardiovasc Surg 1995;109: 1103-15.

(3.) Bourge RC, Naftel DC, Costanzo-Nordin MR, Kirklin JK, Young JB, Kubo SH, et al. Pre-transplantation risk factors for death after heart transplantation: a multiinstitional study. The Transplant Cardiologists Research Database Group. J Heart Lung Transplant 1993;12: 549-62.

(4.) Rodeheffer RJ, Naftel DC, Stevenson LW, Porter CB, Young JB, Miller LW, et al. Secular trends in cardiac transplant recipient and donor management in the United States, 1990 to 1994. A multi institutional study. Cardiac Transplant Research Database Group. Circulation 1996; 94: 2883-9.

(5.) John R, Rajasinghe H, Chen JM, Weinberg AD, Sinha P, Itescu S, et al. Impact of current management practices on early and late death in more than 500 consecutive cardiac transplant recipients. Ann Surg 2000; 232: 302-11.

(6.) Bourge RC, Kirklin JK, Thomas K, Czerska B, Lee F, Kasper EK, et al. The emergence of co-morbid diseases impacting survival after cardiac transplantation, a ten-year multi-institutional experience. Cardiac Transplant Research Database, University of Alabama at Birmingham, Birmingham, AL, USA. J Heart Lung Transplant 2001; 20: 167-8.

(7.) Kirali K, Mansuroglu D, Omeroglu SN, Tuncer A, Eren E, Toker ME, et al. 12-year Kosuyolu experience at cardiac transplantation. J Turkish Thorac Cardiovasc Surg 2001; 9: 62-7.

(8.) Mansuroglu D, Kirali K, Guler M, Tuncer A, Eren E, Akinci E, et al. Follow-up of rejection phenomeniaby using cytoimmunologic monitorisation in the heart transplantations. J Turkish Thorac Cardiovasc Surg 1998; 6: 369-78.

(9.) Tuncer A, Kirali K, Guler M, Omeroglu SN, Tekumit H, Keles C, et al. Noninvasive methods for following of rejection phenomena and echocardiography. Abstracts of the Congress of Transplantation (ONKKD II); 2000 October 25-29; Istanbul, Turkey; ONKKD; 2000.

(10.) Mansuroglu D, Sareyyupoglu B, Guler M, Alp M, Balkanay M, Akinci E, et al. Use of epicardial electrocardiogram in diagnosis of acute rejection after heart transplantation. Abstracts of the Asian Society for Cardiovascular Surgery Annual Meeting; 2004 April 19-22 Istanbul, Turkey; Asian Society for Cardiovascular Surgery; 2004.

(11.) Stewart S, Winters GL, Fishbein MC, Tazelaar HD, Kobashigawa J, Abrams J, et al. Revision of the 1990 working formulation for the standardization of nomenclature in the diagnosis of heart rejection. J Heart Lung Transplant 2005; 24: 1710-20.

(12.) Hosenpud JD, Bennett LE, Keck BM, Fiol B, Boucek MM, Novick RJ. The registry of the International Society for Heart and Lung Transplantation: Sixteenth official report 1999. J Heart Lung Transplant 1999;18: 611-26.

(13.) Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC, et al. and the Cardiac Transplant Research Database. Heart transplant coronary artery disease detected by coronary angiography: A multi-institutional study of preoperative donor and recipient risk factors. J Heart Lung Transplant 1998;17: 744-53.

(14.) Baker AM, Levine TB, Goldberg AD, Levine AB. Natural history and predictors of obesity after orthotopic heart transplantation. J Heart Lung Transplant 1992;11: 1156-9.

(15.) Rickenbacher PR, Kemna MS, Pinto FJ, Hunt SA, Alderman EL, Schroeder JS, et al. Coronary artery intimal thickening in the transplanted heart. An in vivo intracoronary ultrasound study of immunologic and metabolic risk factors. Transplantation 1996;15; 61: 46-53.

(16.) Grady KL, White-Williams C, Naftel D, Costanzo MR, Pitts D, Rayburn B, et al. Are preoperative obesity and cachexia risk factors for post hearttransplant morbidity and mortality: a multi-institutional study of preoperative weight-height indices. Cardiac Transplant Research Database (CTRD) Group. J Heart Lung Transplant 1999;18: 750-63.

(17.) Shiba N, Chan MCY, Valantine HA, Gao S-Z, Robbins RC, Hunt SA. Long-term risks associated with 10-year survival after heart transplantation in the cyclosporine era. J Heart Lung Transplant 2003; 22:1098-106.

(18.) Shiba N, Chan MCY, Kwok BWK, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant 2004; 23: 155-64.

(19.) Prendergast TW, Furukawa S, Beyer AJ 3rd, Browne BJ, Eisen HJ, Jeevanandam V. The role of gender in heart transplantation. Ann Thorac Surg 1998; 65: 88-94.

(20.) Lietz K, John R, Kocher A, Schuster M, Mancini DM, Edwrads NM, et al. Increased prevalence of autoimmune phenomena and greater risk for alloreactivity in female heart transplant recipients. Circulation 2001; 104 (12 Suppl 1): 1177-83.

Basar Sareyyupoglu, Kaan Kirali, Deniz Goksedef, Murat Bullent Rabus, Altug Tuncer, Vedat Erentug, Denyan Mansuroglu, Cevat Yakut

Cardiovascular Surgery Center, Kartal Kosuyolu Yuksek lhtisas Education and Research Hospital, Kosuyolu, Istanbul, Turkey

Yazisma Adresi/Address for Correspondence: Dog. Dr. Kaan Kirali, Cardiovascular Surgery Center, Kartal Kosuyolu Yuksek Ihtisas Education and Research Hospital, Kosuyolu, Istanbul, Turkey Tel: +90 216 467 70 30 Faks: +90 216 369 63 63 E-mail: imkkirali@yahoo.com
Table 1. Comparison of groups for preoperative demographic data

Parameters                          Group A (n =16)

Congestive symptoms, months    15.0 [+ or -] 10.8 (1-36)
Mean follow-up, months          9.1 [+ or -] 8.9 (1-24)
Time in waiting list, months    7.3 [+ or -] 8.7 (1-36)
Demographic variables
  Recipient gender,
    male, n (%)                         15(93.8)
  Recipient age, years         31.6 [+ or -] 13.1 (16-58)
  Donor age, years             30.1 [+ or -] 8.1 (14-48)
  Recipient weight, kg         63.5 [+ or -] 7.9 (46-76)
  Male Donor, n (%)                      8(50)
Etiologic factors
  Ischemic cardiomyopathy,
    n (%)                                12(75)
  Dilated cardiomyopathy,
    n (%)                                4(25)

Parameters                          Group B (n =17)           * p

Congestive symptoms, months    24.3 [+ or -] 12.6 (6-58)      0.028
Mean follow-up, months         49.6 [+ or -] 26.4 (25-98)    <0.001
Time in waiting list, months   12.8 [+ or -] 14.8 (1-58)      0.23
Demographic variables
  Recipient gender,
    male, n (%)                         13(76.5)              0.17
  Recipient age, years         29.5 [+ or -] 10.9 (16-51)     0.85
  Donor age, years             24.5 [+ or -] 6.3 (16-40)      0.017
  Recipient weight, kg         66.3 [+ or -] 12.9 (45-98)     0.56
  Male Donor, n (%)                     14(82.3)              0.05
Etiologic factors
  Ischemic cardiomyopathy,
    n (%)                               12(70.6)              0.95
  Dilated cardiomyopathy,
    n (%)                               5(29.4)               0.78

Data are represented as Mean [+ or -] SD (Min-Max) values and
proprotion/percentage

* Fischer's exact test for categorical data comparison and Mann
Whitney U-test for comparison of continuous variables

Table 2. Comparison of groups by means of preoperative risk factors

Variables                           Group A (n =16)

Preoperative NYHA class        3.75 [+ or -] 0.45 (3-4)
Patients in inotropic
  support, n (%)                        7(43.8)
Family history, n (%)                    1(6.3)
Urea, mg/dl                    54.8 [+ or -] 10.4 (38-78)
Creatinine, mg/dl              1.16 [+ or -] 0.21 (0.8-1.6)
Lung failure, n (%)                      1(6.3)
Liver failure, n (%)                    2(12.5)
Renal failure, n (%)                    3(18.8)
Cardiothoracic index, %        0.59 [+ or -] 0.04 (0.5-0.7)
LVESD, cm                      6.63 [+ or -] 0.52 (5.6-7.8)
LVEDD, cm                      6.99 [+ or -] 0.65 (5.4-8.2)
Mitral regurgitation,
  degree                       2.94 [+ or -] 0.57 (2-4)
Tricuspid regurgitation,
  degree                       0.19 [+ or -] 0.4 (0-1)
Ejection fraction, %           21.7 [+ or -] 5.9 (10-35)
Pulmonary artery
  pressure, mmHg               46.1 [+ or -] 6.2 (40-60)

Variables                           Group B (n =17)           * P

Preoperative NYHA class         3.71 [+ or -] 0.47 (3-4)      0.85
Patients in inotropic
  support, n (%)                        6(35.3)               0.63
Family history, n (%)                    1(5.9)               0.96
Urea, mg/dl                    51.2 [+ or -] 16.7 (27-94)     0.11
Creatinine, mg/dl              0.93 [+ or -] 0.28 (0.5-1.5)   0.033
Lung failure, n (%)                      1(5.9)               0.96
Liver failure, n (%)                    2(11.7)               0.95
Renal failure, n (%)                    2(11.7)               0.59
Cardiothoracic index, %        0.59 [+ or -] 0.02 (0.6-0.7)   0.74
LVESD, cm                      6.59 [+ or -] 0.89 (5.1-8.9)   0.85
LVEDD, cm                       6.6 [+ or -] 0.78 (5.4-8.4)   0.13
Mitral regurgitation,
  degree                       2.41 [+ or -] 0.71 (1-4)       0.041
Tricuspid regurgitation,
  degree                       0.06 [+ or -] 0.2 (0-1)        0.53
Ejection fraction, %           24.2 [+ or -] 9.9 (10-45)      0.53
Pulmonary artery
  pressure, mmHg               47.7 [+ or -] 11.1 (30-70)     0.79

Data are represented as Mean [+ or -] SD (Min-Max) values and
proprotion/percentage

*--Fischer's exact test for comparison of categorical data and
Mann Whitney U-test for comparison of continuous variables

LVEDD--left ventricle end diastolic diameter, LVESD--left ventricle
end systolic diameter, NYHA -functional capacity

Table 3. Comparison of groups for peroperative data and
postoperative follow-up

Variables                           Group A (n =16)

* Anastomoses technique,
  n (%)                                13(81.3)
Ischemic time, min            182.5 [+ or -] 49.2 (120-270)
Cross-clamp time, min          83.6 [+ or -] 7.9 (65-98)
** Total ischemic
  time, min                   265.6 [+ or -] 51.8 (200-345)
Inotropic support, day         6.75 [+ or -] 2.9 (3-14)
Prostavazine usage,
  n (%)                                14(87.5)
Sinus rhythm, n (%)                    10(62.5)
Permanent pacing
  need, n (%)                           6(37.5)
Post-operative PAP, mmHg       39.2 [+ or -] 7.6 (25-50)
Intubations time, hour         27.5 [+ or -] 7.6 (15-48)
*** Drainage , mLs           1759.4 [+ or -] 1740.2 (450-7000)
Chest tube removal, day         8.1 [+ or -] 7.6 (2-28)
Transfusion, blood units        5.0 [+ or -] 1.5 (1-8)
Mobilization, day              4.75 [+ or -] 1.1 (2-7)
Intensive care unit
  stay, day                    30.5 [+ or -] 22.3 (12-100)
Hospital stay, day             87.1 [+ or -] 57.9 (20-193)
Renal function
  impairment, n (%)                     6(37.5)
Infection, n (%)                       10(62.5)
Rejection, n (%)                       13(81.3)
Endomyocardial
  biopsy, n (%)                         3(18.8)
Anti-rejection
  therapy, n (%)                        12(75)
Rejection
  monitorization, n (%)                 9(56.3)
Acute rejection, n (%)                 11(68.8)
Chronic rejection, n (%)                1(6.3)
Early NYHA functional
  capacity                     1.63 [+ or -] 0.72 (1-3)
Hospital mortality, n (%)               9(56.3)
Late mortality, n (%)                   7(43.8)

Variables                           Group B (n =17)            P ****

* Anastomoses technique,
  n (%)                                15(88.2)                 0.59
Ischemic time, min           141.5 [+ or -] 33.2 (110-200)      0.007
Cross-clamp time, min         65.9 [+ or -] 10.2 (48-92)       <0.001
** Total ischemic
  time, min                  208.7 [+ or -] 33.4 (174-280)      0.001
Inotropic support, day           4.5 [+ or -] 2 (2-10)          0.011
Prostavazine usage,
  n (%)                                 9(52.9)                 0.031
Sinus rhythm, n (%)                     17(100)                 0.004
Permanent pacing
  need, n (%)                           5(29.4)                 0.6
Post-operative PAP, mmHg       35.5 [+ or -] 12.4 (25-80)       0.31
Intubations time, hour         31.4 [+ or -] 27.2 (10-129)      0.12
*** Drainage , mLs           1003.5 [+ or -] 545.1 (110-2750)   0.13
Chest tube removal, day         3.1 [+ or -] 0.7 (2-5)          0.006
Transfusion, blood units        3.4 [+ or -] 1.6 (2-7)          0.01
Mobilization, day               5.1 [+ or -] 2.1 (2-12)         0.98
Intensive care unit
  stay, day                   27.1 [+ or -] 16.2 (14-80)        0.76
Hospital stay, day            68.1 [+ or -] 35.6 (30-180)       0.68
Renal function
  impairment, n (%)                     2(11.7)                 0.09
Infection, n (%)                        3(17.6)                 0.007
Rejection, n (%)                        5(29.4)                 0.002
Endomyocardial
  biopsy, n (%)                         5(29.4)                 0.49
Anti-rejection
  therapy, n (%)                        6(35.2)                 0.064
Rejection
  monitorization, n (%)                14(82.3)                 0.1
Acute rejection, n (%)                  2(11.8)                <0.001
Chronic rejection, n (%)               12(70.6)                <0.001
Early NYHA functional
  capacity                         1 [+ or -] 0 (1)             0.014
Hospital mortality, n (%)                  0                   <0.001
Late mortality, n (%)                   7(41.2)                 0.63

Data are represented as Mean [+ or -] SD (Min-Max) values and
proprotion/percentage

****--Fischer's exacttest for comparison of categorical data and
Mann Whitney U-testfor comparison of continuous variables

NYHA--Newyork Heart Association, PAP--pulmonary artery pressure

* Orthotopic, bicaval orthotopic

** Total time from cross-clamping the donor's aorta to releasing
cross-clamp from recipient's aorta

*** Total drainage including postoperative hemorrhage and serous fluid

Table 4. Comparison of groups for mortality analysis

Variables                  Group A (n=16)   Group B (n=17)

Mortality, n (%)              16(100)           7(41)
Rejection, n                     10               7
Acute                            6
Ventricular fibrillation
  during hospitalization         2                3
Sudden death                     1
Chronic                          1                4
Infection, n                     4
Pneumonia                        2
Sepsis                           2
Acute renal failure, n           1
latrogenic, n                    1

Table 5. Risk factors for late death (univariate analysis)

Risk Factor                           p

Demographic variables
  Donor age                         0.011
  Male donor                        0.024
  Preoperative creatinine           0.009

Per operative variables
  Cold ischemic time                0.05
  Cross-clamp time                  0.002
  Postoperative transfusion units   0.002
  Inotropic support                 0.03

Postoperative Follow-up
  Early functional capacity        <0.001
  Rejection monitorization          0.045
  Number of rejection periods       0.004
  Acute rejection                   0.002
  Chronic Rejection                 0.002

Table 6. Cox proportional hazard analysis for risk factors for
late death

Factor                               Hazard ratio (95% CI)     p

Preoperative high creatinine level    42.6 (4.67-388.21)     0.001
Acute rejection                        4.45 (1.44-13.77)     0.01
Early worse functional capacity        4.84 (1.9-12.27)      0.001
Rejection monitorization                0.2 (0.07-0.67)      0.008
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Title Annotation:Orijinal Arastirma/Original Investigation
Author:Sareyyupoglu, Basar; Kirali, Kaan; Goksedef, Deniz; Rabus, Murat Bulent; Tuncer, Altug; Erentug, Ved
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Geographic Code:7TURK
Date:Oct 1, 2008
Words:5361
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