Title:

Analysis of survivors more than 10 years after orthotopic heart transplantation

Author:

Wróbel, Krzysztof

Subject:

heart transplantation ; long term survival ; immunosuppression ; quality of life ; heart failure

Abstract:

Introduction Heart transplantation (HTX) can dramatically improve health related quality of life. Heart failure patient with huge limitations in daily activites can become person with normal heart function living normal family and professional life. Unfortunately this perfect scenario is beyond reach for every patient, because of complicated medical regimen, emotional stress associated with constant risk of rejection, infection, malignancy and potential for other complications during follow up. Objectives 1. Evaluation of transplanted heart function 10 years after HTX: incidence of transplanted heart coronary artery disease (TxCAD), systolic and diastolic function, heart valve competency, heart rhytm evaluation, incidence of acute rejection and exercise capacity. 2. Incidence of most common complications of immunosupressive treatment: hypertension, chronic renal failure, dyslipidemia, malignancy and diabetes mellitus. 3. Health related quality of life 10 years after heart transplantation assessed with polish version of SF-36. Material 35 patients who survived 10 years after HTX underwent rutine follow up evaluation. Proportion of males at HTX 83,9 % has change slightly to 80% after 10 years. Average age at HTX was 43,82 (+/- 10,37), average donor age 30,5 (+/- 8,5) and average age at follow up 55,14 (+/- 10,42). Methods Patients were evaluated with standard 10 year follow up protocol: echocardiography, coronary angiography, heart biopsy, cardiopulmonary exercise test, 24 hour electrocardiography and blood pressure monitoring, lab studies and quality of life questionarre. Results 19 pts (54%) were diagnosed with TxCAD in coronary angiography. 7 pts (20%) had coronary stenosis of 50% or more in 1 coronary artery, 8 pts (23%) in 2 arteries and 4 pts (11%) in 3 arteries. Average ejection fraction (EF) was 52,1 +/- 8,4%. 3 pts had severe systolic dysfunction with EF less than 35%, 13 pts moderate systolic dysfunction EF 35-50%. In 13 pts end diastolic diameter of left ventricle was over 5,5 cm. Left ventricular concentric hyperthophy was diagnosed in 12 pts (34%). 19 pts (54%) had impaired diastolic function. Moderate tricuspid insufficiency was in 10 pts (28,6%). In 7 pts (20%) moderate mitral insuficiency. 2 pts (5,7%) required pacemaker imlantation in early perion after HTX. 3 pts had atrial fibrillation. Average daily heart rate was 117,8/min, while average rest heart rate was 73,7/min. Average heart rate over 24 hours was 73,7/min. In 24 from 29 myocardial biopsy specimens no sings of acute rejection were seen according to ISHLT formula. 5 pts were diagnosed with level 1 acute rejection according to ISHLT. Cardiopulmonary exercise test was performed in 23 pts. 15 pts reached maximal heart rate and unaerobic treshold. Average maximal oxygen consumption at peak exercise was 18,8 ml/kg/min - 59,1% of healthy population in the same age. 3 pts were diagnosed with malignancy of internal organ: myoma uterii were succesully surgically removed; lung cancer following renal cancer in both kidneys were cause of death; colon cancer was also inoperable. 3 pts were diagnosed with skin cancer. In all cases it was surgically removed without recurrence. 19 pts (54%) eGFR was lower than 60 ml/min. 4 pts (11%) required hemodialysis. Only 4 pts (11%) had normal renal fuction Only 2 pts (6%) did not require antihypertensive medications. 22 pts (62,8%) was taking calcium channel blocker. 10 pts with 1 antihypertensive medicatin was taking diltiazem. In 6 pts average systolic pressure and in 13 pts average diastolic pressure was abnormal. Average rest systolic blood pressure was abnormal in 6 pts, while average rest diastolic pressure in 24 pts (82,76%). Renal failure pts required more antihypertensives, but not statistically significant. 3 pts (8,5%) required oral antidiabetic medication, 1 pt insulin. 3 other pts were diagnosed with diabetes mellitus during the study period. Total 6 pts were diabetic. ; 24 pts (68,5%) were using lipid lowering therapy. In 12 pts total cholesterol, in 18 pts LDL, in 11 pts HDL and in 16 pts triglicerides concentrations were abnormal. 35 pts living more than 10 years after OHT average quality of life index according to polish version of SF-36 questionnaire was 71,8 (+/-34,1). Maximal score of 171 points means worst quality of life. In 26 pts quality of life index was lower than 80 points. In 9 pts was higher than 80 points. Average mental health index according to polish version of SF-36 questionnaire was 27 (+/- 13,7). Maximal score of 67 means worst quality of mental health. In 25 pts it was lower than 35 points. In 10 pts it was higher than 35 points. Average physical health index according to polish version of SF-36 questionnaire was 44,8 (+/-23,6). Maximal score of 104 means worst quality of physical health. In 20 pts it was lower than 50 points. U 6 pts it was higher than 70 points. Conclusions 1. Cardiac function more than 10 years after OHT is in most patients good with normal systolic and valvular function, sinus rhythm and good exercise capacity and no acute rejection. More than half patients are diagnosed with TxCAD based on angiography. 2. Immunosupressive therapy complications are frequent after 10 years arterial hypertension, hyperlipidemia and renal faiure, less frequently diabetes mellitus and malignancies. 3. Health related quality of life is good and only few patients are significantly limited in their lifestyle.

Level of degree:

2 - studia doktoranckie

Degree discipline:

choroby układu krążenia ; transplantologia

Degree grantor:

Wydział Lekarski

Promoter:

Jerzy Sadowski

Date:

2011

Date issued:

2010

Type:

Praca doktorska

Format:

application/pdf

Call number:

ZB-113863

ControlNumberVIRTUA:

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Access rights:

nieograniczony

Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego - Collegium Medicum

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