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Thymic function decreases progressively with age but may be boosted in certain circumstances. We questioned whether heart transplantation was such a situation and whether thymic function was related to the onset of rejection. Twenty-eight antithymocyte globulin-treated heart transplant recipients were included. Patients diagnosed for an antibody-mediated rejection on endomyocardial biopsy had a higher proportion of circulating recent thymic emigrant CD4+ T cells and T cell receptor excision circle levels than other transplanted subjects. Thymus volume and density, assessed by computed tomography in a subset of patients, was also higher in patients experiencing antibody-mediated rejection. We demonstrate that thymic function is a major determinant of onset of antibody-mediated rejection and question whether thymectomy could be a prophylactic strategy to prevent alloimmune humoral responses., (© 2017 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Introduction: Fabry disease is a lysosomal storage disorder linked to an alpha-galactosidase A deficiency that can lead to heart and kidney failure. There is little data about the prognosis of patients who undergo a combined heart and kidney transplantation., Case Reports: Two brothers who were diagnosed with Fabry disease after the age of 30 years underwent a combined heart and kidney transplantation at respectively 49 and 42 years of age because of a severe hypertrophic cardiomyopathy with end stage renal failure. They are alive respectively 4 and 9 years after the transplantation. No recurrence of the disease in the transplanted organs has been found., Conclusion: Combined heart and kidney transplantation in Fabry disease is an efficient therapy for the cardiomyopathy and kidney failure. Its prognosis can be good when the patients are carefully selected. However, an early diagnosis is critical in order to avoid a procedure associated with a high perioperative mortality., (Copyright © 2016 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Several factors are known to limit cardiac transplantation, such as number of donors, quality of cardiac graft preservation, and ischemia-reperfusion injury. Some mechanisms of reperfusion injury are now recognized; they include oxygen free radical (OFR), white blood cells activation, changes in calcium influx, alteration of microvascular blood flow, and sympathetic activation. The goal of this study was to assess the effects of two types of cardioplegia with long-term storage, either static or continuous perfusion, in 30 isolated sheep hearts as a model for heart transplantation. We examined myocardial function, histology, ischemic damage, and markers of oxidative stress. Two types of cardioplegia and storage conditions using a Langendorff reperfusion were studied in a combined approach: crystalloid (CP) [groups I and III] or cold oxygenated autologous blood (BC) [groups II and IV], immediate storage during 8h in profound hypothermia (groups I and II), or reperfused with crystalloid (group III), or blood cardioplegia (group IV). All perfusate samples were drawn from the coronary sinus. Lactate levels increased progressively in groups I, II, and IV, but not in group III, as no significant elevation was shown [90 min: 13.6+/-1.7 versus 5.2+/-1.0 mmol/L (P<0.01)]. Arrhythmias were more frequent when using BC (n=5) than CP (n=0). For plasma thiobarbituric acid-reactive substances (TBARS) levels a significant difference was found between group III and the other groups since 15 to 90 min (P<0.05). Vitamin E concentration decreased significantly from 5 min for groups II and IV, 15 min for group I, and 30 min for group III, with a significant difference between groups II and IV (P<0.05) but not between groups I and III. CP followed by a reperfusion with the same solution showed a significantly lower ischemic injury and OFR production, less frequent ventricular arrhythmias while stable hemodynamic parameters carried on. However, this protocol did not act on the early postoperative contractile function., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Xenotransplantation (XT) reveals a growing interest for the treatment of cardiomyopathy. The major barrier is an acute vascular rejection due to an acute humoral rejection. This pathogenesis is a difficult issue and in order to elaborate means for its prevention, we analysed the implication of oxidative stress (OS) on hearts from mini-pigs followed by reperfusion with either autologous or human blood in an attempt to simulate xenotransplantation. About 14 hearts were studied after a Langendorff blood reperfusion: allografts with autologous blood (n = 7) or xenografts with human blood (n = 7). Blood samples were drawn from the coronary sinus to assess ischemia and OS. In xenografts, arrhythmias occurred more frequently (p < 0.01, left ventricular systolic pressure decreased more significantly (p < 0.05), thiobarbituric acid-reactive substances concentrations increased at 30 min (0.7 +/- 0.1 vs. 2.4 +/- 0.3 mmol/l; p < 0.05) while vitamin A levels decreased (p < 0.05). XT was associated with a significant increase in ischemic injury and OS production. OS might play an eminent role in hyperacute humoral rejection.

Background: The significance of anti-human leukocyte antigen immunoglobin G (IgG) detected in the posttransplantation course of heart graft recipients remains unclear., Method: Sera from 121 cardiac allograft recipients transplanted between January 1992 and December 1994 were screened for the presence of lymphocytotoxic antibodies in the first year after transplantation. Dithiothreitol was used to differentiate IgG from immunoglobulin M., Results: Nineteen patients (15%) had cytotoxic IgG develop, mainly during the first month after transplantation. The percentage of women was higher in this group (42% vs 15.7%; P <.05). Donor to recipient mismatches for sex, blood typing, cytomegalovirus serology, and human leukocyte antigen typing were comparable between IgG producers and nonproducers. The frequency of acute allograft dysfunction during the first year after transplantation was significantly higher among patients producing IgG (42% vs 5.9; P <.001). Most of these acute allograft dysfunctions were independent of cellular rejection lesions but were associated with a thickening of the posterior wall and the interventricular septum during the acute episode. Finally, all the patients but one recovered. Recurrences were not uncommon and, at 1 year after transplantation, the dose of cyclosporine used in patients producing IgG was significantly greater, as was the left ventricular thickness., Conclusion: Posttransplantation cytotoxic IgG is not uncommon and appears to be associated with a high rate of acute allograft dysfunction. Development of these antibodies can be caused by a previous undetected immunization, as suggested by the higher percentage of women in the producer group. Correlation with histologic lesions of humoral rejection are discussed.

Leiomyosarcoma of the heart is an uncommon primary malignant tumor with poor postoperative survival that may be measured in months. A leiomyosarcoma of the left atrium was diagnosed in a 47-year-old man. Initial admission was for acute pulmonary edema requiring emergency surgery. The tumor involved the left atrial cavity, and a radical resection was performed. Six months later an isolated myxomatous recurrence was detected. Heart transplantation was then performed. The patient is in good health 20 months after operation with no evidence of residual disease or recurrence. The literature has been reviewed. Surgical resection is not an adequate treatment for leiomyosarcoma of the left atrium and early heart transplantation probably offers the only hope for these patients.

The recognition of alcoholic cardiomyopathy in patients with dilated cardiomyopathy is essential as they may regress, at least partially in a relatively short period, with abstention. The clinical history is the key to diagnosis because no other specific feature can identify the cause. Between January 1984 and July 1995, 26 candidates for cardiac transplantation with dilated cardiomyopathy and chronic alcoholism improved after withdrawal of alcohol. None of these patients was placed on the surgical waiting list. Patients with ischaemic cardiomyopathy, valvular disease or previous surgery for valvular hypertensive or congenital heart disease, documented viral myocarditis or connective tissue diseases, were excluded. The diagnostic criterion of chronic alcoholism was a total alcohol consumption of 292 kg and a duration of alcohol abuse of over 10 years. In addition to the clinical features, biological, electrocardiographic, echocardiographic and haemodynamic parameters were analysed. The mean age of the patients was 48 +/- 8 years. There were 25 men and 1 woman. The total mean alcohol consumption was 1,492 kg. The average follow-up period was 63 +/- 41 months. The interval between the onset of symptoms and abstention was 25 months. Haemodynamic improvement was observed in 25 cases. The average interval between alcoholic abstention and recovery was 11.7 months. One patient died suddenly. Improvement of symptoms, decrease of the cardiothoracic ratio and improvement of echocardiographic parameters were statistically significant. The increase in angiographic or isotopic ejection fraction and cardiac index and the decrease in mean pulmonary artery pressures were also statistically significant. These results confirmed the diagnosis of alcoholic cardiomyopathy. Therefore, patients with chronic alcohol abuse and dilated cardiomyopathy must be identified and treated for this problem and not placed on the waiting list for cardiac transplantation unless no improvement is observed after about 3 months of abstention.

Since April 1986, 82 patients have received a pneumatic total artificial heart, 62 a JARVIK-7, and 20 a Cardiowest. The duration of support ranged from less than 1 day to 603 days (mean duration: 27 +/- 82). The indications were for acute shock (38 cases) or for chronic deterioration on the transplant waiting list (44 cases). The etiology was mainly due to idiopathic and ischemic cardiomyopathy. With the help of our scoring system, we divided our patients in three groups: Chronic Implantation, represented by two females staying on device for 6 and 19 months, respectively; a High-Risk group of 29 patients characterized by high-risk indications; graft failure, rejection, postcardiotomy patient, postpartum cardiomyopathy, and valvular and congenital reoperation. In addition, the dilated and ischemic cardiomyopathy patients with a score over 6 were included in this group; and an Elective Indication group (51 patients) represented all of the dilated and ischemic cardiomyopathy patients with a score under 6. Due to the shortage of donors, our criteria for transplantation are very strict. Transplants should be made only in cases of hemodynamic stability, on an extubated patient with normal renal and liver functions, without coagulation problems or infection. With such criteria, in the high-risk group, only four patients could be transplanted and of these two are still alive. In contrast, in the elective group, 31 were transplanted (61%), and 71% of these patients were discharged. The rate is improved in the most recent cases, with 90% of the Cardiowest patients being survivors.

We describe the technique of blood cardioplegia delivery as we routinely use it in clinical heart transplantation. This technique needs a specific circuit. Perfusion of a first dose of blood cardioplegia is immediately started on the arrival of the graft in the operating room. Cardiac reperfusion of a half-dose of blood solution without potassium is performed each 20 minutes. Myocardial warm reperfusion is started at the end of the aortic suture. This technique of blood cardioplegia and warm reperfusion during heart transplantation provided an improvement in heart preservation when compared with standard crystalloid solution.

Clinical application of heart transplantation goes beyond 25 years experience. The main indications for cardiac transplantation remain idiopathic cardiomyopathies and ischemic diseases. To obtain a suitable donor has become progressively more difficult due to the increase of transplants performed and the shortage of donors. Advances in the detection of early rejection, improved organ preservation procedures, and the introduction of new immunosuppressive therapy protocols have produced dramatic results in heart transplantation. Late graft atherosclerosis remains a serious threat despite retransplantation and, in some cases, mechanical cardiac support.