Type A Aortic Dissection-Experience Over 5 Decades: JACC Historical Breakthroughs in Perspective.

The Stanford classification of aortic dissection was described in 1970. The classification proposed that type A aortic dissection should be surgically repaired immediately, whereas type B aortic dissection can be treated medically. Since then, diagnostic tools and management of acute type A aortic dissection (ATAAD) have undergone substantial evolution.

Outcomes after heart retransplantation: A 50-year single-center experience.

Objectives: To evaluate outcomes after heart retransplantation.

Methods: From January 6, 1968, to June 2019, 123 patients (112 adult and 11 pediatric patients) underwent heart retransplantation, and 2092 received primary transplantation at our institution. Propensity-score matching was used to account for baseline differences between the retransplantation and the primary transplantation-only groups.

Operative technique and pitfalls in donor heart procurement.

We describe a simple and reproducible donor heart procurement technique in sequential steps. A detailed understanding of procurement and organ preservation techniques should be an essential part of a heart transplant training program.

Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation.

Background: Allosensitization has been shown to negatively affect post-heart transplant (HTx) survival even with a negative crossmatch. Whether allosensitization related to mechanical circulatory support (MCS) is associated with worse post-HTx survival remains controversial.

Methods: Adult HTx recipients listed in the United Network for Organ Sharing database (July 2006-December 2012) were identified.

A novel, catheter-based approach to left ventricular assist device deactivation after myocardial recovery.

We describe a case of catheter-based embolization and deactivation of a left ventricular assist device using an Amplatzer plug for a patient demonstrating myocardial recovery after diagnosis of nonischemic cardiomyopathy. This procedure can provide a minimally invasive, low morbidity solution for patients wishing to be separated from left ventricular assist device support who want to avoid invasive surgery for device removal.

Combined heart-liver transplantation in the MELD era: do waitlisted patients require exception status?

Combined heart-liver transplant (HLT) is a viable therapy for patients with concomitant end-stage heart and liver failure. Using data from the United Network for Organ Sharing database, we examined the cumulative incidences of transplant and mortality in waitlisted candidates for HLT, isolated heart transplant (HRT) and isolated liver transplant (LIV) in the Model for End-Stage Liver Disease era. The incidence of waitlist mortality was higher in HLT candidates than in HRT candidates (p = 0.

Heart and combined heart-kidney transplantation in patients with concomitant renal insufficiency and end-stage heart failure.

In patients with end-stage heart failure (ESHF) who are candidates for isolated heart transplant (HRT), dialysis dependence (DD) is considered an indication for combined heart-kidney transplantation (HKT). HKT remains controversial in ESHF transplant candidates with nondialysis-dependent renal insufficiency (NDDRI). Using United Network for Organ Sharing data, we examined the cumulative incidences of transplant and mortality in patients with DD and NDDRI waitlisted for HKT or HRT.

Heart transplant graft survival is improved after a reduction in panel reactive antibody activity.

Background: Allosensitization in potential orthotopic heart transplant recipients is evaluated with the panel reactive antibody assay. Sensitized patients have prolonged wait times and increased waitlist and post-transplant mortality. Although low panel reactive antibody activity at the time of orthotopic heart transplantation is associated with improved outcomes, literature regarding the survival benefit of a panel reactive antibody reduction in the sensitized orthotopic heart transplant recipient remains limited.

Late profound muscle weakness following heart transplantation due to Danon disease.

Introduction: Postoperative muscle weakness is a serious complication in surgical intensive care patients. It is mostly described as critical illness polyneuromyopathy. Risk factors include intensive care length of stay, sepsis, poor glycemic control, and combined use of corticosteroids and neuromuscular blocking agents, malnutrition, and electrolyte imbalance.

Ventricular assist devices: history, patient selection, and timing of therapy.

Timing of therapy and selection of patients in the use of ventricular assist devices (VADs) can be difficult. In general, consideration for VAD implantation is appropriate in patients with endstage heart failure who are failing optimal medical therapy and in whom no alternative traditional surgical treatment options are available. However, identifying when a particular patient has reached this point is not always straightforward.

Changing trends in infectious disease in heart transplantation.

Background: During the past 25 years, advances in immunosuppression and the use of selective anti-microbial prophylaxis have progressively reduced the risk of infection after heart transplantation. This study presents a historical perspective of the changing trends of infectious disease after heart transplantation.

Methods: Infectious complications in 4 representative eras of immunosuppression and anti-microbial prophylaxis were analyzed: (1) 38 in the pre-cyclosporine era (1978-1980), (2) 72 in the early cyclosporine era (1982-1984), where maintenance immunosuppression included high-dose cyclosporine and corticosteroid therapy; (3) 395 in the cyclosporine era (1988-1997), where maintenance immunosuppression included cyclosporine, azathioprine, and lower corticosteroid doses; and (4) 167 in the more recent era (2002-2005), where maintenance immunosuppression included cyclosporine and mycophenolate mofetil.

Trends in invasive disease due to Candida species following heart and lung transplantation.

Although invasive candidiasis (IC) causes significant morbidity and mortality in patients who undergo heart, lung, or heart-lung transplantation, a systematic study in a large cohort of thoracic organ transplant recipients has not been reported to date. Clinical and microbiological data were reviewed for 1305 patients who underwent thoracic organ transplantation at Stanford University Medical Center between 1980 and 2004. We identified and analyzed 76 episodes of IC in 68 patients (overall incidence 5.

Twenty-year survivors of heart transplantation at Stanford University.

Human heart transplantation started 40 years ago. Medical records of all cardiac transplants performed at Stanford were reviewed. A total of 1446 heart transplantations have been performed between January 1968 and December 2007 with an increase of 1-year survival from 43.

Wound healing complications with de novo sirolimus versus mycophenolate mofetil-based regimen in cardiac transplant recipients.

Sirolimus was introduced in de novo immunosuppression at Stanford University in view of its favorable effects on reduced rejection and cardiac allograft vasculopathy. After an apparent increase in the incidence of post-surgical wound complications as well as symptomatic pleural and pericardial effusions, we reverted to a mycophenolate mofetil (MMF)-based regimen. This retrospective study compared the outcome in heart transplant recipients on sirolimus (48 patients) with those on MMF (46 patients) in de novo immunosuppressive regimen.

Outcome analysis of donor gender in heart transplantation.

Background: Several studies have shown a detrimental effect of female donor gender on the survival of solid-organ transplant recipients, including heart, kidney and liver. We evaluated our own experience in heart transplantation in the cyclosporine era, since 1980, to determine the effect of donor gender on survival.

Methods: We retrospectively reviewed 869 consecutive patients who underwent primary heart transplantation at Stanford University Medical Center between December 1980 and March 2004.

Induction therapy for pediatric and adult heart transplantation: comparison between OKT3 and daclizumab.

Background: Induction therapy can reduce morbidity and early mortality in pediatric and adult heart transplant recipients. Monoclonal and polyclonal agents are most widely used; they nonspecifically deplete the T-cell pool and are thus associated with drug-induced side effects. The cytokine release syndrome is one of the most problematic events associated with induction.

Acute type A aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair.

Objective: To clarify the merits of various surgical approaches, we studied the outcome after composite valve graft versus separate valve and graft replacement versus conservative valve treatment with replacement of the ascending aorta in patients with acute type A aortic dissection complicated by aortic regurgitation.

Methods: Between 1967 and 1999, 123 patients (mean age 56 +/- 15 years) underwent composite valve graft replacement (n = 21), separate valve and graft replacement (n = 20), or conservative valve treatment (n = 82 [commissural resuspension in 46]); follow-up averaged 6.5 years (95% complete).

The impact of brain death on survival after heart transplantation: time is of the essence.

Background: It has been suggested that the modality of brain death and time from brain death until harvest impact survival and rejection after heart transplantation.

Methods: Donor files from 475 adult heart-transplant recipients were examined. From these files, a total management time (time from incident leading to brain death until aortic cross clamp) was determined, and the cause of brain death was noted.

Long-term results of heart transplantation in patients older than 60 years.

Background: Advanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years.

Post-transplantation lymphoproliferative disease in heart and heart-lung transplant recipients: 30-year experience at Stanford University.

Background: Post-transplantation lymphoproliferative disease (PTLD) is an important source of morbidity and mortality in transplant recipients, with a reported incidence of 0.8% to 20%. Risk factors are thought to include immunosuppressive agents and viral infection.

Coronary atherosclerosis in cardiac transplant patients treated with total lymphoid irradiation.

Background: Multiple episodes of rejection following cardiac transplantation have been associated with an increased incidence of coronary atherosclerosis. Total lymphoid irradiation (TLI) has been shown to be a successful treatment for persistent allograft rejection, but its effect on coronary arterial disease has yet to be evaluated.

Methods: From 1987 to 1999, 40 patients required TLI for persistent or recurrent allograft rejection following heart transplantation.

Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?

Objective: The optimal treatment of patients with acute type B dissections continues to be debated.

Methods: A 36-year clinical experience of medical and surgical treatments in 189 patients was retrospectively analyzed (multivariable Cox proportional hazards model) with respect to three outcome end points: all deaths, freedom from reoperation, and freedom from late aortic complications or death. Propensity score analysis identified 2 quintiles (quintiles I and II, consisting of 142 comparable patients) for further comparison of the effects of surgical versus medical treatment.

Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection?

Objective: No evidence exists that profound hypothermic circulatory arrest (PHCA) improves survival or reduces the likelihood of distal aortic reoperation in patients with acute type A aortic dissection.

Methods: Records of 307 patients with acute type A aortic dissection from 1967 to 1999 were retrospectively reviewed. The influence of repair using PHCA (n=121) versus without PHCA (n=186) on death and freedom from distal aortic reoperation was analyzed using multivariable Cox regression models.