A model for analyzing the cost of main clinical events after cardiac transplantation.

Using information from the Papworth Hospital heart transplant service, a model was developed to link the main clinical events after cardiac transplantation to survival and costs. On the basis of the clinical and survival experience of 387 patients treated with triple-drug immunosuppression between 1986 and 1993, together with protocols for patient management, resource use, and costs, a 5-year Markov model with three time periods was used to simulate survival and estimate costs. The model accurately mirrors observed actuarial survival; 1- and 5-year survival rates were 81% and 65%, respectively.

Development of bronchiolitis obliterans syndrome in recipients of heart-lung transplantation--early risk factors.

Given the internationally recognized definition of bronchiolitis obliterans syndrome (BOS) and longer follow up of heart-lung transplant recipients, it is possible to establish some of the major risk factors for development and progression of BOS. Between April 1984 and 31 December 1993, 157 patients underwent heart-lung transplantation; 126 survived at least six months after operation and so were at risk of developing BOS. The following early risk factors were assessed for development of BOS grade 1 (21-35% decline in FEV1) and progression from grade 1 to grade 2 (36-50% decline in FEV1): age, gender and underlying diagnosis of the recipient, evidence of acute rejection and cytomegalovirus (CMV) infection within 6 months of operation, peak FEV1 achieved, age and gender of the donor, cold ischemic time of the graft, and matching of CMV serological status and HLA antigens of donor and recipient.

Lung Transplantation in patients with systemic diseases: an eleven-year experience at Papworth Hospital.

Background: The presence of a systemic disease has traditionally been considered a contraindication to lung transplantation.

Methods: We present a retrospective review of 19 patients undergoing lung transplantation for end-stage pulmonary disease associated with a systemic illness since 1984. There were 11 male and 8 female patients, aged from 23 to 59 years (median 43 years) with end-stage pulmonary involvement by sarcoidosis (11 patients), Langerhan's cell histiocytosis (three patients), systemic vasculitis (four patients: three with systemic lupus erythrematosis, one with Churg-Strauss), and common variable immunodeficiency (one patient).

Bronchiolitis obliterans syndrome (BOS) following heart-lung transplantation.

With the increasing number of successfully performed lung transplants and a longer follow up of patients, there is an interest in the analysis of long-term complications and their impact on patient survival. Heart-lung transplantation was performed in 157 patients with 126 patients surviving at least 6 months. Early death was mainly caused by bacterial and viral infection.

Lipids, lipoprotein (a) and coronary artery disease in patients following cardiac transplantation.

Cardiac allograft vascular disease (CAVD) is the most important cause of late mortality in cardiac transplant recipients. While the pathogenesis of the disease is believed to be immunological, other factors like hyperlipidaemia may contribute. Total cholesterol, LDL cholesterol.

Excellent outcome of cardiac transplantation using domino donor hearts.

Objective: Domino cardiac transplantation affords flexible and optimal organ utilization, provides hearts unaffected by brain death, allows prospective tissue matching, and subsequent transplantation with short allograft ischemic times. A retrospective review of our experience with domino cardiac transplantation has been made.

Methods: Seventy-two of 119 patients who underwent heart-lung transplantation from 1988 on served as domino cardiac donors (40 males, 32 females; mean age of 32 years; mean weight of 51 kg).

Coronary care unit ST-trending system: interpreting complex output data.

Analysis of the ST segment is an accepted part of the assessment of coronary ischaemia. Traditionally, such analysis has been applied to 12-lead surface electrocardiograms, but it is increasingly applied to 24-hour Holter recordings and bedside monitoring systems, using complex computer algorithms. There is a potential for results to be misleading as a consequence of uncritical acceptance of complex medical data processing.

Heart transplantation in the United Kingdom: who waits longest and why.

Background: This study aims to identify characteristics that increase the chance of death of potential cardiac transplant recipients before donor organs become available.

Methods: Between June 1, 1988, and May 31, 1993, 332 patients were accepted for heart transplantation; 235 underwent surgery. Ninety-seven patients had not received transplants; of these, 71 died, 13 were transferred to other lists, and 13 were awaiting organs at the close of the study.

Donor and recipient predicted lung volume and lung size after heart-lung transplantation.

Lung volumes after heart-lung transplantation (HLT) were recorded and compared with measurements at the time of assessment for surgery and the predicted values for recipients. The influence of donor lung size and recipients' underlying lung disease was evaluated. All patients underwent HLT between April 1984 and April 1991, and only those 82 who survived for at least 6 mo were studied.

Who waits longest for heart and lung transplantation?

Between August 1982 and December 1992, 260 patients were accepted for heart and lung transplantation, of whom 139 patients underwent transplant surgery. One hundred twenty-one patients have not received transplants, of whom 80 have died, four were transferred to other lists, and 37 were still waiting for suitable organs at the close of the study. Median waiting time for those patients who underwent heart and lung transplantation was 7 months, whereas patients who died waiting spent a median of 5 months on the list.

Risk factors for survival following combined heart-lung transplantation. The first 100 patients.

As the numbers of heart and lung transplant recipients have increased it has become possible to identify major risk factors for early (within 3 months) and later (after 3 months) death after this procedure. For 100 patients receiving organs between April 1984 and February 1991, and followed up until February 1992, patient characteristics, operative details, and early morbidity were assessed for their effects on early and later deaths. Recipient age, sex, and preoperative diagnosis did not have a significant effect on early (within 3 months) or later death.

Heart-lung transplantation for end-stage respiratory disease in patients with cystic fibrosis at Papworth Hospital.

Between October 1985 and July 1992 we performed heart-lung transplantation in 42 patients with end-stage respiratory disease caused by cystic fibrosis. Twenty-eight of these patients are alive at 3 months to 7 years after heart-lung transplantation. Actuarial survival at 1 year and 3 years after transplantation was 78% and 65%, respectively, in this group, which compares favorably with 77% and 60%, respectively, in patients without cystic fibrosis undergoing heart-lung transplantation.

Prognosis of patients with cystic fibrosis awaiting heart and lung transplantation.

Heart-lung transplantation is a successful treatment for patients with cystic fibrosis and chronic respiratory failure. Patients are assessed for surgery when life expectancy is deemed short. This study assesses the ability of measurements of pulmonary function, blood gas levels, and nutritional status to predict survival of patients awaiting heart-lung transplantation and to assess the effect of heart-lung transplantation on survival.

Use of the Gibbs sampler to estimate transition rates between grades of coronary disease following cardiac transplantation.

Coronary occlusive disease following cardiac transplantation is monitored using serial angiography, and graded on a 3 point scale according to the amount of narrowing observed in major vessels. Disease progression is modelled as a continuous time Markov process. The Gibbs sampler is used to estimate the marginal posterior distributions of the transition rates between grades of disease and from each grade to death.

A method of analyzing the onset and progression of coronary occlusive disease after transplantation and its effect on patient survival.

The development of transplant-acquired coronary occlusive disease is monitored with serial angiography and is graded on a three-point scale as normal, mild (< 50% stenosis), or severe (> or = 50% stenosis). Previous studies have provided information about the time to the first sign of disease on angiography or empirical descriptions of progression. The number of observed transitions between grades of disease has been recorded, and a Markov model based on these transitions is used to estimate the rate of progression through angiographically defined disease grades and the mortality rates from each grade.

Lack of association between endomyocardial evidence of rejection in the first six months and the later development of transplant-related coronary artery disease.

The development of transplant-related coronary artery disease (TCAD) is the major determinant of long-term heart transplant survival. To test the hypothesis that TCAD might be related to cellular myocardial rejection, the grades of rejection seen at all biopsies performed in the first 6 months after heart transplantation were analyzed in 108 patients who survived more than 6 months. The development of TCAD was assessed at routine follow-up coronary angiography in 101 patients and at necropsy in seven patients.

Detrusor contraction strength in men undergoing prostatectomy.

Elective prostatectomy is a frequently performed operation but the outcome may not always be satisfactory. This is probably because a significant number of men, despite subjective symptoms, are not urodynamically obstructed before operation and the preoperative assessment of obstruction is not easy using conventional urodynamic criteria. We have calculated detrusor contraction strength (WF) in men before and after prostatectomy.

Hemodynamic evaluation of the Monostrut and spherical disc Björk-Shiley aortic valve prosthesis with Doppler echocardiography.

A Doppler echocardiographic study was performed to assess whether the Monostrut model of the Björk-Shiley valve (Shiley, Inc., Irvine, Calif.) had an improved hemodynamic performance in comparison with the spherical disc model in the aortic position.

Donor heart preservation survey.

A questionnaire requesting information on donor heart preservation technique and outcomes during the first 6 months of 1990 was circulated to heart transplantation centers worldwide. Seventy-nine usable replies representing 1371 clinical transplant operations were received. Twenty-seven percent of the respondents reported using some form of donor pretreatment.

Heart transplantation in patients over 54 years of age with triple-drug therapy immunosuppression.

Between April 1, 1986, and December 31, 1989, 206 patients received orthotopic heart transplants with triple-drug therapy immunosuppression (cyclosporine, azathioprine, prednisone). Forty-six patients were aged 55 years or more at the time of transplantation and 160 patients were less than 55 years of age; these two groups were compared. Selection criteria and treatment regimen were the same in both groups.

Efficacy of pyrimethamine for the prevention of donor-acquired Toxoplasma gondii infection in heart and heart-lung transplant patients.

Seven (11%) of the first 65 patients who received heart transplants at Papworth Hospital were mismatched for Toxoplasma gondii. Of these, four (57%) experienced T. gondii infection and two died.

Impairment of coronary flow reserve in orthotopic cardiac transplant recipients with minor coronary occlusive disease.

Objective: Coronary occlusive disease is the major long-term complication after cardiac transplantation. The relation between minor angiographic abnormalities and myocardial perfusion has not been previously assessed in a large number of cardiac transplant patients.

Design: Prospective study.