Heart and heart-lung transplantation: the Stanford experience

As of October 1989, over 560 patients with end-stage heart disease have received heart transplants at Stanford. In addition, 70 patients have received heart-lung transplants (H-L Tx) and 5 patients received single-lung transplants for end-stage pulmonary disease. Cyclosporine A (CsA) significantly improved survival, especially during the first posttransplant year. All patients now receive maintenance CsA, prednisone (P), and azathioprine (AZA). Fourteen-day prophylactic OKT3 significantly reduces early rejection after heart transplantation. One-year survival for cardiac transplants is 82% using CsA and 73% for our recent H-L Tx group. All 5 patients are alive after single-lung transplantation. Children with heart transplants and patients bridged to transplant with a Novacor ventricular assist system have a 1-year survival rate similar to routine heart transplant patients. Beyond the first year, heart transplant mortality continues at 5% per year. Transplant coronary artery disease (Tx CAD) accounts for 33% of the mortality, and other patients require retransplantation for Tx CAD. Cytomegalovirus contributes to the development of TX CAD and antiviral agents are being used for the early treatment of CMV infections. Cytomegalovirus is also thought to contribute to obliterative bronchiolitis (OB), the late complication that threatens H-L Tx patients. Surveillance bronchoscopy and pulmonary function tests can be used to detect early lung infection and rejection. Hopefully this will lead to improved late graft function. Future immunosuppressive efforts will be directed toward decreasing the morbidity and mortality after the first year in both heart and lung transplant patients.