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Twenty years of heart transplantation at Groote Schuur Hospital
H Reichenspurner1, J A Odell, D K Cooper
1Department of Cardiothoracic Surgery, University of Cape Town Medical School, South Africa.
Insights
A new immunosuppressive regimen improved heart transplant survival rates significantly. This approach, combining quadruple drug therapy with careful patient selection, led to a 94% survival rate in the last 12 months, reducing deaths from rejection and infection.
Area of Science:
- Cardiology
- Immunology
- Surgical Sciences
Background:
- Groote Schuur Hospital performed 110 heart and 12 heart-lung transplantations between 1967 and 1987.
- Patient management evolved through three distinct immunosuppressive protocols over two decades.
Purpose of the Study:
- To evaluate the impact of evolving immunosuppressive strategies on heart transplant outcomes.
- To compare the efficacy of different immunosuppression protocols, including conventional therapy, high-dose cyclosporine, and quadruple therapy.
Main Methods:
- Patients were divided into three groups based on immunosuppressive regimens: conventional (Group A), high-dose cyclosporine (Group B), and quadruple therapy (Group C).
- Outcomes were assessed by survival rates and causes of mortality, including acute rejection, infections, and organ failure.
- The study analyzed results from 110 heart transplantations (61 heterotopic, 49 orthotopic) and 12 heart-lung transplantations.
Main Results:
- Survival rates varied significantly: 16% in Group A, 40% in Group B, and 77% in Group C.
- Deaths in Group A and B were primarily due to acute rejection and infections; Group B also saw significant multi-organ failure.
- Group C, utilizing a modified quadruple immunosuppressive regimen, achieved a 94% actuarial survival rate within 12 months, with comparable outcomes for heterotopic and orthotopic procedures.
Conclusions:
- The modified quadruple immunosuppressive regimen (Group C) dramatically improved heart transplant survival rates.
- Precise donor/recipient selection and advanced rejection monitoring are crucial for successful outcomes.
- While orthotopic transplantations showed a better overall outcome, heterotopic procedures remain viable in specific clinical situations.
Abstract:
Between December 1967 and July 1987, 110 heart transplantations (61 heterotopic and 49 orthotopic) and 12 heart-lung transplantations were done at Groote Schuur Hospital in Cape Town, South Africa. Twelve procedures were retransplantations, including two third interventions. The patients were divided into three groups: Group A (n = 55) from 1967 to 1982 received so-called conventional treatment of azathioprine, methylprednisolone, and antithymocyte globulin. Group B (n = 15) from 1983 to 1984 had cyclosporine in high dosages together with methylprednisolone. Group C (n = 30) received quadruple drug therapy of low-dosage cyclosporine, together with azathioprine, methylprednisolone in lower dosages, and antithymocyte globulin (for the first 4 to 6 days and rescue antithymocyte globulin for severe rejection). From Group A, nine of 55 patients are alive up to 17 years after transplantation. The main causes of death were acute rejections and infections (in 60% altogether). From group B, six of 15 patients are alive. Acute rejections and infections were the causes of death in 12% of the patients, but multiple organ failure was a major cause in 24% most probably because of the high dosages of cyclosporine. From group C, 23 of 30 patients have survived. In this group the results after heterotopic heart transplantation do not differ significantly from orthotopic transplantation, which justifies this procedure in particular situations. If all heterotopic and orthotopic transplantations are compared, orthotopic procedures have a substantially better outcome. With the modified immunosuppressive regimen (group C) combined with precise donor and recipient selection and more sophisticated rejection monitoring, the actuarial survival rate within the last 12 months is 94%.