Methodist DeBakey cardiovascular journal最新文献

The only curative therapy for end-stage heart failure is orthotopic allogeneic heart transplantation. This therapy has extended the survival of patients worldwide but is limited due to the scarcity of donor organs. Potential alternative donor sources of organs for transplantation include genetically-modified (GM) large animal donors (ie, xenografts) and human organs developed in large animal hosts. These strategies utilize gene editing and somatic cell nuclear transfer technologies to engineer partially or completely humanized organs. Preclinical xenotransplantation studies of GM pig hearts into baboons have already provided an important clinical foundation, as two patients have received cardiac xenografts from GM pigs and have survived for up to 2 months. Additional issues need to be addressed in order for patients to survive more than 1 year, which would make these strategies clinically applicable. Thus, in combination with immunosuppression agents, xenogeneic and exogenic organ sources hold tremendous promise for an unlimited and transformative supply of organs for transplantation.

Oliver Wendell Holmes Sr. (1809-1894) was a poet, essayist, educator, and physician who played an important role in the formation of the American medical establishment. After studying medicine in Paris, Holmes penned what may be his most memorable satirical poem, "The Stethoscope Song," which was first published around 1848. He was a master of stethoscopy and used this ballad to reflect upon the initial resistance to its widespread adoption as well as to give a cautionary tale that auscultation should not replace a thorough medical examination. Holmes was a prominent clinician with important contributions to both medical literature and pedagogy, but he also became a notable author who set a precedent upon which future generations of physician-writers could build.

The evaluation for heart transplantation is a comprehensive endeavor requiring multidisciplinary collaboration. The goal of a heart transplant evaluation is to determine if (1) the patient's cardiac status is limited enough, despite optimal medical therapy, to benefit from heart transplantation; (2) the patient does not have comorbidities that would preclude heart transplantation; and (3) the patient demonstrates compliance and possesses adequate social support. The most common indications for heart transplant are highly symptomatic heart failure with reduced ejection fraction, uncontrolled ventricular arrhythmias, or intractable angina. Extracardiac contraindications require specific considerations regarding whether they will (1) confer mortality risk that will negate the expected improvement in survival after transplantation; (2) affect post-transplant quality of life and hamper rehabilitation efforts; and (3) progress with immunosuppression. With careful and appropriate selection, heart transplant recipients are best positioned to experience the improved quality of life and survival expected after transplantation.

We present a case of a 75-year-old female with a history of idiopathic small fiber neuropathy, essential hypertension, and heterozygous familial hypercholesterolemia who was evaluated for exertional dyspnea and fatigue. Coronary computed tomography angiography demonstrated a 16-mm wide-neck windsock aneurysm of the interventricular septum along with a patent foramen ovale and left-to-right shunting. This case underscores the role of advanced cardiac imaging in detecting rare structural abnormalities.

The prevalence of adult congenital heart disease (ACHD) is increasing, with heart failure being the leading cause of death. For many ACHD patients, heart transplantation is the only treatment option for advanced heart failure, though significant extracardiac involvement may require multi-organ transplantation. Despite the rising number of ACHD transplants, multi-organ transplants in this population remain challenging, and a substantial gap remains between those in need and those who receive a transplant. While short-term outcomes may be worse for ACHD patients, long-term outcomes are comparable and even superior to other cardiomyopathies. Extracardiac organ dysfunction is common in ACHD patients, often precluding heart-alone transplantation. Fontan-associated liver disease, pulmonary vascular and restrictive lung disease, and renal dysfunction frequently necessitate multi-organ transplantation. ACHD patients have a unique immunological and sensitization profile, increasing their risk for infection, rejection, and malignancies, requiring specialized pretransplant desensitization and post-transplant immunosuppression strategies. ACHD transplantation presents unique surgical challenges, including chest reentry, vascular access issues, bleeding risks, extensive anatomical reconstruction, the need for longer vascular segments from donors, and prolonged ischemic times. Decisions regarding heart-alone versus heart-liver, heart-lung, or heart-kidney transplantation demand careful evaluation. These complex surgical plans require extensive multimodal imaging and collaboration with ACHD cardiac imaging specialists and abdominal transplant teams. Comprehensive coordination and psychosocial support are crucial for ACHD patients throughout the transplant process. A dedicated multidisciplinary team and an established and separate pathway for pre-, peri-, and postoperative care in centers with ACHD and multi-organ transplant expertise are essential. There is need for a revised organ allocation system to ensure timely access to transplantation for ACHD patients.

Philip Alexander, MD, is a native Texan, retired physician, and accomplished musician and artist. After 41 years as an internal medicine physician, Dr. Phil retired from his practice in College Station in 2016. A lifelong musician and former music professor, he often performs as an oboe soloist for the Brazos Valley Symphony Orchestra. He began exploring visual art in 1980, evolving from pencil sketches-including an official White House portrait of President Ronald Reagan-to the computer-generated drawings featured in this journal. His images, which first appeared in this journal in the spring of 2012, are his own original creations. If you would like to see your art published in the Methodist DeBakey Cardiovascular Journal, submit your creation online at journal.houstonmethodist.org as a "Humanities" entry.

Heart transplantation is a marvel of modern medicine for patients with end-stage heart failure. Decades of research and surgical innovation have overcome challenges in immunology, organ preservation, and patient care. From the earliest heart transplants on canines and primates, the field evolved through immunosuppressive therapies, development of the bioptome for endomyocardial biopsy and, recently, the use of cell free DNA and molecular microscopy for assessing rejection. Newer developments in organ preservation systems and transport systems bring remarkable increases in the availability of donors.

This overview of the history of human cardiac transplant shares detailed illustrations to demonstrate how surgical procedures have improved since the first human transplant was performed in 1967 in Cape Town, South Africa.

The first heart transplantation in the United States was performed in 1968. The first national heart allocation system was developed two decades later in 1988 as a two-tiered system. Our current heart allocation system, adopted in 2018 as a six-tiered system, is evolving to become a continuous distribution model. Herein, we review the history of the Organ Procurement and Transplantation Network, the evolution of the cardiac allocation system, modern day challenges of the current heart allocation system policy, and the future of transplantation given ongoing implementation of the modernization initiative.

While advances in immunosuppression management have led to excellent 1-year survival after heart transplantation, long-term outcomes remain suboptimal. Contemporary therapies are associated with adverse sequalae, dominated by chronic kidney disease, and concomitantly by the inadequate control of humoral alloimmunity that is tightly linked to cardiac allograft vasculopathy. The dichotomy between the need for less toxicity and better control of humoral alloimmunity has driven a search for more effective regimens and for strategies to reverse humoral responses. This review provides an overview of immunosuppression in heart transplantation, beginning with critical historical context and followed by basic immunological principles underlying contemporary immunosuppression, the evolution of therapies over the past decade, and considerations for strategies to mitigate humoral alloimmunity. Perspective on the state-of-the field in the current era and considerations for future directions are also provided.