Exercise as a modality to improve heart transplantation-related functional impairments: An article review

Heart transplantation(HT),the treatment choice of advanced heart failure pa-tients,is proven effective in increasing the survival and functional status of the recipients.However,compared to normal controls,functional status is lower in HT recipients.Exercise given in cardiac rehabilitation has been shown to improve exercise capacity as measured with peak oxygen uptake(VO2 peak)and muscle strength after completion of the program and cessation of exercise results in loss of exercise benefits.Several factors related to cardiac denervation and the use of immunosuppressive agents in HT recipients result in functional impairments including cardiovascular,pulmonary,exercise capacity,psychological,and qua-lity of life(QoL)problems.High-intensity interval training(HIIT)is the most common type of exercise used in HT recipients and given as a hospital-based program.Improvement of functional impairments was found to have occurred due to primarily musculoskeletal adaptations through improvement of muscle structure and aerobic capacity and cardiovascular adaptations.In general,exercise given after transplantation improved VO2 peak significantly and improvement was better in the HIIT group compared to moderate intensity continuous training or no-exercise groups.Improvement of QoL was ascribed to improve-ment of exercise capacity,symptoms,pulmonary function,physical capacity improve-ment,anxiety,and depression.

Cellular strategies to induce immune tolerance after liver transplantation:Clinical perspectives

Liver transplantation(LT)has become the most efficient treatment for pediatric and adult end-stage liver disease and the survival time after transplantation is becoming longer due to the development of surgical techniques and perioperative management.However,long-term side-effects of immunosuppressants,like infection,metabolic disorders and malignant tumor are gaining more attention.Immune tolerance is the status in which LT recipients no longer need to take any immunosuppressants,but the liver function and intrahepatic histology maintain normal.The approaches to achieve immune tolerance after transplantation include spontaneous,operational and induced tolerance.The first two means require no specific intervention but withdrawing immunosuppressant gradually during follow-up.No clinical factors or biomarkers so far could accurately predict who are suitable for immunosuppressant withdraw after transplantation.With the understanding to the underlying mechanisms of immune tolerance,many strategies have been developed to induce tolerance in LT recipients.Cellular strategy is one of the most promising methods for immune tolerance induction,including chimerism induced by hematopoietic stem cells and adoptive transfer of regulatory immune cells.The safety and efficacy of various cell products have been evaluated by prospective preclinical and clinical trials,while obstacles still exist before translating into clinical practice.Here,we will summarize the latest perspectives and concerns on the clinical application of cellular strategies in LT recipients.

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation

BACKGROUND Transplant recipients commonly harbor multidrug-resistant organisms(MDROs),as a result of frequent hospital admissions and increased exposure to antimi-crobials and invasive procedures.AIM To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition,as well as the impact of MDRO acquisition on intensive care unit(ICU)and hospital length of stay,and on ICU mortality and 1-year mortality post heart transplantation.METHODS This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period(2013-2022)in a single transplantation center.Data was collected regarding MDROs commonly encountered in critical care.RESULTS Among the 98 transplanted patients(70%male),about a third(32%)acquired or already harbored MDROs upon transplantation(MDRO group),while two thirds did not(MDRO-free group).The prevalent MDROs were Acinetobacter baumannii(14%),Pseudomonas aeruginosa(12%)and Klebsiella pneumoniae(11%).Compared to MDRO-free patients,the MDRO group was characterized by higher body mass index(P=0.002),higher rates of renal failure(P=0.017),primary graft dysfunction(10%vs 4.5%,P=0.001),surgical re-exploration(34%vs 14%,P=0.017),mechanical circulatory support(47%vs 26%P=0.037)and renal replacement therapy(28%vs 9%,P=0.014),as well as longer extracorporeal circulation time(median 210 vs 161 min,P=0.003).The median length of stay was longer in the MDRO group,namely ICU stay was 16 vs 9 d in the MDRO-free group(P=0.001),and hospital stay was 38 vs 28 d(P=0.006),while 1-year mortality was higher(28%vs 7.6%,log-rank-χ2:7.34).CONCLUSION Following heart transplantation,a predominance of Gram-negative MDROs was noted.MDRO acquisition was associated with higher complication rates,prolonged ICU and total hospital stay,and higher post-transplantation mortality.

Induction of immune tolerance with heart-thymus composite allotransplantation in rats

Objective To study on the role of thymus transplantation for heart allograft in rats. Methods Vascularized heart-thymus combined transplantation was performed with microsurgical technique. Graft survival, histopathology, level of IL-2, IL-4 and its mRNA expression in serum and cardiac grafts were investigated. Results Heart-thymus combined transplantation achieved effect in the prolongation of cardiac graft survival with short-term administration of cyclosporine. Conclusions Vascularized thymus transplantation induced immune tolerance in thymectomized rats.

Clinical operational tolerance in liver transplantation:state-of-the-art perspective and future prospects

BACKGROUND:Liver transplantation is the definite treatment for end-stage liver diseases with satisfactory results.However,untoward effects of life-long immunosuppression prevent the development of alternative strategies to achieve better longterm outcome.Achieving clinical operational tolerance is the ultimate goal.DATA SOURCES:A PubMed and Google Scholar search using terms:"immune tolerance","liver transplantation","clinical trial","operational tolerance" and "immunosuppression withdrawal" was performed,and relevant articles published in English in the past decade were reviewed.Full-text publications relevant to the field were selected and relevant articles from reference lists were also included.Priority was given to those articles which are relevant to the review.RESULTS:Because of the inherent tolerogenic property,around 20%-30% of liver transplantation recipients develop spontaneous operational tolerance after immunosuppression withdrawal,and the percentage may be even higher in pediatric living donor liver transplantation recipients.Several natural killer and γδT cell related markers have been identified to be associated with the tolerant state in liver transplantation patients.Despite the progress,clinical operational tolerance is still rare in liver transplantation.Reprogramming the recipient immune system by creating chimerism and regulatory cell therapies is among newer promising means to achieve clinical liver transplantation tolerance in the future.CONCLUSION:Although clinical operational tolerance is still rare in liver transplantation recipients,ongoing basic research and collaborative clinical trials may help to decipher the mystery of transplantation tolerance and extend the potential benefits of drug withdrawal to an increasing number of patients in a more predictable fashion.

Effects of Kanlijian (坎离煎) on Exercise Tolerance, Quality of Life, and Frequency of Heart Failure Aggravation in Patients with Chronic Heart Failure

Objective： To observe the effects of conventional therapy combined with Kanlijian （ 坎离煎, KLJ） on exercise tolerance, quality of life and frequency of heart failure aggravation in patients with chronic heart failure（CHF）. Methods： Sixty CHF patients differentiated as sufferring from the syndrome of Xin-Shen Yang deficiency were included in the study and randomly assigned at the ratio of 2 ： 1 into the KLJ group （n =39） and the control group（n = 21）. All the patients were treated with conventional therapy of Western medicine, but to those in the KLJ group, KLJ was medicated additionally one dose daily with 24 wks as one therapeutic course. The efficacy on TCM syndrome and changes of scores on TCM syndrome were observed after treatment. The indexes, including 6-minute walking distance （6MWD）, quality of life （QOL, accessed by LHFQ scoring）, NYHA grade, hemodynamic indexes and reducing/withdrawal rate of diuretic and digoxin before and after treatment were recorded and compared. Also the frequency of re-admission due to aggravation of heart failure in one year＇ s time were observed. Results： （ 1 ） The efficacy on TCM syndrome, improvement on scores of TCM syndrome, therapeutic effects on 6MWD, QOL, and NYHA grade in the KLJ group were superior to those in the control group. （2） Hemodynamic indexes after treatment, left ventricular fractional shortening （LVFS） and E peak/A peak （E/A）, between the two groups had no significant difference, while left ventricular ejection fraction （LVEF） was increased significantly in the KLJ group, but with no obvious change in the control group. （3） The reducing/withdrawal rate of diuretic and digoxin in the KLJ group was significantly higher than that in the control group. （4） The 1-year frequency of re-admission significantly decreased in the KLJ group. Conclusion： The adjuvant treatment of KLJ on the basis of Western conventional therapy can significantly improve CHF patients＇ exercise tolerance, quality of life and cardiac function, reduce the dosage of diuretic and digoxin needed, and decrease the re-admission frequency due to aggravation of heart failure.

Effect of TGF-β1 on the Expression of IL-12, IL-15, IL-18, IL-4 and IL-10 in Heart Transplantation Rejection in Rats

To investigate the effect of TGF-β1 on the expressions of IL-12, IL-15, IL-18, IL-4 and IL-10 in heart transplantation rejection in rats, a model of rat cervical heterotopic heart transplantation was set up and the model rats were randomly divided into three groups： control group, transplant group and TGF-β1 group. The mRNA expression levels of IL-12, IL-15, IL-18, IL-4 and IL-10 were determined by RT-PCR at the 5th day after the transplantation. The mRNA expression levels of IL- 12, IL-15, IL-18 were increased obviously and those of IL-4, IL-10 were significantly decreased in the transplant group as compared with the control group （P〈0.01）. In the TGF-β1 group, the mRNA ex- pression levels of IL- 12, IL- 15, IL- 18 were significantly decreased and those of IL-4, IL- 10 were significantly increased as compared with the transplant group （P〈0.01）. The immunosuppressive effect of TGF-β1 on heart transplantation rejection was related to its inhibition of the expressions of Th1-type cytokines （IL-12, IL-15, IL-18 etc） and its promotion of the expressions of Th2-tpye cyto- kines （IL-4, IL-10）.

Withdrawal of immunosuppression in liver transplantation and the mechanism of tolerance

BACKGROUND： Immunosuppression reagents have side effects and cause considerable long-term morbidity and mortality in patients after liver transplantation. Sufficient evidences showed that minimization or withdrawal of immunosuppression reagents does not deteriorate the recipient＇s immune response and physiological function and therefore, is feasible in some recipients of liver transplantation. However, the mechanisms are not clear. The present review was to update the current status of immunosuppression in liver transplantation and the mechanism of minimization or withdrawal of immunosuppression in liver recipients.DATA SOURCES： We searched articles in English on minimization or withdrawal of immunosuppression in liver transplantation in Pub Med. We focused on the basic mechanisms of immune tolerance in liver transplantation. Studies on immunosuppression minimization or withdrawal protocols and biomarker in tolerant recipients were also analyzed.RESULTS： Minimization or withdrawal of immunosuppression can be achieved by the induction of immune tolerance, which may not be permanent and can be affected by various factors. However, accurately evaluating immune status post-transplant is a prerequisite to achieve individualized immunosuppression. Numerous mechanisms for immune tolerance have been found, including immunophenotypic shift of memory CD8＋ T cells and CD4＋ T cell subsets. Activation of the inflammasome through apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain（ASC） in dendritic cells is associated with rejection after liver transplantation. CONCLUSIONS： Minimization or withdrawal of immunosuppression can be achieved by the induction of immune toler-ance via different mechanisms. This process could be affected by immunophenotypic shift of memory CD8＋ T cells and CD4＋ T cell subsets, which may be correlated with activation of the inflammasome through ASC in dendritic cells.

Validation of Veterans Specific Activity Questionnaire to assess exercise tolerance of Chinese elderly with coronary heart disease

Objective The Veterans Specific Activity Questionnaire （VSAQ） has been used to assess exercise tolerance. Nevertheless, there is no val- idated Chinese version. The aim of this study is to determine whether a questionnaire-based method using the Chinese version of VSAQ （the modified VSAQ） is a practical tool to assess exercise tolerance of Chinese elderly with coronary heart disease. Methods One hundred thirty consecutive elderly patients who were diagnosed with coronary heart disease （CHD） （mean age 68.9 -4- 6.0 years） referred for treadmill exercise testing （TET） for clinical reasons were included in the study. They were asked to complete a questionnaire for clinical characteristics information on age, sex, history, exercise habits, medications, the original VSAQ and the modified VSAQ. We investigated the relationship between exer- cise tolerance in metabolic equivalents （METs） estimated by VSAQ and that obtained by TET. Results The METs by the original VSAQ and the modified VSAQ did not difference significantly （P = 0.528）. The modified VSAQ scores were significantly correlated with the METs oh- mined by TET （r = 0.819, 95% CI： 0.7534）.873, P 〈 0.01）, and the scores of original VSAQ also correlated with the METs by TET （r = 0.804, 95% CI： 0.7454）.854, P 〈 0.01）. The Bland-Altman graph analysis showed few values outside the limits of agrcement, suggesting good precision between the METs estimated by questionnaire and the METs obtained by TET. Conclusions The Chinese version of the VSAQ confirmed its validity and equivalence to the original version, especially when evaluating individuals with coronary heart disease and older adults. The results showed that the VSAQ is a valuable tool to assess the exercise tolerance.

Effect of ecdysterone on heteroptopic heart transplantation in rats

Objective： To investigate the protective effects of ecdysterone（EDS） on the allograft heart transplant model of rats. Methods： Fifty healthy Sprayue-Dawley（SD） rats were divided into donors and recipients randomly. Hearts were harvested and placed heterotopically into allogenic recipients. All animals were divided into three groups： sham-operation group（only opening and closing the abdomen, n=l 0）, EDS group（injected intraperitoneally with 20 mg/（kg · day） of EDS, n = 10）, and control group （injected intraperitoneally with normal saline, n = 10）. The pathological changes of myocardial tissue were analyzed by light microscopy and transmission electron microscopy and the levels of myocardial enzymes（GOT, LDH, CPK）, SOD, ET-1, NO, MDA in serum were measured. Tissue samples underwent the detection ofapoptotic cell death by in situ terminal deoxyribonucleotide transferase-mediated dUTP nick end labeling for apoptotic index（M） and also by immunohistochemistry method to study the expressions of Bcl-2 and Bax. Results： Pathological examination and transmission electron microscope observation showed greater myocardium damage in the control group. EDS group showed a decrease in the amount of myocardial enzymes, MDA, ET-1 and an increase in the levels of SOD, NO, compared to the control group. The A1 of EDS group became lower than that of control group, meanwhile the EDS group increased the expression of Bcl-2 and decreased the expression of Bax. Conclusion： EDS has protective effects on heteroptopic heart transplantation, which provides a new idea for myocardial protection in heart transplantation. However, the mechanism of its protective effect needs further research.

Left Ventricle Geometry Remolding after Heart Transplantation:A Two-dimensional Ultrasound Study

The function of the transplanted heart will be affected by acute allograft rejection, chronic rejection, high blood pressure and so on, which may induce the reconstruction of the left ventricle and the increase of left ventricular mass （LVM）, and eventually lead to left ventricular hypertrophy that will significantly affect the prognosis of heart transplantation （HT）. The purpose of this study was to dy- namically monitor the changes of left ventricular geometric patterns after HT using two-dimensional echocardiography and to understand the remodeling process and its possible influencing factors. The left ventricular internal diameter, interventricular septal wall thickness, posterior wall thickness at end dias- tole were measured and the relative wall thickness （RWT）, left ventricular mass, left ventricular mass index were calculated respectively in 34 HT patients and 34 healthy volunteers by two-dimensional echocardiography. The type of left ventricular geometry was identified based on the echocardiographic determination of LVM index （LVMI） and RWT. The HT patients were divided into three groups ac- cording to the time length after surgery： A （3 months postoperatively）, B （6 months postoperatively） and C （12 months postoperatively）. We compared the parameters of left ventricle between HT group and normal control group, and explored the risk factors causing the increase of LVM. The results showed that 4 patients （16%） in group A had concentric remodeling. Nine patients （34.62%） in group B had re- construction, including 5 cases of concentric remodeling, 2 cases of concentric hypertrophy and 2 cases of eccentric hypertrophy. The hypertrophy incidence rate was 15.4% in group B. 15 patients （62.5%） had reconstruction in group C, including 9 cases of concentric remodeling, 5 cases of concentric hyper- trophy, and 1 case of eccentric hypertrophy. The prevalence of hypertrophy was 25%. Multivariate analysis showed that hypertension and acute rejection history were the risk factors that resulted in left ventricular hypertrophy. It is concluded that the left ventricular remodeling occurs following cardiac transplantation at an early stage and the incidence of left ventricular hypertrophy increases with survival time. In this study, the one-year prevalence of left ventricular hypertrophy was 25% after surgery. Hy- pertension and acute rejection history are risk factors that can predict the left ventricular hypertrophy.

Exercise training in heart transplantation

Heart transplantation remains the gold standard in the treatment of end-stage heart failure(HF).Heart transplantation patients present lower exercise capacity due to cardiovascular and musculoskeletal alterations leading thus to poor quality of life and reduction in the ability of daily self-service.Impaired vascular function and diastolic dysfunction cause lower cardiac output while decreased skeletal muscle oxidative fibers,enzymes and capillarity cause arteriovenous oxygen difference,leading thus to decreased peak oxygen uptake in heart transplant recipients.Exercise training improves exercise capacity,cardiac and vascular endothelial function in heart transplant recipients.Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation in order to maintain a higher fitness level and reduce complications afterwards like intensive care unit acquired weakness or cardiac cachexia.All hospitalized patients after heart transplantation should be referred to early mobilization of skeletal muscles through kinesiotherapy of the upper and lower limbs and respiratory physiotherapy in order to prevent infections of the respiratory system prior to hospital discharge.Moreover,all heart transplant recipients after hospital discharge who have not already participated in an early cardiac rehabilitation program should be referred to a rehabilitation center by their health care provider.Although high intensity interval training seems to have more benefits than moderate intensity continuous training,especially in stable transplant patients,individualized training based on the abilities and needs of each patient still remains the most appropriate approach.Cardiac rehabilitation appears to be safe in heart transplant patients.However,long-term follow-up data is incomplete and,therefore,further high quality and adequately-powered studies are needed to demonstrate the long-term benefits of exercise training in this population.

Long-term survival following heart transplantation is possible

Objective:To determine whether long-term survival(>10 years) after heart transplantation is possible and identify complications influencing long-term survival.Methods:We analyzed clinical outcomes in the group of 21 patients who had undergone heart transplantation at the Second Affiliated Hospital of Harbin Medical University since 1992 and 4 of them survived more than 10 years.Results:Nine patients are still alive with normal left ventricular function,and 4 of them have survived more than 10 years.The longest survival patient has lived more than 18 years after transplantation,whose survival is the longest in China and in Asia.We have also found that there has been a high incidence of complications,such as rejection episodes during the first 6 months,and transplant vasculopathy in the long-term survival patients.Conclusion:Long-term survivors maintain normal hemodynamic function of their allografts,and long-term survival following cardiac transplantation is possible.Aggressive preventive and therapeutic measures are essential to limit the risk factors for development of complications such as rejection episodes and transplant vasculopathy,and enable long-term survival after cardiac transplantation.

Nerve allograft regeneration and immunological tolerance of rats with sciatic nerve transplantation after intragastric pretreatment with ultraviolet B-irradiated donor splenocytes

BACKGROUND： Nerve allograft rejection is an unavoidable problem for nerve allografts. Traumatic peripheral nerve injuries are commonly reconstructed using autogenous nerve grafts. However, this form of reconstruction is limited by insufficient autologous nerves for large gap repairs and by morbidity at the nerve donor site. OBJECTIVE： To examine sciatic nerve regeneration and immune tolerance reaction after intragastric administration of ultraviolet B-irradiated （UVB） donor splenocytes. DESIGN, TIME AND SETTING： A complete randomized grouping design and controlled experiment. The experiments were conducted in the Department of Orthopedics, the First Affiliated Hospital to Shanxi Medical University, China, between March and October 2007. MATERIALS： Fourteen adult male SD rats and fourteen male Wistar rats, weighing 250-300 g, were randomly matched as donors and acceptors. A further seven male SD rats （weight 250-300 g, age 12-16 weeks） were used for nerve isografts. Immune preparations and the Epics XL flow cytometer were purchased from B-D Company, USA. A computer-assisted electromyograph machine was provided by Keypoint P, Dantel Company, Denmark. METHODS： Splenocytes from Wistar rats were isolated, purified, and cultured, and then irradiated with ultraviolet B. In the first control group （Group 1）, the SD rats received a syngeneic SD nerve isograft. In the second control group （Group 2）, the SD rats received a nerve allograft from Wistar rats without pretreatment. In the oral-tolerance treated group （Group 3）, the SD recipient rats were inoculated with 2.5×10^7 Lewis UVB-irradiated donor splenocyte cells by intestinal tract administration at seven days before transplantation. MAIN OUTCOME MEASURES： （1） The recent end and the middle and distal end of the transplanted nerve were cut at 8 and 12 weeks after operation. Recovery of nerve regeneration was measured with HE staining using the total number, density, and diameter of the nerve fibers. （2） The level of CD25＋T lymphocytes in peripheral blood was detected with the Epics XL flow cytometer at one week after operation. （3） The bilateral sciatic nerves were exposed from the sciatic notch up to 0.5 mm beyond the distal graft site at eight weeks post-engraftment. Bipolar platinum stimulating electrodes were placed under the sciatic nerve proximally and the mean conduction velocity was recorded with recording electrodes on the posterior tibial nerve at 0.3 cm distal to the nerve graft. RESULTS： Eight weeks after operation, total axon number and fiber density in Group 3 were higher than that in Group 1 （P 〈 0.05）, neural regeneration in Group 3 was lower than that in Group 1 （P 〈 0.05） , The level of CD25＋T lymphocytes in peripheral blood of Group 3 was significantly lower than that of Group 2 （P 〈 0.05）. There was no significant difference between Group 3 and Group 1 （P 〉 0.05）. At eight weeks post-engraftment the mean conduction velocity of Group 3 approximated that of Group 1. The untreated allografts in Group 2 demonstrated no measurable recovery of conduction velocity. CONCLUSION： Pretreatment with a single intragastric dose of UVB-modified donor antigen specifically induced tolerance to peripheral nerve allografts in rats.

Orthotopic heart transplantation with prolonged donor ischemic time:report of 3 cases and literature review

Heart transplantation has become an effective therapy for patients with end stage heart failure. The preservation of the donor heart is an important factor that affects the results of the operation. We performed 3 cases of orthotopic heart transplantation and obtained some experience in the preservation of the donor heart. Methods： Three male patients with end stage heart failure received the operation in our department successfully. Doppler echocardiography showed left ventrieular end diameter （LVED） of the patients were 91, 87, and 83 mm, and ejection fraction （EF） were 24%, 20%, 12.9%, respectively. Once the declaration of brain death had been made, the median stemotomy was performed with a sternal saw. Haparin at a dose of 300 U/kg of body weight was administered. After at least 2-min heparin circulation, the procurement proceeded. The superior vena cava and the inferior vena cava were nearly completely divided. When the heart was empty, the ascending aorta was cross-clamped and the St. Thomas solution was infused by gravity. The heart was excised by transection of the inferior vena cava, the superior vena cava and all pulmonary veins. After donor heart was removed, it was infused with University of Wisconsin （UW） solution by gravity at a temperature of 4-6℃, then placed in UW solution for storage during transportation. The temperature of solution was maintained at about 4-6℃. The ischemic times of donor heart were 9, 8 and 6 h, respectively. The bicaval anastomotic heart transplantation was adopted. The left atrial anastomoses were constructed using 3.0 polypropylene. The inferior vene cava anastomosis was constructed, the donor and native aorta were cut to an appropriate length. Then the aorta and main pulmonary artery anastomosis were performed respectively. The superior vene cava anastomosis was usually constructed during the rewarming phase. The intraoperative course with a cardiopulmonary bypass of the 3 patients was 96, 44 and 49 min, respectively. Standard triple immunosuppression therapy was commenced in the immediate post-operative period. Results： The operation procedure was smooth and no perioperative death occurred. The follow-up was carried out carefully. The patient＇s condition was fine in 25, 30 and 32 months after operation. The blood pressure was 130/90, 140/95 and 120/80 mmHg, respectively, and LVED was 51, 49 and 53 mm; EF was 50%, 54% and 60%, respectively. Cardiothoracic ratio was 0.63, 0.55, and 0.64, respectively. Conclusion： Preservation time of donor heart with St. Thomas solution infusion and UW solution storage at 0-4℃ may exceed 6 h, and receive comparable middle-term outcomes.

Exploring the Experiences of Chinese Patients Waiting for Heart Transplantation

Background: Patients waiting for heart transplantation (HT) have complex physiological and psychosocial problems. Factors such as psychological state, behavior, social relationships, and cultural background of patients influence the HT process, such as causing psychotic disorder, difficult decision and close dependence. Care during the waiting period needs to be aimed at not only treating the symptoms but also the specific status. Purpose: To describe the physical and psychosocial experiences of the patients waiting for HT in one general hospital in the northern part of China. Methods: A qualitative approach was used in this study. Fifteen patients waiting for HT were selected based on purposive sampling, and semi-structured interviews were carried out. Results: In the analysis process, reported experiences of the participants were categorized into five main themes as follows: 1) feeling the impact;2) uncertainty about the future;3) difficult to make decisions;4) negative emotions and 5) request support. Conclusion: This study provides an in-depth description of patients waiting for HT who haveexperienced many physical, psychosocial, and familial problems due to disease and their cultural background. It found that Chinese patients have some special experiences due to their psychosocial background. This study suggests that nurses should focus on not only physical but also psychosocial problems of these patients, and provide understandings to develop more effective strategies to solve their problems. Relevance to Clinical Practice: This study focused on the special patients who are waiting for heart transplantation, and got the special results about the feelings and experiences. The results can help the doctors and nurses to help the patients pass the special period smoothly.

Cardiac rehabilitation in a heart failure patient after left ventricular assist device insertion and subsequent heart transplantation:A case report

BACKGROUND Insertion of a left ventricular assist device(LVAD)and heart transplantation(HT)improve the survival of patients with heart failure.In addition,cardiac rehabilitation(CR)further increases the functional capacity.This case report describes a successful case of CR after LVAD insertion and subsequent HT.CASE SUMMARY In the present case,during the LVAD insertion period,peak oxygen consumption(VO2)increased by 12.16%after CR.HT was performed 7 mo after the LVAD insertion,and the patient participated in phases I and II CR.The peak VO2 increased from 17.24 to 22.29 m L/kg/min.This improvement was more significant than that reported in previous studies on CR after LVAD insertion or HT.The patient’s quality of life also improved.The total average score of the short form-36 questionnaire increased from 29.5 points at admission to 53.3 points 9 mo after HT.CONCLUSION A tailored CR program after LVAD insertion or HT may improve the patients’quality of life and increase survival.

Patients 60 Years of Age and Older Should Have the Same Chance for Heart Transplantation or Not?

Heart transplantation is considered the best treatment modality for advanced heart disease. While old age has conventionally been considered a contraindication for heart transplantation due to the reported adverse effect of advanced age, however donor hearts＇ shortage continues to stimulate the discussion about the recipient＇s upper age limit. Our study was based on a retrospective analysis for the results of 52（18%） patients aged 60 years and older undergoing heart transplantation between May 2008 and December 2015, and these patients were compared with 236（82%） adult recipients who were younger than 60 years at the time of transplantation and during the same period. In older group, 71% were males with the mean age of 63.38±3.55 years, and in younger group, 83.4% were males with a mean age of 43.72±11.41 years（P=0.27）. Dilated cardiomyopathy was the most common indication for transplantation among patients in both groups（P=0.147）. In older group, the 3-month survival rate was higher than that in younger group（P=0.587）, however the 6-month survival rate showed no significant difference（P=0.225）. Although the 1-year survival rate was higher in older group（P=0.56）, yet the 3-year survival rate between the two groups showed no statistically significant difference（P=0.48）. According to our experience among older heart transplant candidates who were 60 years and older, we believe that advanced age should not be an excluding criterion to cardiac transplantation.

Type A aortic dissection following heart transplantation:A case report

BACKGROUND Cardiac transplantation is considered the standard treatment for refractory endstage heart failure.Worldwide,5074 heart transplantations were performed in 2015.About 100 heart transplants are performed at the authors’center each year.The usual complications of heart transplantation include graft rejection,infection,and graft dysfunction.Aortic dissection after heart transplantation is very rare and is a serious complication that requires a hybrid procedure.CASE SUMMARY A 58-year-old female patient was admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in July 2020 because of unprovoked low back pain without precipitating causes.Magnetic resonance imaging and computed tomography angiography showed type A aortic dissection with an aberrant right subclavian artery.After admission,urapidil was used to control blood pressure.Ten days later,the patient underwent ascending aortic and aortic arch replacement,subclavian artery reconstruction,and endovascular repair of abdominal and thoracic aortic aneurysms.A cardiopulmonary bypass was established through the right femoral artery and femoral vein.The aberrant right subclavian artery,innominate artery,left common carotid artery,and left subclavian artery were blocked,and the left and right common carotid arteries were cannulated for bilateral cerebral perfusion.CONCLUSION The right axillary artery could not be selected for cardiopulmonary bypass intubation because of aberrant right subclavian artery.

Application of Six-minute Walk Test in Heart Transplantation Patients

Objectives To analyze the six-minute walk test （6MWT） and gas exchange of 5 heart transplantation patients and to approach the variation tendency of exercise tolerance, oxygen uptake （ VO2 ） and heart rate chronotropic response. Methods 5 cases of heart transplantation patients （ age 25 - 52 years） were undertaken 6MWT 6 - 30 months after operation, synchronizing gas exchanging parameters were measured by wireless portable remote sensing K4B^2 gas analyzer, 51 normal controls were compared. Results The six-minute walk distance （6MWD） of 5 patients were （592.6 ± 26.7 ） m （558 - 625 ） m, the ascending tendency during exercise was slower, the maximum heart rates were 80% ± 6% of age-predicting maximal heart rate, lower than normal control （86%） ; the end point VO2/kg were （21.8 ± 1.4 ） mL/min · kg （ 19. 94 - 23.60） mL/min · kg. Conclusions The 6WMD and VO2 of 5 patients reached normal range, but the heart rate chronotropic response and VO2 ascending tendency were slower than those of normal controls.