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Key Concepts

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  • Epidemiology

    • Heart failure increases as the population ages and becomes increasingly obese. It can be acute or chronic, and systolic or diastolic.

  • Pathophysiology

    • Heart failure may result from untreated hypertension or a myocardial infarction. Viruses may have caused idiopathic dilated cardiomyopathies. Hypertrophic cardiomyopathy is less common. Infiltrating cardiomyopathies also occur.

  • Clinical features

    • Left-heart failure is manifested by shortness of breath, cough, and fatigue. Right-heart failure is responsible for right upper quadrant abdominal discomfort from a congested liver and peripheral edema. Ascites occurs later.

  • Diagnostics

    • Patient with heart failure are evaluated by echocardiography, and right and left cardiac catheterization. Coronary angiography is still the gold standard for evaluating coronary artery disease.

  • Treatment (medical/surgical)

    • Heart transplantation is reserved for patients who are failing medical management and are not thought to have a life expectancy of greater than 2 years. It can be done after the patient has been bridged with a left ventricular assist device (LVAD).

  • Outcomes/prognosis

    • The median survival after cardiac transplantation is 10 years. The mortality rate after 1 year is 3 to 4 percent/year.

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Theodore Billroth could never have imagined that one day cardiac transplantation would be a viable clinical entity. First, surgical techniques needed to be developed. The operation had to be reproducible. Myocardial protection was crucial. The heart was not so important to the organism that the organism would not reject it.1 Over the course of the 20th century cardiac transplantation evolved from an experimental heterotopic model, where a puppy heart was placed in the neck of an adult mongrel dog, to an orthotopic operation where over 4400 heart transplants were performed in 1994.2 Unfortunately, the number of donor hearts are not such that everyone with end-stage heart failure can be treated with transplantation. This has given rise to the evolution of mechanical circulatory assist devices that can be placed in patients to at least postpone cardiac transplantation.

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Since cardiac transplantation became a clinical entity on December 3, 1967, well over 89,000 heart transplants have been performed.3 Records have been collected by the International Society for Heart and Lung Transplantation in the form of a Scientific Registry since 1983. It has been interesting to watch the field evolve over the past 46 years. Over that course of time, decreased lengths of stay and increased ages of the donor and recipient have been realized.4 Recipient waiting list times have increased dramatically, as have times before first rejection episodes.

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Historical Background

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Alexis Carrel and Charles Guthrie performed the first documented cardiac transplant in 1905 at the University of Chicago. The heart of a small dog was transplanted into the neck of an adult mongrel dog. Mann performed a heterotopic cardiac transplant in 1933.5 A canine heart was sewn into the carotid-jugular circulation. The explanted heart revealed dense infiltration of the heart by lymphocytes, large mononuclear cells, and polymorphonuclear cells. It was cellular ...

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