Has the profile of heart transplantation recipients changed within the last three decades?

Heart transplantation remains the most durable treatment for patients with end-stage heart failure refractory to medical treatment. Central elements of the listing criteria for heart transplantation have remained largely unchanged in the last three decades whereas treatment of heart failure has significantly increased survival and reduced disease-related symptoms. It remains unknown whether the improvement of heart failure therapy changed the profile of heart transplantation candidates or affected post-transplant survival. The study investigated a total of 323 heart transplant recipients of the Lausanne University Hospital with 328 transplant operations between 1987 and 2018. Patients were separated into three groups on the basis of availability of heart failure therapy: period 1 (1987-1998; n = 115) when renin-angiotensin system blockade and diuretic treatment were available; period 2 (1999-2010; n = 106) marked by the addition of beta-blocker and mineralocorticoid receptor antagonist treatment in severe heart failure, and the establishment of cardiac defibrillator and resynchronisation therapy; period 3 (2011-2018; n = 107) characterised by the increasing use of ventricular assist devices for bridge to transplantation. The patient characteristics age (all: 53.4 years), male sex (all: 79%) and body mass index (all: 24.5 kg/m2) did not differ between periods. History of arterial hypertension was less prevalent in period 2 (period 1 vs 2 vs 3: 44 vs 28 vs 43%, p = 0.04) whereas other cardiovascular risk factors were equally distributed. Left ventricular ejection fraction, VO2max, and pulmonary vascular resistance were not different between the three periods. The prevalence of ischaemic cardiomyopathy was higher in periods 1 and 3; dilated non-ischaemic cardiomyopathy was more frequent in period 2. Post-transplant 1-year survival was highest in period 3 (1 vs 2 vs 3: 87.2 ± 3.2% vs 70.8 ± 4.4% vs 93.0 ± 2.6%, p always ≤0.02), and the Kaplan-Meier estimates of survivors of the first year post-transplant were not different between the three periods. In descriptive analysis, early mortality was not associated with acknowledged pretransplant predictors of post-transplant mortality. Availability of different medical heart failure treatments did not result in greatly different pretransplant characteristics of heart transplantation recipients across the three periods. This suggests that the maintained central criteria of listing for heart transplantation still identify end-stage heart failure patients with a similar profile. This finding can explain the unchanged overall mortality on condition of 1-year survival across the three periods, since pretransplant characteristics are relevant for long-term survival after heart transplantation

La partie radiologique de l’éthique nucléaire suisse

Les directives officielles de la Confédération suisse (directives R-11) pour la protection des personnes auprès des centrales nucléaires sont reproduites dans le texte en annexe relatif aux objectifs de la protection contre les rayonnements ionisants pour les personnes travaillant dans les centrales nucléaires et pour les personnes du public

Is the rationale behind the new dose limits of ICRP still valid ?

La protection radiologique est basée sur l'hypothèse linéaire attribuant aussi aux faibles doses la capacité potentielle d'induire un détriment sanitaire. La Commission internationale de protection radiologique (CIPR) a publié en 1990 ses dernières estimations du risque radiologique et les recommandations correspondantes. Pour en déduire son coefficient de risque, la CIPR se base surtout sur les observations épidémiologiques des survivants d'Hiroshima et de Nagasaki. En outre, la CIPR a dû prendre en considération le fait que les faibles débits de dose sont, par unité de dose, moins préjudiciables que les hauts débits de dose tels que ceux d'Hiroshima et de Nagasaki. Cette différenciation conduisit à l'introduction du facteur correctif FEDDD (facteur d'efficacité de la dose et du débit de dose) très controversé. La recherche en radiobiologie pendant les 5 dernières années a mis en évidence quelques aspects nouveaux qui modifient légèrement la situation mais qui, globalement, n'invalident pas la base scientifique des recommandations "CIPR 60". Les auteurs estiment donc que la limite principale de dose pour les travailleurs (20 mSv/an) repose sur des bases robustes, et va rester en vigueur pendant de nombreuses années. D'autre part, les auteurs expriment quelques doutes sur une étape du raisonnement conduisant à la limite de dose pour le public qu'ils estiment inutilement basse

Implantation of a HeartMate 3 in a 13-Year-Old Child with Dilated Cardiomyopathy.

Left ventricular assist device is a well-established therapy in heart failure adults, but less in children. A 13-year-old-boy with severe left ventricular dysfunction did not improve under medical treatment. A HeartMate 3 (HM3) was implanted as a bridge to transplantation. Despite the size limitation, the HM3 shows promising results and our case supports its feasibility in children

Case Report: Transcatheter interventional procedure to innominate vein turn-down procedure for failing fontan circulation.

Fontan physiology creates a chronic state of decreased cardiac output and systemic venous congestion, leading to liver cirrhosis/malignancy, protein-losing enteropathy, chylothorax, or plastic bronchitis. Creating a fenestration improves cardiac output and relieves some venous congestion. The anatomic connection of the thoracic duct to the subclavian-jugular vein junction exposes the lymphatic system to systemic venous hypertension and could induce plastic bronchitis. To address this complication, two techniques have been developed. A surgical method that decompresses the thoracic duct by diverting the innominate vein to the atrium, and a percutaneous endovascular procedure that uses a covered stent to create an extravascular connection between the innominate vein and the left atrium. We report a novel variant transcatheter intervention of the innominate vein turn-down procedure without creating an extravascular connection in a 39-month-old patient with failing Fontan circulation complicated by plastic bronchitis and a 2-year post-intervention follow-up