Despite advances in immunosuppressive therapy and prolonged graft and patient survival,
infection after
heart transplantation remains problematic. From January 1987 through June 1989, 104
heart transplantations were performed in 100 patients. Immunosuppression induction was by
antilymphocyte globulin for 7 days, with oral
cyclosporine introduced on stabilization of kidney function (day 3).
Steroid therapy was rapidly tapered, and
azathioprine was added only in cases of positive donor crossmatch or
steroid-resistant rejection. No reverse isolation was used. Twenty-two deaths occurred, one from
sepsis. Actuarial survival at 6 months, at 1 year, and at 2 years was 85% +/- 4%, 81% +/- 3%, and 75% +/- 4%, respectively. Fifty-four patients had 81
infections, of which 21 were bacterial; 83% of these episodes were treated. Sixty
infections were opportunistic (85% viral), and only 23% necessitated treatment. Actuarial
infection-free rates (all types necessitating treatment) at 1 month, at 6 months, and at 2 years were 83% +/- 4%, 75% +/- 5%, and 75% +/- 5%, respectively. Of the 100 transplant recipients, 66% were treated with
azathioprine; 47 patients (69%) had an
infection, whereas only seven (19%) of the patients not receiving
azathioprine became infected (p less than 0.00001). Rejection was noted in 66% of patients, with a median time to the first episode of 4 weeks. A low-intensity immunosuppressive regimen has resulted in fewer serious
infections, with acceptable graft loss from rejection. Increased
infection surveillance is required for the first 30 days postoperatively and
after treatment of rejection episodes.