ALZHEIMER'S DISEASE: BEST MEDICINE AND TREATMENT

A progressive disease of brain is Alzheimer’s Disease (AD). The characteristics of this disease include memory impairment and disturbance in thinking functionality. According to scientists, the cause of the disease is either accumulation or increased production of specific protein that leads to death of nerve cells.

Treatment for Alzheimer’s Disease

Prescription drugs or medications are helpful in treating AD. Medication is useful for treating behavioral, physical and psychological changes that occur due to this degenerative disease.

US Food and Drug Administration approves five drugs for treating AD. These drugs include: Exelon, Cognex, Razadyne, Aricept and Namenda. These drugs can have side effects and research is going on to test its effectiveness. These drugs do not give positive results to some people while on some others it gives significant effects.

Working of Prescription Drugs

Cholinesterase Inhibitors drugs include Exelon, Cognex, Razadyne and Aricept. In the brain, they delay the breakdown of acetylcholine. For communication between nerve cells, acetylcholine is helpful and is important for memory.

Pharmaceutical Effects

In early stages of AD Exelon, Razadyne and Aricept are effective. For slowing down the degeneration of cognitive symptoms, these prescription drugs are effective. People exhibiting behavioral problems due to AD get relief from these drugs. The use of these drugs improves the quality of life.

Namenda (mematine)

Namenda is N-methyl D-aspartate, which acts on another nerve message transmitter known as glutamate. This drug protects brain from glutamate as it contributes in the death of brain’s nerve cells in people suffering from Alzheimer’s disease. The use of this drug is effective in severe and moderate forms of AD. The improvement of the life of people suffering from AD is visible within few weeks by the use of this drug.

Side Effects of Drugs

Namenda – Headache, dizziness, skin rash, confusion and constipation are the major side effects. Some lesscommon side effects include back pain, insomnia, vomiting, fatigue, hallucinations, high blood pressure and shortness of breath.

Exelon Upset stomach, vomiting, fatigue, nausea and weight loss are some side effects. Dizziness, abdominal pain, tremor, sweating, psychiatric disturbance, diarrhea are some of the less common effects. Gastro intestinal bleeding may occur due to the drug.

Razadyne – If you are taking the drug for the first time you may commonly feel weight loss, nausea, appetite loss, vomiting. Headaches, urinary tract infections, tremor, dizziness, runny nose, blood in urine are some less common effects.

Aricept – Nausea, fatigue, muscle cramps are common effects. Rarely gastric or duodenal ulcers, liver damage, bladder overflow obstruction etc occurs.

Cognex – This is less commonly used as it can cause liver damage. Seizures, heart problems are serious side effects.

Make sure that you consult your doctor and do a lot of research before starting these medicines.

BIPOLAR DISORDER: RISK FOR SUICIDE

Bipolar Disorder and Risk for Suicide
It is important to note that an estimated 15% to 20% of patients who suffer from bipolar disorder and who do not receive medical attention commit suicide. The risk is greater in the following individuals:
•In a 2001 study of bipolar disorder I disorder, more than 50% of patients attempted suicide; the risk was highest during depressive episodes.
•Some studies have suggested that the risk with bipolar disorder II patients is even higher than it is in patients with bipolar disorder I or major depression disorder
•Patients with mixed mania, and possibly when it is marked by irritability and paranoia, are also at particular risk.
•Many young pre- and early adolescent children with bipolar disorder are more severely ill than are adults with the disease. According to a 2001 study, 25% of children with bipolar disorder are seriously suicidal. They have a higher risk for mixed mania (simultaneous depression and mania), multiple and frequent cycles, and a long duration of illness without well periods.


Rapid cycling, although a more severe bipolar disorder variation, does not appear to increase the suicide risk for patients with bipolar disorder.

Thinking and Memory Problems in Those With Bipolar Disorder
A 2000 study reported that bipolar disorder patients had varying degrees of problems with short- and long-term memory, speed of information processing, and mental flexibility. Medications used for bipolar disorder, however, could have been responsible for some of these abnormalities and more research is needed to confirm or refute these findings.

Behavioral and Emotional Effects of Manic Phases on the Patient
A small percentage of bipolar disorder patients demonstrates heightened productivity or creativity during manic phases. More often, however, the distorted thinking and impaired judgment that are characteristic of manic episodes can lead to dangerous behavior, including the following:
•A person may spend money with abandon, causing financial ruin in some cases.
•Angry, paranoid, and even violent behaviors are not uncommon during a manic episode.
•Some people are openly promiscuous.
Often such behaviors are followed by low self-esteem and guilt, which are experienced during the depressed phases. During all stages of the illness, patients need to be reminded that the mood disturbance will pass and that its severity can be diminished by treatment.

Bipolar Disorder and Substance Abuse
Cigarette smoking is prevalent among bipolar patients, particularly those who have frequent or severe psychotic symptoms. Some experts speculate that, as in schizophrenia, nicotine use may be a form of self-medication because of its specific effects on the brain; further research is necessary.

Up to 60% of patients with bipolar disorder abuse other substances (most commonly alcohol, followed by marijuana or cocaine) at some point in the course of their illness.

The following are risk factors for alcoholism and substance abuse in bipolar disorder patients:
•Having mixed-state episodes rather than ones of pure mania.
•Being a man with bipolar disorder.
Effects of Untreated Bipolar Disorder on Loved Ones
Patients do not work out their negative behaviors (e.g., spending sprees or even becoming verbally or physically aggressive) in a vacuum. They have a direct effect on others around them. It is very difficult for even the most loving families or caregivers to be objective and consistently sympathetic with an individual who periodically and unexpectedly creates chaos around them.

Many patients and their families, therefore, cannot admit that these episodes are part of an illness and not simply extreme, but normal, characteristics. Such denial is often strengthened by patients who are highly articulate and deliberate and can intelligently justify their destructive behavior, not only to others, but also to themselves.

Often family members feel socially alienated by the fact of having a relative with mental illness, and they conceal this information from acquaintances. (This is particularly true if the patient is female and lives away from home.) People with more education are more likely to feel ostracized by their acquaintances than are those with less education.

Economic Burden
The economic burden of bipolar disorder is significant. In 1991, the National Institute of Mental Health estimated that the disorder cost the country $45 billion, including direct costs (patient care, suicides, and institutionalization) and indirect costs (lost productivity and involvement of the criminal justice system). In spite of the obvious need for professional help, access to medical therapies is not always available for patients with bipolar disorder. In one major survey, 13% of patients had no insurance and 15% were unable to afford medical treatment.

Bipolar's Association with Physical Illnesses
Diabetes. Diabetes is diagnosed almost three times more often in people with bipolar disorder than it is in the general population. A 2002 study reported that 58% of bipolar patients were overweight, with 26% meeting the criteria for obesity. Being overweight is a significant risk factor for diabetes and so it may be the common factor in both diseases. Drugs used to treat bipolar also pose a risk for weight gain and diabetes. Common genetic factors have also been implicated in diabetes and bipolar disorder, including those causing a rare disorder called Wolfram syndrome and those that regulate carbohydrate metabolism.

Migraine Headaches. Migraines are common in patients with a number of mental illnesses, but they are particularly common among bipolar II patients. In one study, 77% of bipolar II patients had migraines while only 14% of bipolar I had this headache, suggesting that difference biologic factors may be involved with each bipolar form.

Hypothyroidism. Hypothyroidism (low thyroid levels) is a common side effect of lithium, the standard bipolar treatment. However, evidence also suggests that bipolar patients, particularly women, may be at higher risk for low thyroid levels regardless of medications. It may in fact be a risk factor for bipolar disorder in some patients.

MANAGING CHRONIC PAIN: OVER THE COUNTER MEDICINES

Chronic pain — what can I do?

Chronic or persistent pain is when pain occurs most days of the week, for at least a three month period. About 1 in 5 Australians suffer from chronic pain and it most commonly occurs in older people.

People experience pain differently and will have different responses to pain treatment. There are many ways to manage pain. You need to find the one that works best for you.

Managing pain involves strategies that help you reduce the impact of pain on your daily activities. It may include individually tailored exercises, performing activities that are within your pain tolerance and using pain relief medicines.

If you need a pain relief medicine, you may purchase it over the counter or get a prescription from your doctor. It is important to see your doctor, who can review your medicines, recommend options and help you decide what is best for you.

Using over-the-counter medicines

There are a range of pain relief medicines that can be bought without prescription as over-the-counter pain relievers, including paracetamol and aspirin. One of the most commonly used is paracetamol, which is effective for mild to moderate pain, if used correctly. When you take paracetamol, check that none of your other medicines contain the same active ingredient, as it can cause serious liver damage if taken in larger doses than recommended.

Speak to your doctor or pharmacist about the best options for you before buying any over-the-counter medicines. This is particularly important if you suffer from any other medical conditions, such as stomach, kidney, liver or heart problems.

To ensure the safest and most effective pain management from these medicines, talk to your doctor or pharmacist about:

• the location of the pain and how long you have had it
• possible side effects
• whether a particular pain management approach is right for you
• whether the medicine will interact with any other medicines you are taking.

When pain is caused by osteoarthritis, some people use glucosamine and/or chondroitin. However, the long-term benefits are unclear. If you use an over-the-counter medicine you should tell your doctor and pharmacist as it may affect other medicines you are taking. Add it to your Medicines List to help you keep track of your medicines. You can print the Medicines List form from our website. A consumer medicine information (CMI) leaflet gives you important facts to know before, during and after taking your medicine. Ask your pharmacist or doctor for the CMI for your medicine.

Using other pain relief medicines

• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should be used at the lowest dose that improves your symptoms and only be used for a short time. These medicines may not be suitable for people with stomach troubles, heart problems, kidney impairment, high blood pressure or asthma.
• Combination pain relievers contain more than one active ingredient. Examples include Nurofen Plus, which is a combination of ibuprofen and codeine; Aspalgin, which is a combination of aspirin and codeine; or Codalgin that is a combination of paracetamol and codeine. Check with your doctor or pharmacist before using these.
• Opioids include buprenorphine, codeine, fentanyl, morphine, oxycodone and tramadol. These medicines may be addictive and may have side effects such as nausea and vomiting. Due to their sedative effect, your driving abilities might be impaired. Never mix alcohol with opioids. For some people opioids are effective in controlling pain but others may not be able to tolerate them. 

Your checklist for pain management medicines

There are a number of important things to talk to your doctor or pharmacist about when working out the best pain medicine for your individual circumstances and preferences:

• Should I take this medicine at regular intervals or only when I feel pain?
• How long will it take to work?
• Is it safe to use in the long term?
• How will this medicine benefit me?
• Will this medicine make me feel drowsy?
• What side effects should I expect or watch out for?
• What can I do to minimise any side effects?
• How will this medicine interact with my other medicines?
• Could I become addicted to this medicine?
• What should I do if the pain doesn’t go away?
• What alternative kinds of pain medicine or management could I consider?

Non-medicine treatments

You need to find the right treatment for your individual needs. You may consider seeing a physiotherapist, chiropractor or other allied healthcare professional who may be able to help reduce and/or manage the pain. Keeping active may prevent or reduce the likelihood of further pain. You may find it useful to participate in support or self-help groups, where you can share experiences and learn about ways to manage pain from others in similar situations.

Talk to your doctor about a pain management plan.

CONSUMER'S MEDICINE INFORMATION

Consumer Medicine Information (CMI) is designed to inform consumers about prescription and pharmacist-only medicines. It provides information about a medicine and is written by the pharmaceutical manufacturer.

A CMI gives you important facts to know before, during and after taking your medicine.

The content of a CMI is defined by legislation and includes headings such as how to take your medicines, side effects and a description of the product. The legislation ensures the leaflet is accurate, unbiased and easy to use.

How do you use it?

Be sure to check that the brand name (usually in largest text) on your medicine exactly matches with the leaflet, to ensure you've chosen the right one.

Read the entire CMI before taking a new medicine, or to learn more about a medicine you're already taking, to ensure you get the best and safest use of the medicine.

Take it with you to your doctor or pharmacist to discuss any questions about medicines.

Keep it handy so you can refer to it later.

Don't use it to try and diagnose, treat, cure or prevent illness yourself.

Where else can you get a copy?

Ask your pharmacist or doctor and they will print it from their computer.

Contact the Medical Information Department of the pharmaceutical manufacturer of your medicine. Find their number in the phone book.

Sometimes you get the Consumer Medicine Information leaflet inside the medicine packet or box.

Sometimes you can find the CMI inside the packet or box. If not, you can:

• search the name of your medicine above and download it from this website
• call Medicines Line on 1300 633 424 for the cost of a local call. You can ring Mon – Fri, 9am – 5pm, Eastern Standard Time
• ask your pharmacist or doctor and they will print it from their computer
• contact the Medical Information Department of the pharmaceutical company that made your medicine. Find their number in the phone book.

RADIATION: SIDE EFFECTS ON HUMAN BODY

Radiation Side Effects

The radiation side effects experienced by the normal body tissues during and after radiotherapy can be loosely divided into Acute and Late effects.

Acute radiation side effects constitute the acute reaction occurring during radiation and in the immediate weeks and months following treatment.

Acute Radiation Side Effects

Radiation treatment is painless and without sensation, with the exception of some mechanical sounds produced by the treatment machine associated with the start and finish of the treatment. Many patients receiving radiation therapy will experience very little reaction, but in most the normal tissues will develop some degree of radiation reaction. This varies in amount and type, depending on the part of the body treated and the amount of normal tissue included in the radiation treatment.

The degree to which individuals experience reaction varies considerably, but this section will deal with some general principles of radiation reaction. Where large areas of a patient are treated, such as the whole abdomen or chest, the reaction experienced will be mainly of a general nature. When small areas are treated the reaction will be confined to that area of the body that is radiated and to the individual tissues included in the treatment volume. Any general reaction will be much less or absent altogether.

General Side Effect Symptoms

Radiation Nausea. The degree to which patients experience nausea following treatment is very variable. Some people will experience hardly any at all, whereas others will be troubled by nausea or vomiting during the early part of the treatment and, in some instances, throughout the treatment. If it occurs, nausea is likely to be worst from two to several hours after treatment. The patient should be encouraged to maintain fluid intake.

The following dietary steps may prove helpful:

1.Salty foods or ice cold drinks help control nausea
2.Avoid greasy foods, strong-smelling or overly sweet foods
3.Small, frequent meals eaten slowly

If insufficient, anti-nausea medication may be prescribed. In most patients nausea improves as the treatment progresses.

Hair Loss. Hair loss will only occur within the radiation field. Scalp hair will only be affected if the head receives radiation.

Fatigue / Malaise. Some degree of tiredness and lack of energy is often experienced. This will not prevent most people from working or undertaking normal duties but, in some, reduction in activities during treatment and immediately afterwards will be advised.

Low Blood Count. Reduction in certain elements of the blood is often seen following radiation therapy. This results from radiation exposure of bone marrow, and to a lesser extent, direct damage to lymphocytes in the blood stream and lymph nodes.

The white cell count will be reduced, particularly the lymphocyte count, and the number of platelets will be reduced. These drops are seldom enough to cause clinical problems, but if they are, an interruption in treatment for a few days is usually sufficient to allow recovery. Reduction in red cells does not occur to any degree in radiation treatment, but may occur from blood loss due to bleeding.

Changes in the peripheral blood count are much more marked in patients who have also received chemotherapy.

Organ Specific Side Effect Symptoms

Localized reactions will occur in any tissues exposed to radiation treatment. The acute reactions expected for different treatments will be considered later, but in general acute reactions result from radiation of skin, mucous membranes and accessory glands.

Skin. Where the skin receives a significant dose of radiation a reaction will develop which progresses through erythema to dry desquamation and moist desquamation. The reaction may only progress part way through these steps and healing occurs through the same steps in reverse. If desquamation has occurred, crusts will form which protect the re-epithelialisation occurring underneath and will only come away and not reform when the skin is healed underneath.

The reaction develops two or three weeks after the initiation of treatment and may take four to six weeks to heal. It is best managed by:

1. Avoiding irritation from clothing, deodorants, perfumes, heat, dust and trauma
2. Best of all, leaving the area open to the air
3. Using non-stick dressings
4. Opinions vary about moisture. If the area is bathed, dry carefully, do not rub or inflame with soaps, and dust with corn starch
5. Steroid creams may help
6. Hair loss may be temporary or permanent, depending on the amount of radiation. Hair loss only occurs in skin exposed to radiation treatment
7. Avoid direct sunlight on the treated area
8. Have patience, the reaction will heal

Mucous Membranes. Wherever mucous membranes are included in a radiation field similar reactions will be experienced: Whether in the mouth, pharynx, esophagus, trachea, bowel, bladder or rectum, mucositis may develop.

As with the skin, the mucosa is reddened at first but then may be covered with a plaque-like fibrin similar to crusting of the skin. The mucous membrane remains moist and the surface covered by fibrin until the underlying mucosa is healed, when the fibrinous plaque is lost and the reaction healed.

The symptoms resulting from the inflammation, irritation and dysfunction caused by the mucosal reaction depend on the site of the reaction. There may be discomfort and dysphagia or cough, hoarseness and tracheitis, or dysuria and frequency, or diarrhoea and abdominal cramps. The management varies from site to site, but depends on the same principles as the care of skin reaction.

1. Avoid irritation by keeping food or stools soft and preventing trauma of any kind.
2. Local analgesic mixtures, antibiotics where indicated, and steroids may help.
3. Maintain hydration by encouragement and intravenous fluids if necessary.
4. Low fibre diet for those with bowel reaction.
5. Best of all, have patience, the reaction will heal.

Accessory Glands. The acute effects of radiation will be felt by accessory glands producing saliva and mucous for example. This leads to a degree of stickiness, leading to oral discomfort, dryness and change in taste, irritating cough and discomfort, and urinary or bowel symptoms, depending on the site of radiation.

Management consists of providing replacement lubricants such as frequent small drinks, adequate urinary and bowel fluid, cough suppressants, soothing creams or lotions and patience.

Late Radiation Side Effects

The late effects of radiation treatment develop gradually over several months or years. The changes that result may be sufficiently slight as to cause no clinical symptoms, or so rare as to present minimal risk to the individual. Nevertheless, the late changes that do occur warrant notice and care in all patients who have received radiation treatment. In those few individuals with serious late effects (generally less than 5% of patients who have received high-dose radiation) the results are often disastrous and treatment extremely difficult.

Scarring. Radiation treatment results in increased connective tissue, fibrosis and scarring often associated with atrophy of accessory tissues. This leads to some increased rigidity of tissues, less suppleness and less resistance to injury.

In addition, the walls of small blood vessels may be thickened and distorted, leading to reduction in blood supply to some tissues. This particularly leads to less ability to deal with injury or trauma such as that resulting from infection or surgery.

Any area of the body that has received radiation treatment should be treated "gently" for the rest of the patient's life.

Carcinogenicity. Radiation is one of the causes of cancer. Very rarely leukemia may result some five to twenty years after radiation exposure, due to bone marrow cells being damaged during radiation therapy. Similarly cancer can result in the area treated twenty or more years later.

The chances of either of these occurring are very small indeed.

The patient's risk of dying of the original disease, unless successfully treated, are much higher than the risk of developing cancer from the treatment.

Nevertheless, the risk is there and is one of the reasons why benign diseases are not treated by radiation unless absolutely necessary.

Genetic Effects. Exposure of the gonads to radiation increases the risk of abnormal mutations and genetic changes. Most chromosome damage from radiation results in a failure of conception and not an abnormal child. Even if both parents have been exposed to radiation, the risks of abnormal children being produced are so small as to be almost negligible. Late genetic effects in the individual are much less important than the increased risk of inducing cancer or the late vascular changes produced by radiation treatment.

IMMUNIZATION DURING CANCER TREATMENT (e.g. radiation)

1. When a child or adult has cancer and is receiving treatment which may be suppressing their immune system, such as whole body irradiation, "live" vaccines should not be given until six months after treatment is completed- "Killed" vaccines may be given although it is unclear as to their effectiveness in the immunosuppressed patient.
2. Immunosuppressed cancer patients should avoid changing diapers of infants or children for six weeks, who have recently been immunized with live (oral) polio vaccine. Immunosuppressed grand-parents are particularly at risk if they have never been immunized for polio. The risk is eliminated if the polio vaccine is given by injection (killed vaccine).
3. There is no risk from "flu" vaccines as they are not live vaccines.
4. Advice should be sought from the Infection Control Service or the Transplant Service of the Children's or Vancouver General Hospitals or family physician.
5. Travel Immunizations: The same rules apply as in 1-2 above.

MEDICINE UPDATES

Medicine Update issues

Medicine Update lets you know about new medicines and new PBS listings. Each issue provides an independent assessment of current information and research about a different medicine.

Title	Date	Why read this
Denosumab (Prolia) for postmenopausal osteoporosis.	December 2010	Information on denosumab, a medicine used for treatment of postmenopausal osteoporosis.
Exenatide (Byetta) for type 2 diabetes	December 2010	This issue provides information on exenatide (Byetta) for the treatment of type 2 diabetes.
Panadol Extra (paracetamol and caffeine) for pain	December 2010	This Medicine Update is for people who are taking, or thinking about taking, Panadol Extra.
Sitagliptin (Januvia) for type 2 diabetes	August 2010	This Medicine Update is for people who are taking, or thinking about taking, sitagliptin for type 2 diabetes.
Vildagliptin (Galvus) for type 2 diabetes	August 2010	This Medicine Update is for people who are taking, or thinking about taking, vildagliptin for type 2 diabetes.
Pramipexole (Sifrol and Sifrol ER) for Parkinson’s disease	August 2010	A new, long-acting form of pramipexole (Sifrol ER) is available for Parkinson’s disease. This revised Medicine Update describes the potential benefits, side effects and issues to be aware of with pramipexole (Sifrol) or the long-acting form (Sifrol ER).
Dabigatran (Pradaxa) for preventing blood clots after hip or knee replacement surgery	April 2010	Dabigatran is a new medicine to prevent blood clots forming after hip or knee replacement surgery. It works by thinning the blood.
Rivaroxaban (Xarelto) for preventing blood clots after hip or knee replacement surgery	April 2010	Rivaroxaban is a new medicine to prevent blood clots forming after hip or knee replacement surgery. It works by thinning the blood.
Zoledronic acid (Aclasta) for osteoporosis	April 2009	Information for consumers about zoledronic acid (Aclasta), a new treatment for osteoporosis. This treatment is used only once a year, and is given through a drip into a vein.
Tramadol for pain	December 2008	Information for consumers about tramadol, a painkiller prescribed by your doctor.
Duloxetine (Cymbalta) for major depression	August 2008	Information for consumers about duloxetine (Cymbalta), a new antidepressant for major depression.
Strontium ranelate (Protos) for osteoporosis in postmenopausal women	April 2008	Information for consumers about strontium ranelate (Protos) for osteoporosis in postmenopausal women.
Alendronate (Fosamax) for osteoporosis - preventing fractures in people with very fragile bones (low bone mineral density)	January 2008	Information for consumers about the drug Alendronate for preventing fractures in people with very fragile bones (low bone mineral density) and osteoporosis.
Fluticasone with salmeterol (Seretide) for chronic obstructive pulmonary disease	January 2008	Information for consumers about the drug Seretide, for chronic obstructive pulmonary disease.
Varenicline (Champix) for quitting smoking	January 2008	An updated version of this article is coming soon. You can read this original version, but note that the information about PBS listings is now out of date.
Lumiracoxib (Prexige) for osteoarthritis	April 2007	Since this issue of Medicine Update was published, lumiracoxib (Prexige) has been withdrawn by the Therapeutic Goods Administration.

HEART TRANSPLANT: PROCEDURES

Cardiac transplantation is a widely accepted therapy for the treatment of end-stage congestive heart failure. Most candidates for cardiac transplantation have not been helped by conventional medical therapy and are excluded from other surgical options because of the poor condition of the heart. About 45% of the candidates have ischemic cardiomyopathy; however, this percentage is rising because of the increase in coronary artery disease in younger age groups. Of the candidates, 54% have some form of dilated cardiomyopathy, which often has an unclear origin. The remaining 1% of candidates fall into the category of other diseases, including congenital heart disease, that are not amenable to surgical correction.

Candidacy determination and evaluation are key components of the process, as is postoperative follow-up care and immunosuppression management. Proper execution of these steps can culminate in an extremely satisfying outcome for both the physician and patient.

Christian Barnard performed the first successful heart transplant in a human in 1967 in South Africa. The origins of the procedure date to 1905, when Alexis Carrel transplanted a puppy's heart into the neck of a dog. Because of the lack of immunosuppression, the experiment was unsuccessful; however, the work spurred numerous investigations that culminated in the success the procedure has today. Early investigators included Frank C. Mann of the Mayo Clinic, V.P. Demikov of the Soviet Union, and Marcus Wong. These early efforts in transplantation were thwarted by the infancy of cardiopulmonary bypass and a lack of understanding of the immune system. As knowledge in these areas advanced, so did the field of cardiac transplantation.

The clinical use of cyclosporine as an immunosuppressant revolutionized the field of cardiac transplantation in 1983. Recipient survival rates improved, thus producing an explosive increase in the number of transplant centers offering cardiac transplantation. The remaining limiting factor was the number of available organ donors.

During the cardiac transplantation procedure, the ventricles are excised, leaving the great vessels, right atrium, and left atrium of the recipient.

View of the recipient's chest after the heart is removed, with the patient on cardiopulmonary bypass.

The donor heart is then sewn to these areas.

Suturing of the donor heart. Note that the left atrial anastomosis is performed first.The completed operation. Note the suture lines on the now-implanted heart.

A recent trend has been to revert to bicaval anastomoses rather than right atrial anastomoses in an attempt to decrease the incidence of postoperative tricuspid insufficiency.

In the transplantation process, the sinoatrial nodes of the donor and recipient remain intact, and both are present within the recipient. For approximately 3 weeks after surgery, the electrocardiogram demonstrates 2 P waves; however, the heart rate and electrical activity of the new heart are purely dependent on the intrinsic electrical system of the heart and not on the neurological input from the recipient.

Indications

The general indications for cardiac transplantation include deteriorating cardiac function and having a prognosis of less than 1 year to live.

Specific indications

• Dilated cardiomyopathy
• Ischemic cardiomyopathy
• Congenital heart disease for which no conventional therapy exists or that conventional therapy has failed
• Ejection fraction less than 20%
• Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been exhausted
• Pulmonary vascular resistance of less than 2 Wood units
• Age younger than 65 years
• Ability to comply with medical follow-up care