European Journal of Cardio-Thoracic Surgery, Vol 12, 70-74, Copyright © 1997 by European Association for Cardio-thoracic Surgery
Smoking after heart transplantation: an underestimated hazard?
H Nagele, P Kalmar, W Rodiger and HM Stubbe
Department of Cardiovascular Surgery, University-Hospital Hamburg- Eppendorf, Hamburg, Germany.
OBJECTIVE: Risk factors for the development of vasculopathy and
malignancies as the most important causes of morbidity and mortality after
heart transplantation are not well defined. METHODS: Univariate and
multivariate Cox regression analysis of the data derived from our 84
survivors of more than 3 months after orthotopic heart transplantation
between 1984 and 1996. Measurement of carbonmonoxide- hemoglobin blood
levels with an ABL 520 analyzer. RESULTS: Recipient or donor age, the mode
of immunosuppression, total-, LDL- and HDL- cholesterol, the HDL/LDL-ratio,
triglycerides, hypertension, diabetes mellitus, CMV status and rejection
episodes had no independent influence on total mortality or the occurrence
of graft vasculopathy or cancer. By means of an intensive questionnaire (in
case of deceased patients, by their relatives) and measurement of CO-Hb
blood levels we detected a high rate of patients who smoked after
transplantation (22/84 = 26%). Four patients confessed smoking after
undergoing the blood test. Non-smokers were defined as denying it in the
questionnaire and having CO-Mb levels < 2.5% in repeated measurements.
All but one were smokers before heart transplantation. Mean consumption was
11 cigarettes per day. Five and 10 years survival was significantly reduced
in smokers vs. non-smokers (37 vs. 80% and 10 vs. 74%, respectively, P <
0.0001). Survival curves diverged dramatically after 4 years of
observation. Smokers had a higher prevalence of transplant vasculopathy as
revealed by coronary angiography and/or autopsy (10/22 smokers vs. 2/62
non-smokers, P < 0.00001) and a higher rate of malignancies (7/22
smokers developed cancer, as compared to 4 cancers in 62 non-smokers, P =
0.0001). The primary site of cancer was the lung in 5/6 smoking and
lymphoma in all non-smoking cancer patients. CONCLUSIONS: Our data show
that the prevalence of smoking after heart transplantation may be
relatively high, especially in former smokers. Repeated measurements of
CO-Hb could be helpful in its detection. Despite a relatively low cigarette
count, smoking is a major risk factor of morbidity and mortality after
heart transplantation (HTx). Approximately 4 years of exposure time is
needed to uncover its negative influence. These findings should lead to
aggressive smoking screening and weaning programs in every HTx center.
