Cardiaco
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Trasplante Cardiaco |
Bibliografía |
Cardiovasc Res 1998 Sep;39(3):683-90
Department of Cardiac Surgery, University of Heidelberg, Germany.
[Medline record in process]
OBJECTIVE: Previous studies suggested that endothelin-1 (ET-1) may play a pathophysiological role in myocardial ischemia/reperfusion injury. This study was designed to investigate the effects of the selective ET-A receptor antagonist BQ123 and the selective ET-B receptor antagonist BQ788 on myocardial and endothelial function after reversible deep hypothermic ischemia in a heterotopic rat heart transplantation model. METHODS: Isogenic intraabdominal heterotopic transplantation was performed in Lewis rats. After 1 h of cold ischemic preservation reperfusion was started either after application of placebo (control), BQ123 (3 mumol/kg/min). BQ788 (3 mumol/kg/min), ET-1 (8 pmol/kg/min) or simulataneous infusion of BQ123 or BQ788 and ET-1, respectively (n = 12 each). An implanted balloon was used to obtain pressure-volume relations of the transplanted heart. Myocardial blood flow (MBF) was assessed by the hydrogen-clearance method. Measurements were taken after 1 and 24 h of reperfusion. Endothelium-dependent vasodilation to acetylcholine (ACH) and endothelium-independent vasodilation to sodium nitroprusside were also determined. RESULTS: Both BQ123 and BQ788 significantly improved myocardial and endothelial functional recovery during early reperfusion, whereas ET-1 significantly impaired myocardial and endothelial function. Simultaneous infusion of ET-1 diminished the effects of BQ123 and BQ788. Although myocardial function and baseline MBF were similar in all groups after 24 h of reperfusion, endothelium dependent vasodilation to ACH was still significantly higher in the BQ123 and BQ788 groups and lower in the ET-1 groups (p < 0.05). CONCLUSIONS: These results suggest that endogenous ET release is involved in the pathogenesis of reperfusion injury after heart transplantation. ET-A and ET-B receptor antagonists may be useful to reduce ischemia/reperfusion injury.
PMID: 9861312, UI: 99078305
Cardiovasc Res 1998 Sep;39(3):556-62
Laboratoire des Regulations Physiologiques et des Rythmes Biologiques chez l'Homme, Faculte de Medecine, Strasbourg, France.
[Medline record in process]
PMID: 9861297, UI: 99078290
Eur Heart J 1998 Nov;19(11):1719-24
Thoraxcenter, University Hospital Rotterdam, The Netherlands.
[Medline record in process]
AIM: To evaluate the clinical and prognostic value of the heart rate variability index in patients with congestive heart failure. METHODS: Sixty-four patients with chronic congestive heart failure and sinus rhythm underwent clinical assessment, 24-h ambulatory electrocardiography and echocardiography. Patients were followed for 6 to 30 months. Cardiac death or heart transplantation constituted the primary end-point of the study. RESULTS: The heart rate variability index was related to left ventricular ejection fraction (r=0.29, P=0.02) and New York Heart Association class (P=0.01). Patients with a restrictive left ventricular filling pattern had a lower heart rate variability index compared to patients with a non-restrictive pattern (26+/-11 vs 33+/-9 units, P=0.01). Patients who died (n=11) or underwent heart transplantation (n=4) had a lower heart rate variability index compared to survivors (21+/-10 vs 33+/-9 units, P<0.0001). In multivariate survival analysis, a reduced heart rate variability index was related to survival independent of parameters of left ventricular function. CONCLUSION: The heart rate variability index provides independent information on clinical status and prognosis in patients with chronic congestive heart failure.
PMID: 9857926, UI: 99073637
Z Kardiol 1998 Oct;87(10):808-16
[Article in German]
Medizinische Klinik Klinikum Innenstadt der LMU Abteilung Kardiologie, Munchen.
[Medline record in process]
This prospective study was designed to compare quality of life, life satisfaction, and subjective ratings of health before and at variable time intervals after heart transplantation (HTx). 175 patients were included between February 1994 and December 1997. Every six months before and 1 1/2, 3, 6, and 12 months after HTx, they received the following standardized and validated questionnaires: German SF 36, heart failure and specific transplant symptom list, global quality of life assessment, Munich life quality dimension list, expected/experienced life changes after HTx. Inclusion criteria were the acceptance of the patient on the waiting list for HTx, good command of the German language, and a minimum age of 18 years. During data evaluation, median (Me), mean (M), and standard deviation (SD) were created from individual parameters. Quality of life was rated as very poor by 84% of patients with congestive heart failure. Only 6 weeks after HTx, 74% rated their quality of life as significantly better. Before HTx 80% were very unsatisfied about their health status and 87% about physical performance. Six weeks after HTx, this parameter improved significantly and 76% were very satisfied about their health status and 50% about physical performance. While somatic changes expected before HTx corresponded well with experienced ones, psychological improvements were smaller than expected, but one year after HTx they were significant (before: M = 3.66; SD = 0.9; Range (R) = 3.78 vs 12 months postop: M = 4.61; SD = 0.6; R = 2.67; p < 0.05). Quality of life correlated before HTx best with subjectively rated health (r = 0.61, p < 0.01) and 6 months after with satisfaction about health status (r = 0.76, p < 0.01). Only in 25% were expected improvements fulfilled regarding sexual activity/satisfaction, professional situation, and recreational activities. 90% of post-transplant patients reported physical complaints, most by effects of immunsuppression, but were coping well. The study shows that already 6 weeks after successful HTx all quality of life parameters improved significantly. Despite some unfulfilled expectations and complaints, the postoperative life situation of HTx patients appeared significantly improved.
PMID: 9857456, UI: 99074783
Am J Cardiol 1998 Dec 1;82(11):1377-81
Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
[Medline record in process]
This study tests the hypothesis that myocardial blood flow and coronary microvascular dilator capacity vary as a function of time after orthotopic heart transplantation in humans. Positron emission tomography measurements of myocardial blood flow were obtained at rest and during adenosine in 24 patients between 1 and 86 months after heart transplantation. At the time of the study all patients were clinically well and had angiographically normal epicardial coronary artery vessels. Patients were divided into 3 groups based on time from transplant to positron emission tomography measurement of myocardial blood flow: group 1 to 12 months (n = 9); group 13 to 34 months (n = 8); and group > or = 37 months (n = 7). Basal myocardial blood flow in group 1 to 12 months (1.86+/-1.01 ml/min/g) exceeded (p <0.05) that of group 13 to 34 months (1.17+/-0.73) and group > or = 37 months (0.98+/-0.34). In group 13 to 34 months, basal myocardial blood flow and maximal dilator capacity (minimal coronary vascular resistance with adenosine 36+/-12 mm Hg/ml/min/g) were comparable to that of normal volunteers (1.01+/-0.20 and 37+/-, respectively). In group > or = 37 months, maximal flow response to adenosine was reduced (2.54+/-1.25 vs 3.16+/-0.52, respectively, p = 0.06). Maximal dilator capacity in group > or = 37 months (60+/-34) was impaired versus group 1 to 12 months (36+/-10) and group 13 to 34 months (36+/-12; both p <0.05) as well as normals (37+/-9, p <0.05). During the first year after cardiac transplantation basal myocardial blood flow is elevated out of proportion to external determinants of myocardial oxygen demand, but maximal dilator capacity of the coronary microcirculation is normal. Between 1 and 3 years both basal myocardial blood flow and microvascular function tend to normalize. After 3 years, although basal myocardial blood flow is normal, microvascular dilator capacity is impaired.
PMID: 9856923, UI: 99072743
J Heart Lung Transplant 1998 Nov;17(11):1133-8
Department of Thoracic and Cardiovascular Surgery, University Hospital, Caen, France.
[Medline record in process]
Leiomyosarcoma of the heart is an uncommon primary malignant tumor with poor postoperative survival that may be measured in months. A leiomyosarcoma of the left atrium was diagnosed in a 47-year-old man. Initial admission was for acute pulmonary edema requiring emergency surgery. The tumor involved the left atrial cavity, and a radical resection was performed. Six months later an isolated myxomatous recurrence was detected. Heart transplantation was then performed. The patient is in good health 20 months after operation with no evidence of residual disease or recurrence. The literature has been reviewed. Surgical resection is not an adequate treatment for leiomyosarcoma of the left atrium and early heart transplantation probably offers the only hope for these patients.
PMID: 9855454, UI: 99071096
J Heart Lung Transplant 1998 Nov;17(11):1089-96
Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA. es54@columbia.edu
[Medline record in process]
BACKGROUND: Heart transplantation, with its attendant glucocorticoid and cyclosporine therapy, has deleterious effects on the skeleton. We have previously reported rapid bone loss and high fracture rates (36% of patients) during the first year after heart transplantation. The bone loss was accompanied by declines in serum 1,25-dihydroxyvitamin D and osteocalcin levels and increased urinary excretion of markers of bone resorption (hydroxyproline, pyridinoline, and deoxypyridinoline). We therefore investigated whether bone loss could be prevented by bisphosphonates, agents that inhibit bone resorption. METHODS: Serial measurements of bone mineral density (BMD) and biochemical indexes of mineral metabolism were compared in 18 group A patients who received a single intravenous infusion of pamidronate (60 mg) within 2 weeks of heart transplantation, followed by 4 cycles of oral etidronate (400 mg daily for 14 days every 3 months) and oral calcitriol 0.25 microg daily, to those of 52 patients who previously underwent transplantation (group B) who did not receive antiresorptive therapy. Both groups received elemental calcium 1000 mg and vitamin D 400 IU daily. RESULTS: At 12 months after transplantation, there was virtually no lumbar spine bone loss in group A patients, whereas lumbar spine BMD had declined significantly in group B patients (0.2% +/- 0.9% vs 6.8% +/- 1.0%, respectively; P < .0001). Similarly, femoral neck BMD fell by 10.6% +/- 1.1% in group B patients and by only 2.7% +/- 1.4% in group A patients (P < .0001). Three incident vertebral fractures occurred in two group A patients, whereas 17 group B patients sustained 30 incident vertebral fractures, one hip fracture and three episodes of rib fractures (P < .02; test of proportions). With respect to markers of bone resorption, urinary deoxypyridinoline fell by 51% +/- 9% in group A patients and increased by 65% +/- 22% in group B patients by 3 months after transplantation (P < .0001). CONCLUSION: In summary, heart transplant recipients treated with bisphosphonates and replacement doses of calcitriol sustained less bone loss and fewer fractures than those treated with calcium and vitamin D. We conclude that bisphosphonate therapy, in conjunction with calcitriol, shows promise for prevention of transplantation-related osteoporosis.
PMID: 9855448, UI: 99071090
J Heart Lung Transplant 1998 Nov;17(11):1065-74
Department of Cardiology, Montescano Medical Center, Salvatore Maugeri Foundation, Pavia, Italy.
[Medline record in process]
BACKGROUND: Atrial function is an important determinant of cardiac performance. In patients who undergo operation by standard heart transplantation atrial enlargement, distortion of geometry and asynchronous contraction resulting from the donor/recipient atrial connections may affect atrial function. The bicaval anastomosis technique should be free from these limitations. METHODS: We used the echocardiographic automatic boundary detection technique to obtain on-line time/volume curves of right and left atria from patients who had undergone bicaval (n = 22) or standard (n = 27) heart transplantation and from 15 control subjects. Maximal, middiastolic, preatrial contraction, and minimal volumes of both atria were measured. Reservoir volume (defined as the difference between maximal and middiastolic atrial volumes); pump volume (defined as the difference between preatrial contraction and minimal atrial volumes); and conduit volume (defined as the difference between left ventricular stroke volume and the sum of reservoir and pump volumes) were derived for both atria. Atrial emptying fraction was calculated as the difference between maximal and minimal volumes divided by the maximal volume and expressed in percent and pump fraction as the pump volume divided by the sum of reservoir and pump volumes. Tricuspid and mitral regurgitation, evaluated by color-flow Doppler scanning, were considered significant when they were greater than grade 1. Atrial ejection force was calculated from mitral and tricuspid flow velocities at atrial contraction. RESULTS: In patients who had bicaval heart transplantation, both atria were smaller than in patients who underwent standard heart transplantation. With the bicaval technique right and left atrial emptying (right 45% +/- 9% vs 36% +/- 10%, p < .05; left 51% +/- 8% vs 39% +/- 8%, p < .001) and pump fractions (right 57% +/- 17% vs 19% +/- 13%, p < .001; left 45% +/- 28% vs 22% +/- 12%, p < .01) were greater than with the standard technique and similar to those in control subjects. Right atrial ejection force was significantly greater in bicaval (10.0 +/- 5.6 kdyne) than in standard heart transplantation (4.5 +/- 2.2 kdyne, p < .0001). Significant tricuspid or mitral regurgitation was rarely found in bicaval heart transplant recipients (3 and 1 of the 22 patients, respectively), although they were much more frequent after standard heart transplantation (13 and 8 of the 27 patients, respectively). CONCLUSIONS: Heart transplantation performed with the bicaval anastomosis technique determines smaller atrial volumes, yields better right and left atrial function and fewer atrioventricular valve regurgitation than the standard technique.
PMID: 9855445, UI: 99071087
J Heart Lung Transplant 1998 Nov;17(11):1057-64
Monash University, Department of Surgery, Monash Medical Centre, Melbourne, Australia. Kirsty.Baxter@med.monash.edu.au
[Medline record in process]
BACKGROUND: A rapid, reproducible screening model is essential for evaluation of novel preservation regimens. This study describes a modification of the abdominal rat heart transplantation model reducing anastomosis time and allowing quantitative assessment for 7 days. METHODS: Hearts, obtained from inbred Dark Agouti rats, were arrested and stored in cold colloid-free University of Wisconsin solution until transplantation. The Dark Agouti recipient underwent a left nephrectomy. The donor left common carotid artery was anastomosed to the recipient left renal artery with a "sleeve" anastomosis. The "cuffed" donor left pulmonary artery was inserted into the left renal vein. Study 1 examined continuing viability by daily palpation and morphologic study by examination of hematoxylin and eosin-stained sections on days 4 or 90. Study 2 examined quantitative assessment of cardiac function in the anesthetized recipient. The model was further modified by introducing an externalized, fluid-filled, balloon-tipped catheter into the left ventricle. RESULTS: The new technique allowed vascular anastomoses to be completed in 5 to 12 minutes, minimizing rewarming of the graft. Most (25 of 28) grafts beat for 90 days, and 80% of these showed normal structure. There was evidence of myocyte damage or arteriosclerosis in 5 of 25 at 90 days and in 4 of 17 at 4 days. Cardiac function parameters were similar in consecutive runs and did not change between days 1 and 7. CONCLUSION: This abdominal rat heart transplant model is quick and easy to perform, minimizes warm ischemia, and is suitable for both short- and long-term studies. Quantitative parameters, assessed by use of an in situ intraventricular balloon-tipped catheter, are reproducible and maintained for 7 days.
PMID: 9855444, UI: 99071086
J Heart Lung Transplant 1998 Nov;17(11):1045-8
Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia, USA.
[Medline record in process]
Nine heart transplant recipients were treated with single-field total lymphoid irradiation (TLI) for early (<1 year) or late (>1 year) rejection that was refractory to multiple regimens of immunosuppressive therapy. For patients with early rejection (n = 6), the rejection frequency (rejections/patient/month) decreased from pre-TLI of 1.63 to post-TLI of .02 (p < .001), and for patients with late rejection (n = 3), the rejection frequency decreased from pre-TLI of .23 to post-TLI of .05 (p < .02). The reduced rejection frequencies have been maintained for a mean follow-up of 28.6 (8 to 78) months, and adverse events during or late after TLI were uncommon. Single-field TLI is a safe and effective technique in the management of refractory rejection early or late after heart transplantation.
PMID: 9855442, UI: 99071084
Circulation 1998 Nov 10;98(19 Suppl):II163-8; discussion II168-9
Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA 15261, USA.
[Medline record in process]
BACKGROUND: Thoracic organ transplantation remains limited by the reciprocal problems of rejection and the toxicities of nonspecific immunosuppression. Mixed bone marrow chimerism reliably produces donor-specific transplantation tolerance without immunosuppressive drugs. We have previously described a nonmyeloablative conditioning regimen based on recipient treatment with antilymphocyte serum, tacrolimus, and low-dose total-body irradiation that yields long-term multilineage allogeneic bone marrow chimerism in the rat. We have now investigated whether mixed bone marrow chimerism that arises from this partial conditioning strategy produces permanent acceptance of donor-specific cardiac allografts. METHODS AND RESULTS: Mixed allogeneic chimeras (ACI-->WF) were prepared by treating Wistar Furth recipients with a single dose of antilymphocyte serum 5 days before bone marrow transplantation and tacrolimus 1 mg/kg/d from days -1 to 10. Five hundred cGy total-body irradiation was administered immediately before infusion of 1 x 10(8) donor (ACI) T-cell depleted marrow cells. All recipients were chimeric, with a mean level of donor chimerism = 26.3 +/- 3.5%. Chimeras underwent heterotopic cardiac transplantation 4 weeks after bone marrow transplantation. All donor-specific (ACI) grafts were permanently accepted (follow-up, 230 to 360 days). Third-party grafts were rapidly rejected. Histology of long-surviving donor-specific grafts was without evidence of acute or chronic rejection. Second-set donor-specific skin grafts transplanted to chimeras 135 days after heart transplantation showed long-term survival (> 130 days), whereas third-party skin grafts were rapidly rejected. Mixed lymphocyte reaction demonstrated in vitro donor-specific hyporeactivity. CONCLUSIONS: A tacrolimus-based nonmyeloablative recipient conditioning regimen produces mixed bone marrow chimerism and donor-specific tolerance to cardiac allografts in the rat.
PMID: 9852899, UI: 99070001
Circulation 1998 Nov 10;98(19 Suppl):II157-61; discussion II162
Division of Cardiothoracic Surgery, University of Wisconsin Hospitals and Clinics, Madison, USA.
[Medline record in process]
BACKGROUND: The University of Wisconsin Solution (UW) has extended preservation of abdominal organs but has not allowed equally extended preservation of the heart. Therefore, the impact of UW on clinical heart transplantation has remained unclear. METHODS AND RESULTS: Between June 1986 and March 1994, 161 orthotopic heart transplants were performed at our center. Of these, 66 were preserved for > or = 3 hours. Of these, 17 hearts were preserved with Stanford solution (STNF), which was used before 1990, and 49 were preserved with UW. These groups were compared for indexes of ischemic injury, ventricular function, and survival. The UW group contained more status-1 recipients (57% versus 29%, P < 0.05) and a higher mean donor age (30.7 versus 22.1 years, P = 0.008). Mean ischemic time was slightly but not significantly higher with UW (228 versus 205 minutes for UW versus STNF, respectively; P = 0.085). The time to wean from bypass after cross-clamp removal was nearly twice as long with STNF than with UW (80.6 versus 44.3 minutes, P < 0.001). There was no difference in the incidence of primary graft failure (2% for UW versus 6% for STNF, P = 0.43). The average need for inotropic support over the first 8 posttransplant hours was significantly higher with STNF than UW. Neither hospital stay nor survival differed. Nevertheless, the ability to use donor organs from more distant sites was increased. Of all hearts preserved with STNF, 26% were stored for > or = 3 hours, whereas 51% of all hearts preserved in UW were stored for this length of time. Donor use of hearts increased from 20% in 1989 to 63% in 1993, largely because of greater use of more distant donors. CONCLUSIONS: We conclude that heart preservation with UW limits ischemic damage from prolonged storage and improves myocardial function in the early posttransplant period, thus allowing greater use of available donors from distant sites to patients awaiting heart transplantation.
PMID: 9852898, UI: 99070000
Am J Pathol 1998 Dec;153(6):1813-24
Department of Pathology, University Hospital, Utrecht, The Netherlands.
[Medline record in process]
It is unclear whether the intracardial immune reactivity after heart transplantation influences the peripheral immunological status (activation or nonresponsiveness) of the patient. Co-stimulation and activation-induced cell death (AICD) or apoptosis play an important role in determining the balance between lymphocyte reactivity and nonreactivity. Therefore, we studied the expression of co-stimulatory molecules and the process of apoptosis in biopsies of human heart allografts, using immunohistochemistry. Although a normal expression of co-stimulatory molecules on antigen-presenting cells was observed, the expression of their counter-structures on T cells was absent. This may be due to chronic T cell activation, which can lead to the induction of apoptosis via the Fas/Fas ligand pathway. In the infiltrates, a considerable percentage of the lymphocytes, but not the macrophages, were apoptotic. Apoptosis was confirmed by DNA fragmentation analysis. Increased numbers of Bax-expressing versus decreased numbers of Bcl2-expressing lymphocytes in comparison with normal lymphoid tissue confirmed a imbalance in favor of apoptosis. Apoptosis was biased towards CD4+ T cells (65.7% versus 26.6% in CD8+ T cells). Fas was expressed on most of the infiltrating cells. Fas ligand expression was also observed, not only on most of the T cells but also on all macrophages. Because macrophages were often detected in close contact with T cells, they may play a role in T cell regulation via the Fas/Fas ligand pathway. This study indicates that, during rejection, not only is tissue damage induced by infiltrating T cells, but also the infiltrating lymphocytes themselves are actively down-regulated (eg, AICD) by one another and by macrophages in the infiltrate. This regulatory process may affect the immunological status of the patient after heart transplantation.
PMID: 9846972, UI: 99061429
Transplantation 1998 Nov 27;66(10):1347-53
Department of Gastroenterology, Medizinische Hochschule Hannover, Germany.
[Medline record in process]
BACKGROUND: Hepatitis B is common in organ transplant recipients. It adversely affects the prognosis after liver and kidney transplantation. The long-term outcome of hepatitis B virus (HBV) infection in heart transplant recipients has not been studied before. METHODS: Between July 1984 and June 1993, 436 patients underwent heart transplantation at the Hannover Medical School. A total of 345 patients survived for more than 1 year and were included in this study. Of these, 74 were found to be hepatitis B surface antigen (HBsAg)-positive during follow-up; 69 acquired HBV infection at known time points 25+/-17 months after transplantation, and 5 had already been infected before heart transplantation. Mean follow-up was 105 (range, 25-157) months. RESULTS: Patients developed significant alanine aminotransferase (ALT) elevations after HBV infection, which peaked and then remained above normal. Preinfection levels of ALT were 15.4+/-6.4 U/L, peak values were 71.2+/-47.2 U/L, and mean values after HBV infection were 28.9+/-14.6 U/L. All patients remained HBsAg-positive. Thirteen patients (18%) became HBeAg-negative during follow-up, 10 with negative quantitative HBV-DNA assays. Mean HBV-DNA levels in the remaining patients were 292+/-267 (range, 0-978) pg/ml. Thirty-four patients died during follow-up (45.9%) compared to 78/271 (28.8%) in the control group (P=0.008). Six of the HBsAg-positive patients (17.1%) died of liver failure 6.2-10.6 years (mean, 8.6) after transplantation. Histology of 25 HBsAg-positive patients more than 5 years after infection revealed severe fibrosis or cirrhosis in 14 (56%), mild fibrosis in 9 (36%), and chronic hepatitis without fibroproliferation in 2 (8%). CONCLUSIONS: Hepatitis B infection after heart transplantation leads to chronic liver disease in the majority of the affected patients, causing cirrhosis in more than 55% within the first decade after transplantation. Liver failure is a common cause of death in the infected group of patients. Active HBV vaccination is mandatory for all organ transplant candidates, in particular before heart transplantation.
PMID: 9846521, UI: 99060955
Transplantation 1998 Nov 27;66(10):1340-7
Department of Cardiology, Medical University Hospital, University of Heidelberg, Germany. thomas.dengler@yale.edu
[Medline record in process]
INTRODUCTION: Patients after solid organ transplantation are at an increased risk for microbial infections. Due to therapeutic immunosuppression, the response to active immunizations may be reduced. The serological efficacy of pneumococcal and influenza vaccination was studied in heart transplant recipients. PATIENTS AND METHODS: Sixteen patients over 1 year after heart transplantation and control patients were immunized with a 23-valent pneumococcal vaccine and a triple-split influenza vaccine. Preand postvaccinal antibody titers were serologically determined, including quantitation of specific antibodies against nine pneumococcal serotypes. RESULTS: Both vaccines were well tolerated without systemic reactions or infectious complications. Median postvaccinal pneumococcal antibody titers in the transplant patients were comparable to controls (5513 U/ml, range: 694-41007, vs. 5490 U/ml, range: 1088-38042; P=NS); vaccination was successful in 23/23 (100%) of controls and in 15/16 (94% plus 1 borderline positive case) of the transplant recipients. Specific antibody titers were similar for eight of nine serotypes; only the immune response against serotype 3 was reduced after transplantation. The efficacy of influenza vaccination was significantly impaired in transplant patients against all three virus strains (62% vs. 97%, P<0.01/50% vs. 94%, P<0.001/37% vs. 80%, P<0.01), but 9/16 (56%) of patients still showed a sufficient immune response to two out of three virus strains. No clinical or demographic predictors of successful vaccination could be established. CONCLUSIONS: Pneumococcal vaccination under cyclosporine-based immunosuppression after heart transplantation is safe and equally effective as in healthy controls. In contrast, the immune response to influenza vaccination is significantly reduced, although not completely abolished. This differential response might be accounted for by T cell-independent antibody production against polysaccharide antigens contained in the pneumococcal vaccine.
PMID: 9846520, UI: 99060954
J Appl Physiol 1998 Dec;85(6):2270-6
Laboratoire des Regulations Physiologiques et des Rythmes Biologiques chez l'Homme, Faculte de Medecine, Institut de Physiologie, F-67085 Strasbourg Cedex, France.
[Medline record in process]
We investigated the atrial (ANP) and brain natriuretic peptides (BNP), catecholamines, heart rate, and blood pressure responses to graded upright maximal cycling exercise of eight matched healthy subjects and cardiac-denervated heart transplant recipients (HTR). Baseline heart rate and diastolic blood pressure, together with ANP (15.2 +/- 3.7 vs. 4.4 +/- 0.8 pmol/l; P < 0.01) and BNP (14.3 +/- 2. 6 vs. 7.4 +/- 0.6 pmol/l; P < 0.01), were elevated in HTR, but catecholamine levels were similar in both groups. Peak exercise O2 uptake and heart rate were lower in HTR. Exercise-induced maximal ANP increase was similar in both groups (167 +/- 34 vs. 216 +/- 47%). Enhanced BNP increase was significant only in HTR (37 +/- 8 vs. 16 +/- 8%; P < 0.05). Similar norepinephrine but lower peak epinephrine levels were observed in HTR. ANP and heart rate changes from rest to 75% peak exercise were negatively correlated (r = -0.76, P < 0.05), and BNP increase was correlated with left ventricular mass index (r = 0.83, P < 0.01) after heart transplantation. Although ANP increase was not exaggerated, these data support the idea that the chronotropic limitation secondary to sinus node denervation might stimulate ANP release during early exercise in HTR. Furthermore, the BNP response to maximal exercise, which is related to the left ventricular mass index of HTR, is enhanced after heart transplantation.
PMID: 9843552, UI: 99059784
Transplant Proc 1998 Nov;30(7A):3862-4
First Department of Surgery, Yamaguchi University, School of Medicine, Japan.
[Medline record in process]
PMID: 9838690, UI: 99056069
Transplant Proc 1998 Nov;30(7):3408-9
Department of Surgery, National Taiwan University, Taipei, Taiwan.
[Medline record in process]
PMID: 9838502, UI: 99055881
Transplant Proc 1998 Nov;30(7):3407
Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea.
[Medline record in process]
PMID: 9838501, UI: 99055880
Transplant Proc 1998 Nov;30(7):3405-6
Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea.
[Medline record in process]
PMID: 9838500, UI: 99055879
Transplant Proc 1998 Nov;30(7):3401-2
Department of Surgery, National Taiwan University, Taipei, Taiwan.
[Medline record in process]
PMID: 9838498, UI: 99055877
Transplant Proc 1998 Nov;30(7):3347-9
Department of Surgery, Cheng Hsin General Hospital, Taipei, China.
[Medline record in process]
PMID: 9838477, UI: 99055856
J Psychosom Res 1998 Nov;45(5):465-70
Department of Internal Medicine II, University of Heidelberg, Germany. stefan_zipfel@krzmail.krz.uni-heidelberg.de
[Medline record in process]
Heart transplantation has become an established procedure for the treatment of terminal heart failure. However, due to a shortage of donor organs, the waiting period for a donor organ is increasing. Cross-sectional and retrospective studies have indicated that there is tremendous psychological distress during this waiting period. The aim of this study was to assess this phase systematically and longitudinally. At the beginning of their waiting period, 62 patients at the Heidelberg Transplantation Centre were examined with regard to their physical complaints, quality of life, and level of depression. Four months later the remaining 42 patients were re-examined. The sample showed a significant increase (p<0.001) in subjective physical symptoms and an impairment in social activities (p<0.05) and everyday life (p<0.05), and a significant increase in depression (p<0.001), despite the relatively short time period. These results show the necessity of supportive psychotherapy for patients undergoing heart transplantation.
PMID: 9835241, UI: 99050905
J Thorac Cardiovasc Surg 1998 Dec;116(6):973-80
Departments of Surgery and Medicine, Columbia University College of Physicians and Surgeons, New York.
[Medline record in process]
BACKGROUND:Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure. METHODS: Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m2, and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively. RESULTS: Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 +/- 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements. CONCLUSIONS: Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.
PMID: 9832689, UI: 99054781
J Thorac Cardiovasc Surg 1998 Dec;116(6):924-31
Divisions of Cardiology and Cardiothoracic Surgery, Children's Hospital of Philadelphia, and the Departments of Pediatrics and Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
[Medline record in process]
OBJECTIVE:Pulmonary atresia with intact ventricular septum is an anatomically heterogeneous anomaly with a variety of surgical strategies possible. We sought to compare the outcome of patients with a single ventricle approach to those with a biventricular repair and to compare outcome of patients with coronary abnormalities to those with normal coronary arteries. METHODS: A retrospective review of our surgical database revealed 67 patients with pulmonary atresia with intact ventricular septum operated on between 1981 and 1998. Patients were categorized on the basis of initial surgical strategy: strategy A, aortopulmonary shunt alone (n = 31); strategy B, right ventricular recruitment (n = 32); strategy C, heart transplantation (n = 4). Tricuspid valve size (Z-score) and coronary anatomy were determined. Right ventricular-coronary artery dependency was noted in 8 patients. RESULTS: Overall actuarial survivals at 1, 5, and 8 years were 82%, 76%, and 76%. Mortality was highest in infancy (10 of 16 deaths). Outcome was equivalent for all 3 strategies. There was no difference in tricuspid valve size between survivors and nonsurvivors (mean Z-score -2.0 (2.5) vs -2.0 (1.9), P =.83). There was no difference in survival based on severity of coronary abnormality. Only one third of patients had a successful biventricular repair, and the tricuspid valve was significantly larger in these than in patients who had Fontan operation (mean Z-score -0.53 [1.6], range -3.5 to 1, versus mean Z-score -3.03 [2.7], range -5.5 to 0, P =.002). CONCLUSIONS: Surgical outcome for patients born with pulmonary atresia with intact ventricular septum is satisfactory. The strategies of biventricular repair, single ventricle palliation, and heart transplantation allow for equal outcome among all anatomic subtypes.
PMID: 9832682, UI: 99054774
Circulation 1998 Dec 1;98(22):2383-9
Divisions of Circulatory Physiology (D.M.M., A.B., M.E.C.) and Cardiology (D.M.M., A.B., H.L., M.D., S.S.) and the Division of Cardiothoracic Surgery (K.C., M.F., E.R., M.O.), Columbia Presbyterian Medical Center, New York, NY.
[Medline record in process]
Background--Mechanical, histological, and biochemical improvement has been described in patients after left ventricular assist device (LVAD) support. Explantation of the LVADs without heart transplantation has been described in selected patients who received this therapy as a bridge to transplantation. Methods and Results--A retrospective review of patients receiving a mechanical bridge to transplantation at Columbia Presbyterian Hospital after July 21, 1991, was performed to determine the incidence of patients in whom the device was successfully explanted. From August 1, 1996, to February 1, 1998, we prospectively attempted to identify potential explant candidates by the use of exercise testing. During this time, we recruited 39 consecutive patients after insertion of the Thermo Cardiosystems vented electric device to participate in the following study. Approximately 3 months after device implantation, a maximal exercise test with hemodynamic monitoring and respiratory gas analysis was performed with the LVAD in the automated mode. The electric device was interfaced with a pneumatic console such that the rate could be decreased to 20 cycles/min. Hemodynamic measurements were recorded as the device rate was decreased. A repeat exercise test was then performed if the patient remained hemodynamically stable. A retrospective chart review of 111 LVAD recipients at our institution identified only 5 successful explant patients. Eighteen of the 39 patients were studied. Fifteen patients exercised with maximal device support. At peak exercise, &f1;O2 averaged 14.5+/-3.6 mL. kg-1. min-1; LVAD flow, 8.0+/-1.3 L/min; Fick cardiac output, 11.4+/-3.3 L/min; and pulmonary capillary wedge pressure, 13+/-4 mm Hg. Seven patients remained normotensive and could exercise at a fixed rate of 20 cycles/min. In these patients, peak &f1;O2 declined from 17.3+/-3.9 to 13.0+/-6.1 mL. kg-1. min-1. In one of these patients, the device was explanted. Conclusions--Significant myocardial recovery after LVAD therapy in patients with end-stage congestive heart failure occurs in a small percentage of patients. Most of these patients have dilated cardiomyopathy. Exercise testing may be a useful modality to identify those patients in whom the device can be explanted.
PMID: 9832482, UI: 99051518