Detection of human cytomegalovirus myocardial involvement by polymerase chain reaction during systemic infection and correlation with pp65 antigenemia and DNAemia in infected heart recipients.

The presence of human cytomegalovirus DNA was investigated in 103 unfixed endomyocardial biopsies, performed during the first 4 months in 17 heart transplant recipients by polymerase chain reaction. Results were correlated with human cytomegalovirus systemic infection, as detected by the test for the viral lower matrix phosphoprotein pp65 (antigenemia) and by polymerase chain reaction for viral DNA in blood leukocytes (DNAemia). Three patients out of 17 did not develop cytomegalovirus infection and 14 did: 5 had symptomatic disease treated with ganciclovir and 9 developed asymptomatic infection and were not treated. Viral DNA was detected in 24 out of 103 biopsies (23%) from 13 patients: 5 with symptomatic infection during the acute phase of disease (mean levels of pp65: 125+/-232 pp65 positive leukocytes/200,000 examined cells) and 8 patients with asymptomatic infection when the mean antigenemia was 5+/-15/200,000 (4 patients) or when DNAnemia was present in the blood (4 patients). No histological evidence of myocarditis was shown in viral DNA-positive biopsies. No difference in acute rejection was found in viral DNA-positive and DNA-negative biopsy specimens in symptomatic and asymptomatic infected patients. Our experience suggests that during systemic symptomatic and asymptomatic cytomegalovirus infection, polymerase chain reaction can detect a relatively frequent myocardial involvement, but this involvement is not associated with myocarditis or with a higher incidence of acute rejection. THe presence of viral DNA in myocardial biopsies can be a result of high viremia, but it also can be due to low level of viral DNA in circulating infected leukocytes. Polymerase chain reaction is the most sensitive method for cytomegalovirus DNA detection in biopsies, but its results need to be evaluated together with morphology-preserving methods and systemic markers of infection in order to make a correct diagnosis.

Histologic and molecular diagnosis of myocardial human cytomegalovirus infection after heart transplantation.

A total of 879 paraffin-embedded endomyocardial biopsy specimens from 69 heart transplant recipients were studied. In 30 biopsy specimens, the presence of human cytomegalovirus was investigated by routine histologic and immunohistochemical evaluation, in situ hybridization, and polymerase chain reaction. These 30 biopsies were performed in seven patients with clinical human cytomegalovirus infection (four primary and three recurrent infections) and in eight patients with asymptomatic human cytomegalovirus recurrent infection. These endomyocardial biopsy specimens showed grade 0 (n = 9), 1A (n = 12), 1B (n = 7), or 2 (n = 2) acute rejection. No myocarditis with human cytomegalovirus-like inclusion bodies was observed by routine histologic evaluation. Human cytomegalovirus DNA or antigens were not shown by in situ hybridization or by immunohistochemical evaluation, respectively. Viral DNA was detected by polymerase chain reaction in two grade 1A endomyocardial biopsy specimens from two patients with systemic human cytomegalovirus primary infection. These two biopsy specimens were shown to be positive by polymerase chain reaction at the time of the acute phase of the infection as shown by laboratory findings. Therefore cytomegalovirus DNA detected by polymerase chain reaction could result from viral carriers, that is, leukocytes of rejection-related infiltrates or within intramyocardial vessels as a result of a more aggressive expression of the systemic infection in seronegative recipients with cytomegalovirus seropositive donors. Polymerase chain reaction is the most sensitive method for viral DNA detection on paraffin-embedded biopsy specimens, but a multitechnologic approach, including routine histologic evaluation, is required for a proper diagnosis of human cytomegalovirus myocardial infection.

Successful orthotopic transplantation of a fresh tricuspid valve homograft in a human.

We report a successful transplantation of a human tricuspid valve in a human. We used a fresh tricuspid homograft with its chordae tendineae and papillary muscles, harvested 5 days earlier under sterile conditions from a multiorgan donor a few minutes after cardiectomy (the heart was not suitable for cardiac transplantation) and immediately stored at 4 degrees C. We elected to implant the homograft in a young heroin addict. Our experience demonstrates that the implantation of an atrioventricular homograft in the orthotopic position is technically feasible and can achieve good results, at least in the short term.

Twelve-year follow up with the Sorin Pericarbon bioprosthesis in the mitral position.

BACKGROUND AND AIMS OF THE STUDY: The aim of this study was to evaluate the long-term follow up of the Pericarbon pericardial bioprosthesis implanted in the mitral position. METHODS: Between January 1985 and January 1991, 78 patients (26 males, 52 females; mean age 56.9 +/- 7.8 years) underwent isolated mitral valve replacement with a Pericarbon valve. All bioprostheses were size 29 mm and implanted by the same surgeon. RESULTS: Total follow up was 663.2 pt-years and it was 97% complete. Early mortality was 1.3% (1/78); two minor cerebral embolisms were observed as early complications. At 12 years the overall survival rate was 85.0 +/- and valve-related survival 93.1 +/- 3.0%; freedom from embolic events was 83.0 +/- 4.5% and from endocarditis 98.7 +/- 1.3%. Freedom from primary tissue failure was 56.8 +/- 6.6%; it was 86.3 +/- 7.5% in patients aged > 60 years and 36.8 +/- 8.2% in younger patients. There were 27 reoperations, 26 for primary tissue failure, one for endocarditis. Comparison between basal and follow up echocardiographic studies showed a significant stenotic deterioration of the bioprosthesis and a negligible incidence of regurgitation. Morphological findings of explanted bioprostheses were characterized by stenotic and diffuse microcalcification, but no tissue tear was observed. CONCLUSIONS: These results confirm that the Pericarbon bioprosthesis is structurally safe and free from the fatigue problems which afflicted the first and second generation of pericardial valves. As with other tissue valves, the rate of calcification is age-dependent, suggesting preferential use of the Pericarbon prosthesis in elderly people.

Protection of the heart by nifedipine cardioplegia during coronary artery surgery. A clinical-haemodynamic evaluation.

This study was undertaken to evaluate the myocardial preservation obtained by adding a Ca++ channel blocker, nifedipine, to cold potassium cardioplegia (4 mcg/Kg/L) in 24 patients undergoing coronary artery surgery. They were randomly divided into a treated (N) and a control (C) group. Significant differences between the two groups were noted in the cardiac arrest time (p less than 0.001), in the mechanical recovery mode (p less than 0.01) and in the inotropic support needed (p less than 0.01). Cardiac index increased significantly in group N but decreased in group C (p less than 0.01). Peripheral delta P/delta t and endocardial viability ratio (EVR) decreased in both groups. Coronary sinus and serum CK and CK-MB release were significantly lower in the treated group. ECG ischaemic changes occurred in 8 patients in group C but only in 1 case in group N (p less than 0.001). Arrhythmias occurred in 3 cases in group C (p less than 0.05). The incidence of perioperative myocardial infarction was not significant (2 cases in group C). These data suggest that nifedipine can protect the myocardial cell from ischaemic injury without depressing myocardial contractility or AV conduction.

The De Vega tricuspid annuloplasty. Perioperative mortality and long term follow-up.

One hundred and fifty-three patients undergoing De Vega tricuspid annuloplasty, with or without other associated cardiac procedures between January, 1979, and June, 1987, were evaluated. There were 136 hospital survivors. The follow-up was 98.1% complete for a mean of 3.7 years/patient. Operative mortality was 11.1%; preoperative NYHA class and length of CPB were significant risk factors of perioperative mortality. The actuarial survival of operative survivors at 9 years was 73.5 +/- 11.8%. There were 7 late cardiac deaths among a total of 12 late deaths. Eleven patients required reoperation (2.1 +/- 0.6% patient-year). In seven patients it was necessary for recurrence of tricuspid regurgitation; six of these had also a mitral prosthesis malfunction or a periprosthetic leak. Residual tricuspid regurgitation was judged as mild, moderate or severe in 29.9%, 11.9% and 4.3% of the patients respectively. De Vega tricuspid annuloplasty is the method of choice for mild and moderate tricuspid insufficiency; in selected cases, with a more severe degree of regurgitation, better results could be achieved with a different surgical approach.

Coronary artery bypass grafting for unstable angina. Risk factors of operative mortality.

In order to identify factors affecting early mortality in patients undergoing CABG for unstable angina, several risk factors have been analysed in a group of 120 patients. Systemic hypertension and left ventricular impairment were shown to be significant risk factors (Systemic hypertension, P less than 0.01; EF less than or equal to 0.35, P less than 0.01; LVEDP greater than or equal to 20 mmHg, P less than 0.025). Overall mortality rate was 5% (6/120). No influence could be recognized for age, sex, previous MI, emergency surgery, extension of coronary disease, completeness of revascularization and mode of onset of symptoms.

Diltiazem cold cardioplegia in coronary artery surgery: effects on myocardial function and ischemia.

This study was undertaken to evaluate the myocardial preservation obtained by adding a calcium channel blocker, diltiazem (200 mcg/kg of body weight) to cold potassium cardioplegia in 24 patients with coronary artery disease who underwent myocardial revascularization, and were randomly divided into a treated Group D and a Control Group C. No significant differences were noted between the groups in cardiac electrical arrest and recovery time, recovery rhythm, mechanical function recovery, inotropic support, stroke index, or cardiac index. After cardiopulmonary bypass, the stroke index decreased by 13.1% in Group D and by 20.7% in Group C; cardiac index increased in both--18.6% and 14.0%, respectively--but the results were possibly from compensatory heart rate increases. Peripheral deltaP/deltat and endocardial viability ratios decreased in both groups. Coronary sinus enzymes and serum CK were slightly lower in the treated group. Serum CK-MB, however, was significantly higher in the Control Group. Electrocardiographic ischemic changes occurred in four patients, all in Group C (p =.046). Hyperkinetic arrhythmias occurred in five of the controls, but in none of the treated patients (p =.018). One perioperative myocardial infarction was diagnosed in the Control Group. These data suggest that diltiazem has no negative side effects on hemodynamics or cardiac rhythm and does not reduce impairment of myocardial function due to ischemia, but it does decrease the incidence of ischemic lesions in patients undergoing coronary artery bypass procedures.

[Single cell preparation of the human heart. Technic of dissociation and isolation of myocytes]. / Preparato unicellulare di cuore umano. Tecnica di dissociazione ed isolamento del miocita.

This paper describes a procedure of cellular dissociation which allows the isolation of single cells from the human heart while preserving their integrity and physiological function necessary for electrophysiological studies in vitro. During open heart surgery, biopsies were obtained from the right atrium of the beating heart in 16 patients immediately before starting the extracorporeal circulation. The tissue was immediately placed in a cardioplegic solution at 4 degrees, and subsequently in a free-calcium solution at 20 degrees from 20' to 30'. It was then exposed to the proteolytic action of Collagenase type I and Protease type VII (Sigma Chemical Co., St Louis, USA) at 35 degrees for a maximum of 5 hours. The cells were finally transferred into a Tyrode solution at room temperature. With this method we obtained up to 70% of intact human myocytes, 40% of which calcium-tolerant. The subsequent electrophysiological studies performed showed that the cells maintained their morphological and physiological properties.

["Heart transplantation program" in Piedmont. Results of a 3-year activity]. / "Programma trapianto di cuore" della Regione Piemonte. Risultati dopo tre anni di attività.

Since 1990 the "Heart Transplant Program" has been instituted in the Piemonte Region. Until now the program had regular development according to the number of transplantations and the high quality of clinical results. Sixty heart transplantations has been performed with a 36 month survival close to 80%. Our data demonstrate that after heart transplantation prognosis of end-stage cardiac disease is highly improved either for life expectancy and for quality of life. Our program includes several aspects of scientific research from physiology to clinic, from biochemistry to immunology, from infectivology to pathology, from intensive care to surgery. Several very positive multi disciplinary investigations have been activated.