Extracorporeal membrane oxygenation in lung transplantation.

The use of extracorporeal techniques in cardiopulmonary support has spread in the last 20 years. ECMO (extracorporeal membrane oxygenation) devices are the most commonly employed option, and have been used for years in lung transplant programs. Nevertheless, few articles on the results of ECMO involving large numbers of cases have been published to date. The use of ECMO in respiratory failure affords immediate oxygen support in patients with severe hypoxia and/or acidosis, and moreover provides pulmonary protection, since it allows an instantaneous decrease in the ventilator pressure and FiO2 needs. The complications of ECMO have been minimized thanks to the technological improvements found in the latest devices, though renal failure, infections, bleeding, and vascular and mechanical complications are still reported in many studies. At present there is less controversy regarding the use of cardiorespiratory assists with ECMO as an alternative in decompensated patients who are on the waiting list, referred to the intra- and postoperative periods of lung transplantation.

[Global experience and results of heart transplantation]. / Experiência global e resultadod actuais do transplante cardíaco.

OBJECTIVES: This article summarizes the general experience and results achieved by heart transplantation during 19 years of activity. MATERIALS AND METHODS: Between 1987 and 2005, 439 heart transplantations and 24 cardiopulmonary transplantations were performed by the Cardiovascular Surgery Department of Hospital Universitario La Fe, Valencia, Spain. Indication variation over time, donor/receptor profiles, urgent vs. programmed transplantations and short/long term results over different periods of time were subject to analysis, while correlating the results with changes of surgical technique, myocardial protection and immunosuppression protocols. RESULTS: For the last 5 years, the number of heart transplantations remained stable at 30 cases per year. The most frequent etiology was ischaemic cardiopathy (41%); 25% of the emergency heart transplantations were carried out in patients with inotropic support, mechanical ventilation and/or intraaortic balloon pump contrapulsation. The early mortality rate was 8%, and 4,7% considering only the last period; the most frequent cause of death during the first postoperative month was acute graft failure, followed by infection. After the first year, graft vascular disease was the leading cause of mortality. Emergency transplantation and re-transplantation had a significantly higher mortality. CONCLUSIONS: Cardiac transplantation is the best treatment for terminal miocardiopathies. The early mortality rate was low. At present time, the number of heart transplantations became stable due to a low number of donors. In the future, better prevention and treatment of graft vascular disease shall be achieved in order to increase long-term survival. The comparative analysis of survival shows similar results to others published in the world scientific literature, including a continuing trend towards improving survival over the last years.

Induction of pulmonary immunity in cattle by oral administration of ovalbumin in alginate microspheres.

Respiratory infectious diseases are an important cause of economic losses to the cattle industry. There is a need for an effective, easy to administer vaccine to the critical bacterial pathogens that cause pneumonia in cattle. An orally administered vaccine could be given to a large number of animals without significant stress to the animals and with minimal labor. The purpose of this study was to determine whether the oral administration of a model antigen (ovalbumin) in alginate microspheres could induce pulmonary immunity in cattle. Calves were vaccinated orally with ovalbumin (OVA) following either a subcutaneous (s.c.) or oral priming dose of OVA. Calves primed and boostered by oral administration (oral/oral) of OVA encapsulated in alginate microparticles had increased numbers of antigen-specific IgA ASCs (ASCs) in bronchoalveolar lavage (BAL) fluids. Calves that received a s.c. priming followed by an oral booster inoculation (s.c./oral) of OVA in alginate microspheres had a greater number of anti-OVA IgA, IgG1 and IgG2 ASCs in BALF. S.c./oral calves also had increased numbers of anti-OVA IgG1 ASCs in peripheral blood whereas oral/oral calves had none. S.c./oral calves had increased anti-OVA IgG1, IgG2, and IgA titers in BALF, and IgG1 and IgG2 in serum compared to both oral/oral and sham vaccinated calves. These results indicate that oral administration of antigen encapsulated in alginate microspheres results in a mucosal immune response in the respiratory tract of cattle. Furthermore, s.c. priming both enhanced the IgA response and stimulated an IgG1 and IgG2 response not seen in oral/oral calves. The difference in antibody isotype results suggest that design of the vaccination protocol can direct antibody responses as needed for a specific immunization program.

Long-term clinical experience with the Omnicarbon prosthetic valve.

BACKGROUND: From February 1985 to December 1994, 781 Omnicarbon valve prostheses were implanted in 647 patients. These were 357 male and 290 female patients with a mean age of 53.5+/-10.5 years (range, 4 to 78 years). Before operation, 81% of the patients were in New York Heart Association class III or IV, 16% were in class II, and only 3% were in class I. METHODS: There were 227 aortic valve replacements (AVR) (35%), 286 mitral valve replacements (MVR) (44%), and 134 double-valve replacements (DVR) (21%) (AVR + MVR). Follow-up was 96.3% complete and consisted of 2,746 patient-years (mean follow-up, 4.6 years, and maximum follow-up, 10.7 years). RESULTS: Hospital mortality rates were 7.0% for AVR, 8.0% for MVR, and 8.2% for DVR. The annualized rate of anticoagulant-related hemorrhage was 0.8% per patient-year, and thromboembolism occurred at a rate of 0.7% per patient-year. No structural failure was observed during 10-year follow-up. Twenty-one instances of nonstructural dysfunction (two, pannus growth, and 19, dehiscence) of the Omnicarbon valve occurred in 20 patients, an incidence of 0.8% per patient-year. Hemolytic anemia was observed only in the presence of valvular dehiscence (6 of 19). Eight patients (0.3% per patient-year) had development of prosthetic valve endocarditis (4, AVR; 2, MVR; and 2 DVR). At the end of 10 years of follow-up, 91% of the survivors were in New York Heart Association class I or II. The overall survival rate at 10 years was 82.5%+/-2.6% (85.0%+/-3.9%, AVR; 81.0%+/-4.1%, MVR; and 82.5%+/-2.6%, DVR). Considering only valve-related deaths, the survival rate at 10 years was 91.9%+/-2.4% (90.0%+/-2.7%, AVR; 93.1%+/-3.8%, MVR; and 90.0%+/-1.8%, DVR). CONCLUSIONS: Clinical results over a 10-year follow-up are excellent with the Omnicarbon prosthesis.

Systemic and pulmonary immune response to intrabronchial administration of ovalbumin in calves.

Local immunization of the respiratory tract may be the best way to achieve protection against respiratory pathogens. In order to do so successfully, it is important to fully understand how the immune response to antigen administered via the respiratory route develops. We studied the respiratory and systemic immune response after subcutaneous (SC) and intrabronchial (IB) inoculation of calves with ovalbumin (OVA). Eight calves received two SC inoculations of OVA and eight other calves received two SC and three additional IB inoculations of OVA. The occurrence of OVA-specific antibodies and antibody-secreting cells (ASC) was measured over time using isotype-specific enzyme linked immunosorbent assay (ELISA) and ELISPOT. SC immunization of calves did not result in OVA-specific IgA in bronchoalveolar lavage (BAL) fluid. Subcutaneous priming followed by intrabronchial challenge caused an initial IgG1 response in the bronchoalveolar lavage fluid, followed by a large IgA response. The presence of IgG1-ASCs indicated that the IgG1 was at least partially locally produced. Most of the OVA-specific IgA in the BAL fluid was secreted by pulmonary ASCs as indicated by the large number of IgA-ASCs in BAL samples and the low serum level of OVA-specific IgA. Antigen-specific IgG1 ASCs were detectable among peripheral mononuclear cells after culture with OVA.

[Predictive variables of early mortality after orthotopic heart transplant in adults]. / Variables predictoras de mortalidad precoz tras el trasplante cardíaco ortotópico en adultos.

OBJECTIVE: The purpose of the study was to analyze some variables of donors, recipients and surgical procedures in order to discover factors that could predict mortality during the early stage (< 30 days) of orthotopic heart transplants. MATERIAL AND METHOD: 125 consecutive orthotopic heart transplants in adults were analyzed. The average age was 51 +/- 11 (range: 12-67), 109 (87%) were men, 16 were women (13%). Two groups were compared: 15 patients who died within 30 days after heart transplant and 110 who survived during that period. Immunosuppressive protocol: preoperative: Cyclosporin + Azathioprine. Intraoperative: Methylprednisolone Postoperative: Methylprednisolone (first 24 h), antilymphocyte monoclonal antibodies (7-10 days after heart transplant) + Cyclosporin + Azathioprine + Corticoids. The following parameters of the recipient were analyzed: sex, age, weight, size, thoracic perimeter, pretransplant cardiopathy, previous thoracic operations, functional stage or need for catecholamines during the days prior to the transplant, pulmonary artery pressure and resistance, history of systemic arterial hypertension, elevation of creatinine, blood type, urgent transplant indication, receptor/donor weight relationship. The following parameters of donors and operation were analyzed: sex, age, weight, thoracic perimeter, period in intensive care unit, dose of dopamine and dobutamine, blood type, origin of the organ, cause of death, ischaemia time, cardiopulmonary by-pass time and cardioplegia type. RESULTS: The rate of early mortality was 12%. The univariate analysis showed differences in: prior cardiovascular surgery, receptor blood type, need for urgent transplantation, pulmonary artery resistance > 2.5 Wood Units, cardiopulmonary by-pass time, weight relationship between receptor and donor. The death cause of the donor proved significant. On multivariate analysis, the following parameters independently predicted early mortality: history of operation with extracorporeal circulation, high pulmonary artery resistance, urgent transplant, receptor/donor weight relation and time of extracorporeal circulation. CONCLUSIONS: We believe that the results of our experience can help to stratify the risk in the orthotopic heart transplant recipient and even to contraindicate the procedure in some cases showing an accumulation of poor prognostic factors in borderline recipients.

[Heart angiosarcoma and heart transplantation. Report of a case]. / Angiosarcoma cardíaco y trasplante cardíaco. A propósito de un caso.

We present the case of a 29-year-old women with a cardiac primary angiosarcoma diagnosis. The initial symptom was a cardiac tamponade. The tests for screening metastasis proved negative. She was preoperatively treated with chemotherapy, followed by a heart transplant. There were no incidents related to surgery nor to the transplant except for a rejection in the second week biopsy. Four weeks after the transplant, the patient had a sudden dyspnea, the radiological tests confirmed the existence of a massive pleural overflow and lung and pleural metastasis. All types of therapeutical approaches were rejected except for pleurodesis. The patient died 60 days after the heart transplant.

[Which variables predict the appearance of right bundle-branch block and its course after heart transplantation?]. / Qué variables predicen la aparición de un bloqueo de rama derecha del haz de His y su evolución tras el trasplante cardíaco?

AIM: The purpose of this study was to analyze a series of variables in donors as well as of the preoperative and early and late postoperative of patients developing a right branch block of the bundle of His (RBBBH) in the first week after heart transplantation (HT), and to evaluate factors predicting the disappearance or progression of this conduction disorder. MATERIAL AND METHODS: 58 consecutive patients having undergone an orthotopic HT were studied. 15 of them showed a RBBBH after the HT (age: 43 +/- 13, 12 male, 3 female) and 43 did not (age: 54 +/- 17, 40 male and 3 female). ECGs and echocardiographic studies were performed after 1 week, 1, 3 and 6 months and 1 year. The following factors were analyzed: age and sex of the donor baseline cardiopathy, donor's weight related to recipient's weight, time of ischaemia and cardiopulmonary by-pass, number of rejections per patient/year, previous pulmonary vascular resistance. These parameters were compared among the patients who showed RBBBH and those who did not, and between those whose blocks disappeared in the follow-up and those whose blocks persisted. RESULTS: We found differences is the sex of donors, age of recipients, baseline etiology and time of cardiopulmonary by-pass (with block: 43 +/- 13 years old, dilated cardiomyopathy 73%, 106 +/- 25 minutes, whereas without block: 54 +/- 17 years old, dilated cardiomyopathy 42%, 92 +/- 18). The different parameters between the patients whose block underwent a regression or a progression were sex, lung resistances and right ventricle diameter (progression of the block: men 100%, 3.43% +/- 1.05 UW, progressively growing ventricular diameters. No progression or regression of the block: men 67%, 1.63 +/- 0.74 UW, ventricular diameters with progressive decrease). CONCLUSION: Younger recipients, with a diagnosis of dilated cardiomyopathy, to whom a woman's heart is implanted and who show a longer extracorporal circulation time are those who show a higher incidence of RBBBH: Male patients with high pulmonary resistances undergo a progressive increase in the diameter of the right ventricle and a progressive increase in the RBBBH degree.

Should supraclavicular brachial plexus block be avoided in pregnancy?

Unilateral phrenic nerve block is common after supraclavicular brachial plexus block techniques, although it is rarely symptomatic in patients without respiratory disease. A 24-weeks-pregnant woman was scheduled for a carpal tunnel release because of intractable pain. After a perivascular subclavian brachial plexus block with 30 ml of 0.33% plain bupivacaine was performed, the patient developed a right phrenic nerve block manifested by acute dyspnea and cough. No deleterious consequences followed, but surgery was canceled. Respiratory changes produced by pregnancy might compromise ventilatory reserve. Thus, we suggest avoiding supraclavicular approaches to brachial plexus block in pregnant women, since they may be as prone to developing respiratory embarrassment, secondary to phrenic block, as patients with pulmonary pathology.

[Extracorporeal membrane oxygenation in primary graft dysfunction in a paediatric double lung transplant: presentation of a case]. / Oxigenación con membrana extracorpórea en la disfunción primaria del injerto en trasplante bipulmonar pediátrico: a propósito de un caso.

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant. We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

[Morphine infusion for postoperative pain management in patients who have undergone upper abdominal surgery]. / Infusión de morfina para el manejo del dolor postoperatorio en pacientes sometidos a cirugía abdominal alta.

We compared the efficacy and side effects of postoperative continuous infusions versus intermittent intravenous on-demand morphine, with or without the addition of clonixin. Eighty five healthy patients, aged 18 to 65 years, scheduled for elective cholecystectomy, were prospectively randomized: Group 1 (n = 22) received morphine 2.5 mg i.v. on-demand; group 2 (n = 22) received a clonixin 400 mg/day i.v. infusion; group 3 (n = 19) a morphine 0.4 mg/kg/day i.v. infusion; and group 4 (n = 22) received a clonixin 400 mg/day plus a morphine 0.4 mg/kg/day i.v. infusion. Groups 2, 3 and 4 also received, on-demand, 2.5 mg i.v. bolus doses of morphine. A blind observer recorder analogue and descriptive pain scores, respiratory rates and side-effects for 72 hours postoperatively. Groups with morphine infusions had less overall pain scores for the first day when compared with intermittent dosing (p < 0.05); these groups also had less pain during the night (p = 0.0016) and required less additional morphine (p < 0.0001). Side-effects were similar and no cases of heavy sedation or respiratory depression were observed. We conclude that a morphine 0.4 mg/kg/day infusion is a safe and effective alternative to on demand dosing in healthy patients after elective cholecystectomy, achieving better analgesia without increasing side-effects. Clonixin 400 mg/day seems to add no significant benefits.

[Acute non-cardiogenic pulmonary edema secondary to upper airway obstruction. Clinical case]. / Edema pulmonar agudo no cardiogénico secundario a obstrucción de vía aérea alta. Caso clínico.

Noncardiogenic pulmonary edema is a well recognized complication of upper airway obstruction. We report the case of a previously healthy 18-year-old male who presented this complication following laryngospasm after anesthesia. He developed severe pulmonary edema with hypoxemia, high cardiac output and low pulmonary capillary pressures. He was managed with mechanical ventilation and PEEP. Pulmonary edema resolved within 24 hours. The clinical picture, etiology, differential diagnosis and prevention are also discussed.

Increased expression of type 2 cytokines in chronic proliferative dermatitis (cpdm) mutant mice and resolution of inflammation following treatment with IL-12.

Chronic proliferative dermatitis (cpdm) is a spontaneous mutation that results in eosinophilic inflammation in multiple tissues, including the skin. To determine the mechanisms underlying the eosinophilic inflammation, the expression of cytokines in the skin was determined. There was increased expression of IL-4, IL-5, IL-13, and granulocyte-macrophage colony-stimulating factor in the skin of cpdm/cpdm mice, and no change in IL-10 and TNF expression. Supernatants of cultured spleen cells of cpdm/cpdm mice contained an increased amount of IL-5 and IL-13, and a decreased amount of IFN-gamma. The ability of the cpdm/cpdm mice to mount a delayed-type hypersensitivity response was greatly reduced. These data are consistent with impaired type 1 and excessive type 2 cytokine production in cpdm/cpdm mice. The significance of this imbalanced cytokine production was evident in the efficacy of systemic treatment of cpdm/cpdm mice with IL-12. Mutant mice treated for 3 weeks with IL-12 had minimal changes in the skin as opposed to the severe dermatitis in mice treated with the vehicle. Treatment with IL-11, which opposes the effect of IL-12, had no effect.

[Nocturnal hypoxemia after abdominal surgery: associated factors and usefulness of oxygen therapy]. / Hipoxemia nocturna después de cirugía abdominal: factores asociados y rol de la oxigenoterapia.

BACKGROUND: Postoperative nocturnal hypoxemia (PONH) is a main factor in the genesis of respiratory, cardiac and neurologic complications after surgery. AIM: To describe the phenomenon of PONH after elective laparoscopy and laparotomy, and to evaluate the usefulness of oxygen therapy in its prevention. PATIENTS AND METHODS: Fifteen elective patients (6 M, 9 F, 51 +/- 8 years old) scheduled for laparotomy (n = 8) or laparoscopy (n = 7) were studied. Ventilatory parameters and pulse oximetry were measured pre and postoperatively. Patients were randomly assigned to receive oxygen by nasal cannula either during the first or the second postoperative night. RESULTS: PONH (SatO2 < 85) developed in seven patients (47%), of which four had undergone laparoscopic surgery. PONH was more frequent in mildly obese patients and those presenting preoperative hypoxemia (p = 0.03). Peak Flow was lower in patients presenting PONH (p = 0.04). In five patients, PONH was associated with significant tachycardia. Oxygen administration was associated with a higher SatO2 and prevented PONH in 6/7 patients. CONCLUSIONS: PONH is a common event in patients older than 40 years scheduled for open or laparoscopic abdominal surgery, and develops more frequently in those with preoperative nocturnal hypoxemia and greater ventilatory impairment. PONH can be prevented, most of the time, with oxygen administration.

Oral vaccination of animals with antigens encapsulated in alginate microspheres.

Most infectious diseases begin at a mucosal surface. Prevention of infection must therefore consider ways to enhance local immunity to prevent the attachment and invasion of microbes. Despite this understanding, most vaccines depend on parenterally administered vaccines that induce a circulating immune response that often does not cross to mucosal sites. Administration of vaccines to mucosal sites induces local immunity. To be effective requires that antigen be administered often. This is not always practical depending on the site where protection is needed, nor comfortable to the patient. Not all mucosal sites have inductive lymphoid tissue present as well. Oral administration is easy to do, is well accepted by humans and animals and targets the largest inductive lymphoid tissue in the body in the intestine. Oral administration of antigen requires protection of antigen from the enzymes and pH of the stomach. Polymeric delivery systems are under investigation to deliver vaccines to the intestine while protecting them from adverse conditions that could adversely affect the antigens. They also can enhance delivery of antigen specifically to the inductive lymphoid tissue. Sodium alginate is a readily available, inexpensive polymer that can be used to encapsulate a wide variety of antigens under mild conditions. Orally administered alginate microspheres containing antigen have successfully induced immunity in mice to enteric (rotavirus) pathogens and in the respiratory tract in cattle with a model antigen (ovalbumin). This delivery system offers a safe, effective means of orally vaccinating large numbers of animals (and perhaps humans) to a variety of infectious agents.