Late noncardiac surgery in heart transplant patients.

OBJECTIVE: Because of improved long-term survival of heart transplants (HT), patients often need noncardiac surgery (NCS). Immunosuppression may increase the infection rate. Inadequate management may increase the risk of dysfunction or acute rejection episodes (ARE). Long-term outcomes of NCS and optimal immunosuppressive management in the perioperative period are not well known. The objective of this study was to analyze the incidence, morbidity, and mortality of late NCS after HT. METHODS: We retrospectively evaluated the incidence and type of late NCS as well as the risk factors for complications and the mortality among 207 HT patients. Immunosuppression and ARE rates were also analyzed. RESULTS: One hundred and sixteen late NCS (84.5% elective) were performed in 72 HT patients (34.8%). Interventions were: 35 urologic (30.2%), 29 abdominal (25%), 14 vascular (12.1%), 13 ENT (11.2%), 11 skin and soft tissue (9.5%), and 7 orthopedic (6%). Malignancy was the main indication for NCS (33.6%). Only 4 patients (5.6%) died preoperatively. Mortality was higher among emergent vs elective procedures (16.6% vs 1%; P = .012) and among patients with preoperative high vs middle/low risk (26.6% vs 0%). Postsurgical infection was the most frequent complication (6.9%). However, there were no relevant complications in 82.8% of HT patients. Hospitalization time was <15 days in two thirds of patients. Immunosuppression was modified in 33 patients (28.4%), especially when the surgical indication was neoplasia (P < .001). None of the patients with NCS displayed allograft dysfunction or an ARE. CONCLUSIONS: More than one-third of HT patients needed a late NCS. In our experience, elective surgical procedures with middle/low preoperative cardiovascular risk are safe. In this context, the risk of rejection was low when immunosuppression was carefully monitored to reduce the risk of infection.

Inhaled nitric oxide through a noninvasive ventilation device to assess reversibility of pulmonary hypertension in selecting recipients for heart transplant.

INTRODUCTION: Pulmonary hypertension (PHT) is an independent risk factor for right ventricular failure and death after heart transplant. Nitric oxide (NO) is a powerful and selective vasodilator, indicated in this scenario, but its response is unpredictable. Thus, it should be assessed prior to the intervention. However, preoperative assessment has not been widespread due to its difficulties and risks. OBJECTIVE: We describe herein a pulmonary vasodilatory test with NO administered through a noninvasive ventilation (NIMV) device. We also assessed the effect of NO in patients with severe PHT owing to cardiac disease. Assessment of the utility of the test to select patients for heart transplant. METHODS: We enrolled 19 patients with severe PHT for a preoperative assessment for heart transplant. Thresholds used were as follows: systolic pulmonary arterial pressure (SPAP) > or =65 mm Hg, transpulmonary gradient (TPG) > or =15 mm Hg, and pulmonary vascular resistance (PVR) > or =4.5 Wood units (WU). NO was administered through a modified noninvasive ventilation device. Cardiac output and pulmonary pressures were measured simultaneously by right heart catheterization. RESULTS: All patients agreed to be enrolled in the test. No difficulties, interruptions, or severe complications happened in any case. Basal and NO average measured values were SPAP (74.16 and 57.95 mm Hg), PVR (7.5 and 3.7 WU), and TPG (23.25 and 12.58 mm Hg). The differences were significant (P < .05) for all three tests. We consider acceptable for heart transplant a response that reduces PHT to a moderate grade. Using these criteria 14 patients were accepted and 11 underwent heart transplant. Two deaths in the postoperative period were both secondary to mediastinal bleeding and not related to right ventricular failure. CONCLUSIONS: A pulmonary vasodilatory test with NO administered through a NIMV device was feasible and useful to select suitable heart transplant recipients with severe pulmonary hypertension.

Long-term results of heart transplant in recipients older and younger than 65 years: a comparative study of mortality, rejections, and neoplasia in a cohort of 445 patients.

BACKGROUND: Whether being older than 65 years should be considered an absolute counterindication to heart transplant (HT), as it is in some centers, is controversial. In our centre, patients older than 65 years are accepted for HT if they satisfy stringent conditions. The aim of this study was to examine whether heart recipients older than 65 years have a greater risk of rejection, neoplasia, or mortality than younger ones. METHODS: We studied 445 patients who underwent HT between April 1991 and December 2003, 42 of whom were older than 65 years and 403 who were 65 years or younger. The parameters evaluated were the cumulative incidences of neoplasias and rejections (ISHLT grade > or = 3A), and the survival rates 1 month, 1 year, and 5 years post-HT. RESULTS: The two groups had similar percentages of patients with at least one rejection episode (< or =65 years 56.9%, >65 years 51.3%; P > .05), and although there were proportionally almost twice as many tumors in the older group (14.2%) as in the younger (7.9%), this difference was not statistically significant either. Nor were there any significant differences in survival, the 1-month, 1-year, and 5-year rates being 87.8%, 82.1%, and 68.8%, respectively, in the younger group and 85.7%, 78.6%, and 73.4%, respectively, in the older. CONCLUSIONS: Among carefully selected patients aged more than 65 years, HT can be performed without incurring greater risk of rejection, malignancy, or death than is found among recipients younger than 65 years.

Cytomegalovirus colitis mimicking a colonic neoplasm or ischemic colitis 4 years after heart transplantation.

BACKGROUND: Cytomegalovirus (CMV) colitis is a polymorphous disease presenting in immunodepressed patients in a variety of clinical forms that can delay diagnosis and therapy. We report the case of a patient who presented with abdominal pain 4 years after heart transplantation; clinical and x-ray findings were suggestive of a neoplastic or ischemic stenosis, and histopathological examination likewise initially suggested an ischemic etiology. METHODS: Tissue samples were fixed in 10% formaldehyde, embedded in paraffin, cut, and stained with hematoxylin/eosin and periodic acid-Schiff-Alcian Blue. Immunohistochemistry with monoclonal antibodies was performed using an indirect immunoperoxidase method. RESULTS: CMV colitis was eventually diagnosed and resolved with surgery and specific anti-CMV therapy. CONCLUSIONS: CMV colitis should be suspected in any heart transplant patient with signs or symptoms of abdominal pathology, even without classical signs or symptoms of CMV infection. If stenotic lesions are present, surgery may be required not only to remove the obstruction but also to rule out malignancy.

Continuous warm reperfusion during heart transplantation.

From April 1991 to January 1993, 37 orthotopic heart transplantations were performed at our institution. Conventional preservation technique with cold crystalloid cardioplegia++ and topical hypothermia during storage and implantation was used in the first 15 cases (group A). After January 1992, for the next 22 patients (group B), we administered a first dose of hyperkalemic blood cardioplegia on arrival of the graft and thereafter instituted continuous warm reperfusion by infusion of oxygenated blood with added potassium. The groups were compared retrospectively, and significant differences were observed. In group B, the ischemic time was shortened by 31 minutes, the suture time lasted 12 minutes longer, sinus rhythm recovered spontaneously, the duration of inotropic support was reduced, postoperative arrythmias decreased, length of intensive care and hospital stays were reduced, there was less ischemic damage in the first endomyocardial biopsy sample, and right ventricular pressures a month after operation were lower. Continuous warm reperfusion during implantation of the donor heart is technically feasible and seems to provide enhanced myocardial preservation.

Direct extension of bronchogenic carcinoma through the pulmonary veins.

We present two surgically treated cases of lung cancer that showed progression of the tumor through the pulmonary veins toward the left atrium. The surgical technique and the influence of improper handling on the production of systemic emboli are discussed.

Thrombectomy: surgical treatment of the thrombosed Björk-Shiley prosthesis. Report of seven cases and review of the literature.

Among 1,000 patients with 1,225 Björk-Shiley prostheses, we have detected 12 cases (0.98%) of late thrombosis of the Prosthesis, seven of which were successfully managed by thrombectomy. A review of other authors' experience with this procedure shows no deaths directly attributable to thrombectomy, although two patients had cerebral embolization during the procedure. For prevention of this complication, we propose that both the aorta and the left atrium be explored during thrombectomy of either the mitral or the aortic prosthesis so as to achieve complete exposure of the left ventricular outflow tract and complete removal of any thrombus located in the ventricle. We consider this the procedure of tract and complete removal of any thrombus located in the ventricle. We consider this the procedure of choice in thrombosis of the Björk-Shiley prosthesis. Replacement of the prosthesis would then be restricted to cases of prosthesis damage or those in which adequate anticoagulation cannot be maintained.

Supravalvular stenotic mitral ring. A new case with surgical correction.

In this report, we present a case of supravalvular stenotic mitral ring in a child. The lesion created a picture of severe mitral stenosis and was successfully managed by resection of the ring. No other malformations of the mitral apparatus or left ventricular outlfow tract were found. On analyzing the diagnostic criteria, we concluded that there appears to be only one useful criterion--the angiographic morphology. However, when ther- is an associated ventricular septal defect or findings of Shone's complex, we should suspect supravalvular ring rather than any other form of mitral stenosis.

Prosthetic valve endocarditis by opportunistic pathogens.

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. We report six cases of endocarditis produced by opportunistic microorganisms (two cases by Candida, and the remaining by Serratia, Actinobacillus, Acinetobacter calcoaceticus, and Bacteroides fragilis, and by Corynebacterium diphtheriae) in four male and two female patients, making special comment on our findings, diagnostic criteria, and treatment. The patients' ages ranged from 9 to 54 years, and all six patients had long-term complications, with symptoms appearing between 45 days and four years after prosthetic valve surgery. The progressive increase of this new type of prosthesis infection is favored by the indiscriminate use of certain drugs and especially by the prophylactic use of antibiotics.

Cardiac echinococcosis: report of 3 cases and review of the literature.

Three patients who underwent successful surgical treatment of cardiac hydatid disease are discussed. The nonspecificity of diagnostic measures and the importance of keeping this diagnosis in mind when faced with a patient coming from an area where hydatidosis is endemic are stressed. We propose the use of cardiopulmonary bypass in the surgical treatment of this problem.

Long-term results of cardiac valve replacement with the Delrin-disc model of the Björk-Shiley valve prosthesis.

One hundred two Björk-Shiley valve prostheses with the Delrin-disc occluder were implanted in 83 patients between January, 1971, and July, 1972. Fifty-eight were in the mitral position, 42 in the aortic, and 2 in the tricuspid. Complete follow-up until 1981 was obtained in 93% of the patients (mean follow-up, 66.8 months). Hospital mortality was 18% and late mortality, 19%. Survival according to actuarial methods was 84.8% at 5 years and 78.1% at 9 years after operation. Thromboembolism was detected in 8.8% of patients but caused no deaths. The incidence was 1.2% and 1.5% per year in those patients treated with Coumadin and antiplatelet agents, respectively. Reoperation was necessary in 13% of the patients. Most survivors (72%) are in New York Heart Association Functional Class I, despite a preoperative status of Class III or IV in 57% of the patients. Hospital mortality may be due to poorer understanding of patient management and less refined techniques of myocardial protection. Long-term survival with this prosthesis is similar to that in more recent studies, and rates of thromboembolism and malfunction compare favorably with other prosthetic valves.

Coarctation of the aorta and severe aortic insufficiency: What to repair first?

A new surgical approach is proposed for patients with coarctation of the aorta associated with severe aortic valvular insufficiency. The valvular lesion should be repaired first and the coarctation corrected during a second operation; both interventions should be done during the same hospital stay. We base our approach on the belief that improved coronary perfusion can be achieved when the aortic insufficiency is corrected first. The disadvantages of the opposite surgical approach, such as anticoagulation problems, renal underperfusion, and hypertensive complications are easily avoided.

Is the femoral cannulation for minimally invasive aortic valve replacement necessary?

INTRODUCTION: Minimally invasive cardiac surgery through a small transverse sternotomy is a new promising technique that can be considered an alternative in most cases to aortic valve replacement thus reducing surgical trauma and subsequent time of hospitalization. The need to avoid the risks associated with femoro-femoral bypass has lead to the interest in aortic valve replacement (AVR) operations without femoral vessels cannulation. We want to emphasize a few important points of our technique, which differs somewhat from the one applied by Cosgrove and associates. OBJECTIVE: This study details the approach to the minimally invasive AVR as first described by. Cosgrove et al. without standard femoral cannulation and points out our preliminary clinical experience. PATIENTS AND METHODS: From October 1996 to May 1997 we have operated on 25 patients using minimally invasive AVR (MI-AVR) In 23 cases, access through transverse sternotomy as described by Cosgrove et al., was performed. In two additional cases the chest is opened via a mini-median sternotomy with an 'L'-shape extending from the sternal notch to the superior edge of the third interspace. Twenty-three patients underwent AVR through transverse sternotomy. The male/female ratio was 13:10. The mean age was 67 years (range 45-78 years). Seventy-four percent of the patients were over 65. Predominantly, in 43% of cases aortic valve stenosis and in 25% of cases aortic valve regurgitation isolated is presented. In 19 cases, a 10-cm transverse incision is performed over the second interspace. Likewise, in four cases over the third interspace according to the thorax morphology and length of the ascending aorta assessed by chest X-ray films. By convention, cannulation of the ascending aorta and right atrial appendage was performed as usual. In contrast, in one patient (5.5%), cannulation was placed in the superior vena cava and right common femoral vein into the inferior vena cava. In the present series, 15 mechanical prostheses and eight bioprostheses whose used sizes were 19, 21,23, and 25 mm in diameter were placed in four, nine, nine, and one of the cases, respectively. All patients underwent AVR electively and a transesophageal echocardiography probe is made. RESULTS: During surgery, conversion to median sternotomy was not required in any patient. Mean aortic cross-clamp time was 68 min (range 38-90 min). Mean total bypass time was 87 min (range 50-120 min). Mean postoperative bleeding was 434 ml. (range 200-850 ml). Perioperative blood transfusion was required in 17% of the patients. Mean mechanical ventilation time was 7.3 h (range 3-24 h), with a mean ICU stay of 18 h. Mean postoperative hospital stay was 4.5 days (range 3-10 days). In all cases, transthoracic and transesophageal echocardiography were performed postoperatively Prosthetic valve dysfunction was not observed. On the other hand, just one patient (4%) died 5 days after operation due to sudden cardiac death. Further, in two patients (8%), during follow-up, pericardial effusion is detected. In one case, cardiac tamponade with hemodynamic instability required a pericardial window procedure. In addition, in two patients (8%), non-infectious sternal dehiscence required reinforced sternal closure. CONCLUSIONS: Minimally invasive AVR surgery without femoral vessel cannulation is a safe procedure with less surgical aggression. After a learning curve, benefits on fast-track programs will be accomplished.

Hypotension, acidosis and vasodilation syndrome after heart transplant: incidence, risk factors, and prognosis.

BACKGROUND: HAV syndrome, the combination of hypotension, acidosis and vasodilation (HAV), is a serious postoperative complication after heart transplantation (HT). Its etiology and prognosis are poorly understood. AIM: To determine the incidence and prognosis of post-HT HAV syndrome and examine possible risk factors. METHODS: Retrospective examination of the records of 85 consecutive patients who underwent HT between December 1999 and June 2002 sought the HAV criteria: systolic BP <85 mm Hg plus HCO3 <19 mEq/l whole excluding cardiogenic, hypovolemic and septic shock. Donor variables included sex, age, weight, height, cause of death, time in ICU, and ischemic time; while recipient variables, sex, age, weight, height, etiology of cardiopathy, previous cardiopulmonary bypass surgery, preoperative amiodarone, beta-blockers, catecholamines, mechanical ventilation or intra aortic balloon pump (IABP), RVP, time on waiting list, pump time, reoperations, polytransfusion, preoperative creatinine, GOT, GPT and GGT, induction with OKT3 or anti-CD25, bypass-to-HAV time, duration of catecholamine treatment, and 1 month survival after HT. RESULTS: The 11 HAV cases (13%) appeared between 1 and 72 h after HT (75% in the first hour). Catecholamines were used for 1 to 6 days; control was achieved within 48 h in 58% of cases. Two HAV patients (18%) died within the first month versus six non-HAV patients (8.1%) (P=.275). Only polytransfusion showed more than a borderline value to predict HAV syndrome. CONCLUSIONS: HAV syndrome has an incidence of 13% and a mortality of 18% within 1 month post-HT. The only likely risk factor is polytransfusion.

A new surgical technique for aneurysmal right atrium.

A new surgical technique for reduction in size of aneurysmal right atrium (ARA) is described. The extracorporeal perfusion is based on extrapleural single stage caval return and profound hypothermia, with circulatory arrest. This method enabled us to diminish the cavity dimensions in the presence of a giant friable ARA, by excising the thinned portion of the free atrial wall and double-layer closure of the remaining edges (close to the AV groove) to the crista terminalis.

Plasma levels of glucose and insulin during deep hypothermia with varying degrees of hemodilution in dogs.

The variations of plasma glucose and insulin levels were studied during the course of deep hypothermia with cardiocirculatory arrest of 60 minutes in 3 experimental groups of dogs using a pump mixture of homologous blood and Ringer's lactate solution at 33%, 50%, and 100% hemodilution. Insulin levels decreased in all groups during the cooling period and remained stable throughout the rest of the experiments, showing a slight significant increase only at the end of rewarming after a temperature of 30 degrees C was reached. Glucose levels reacted similarly except during rewarming, where an important increase in glucose concentration greatly preceded the rise in insulin. We stress the importance of this dissociation in view of the possible clinical implications that may exist.

Anoxic cardiac arrest: Its effect on myocardial mitochondrial metabolism.

Forty eight healthy dogs are subjects to cardiopulmonary bypass and divide into two groups according to whether the perfusion is performed in normothermia or moderate hypothermia (30 degrees C). The effects on oxidative phosphorylation and mitochondrial respiration, produced by increasing periods of myocardial anoxia from aortic cross clamping, are studied. A clear correlation is found between the disturbances of mitochondrial metabolism and the future cardiac recovery. Hypothermia shows a protective effect on the anoxic myocardium. It is concluded that the period of absolute safety in cardiac anoxia, as far as mitochondrial function is concerned, is 15 minutes in normal thermic perfusion and 90 minutes in moderately hypothermic ones.

Isolated mitral valve replacement with the Björk-Shiley prosthesis in 100 consecutive patients. Short- and long-term results.

Single mitral valve replacement with the Björk-Shiley tilting disc prosthesis was performed in 100 consecutive patients between March 1971 and December 1973. The hospital mortality was 13% and the late mortality was 6%. 74 of the patients were followed for periods ranging between 12 and 46 months (mean follow-up: 24 months): clinical improvement was noted in 92%. The incidence of postoperative embolism, including 1 case of prosthesis thrombosis, was 6.7%, and all cases occurred within the first 9 months after surgery. 6 patients required reoperation because of prosthesis dysfunction due to thrombosis (1 patient), leakage (3), and late disc entrapment (2).

Chylous ascites following heart transplantation.

We report a case of chylous ascites in a 52-year-old woman after an orthotopic heart transplantation. The patient was successfully managed with conservative treatment including dietetic measures and repeated paracentesis. The potential aetiopathological factors involved and other implications for cardiac transplant patients are discussed.

Budd-Chiari syndrome due to obstruction of the inferior vena cava. A report of two cases.

Two cases of Budd-Chiari syndrome caused by membranous occlusion of the proximal portion of the inferior vena cava are presented. Both were treated surgically, using the modified technique of Kimura in one case, and a resection with direct vision and extracorporeal circulation in the other. Both patients progressed well. We discuss the etiology and pathogenesis of the syndrome, the diagnostic means that can be used, and the importance of early treatment.