Electron microscopic analysis of lymph node cellular activity in Hodgkin's disease.

Five hundred and two cells, selected at random within the pretreatment-involved lymph nodes of patients with the nodular sclerosis type of Hodgkin's disease, were analyzed by electron microscopy for in vivo subcellular activity and intercellular interaction. Subpopulations of neoplastic cells and of lymphocytes were recognized by ultrastructural criteria. Neoplastic cells displayed definite sequences of cell maturation, whereas lymphocytes displayed definite sequences of cell activation. Active lymphocytes were most often found apposed to the more active of the neoplastic cells, and the nuclei of such apposed lymphocytes displayed a progressive preferential asymmetry of distribution of active DNA templates into that half of the lymphocyte nucleus closest to the neoplastic cell. Such close apposition of active polysomal lymphocytes to neoplastic cells may correlate with increased patient survival in Hodgkin's disease.

Adriamycin cardiotoxicity: endomyocardial biopsy evidence of enhancement by irradiation.

Endomyocardial biopsies were examined in 12 patients receiving total doses of Adriamycin from 90 to 445 mg/M2. These patients had also received previous mediastinal irradiation (from less than 600 to 5700 rad) over periods varying from 6 months to 14 years prior to the endomyocardial biopsy. Severity of pathological change in these 12 patients was compared with that of dose-matched control patients who had not received mediastinal radiation. The severity of the histopathologic changes was scored on a scale from 0 (normal) to 3 (marked abnormality). The mean score of the group receiving irradiation (2.0 +/- 0.89) was significantly higher than the score in those not irradiated (1.18 +/- 0.23) (p less than 0.001). Morphological demonstration of a "recall phenomenon" of latent radiation changes by Adriamycin was demonstrated in small intramyocardial vessels. This study indicates that radiation, even if remote, enhances Adriamycin-induced cardiomyopathy. Therefore, Adriamycin must be given cautiously in patients who have received previous mediastinal radiotherapy.

Myocyte hypertrophy in the transplanted heart. A morphometric analysis.

In order to better define long-term changes in the transplanted heart with respect to the effects of cyclosporine and the ischemic time of the donor heart, endomyocardial biopsies were examined ultrastructurally from 20 cardiac transplant recipients three years posttransplantation. The biopsies were divided into four groups of five based on the donor heart ischemic time in "on-site" versus "distantly procured" hearts and on the immunosuppression protocol: group A: "on site" donor hearts and cyclosporine-based immunosuppression; group B: "on site" donor hearts with conventional immunosuppression (azathioprine-based immunosuppression without cyclosporine); group C: distantly procured donor hearts treated with cyclosporine; and group D: distantly procured donor hearts treated with conventional immunosuppression. All four groups showed a significant increase in the average width of myocytes when compared with normal myocardium, (group A, P less than 0.05; groups B, C, D, P less than 0.01). Also, there was a significant difference between the average widths of myocytes from on-site donor hearts and distantly procured donor hearts (P less than 0.04). There was no significant difference between the average myocyte widths of groups treated with cyclosporine and those with conventional immunosuppression. This study shows that despite the hypertension induced by cyclosporine, myocyte hypertrophy at 3 years posttransplantation does not appear to be significantly greater than in patients treated with conventional immunosuppression. Distantly procured donor hearts have more hypertrophy. Due to the increasing evidence that cardiac hypertrophy per se may predispose to serious ventricular arrhythmias, this study supports the use of on-site as opposed to distantly procured donor hearts.

"Quilty" revisited: a 10-year perspective.

The goals of this study were to better define Quilty lesions, facilitating differentiation from other endocardial infiltrates; to correlate Quilty lesions with clinical parameters; and to assess whether classification into Quilty A (noninvasive lesions) and Quilty B (invasive lesions) had clinical utility. Two hundred seventeen adults who received transplants between 1981 and 1987 and 22 children who received transplants between 1981 and 1989 were studied. Allograft survival for over 1 year was the selection criterion. Clinical, angiographic, and biopsy data were reviewed up to 1992, obtaining a minimum follow up of 5 years for adults and 3 years for children. All 7,439 endomyocardial biopsy cases were allotted an International Society for Heart and Lung Transplantation (ISHLT) grade for rejection, and Quilty was classified as Quilty A or B. Quilty was correlated with transplant recipient age and gender, cytomegalovirus and Epstein-Barr virus (EBV) infection, treatment protocols, allograft rejection, graft vascular disease (GVD), and lymphoma. Immunohistochemistry was performed to determine Quilty cell composition. Quilty incidence was 49.77% in adults and 68.18% in children, and did not appear to be influenced by cyclosporine dosage. Quilty showed no gender variation nor association with cytomegalovirus (CMV) or EBV infection or lymphoma. A total of 74.04% of adults developed Quilty within the first year posttransplant and 81.48% had multiple Quilty-positive biopsies. One hundred eight of 217 Quilty-positive adults had 456 Quilty-positive endomyocardial biopsies, 82.24% of which were associated with an ISHLT grade of 0 or I, and only 12.28% being associated with a grade III rejection. Histological division into Quilty A and Quilty B did not appear to have clinical significance. Graft vascular disease appears to have decreased significantly more in Quilty-positive patients. Although our findings in children were similar to those in the adults, we were unable to draw definite conclusions, the number of children being too small to permit valid statistical correlations.

Graft vascular disease in the great vessels and vasa vasorum.

To determine whether the great vessels were subject to transplantation-associated arteriosclerosis (graft vascular disease) we studied sections of aorta and pulmonary arteries from 19 cardiac explant cases. Sections of the same vessels from five autopsied hearts from patients who had received liver and/or kidney transplants with immunotherapy as well as from eight recipient hearts served as controls. In addition, eight donor hearts (three aortae and eight pulmonary arteries) that were not used for heart transplantation were examined. Intimal proliferation was noted in the aorta but affected the pulmonary arteries only slightly, whereas the vasa vasorum of both vessels were involved and were occluded or stenosed by thickened intima containing recanalized capillaries. On morphometric study the ratio of intima to media in the aorta was significantly higher in the heart transplant group than in the control group (0.14 +/- 0.14 [n = 19] v 0.02 +/- 0.02 [n = 16]; P < .01). This intimal thickening was not correlated with the use of cyclosporine or with other clinicopathologic factors. The cytomegalovirus infection rate was higher in the heart transplant group (85%) than in the control group (40%).

Ultrastructural and functional studies on prolonged myocardial preservation in an experimental heart transplant model.

The effect of ischemia with hypothermic cardioplegic preservation were studied in a heterotopic isograft rat heart transplant model. Hearts with ischemic time periods of 0.5, 4, 8, and 12 hours (n = 5 to 7 transplants per ischemic time period) were analyzed for structural and functional changes 50 days after transplantation. Postoperative recovery was prolonged with increasing duration of preservation times, but all transplants functioned normally 20 minutes and 50 days after transplantation. Function of right ventricular strips from graft and normal hearts were compared in a muscle bath. No differences were observed between baseline or isoproterenol-stimulated myocardium from all grafts or normal hearts. Electron and light microscopy studies of right and left ventricle and ventricular septum samples demonstrated marked fibrosis at 4, 8, and 12 hours of preservation with no differences between the 4, 8 and 12 hour grafts. There were no other differences in other features examined, including necrotic, mitochondrial, I-band, contractility, nuclear, endothelial cell, or intracellular lipid changes. We conclude that (1) except for significant fibrosis, transplants have normal structure and function after 4, 8, and 12 hours of preservation, (2) in assessing the efficacy of hypothermic cardioplegic preservation, chronic structural changes are more sensitive than functional changes, and (3) hypothermic cardioplegic preservation is feasible up to 12 hours but fibrosis may be the ultimate limiting factor in man.

Acute rejection: significance of elapsed time after transplantation.

In July 1990 the new standardized grading scheme for the International Society for Heart and Lung Transplantation was established. One of the purposes of "splitting" the grades was to learn the significance and outcome of the various grades proposed. Between January 1990 and November 1992, 263 grade 1A, 19 grade 1B, and 100 grade 2 "new" rejection episodes were identified at our institution. These episodes occurred in 86 adult recipients who underwent transplantation between January 1990 and August 1992 and 98 recipients who underwent transplantation before January 1990, in whom the episodes occurred more than 1 year from the date of transplantation. The outcome of the episode was determined on subsequent endomyocardial biopsy samples to be resolution or "progression" to a higher grade. The percentage of focal mild (grade 1A) rejection episodes progressing to a moderate (grade 3A) rejection in the first 6 months after transplantation was 24.4% (20 of 82) compared with a progression rate of 5.1% (3 of 59) and 2% (3 of 149) in episodes occurring beyond 6 months and 1 year after transplantation, respectively (p < 0.005). Of the focal moderate (grade 2) rejection episodes receiving no augmentation of immunosuppression, 35.7% (5 of 14) occurring within the initial 6 months and 7.3% (3 of 41) of all such episodes diagnosed beyond 1 year after transplantation progressed to a moderate rejection. A similar trend was seen in the focal moderate rejection episodes that received augmentation of immunosuppression: 26.3% (5 of 19) of episodes occurring within 6 months and 0 of 15 of all episodes occurring beyond 1 year after transplantation progressed to a moderate rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Reliability and usefulness of immunofluorescence in heart transplantation.

BACKGROUND AND METHODS: To study the reliability and usefulness of immunofluorescence on heart biopsy specimens for routine monitoring of heart transplant recipients for rejection, frozen sections of 72 consecutive endomyocardial biopsy specimens from 18 heart transplant recipients during the first 6 weeks after transplantation (and later) and from 11 control specimens from donor hearts and other nontransplantation patients were studied. Fifteen patients received OKT3 induction. The diagnosis of vascular (humoral) rejection pattern as defined by Hammond was based on the microvascular deposition of immunoglobulin and C3 or C1q. Echocardiographic data and right-sided heart catheterization were obtained simultaneously. RESULTS: The results showed that immunofluorescence was positive for a vascular rejection pattern in 60% (43 of 72) overall, in heart transplant recipients it was positive in 59% (36 of 61), and in control subjects it was positive in 63% (7 of 11). Most of the patients who had positive immunofluorescence had no hemodynamic compromise. Humoral rejection was not predicted by positive immunofluorescence in our study. We also found no correlation with either positive or negative immunofluorescence for the short-term or long-term outcome during the first 6 weeks after transplantation. CONCLUSION: The usefulness of routine immunofluorescence in all surveillance heart biopsies is questionable as determined by this study.

Ultrastructural morphometric analysis of endomyocardial biopsies. Idiopathic dilated cardiomyopathy, anthracycline cardiotoxicity, and normal myocardium.

Anthracycline cardiotoxicity has been regarded as a model of idiopathic dilated cardiomyopathy, and similar histopathologic changes have been described in both. Our purpose was to quantify these changes, using computer-assisted ultrastructural morphometry, and compare them with normal myocardium. Right ventricular endomyocardial biopsies were taken from 10 patients with anthracycline cardiotoxicity (AC), 10 patients with idiopathic dilated cardiomyopathy (CM), and 10 disease-free transplant donor heart controls (C). Mean myocyte width (corrected for sarcomere length) was significantly greater in CM (29.3 microns +/- 7.2) than in AC (19.2 +/- 3.2) or C (20.3 +/- 3.4). Mean nuclear area was significantly greater in CM (88.7 microns 2 +/- 27.1) than in AC (54.2 +/- 15.3) or C (45.0 +/- 9.2). Nuclear form factor (corrected for sarcomere length) was significantly lower (indicating a more irregular outline) in CM (0.28 +/- 0.09) than in AC (0.46 +/- 0.06) or C (0.36 +/- 0.04). Mean mitochondrial area was significantly smaller in CM (0.30 microns 2 +/- 0.05) than in C (0.35 +/- 0.05), but differences between AC (0.35 +/- 0.09) and the other groups were not significant. These results suggest that anthracycline cardiotoxicity is not, quantitatively, a faithful model of idiopathic dilated cardiomyopathy.

Distant heart procurement for human transplantation. Ultrastructural studies.

The paucity of donor hearts for human transplantation can be remedied by distant heart procurement. In the present study, 12 donor hearts obtained at distant locatins were preserved by infusion with 500 ml of cardioplegic solution at 4 degrees C at 150 mm Hg and immersion in 4 degrees C saline for rapid transmural cooling. They were transported in ice-cold saline. Maximal ischemic times were 110-182 minutes. Septal biopsies before coronary reperfusion showed normal mitochondria (11 and 12), normal nuclei (seven of 12), myofibrillar I-bands (six of 12), and capillary endothelial swelling (12 of 12). Septal biopsies 30 minutes after reperfusion showed mitochondrial swelling (six of 10), nuclear damage (10 of 10), myofibrillar contraction (10 of 10), and endothelial swelling (eight of 10). All grafts functioned satisfactorily. Eight of the 12 patients were alive 6-15 months later; four patients died (one of pulmonary hypertension and three of infection). We concluded that (1) human hearts show significant ultrastructural changes after 3 hours of ischemia, but (2) these worsen after reperfusion, and (3) distant heart procurement is feasible for human transplantation.