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.

Differences in heart transplant physiology according to surgical technique.

A new cardiac transplantation technique that preserves the shape of the left atrium and leaves the right atrium intact has been introduced. To compare the new and the standard techniques, we studied cardiac physiology with Doppler echocardiography and catheterization in 26 patients who underwent operation with the standard technique (group A) and I1 who underwent operation with the new technique (group B). Right atrial dimensions were significantly lower in group B (right atrial area index 8.4 +/- 1.5 vs 14.5 +/- 1.9 cm2/m2, p < 0.001), whereas left atrial dimensions were slightly lower (left atrial area index 10.8 +/- 2.0 vs 16.4 +/- 7.0 cm2/m2, p = 0.07). Right atrial contraction, as reflected by peak late tricuspid velocity, was greater in group B (37 +/- 15 vs 30 +/- 10 cm/sec, p < 0.05). The subsequent systolic vena caval flow-velocity integral was also greater in group B at all respiratory phases (inspiration 10.0 +/- 4.0 vs 5.2 +/- 4.0 cm, p < 0.001; expiration 4.8 +/- 1.9 vs 2.9 +/- 1.4 cm, p < 0.001; apnea 5.3 +/- 2.0 vs 2.9 +/- 1.9 cm, p < 0.001) suggesting better atrial relaxation. Filling pressures on the right side of the heart were lower in group B (mean right atrial pressure 5.5 +/- 2.4 vs 6.6 +/- 2.8 mm Hg, p = 0.1; right atrial A wave 6.0 +/- 3.1 vs 8.3 +/- 3.2 mm Hg, p < 0.01; right atrial V wave 6.8 +/- 3.1 vs 9.2 +/- 3.2 mm Hg, p < 0.01; right ventricular end-diastolic pressure 5.6 +/- 3.2 vs 7.3 +/- 2.9 mm Hg, p < 0.05); however, no significant differences were found in left ventricular end-diastolic pressure or cardiac index. We conclude that patients undergoing the new technique exhibit cardiac physiologic improvements. Follow-up study is indicated to ascertain whether this finding implies improved long-term prognosis.

Heart transplantation for cardiac angiosarcoma: should its indication be questioned?

Two men, aged 31 and 32 years, respectively, underwent orthotopic heart transplantation, in both cases to treat primary cardiac angiosarcoma of the right atrium. Total removal of the tumor was performed, and no evidence was found of distant dissemination at the time of surgery. Their postoperative progress was good; however, the patients died 8 and 9 months after transplantation, respectively, of multiple brain metastases. We do not consider heart transplantation to be indicated in the management of malignant cardiac tumors.

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.

Atrial Fibrillation and Stroke Risk After Coronary Artery Bypass Grafting Surgery.

Background: The present multicentre study was aimed at determining the effect of preoperative atrial fibrillation (preop-AF) as stroke risk factor in coronary artery bypass graft surgery (CABG) during the perioperative period. Methods: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish centers. Baseline variables related with perioperative stroke risk were recorded and analysed. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) stroke risk schema was used to stratify stroke risk and compare predicted vs observed neurologic outcomes in this study. Results: 26347 patients were enrolled in the study. Prevalence of preop-AF was 4.2%, and was associated significantly with major cardiovascular comorbidities. The stroke rate was 1.38% (365 strokes), and it was slightly higher for patients with preop-AF vs non preop-AF, 1.82% vs 1.36%, p = 0.2. NNECVDSG schema showed good predictive ability calculating the area under the receiver operating characteristic curve (c-statistic 0.696; 95% CI 0.668 to 0.723). To investigate the associations of baseline preoperative variables with perioperative CABG-stroke a logistic regression model was performed. Preop-AF impact on perioperative stroke was lower that other variables. Preop-AF did not show an adverse impact in the quartiles groups according to NNECVDSG Stroke Risk Index. Conclusion: Risk of perioperative stroke in isolated CABG surgery patients is not significantly increased by preop-AF.

Crystallization of ADP-ribosyl cyclase from Aplysia californica.

ADP-ribosyl cyclase synthesizes the secondary messenger cyclic ADP-ribose from NAD+. Diffraction quality crystals of the enzyme from ovotestes of Aplysia californica have been obtained. Crystallographic analysis of this enzyme will yield insight into the mode of binding of the novel cyclic nucleotide and the mechanism by which NAD+ is cyclized.

Septic arthritis by Salmonella enteritidis after heart transplantation.

A 13-year-old boy underwent orthotopic heart transplantation for end-stage idiopathic dilated cardiomyopathy. Immunosuppressive therapy consisted of cyclosporine, azathioprine, prednisone, and antithymocyte globulin. Endomyocardial biopsies revealed persistent moderate rejection, which was treated aggressively. In the sixth week, septic arthritis by Salmonella enteritidis developed. We discuss our management of this exceptional complication and the poor results obtained because of superimposed cytomegalovirus infection.

Combined transplantation of heart and liver from two different donors in a patient with familial type IIa hypercholesterolemia.

A 12-year-old child with terminal ischemic heart disease as a result of homozygotous familial type IIa hypercholesterolemia received an orthotopic heart transplant and, 21 days later, an orthotopic liver transplant. Six months after heart transplantation, the patient is asymptomatic and evidences normal liver function and cholesterol levels; there are no signs of heart rejection. To our knowledge, this is the first instance of two-step heart-liver transplantation with organs from different donors.

Endocarditis aislada de válvula pulmonar en un corazón sano / Isolated pulmonary valve endocarditis in healthy heart

No disponible

Tratamiento quirúrgico de la hipertensión portal: analisis a largo plazo de 210 casos / Surgical treatment of the portal hypertensión: long term analysis of 210 cases

Se estudiaron 210 enfermos de hipertensión portal, en los que se practicaron 226 intervenciones. Se analizan sus etiologías, el tratamiento quirúrgico y los resultados obtenidos