Report From the American Society of Transplantation Conference on Donor Heart Selection in Adult Cardiac Transplantation in the United States.

Cardiac transplantation remains the only definitive treatment for end-stage heart failure. Transplantation rates are limited by a shortage of donor hearts. This shortage is magnified because many hearts are discarded because of strict selection criteria and concern for regulatory reprimand for less-than-optimal posttransplant outcomes. There is no standardized approach to donor selection despite proposals to liberalize acceptance criteria. A donor heart selection conference was organized to facilitate discussion and generate ideas for future research. The event was attended by 66 participants from 41 centers with considerable experience in cardiac donor selection. There were state-of-the-art presentations on donor selection, with subsequent breakout sessions on standardizing the process and increasing utilization of donor hearts. Participants debated misconceptions and established agreement on donor and recipient risk factors for donor selection and identified the components necessary for a future donor risk score. Ideas for future initiatives include modification of regulatory practices to consider extended criteria donors when evaluating outcomes and prospective studies aimed at identifying the factors leading to nonacceptance of available donor hearts. With agreement on the most important donor and recipient risk factors, it is anticipated that a consistent approach to donor selection will improve rates of heart transplantation.

Chemo-Marangoni convection driven by an interfacial reaction: pattern formation and kinetics.

A combined study devoted to chemo-Marangoni convection and the underlying kinetics is presented for a biphasic system in which surfactants are produced in situ by an interfacial reaction. The pattern formation studied in a Hele-Shaw cell in both microgravity and terrestrial environments initially shows an ensemble of chemo-Marangoni cells along a nearly planar interface. Soon, a crossover occurs to periodic large-scale interfacial deformations which coexist with the Marangoni cells. This crossover can be correlated with the autocatalytic nature of the interfacial reaction identified in the kinetic studies. The drastic increase in the product concentration is associated with an enhanced aggregate-assisted transfer after the critical micellar concentration is approached. In this context, it was possible to conclusively explain the changes in the periodicity of the interfacial deformations depending on the reactant concentration ratio.

Skeletal muscle as the potential power source for a cardiovascular pump: assessment in vivo.

Skeletal muscle ventricles (SMVs) were constructed from canine latissimus dorsi and connected to a totally implantable mock circulation device. The SMVs, stimulated by an implantable pulse generator, pumped continuously for up to 8 weeks in free-running beagle dogs. Systolic pressures produced by the SMVs, initially of 139 +/- 7.2 mmHg and after 1 month of continuous pumping of 107 +/- 7 mmHg, were comparable to normal physiologic pressures in the adult beagles (114 +/- 21 mmHg). After 2 weeks of continuous pumping, the mean stroke work of the SMVs was 0.4 X 10(6) ergs, a performance that compares favorably with the animal's cardiac ventricles. This study shows that canine skeletal muscle which has not received prior training or electrical conditioning can perform sustained work at the high levels needed for an auxiliary cardiovascular pump. It might be possible eventually to use such muscle pumps in humans to assist the failing circulation and to provide support in children with certain types of congenital heart defects.

[Effect of propriocetiv trainings tools for the muscles in stance stability]. / Auswirkung propriozeptiver Trainingsgeräte auf beteiligte Muskulatur im Einbeinstand.

Today in each therapy and training program proprioceptive exercises are integrated. A lot of equipment you can buy. But for an more effective training exercises and equipment should be select more regarding the aim and the problem of the training. In literature is not much written about the specific way proprioction equipment stimulate different muscles. In this study 15 students of sport sciences (25.7 +/- 2.2 years, 8 male, 7 female) were tested for a period of 15 seconds in a single-leg standing position on a small rocker board, a wobble board, a gym mat and the Posturomed(c). The exercise was done just one time on each tool in a random way. The effect of the exercise was measured by EMG on six main stabilising muscles, m. tibialis ant., m. peroneus long., m. gastrocnemius med. And lat., m. semimembranosus and m. vastus med. At the end of the test series MVC of each muscle was tested. For the analysis we regarded the first, middle and last second of the test. Also the maximum peak over 0.5 sec. and the average of the whole test was integrated into the data base. The statistics was done with the Wilcoxen-Test. The experimental standard deviation was defined of 5 %. The highest EMG activity we noticed on the small rocker board. The activity was over the whole test series significant higher in the muscles m. tibialis ant., m. peroneus long. and m. gastrocnemius. The m. semimebranusus shows in all exercises the slightest EMG activity, the m. peroneus long. shows the highest activity. During the test all muscles decrease in EMG activity except m. peroneus long. on the small rocker board and the Posturomed. With these facts of EMG activity during proprioceptive exercises we are able to advice training more specifically: Because of the decreasing activity we advice doing repeated intervals not longer than 15 seconds. In the aim of ankle stabilisation use the small rocker board and the gym mat. For rehabilitation and prevention on the knee use the Posturomed, the mat or even the small rocker board. The advocacies are given looking to the tested rehab tools.

In rat uterus 17 beta-estradiol stimulates a calcium-binding protein similar to the duodenal vitamin D-dependent calcium-binding protein.

A calcium-binding protein (CaBP) similar to rat duodenal vitamin D-dependent CaBP was identified in rat uterus. Uterine CaBP and duodenal CaBP had the same mol wt (9,000-10,000), exhibited the same calcium-dependent electrophoretic mobility, and were immunologically identical. The localization of CaBP in the rat uterus was explored using indirect immunoperoxidase methods, and by CaBP RIA in the endometrium and myometrium after enzyme separation. In the endometrium CaBP was found in the cytoplasm of the stroma cells but not in the epithelium or in the glandular cells. In the myometrium, it was located inside the smooth myometrial fibers. Hormonal regulation of CaBP was shown to differ in the uterus and duodenum. Duodenal CaBP concentrations increased in response to 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), and were not influenced by ovariectomy or sex steroids administration. By contrast, CaBP synthesis fell drastically in the uterus of ovariectomized rats, but was greatly enhanced by low physiological doses of 17 beta-estradiol. This effect of 17 beta-estradiol on uterine CaBP was dose dependent. Medroxyprogesterone and more especially 1,25(OH)2D3 exerted no such stimulating effect on uterine CaBP. In vitamin D-deficient ovariectomized rats, administration of 17 beta-estradiol alone restored the uterine CaBP concentrations to normal and this potency contrasted with the apparent inability of 1,25(OH)2D3 to affect the uterine CaBP concentrations. Our data suggest that, unlike duodenal CaBP regulation, the expression of the CaBP gene in rat uterus is predominantly controlled by 17 beta-estradiol.

Detection of anti-HLA antibody by flow cytometry in patients with a left ventricular assist device is associated with early rejection following heart transplantation.

BACKGROUND: Patients with a left ventricular assist device (LVAD) as a bridge to heart transplantation (HT) often have elevated levels of panel reactive antibodies (PRA). The clinical significance of anti-human histocompatibility leukocyte antigen (HLA) antibodies detected by flow cytometry in PRA negative patients remains unclear. METHODS: Eighteen patients who underwent LVAD placement as a successful bridge to HT had standard anti-human globulin complement-dependent cytotoxicity and retrospective flow cytometry assays performed to detect class I anti-HLA antibodies. A positive flow result was defined as a fluorescent ratio of 23:1 versus a negative control. RESULTS: Six patients had anti-HLA antibodies detected by flow cytometry. Univariate analysis demonstrated more moderate-severe rejection episodes (ISHLT > or = IIIA) at 2 months (0.83+/-0.75 vs. 0; P=0.04) and a trend toward decreased time to first rejection (61+/-17 vs. 225+/-62 days; P=0.06) in these patients. No differences were observed in donor-recipient HLA mismatch or 1 year Kaplan-Meier survival between patients with or without anti-HLA antibodies. CONCLUSION: Despite a negative PRA, LVAD patients with class I anti-HLA antibodies detected by flow cytometry have a greater incidence of moderate-severe rejection in the first 2 months after HT. Flow cytometry may be a useful clinical tool in screening PRA negative LVAD patients before transplantation. Patients with positive anti-HLA antibody screening by flow cytometry may require more intensive immunosuppression in the early post-HT period.

Frequency, risk factors, and clinical outcomes of left ventricular assist device-associated ventricular thrombus.

A retrospective, transesophageal study of 51 consecutive patients receiving a left ventricular (LV) assist device (AD) over a 2-year period showed that LVAD-associated LV thrombosis (16%) was predicted by acute myocardial infarction, atrial cannulation, and postimplantation bleeding, and was associated with a fourfold increased risk of stroke compared with patients without thrombosis. LV cannulation, when using short-term LVADs, may decrease the incidence of LV thrombosis, and early transition to Heartmate-LVAD support may improve outcome.

An autologous biologic pump motor.

Latissimus dorsi skeletal muscle ventricles were constructed in six beagles. They first underwent a period of vascular delay and of electrical preconditioning over several weeks. The skeletal muscle ventricles were then connected to a totally implantable mock circulation that allowed for the chronic measurement of pressures and flows produced by the muscle. The skeletal muscle ventricles were actuated by stimulation of the motor nerve with an implanted generator that delivered brief pulse trains. The skeletal muscle ventricles pumped continuously against an afterload of 80 mm Hg with a preload of 40 to 50 mm Hg at a rate of 54 times per minute. At initiation of pumping, systolic pressure was 135 +/- 24 mm Hg and flow was 464 +/- 116 ml/min. After 2 weeks of continuous pumping, the systolic pressure was 104 +/- 1 mm Hg and continuous flow was 206 +/- 16 ml/min. Two of the skeletal muscle ventricles pumped continuously for 5 and 9 weeks, respectively. At the end of that time one was still capable of generating pressure up to 205 mm Hg and the other, 160 mm Hg. These results suggest that a chronic auxiliary skeletal muscle ventricle is a feasible approach to the treatment of end-stage cardiac failure.

Oxygen consumption of chronically stimulated skeletal muscle.

The latissimus dorsi muscles of six dogs were made fatigue resistant by chronic electrical conditioning. Once the muscles were conditioned, oxygen consumption was measured during periods of exercise. The ratio of the tension developed to oxygen consumed during moderate stimulation (300 msec on) for the control and the electrically conditioned muscles was 16.3 +/- 3.5 and 36.5 +/- 6.7 kg-sec/ml oxygen, respectively. During intense stimulation (800 msec on) the ratio was 12.6 +/- 2.1 and 54.2 +/- 8.9 kg-sec/ml oxygen, respectively. Thus the conditioned muscle was able to develop and maintain tension with a considerably reduced oxygen expenditure. The increased efficiency of the conditioned muscle helps to explain its increased resistance to fatigue and the ability of pumping chambers constructed from electrically preconditioned skeletal muscle to perform sustained cardiac type work.

Skeletal muscle ventricles in circulation. One to eleven weeks' experience.

Skeletal muscle ventricles were constructed from canine latissimus dorsi and connected to the thoracic aorta in six dogs. These ventricles were stimulated to contract synchronously during diastole. The skeletal muscle ventricles were capable of continuous stroke work when placed within the arterial circulation for several weeks. Effective synchronous diastolic counterpulsation was produced. These results demonstrate that diastolic counterpulsators can be constructed from skeletal muscle and in the future may provide a feasible therapeutic alternative for the treatment of end-stage cardiac failure.

Dynamic cardiomyoplasty: its chronic and acute effects on the failing heart.

OBJECTIVES: Dynamic cardiomyoplasty is an alternative therapy for end-stage heart failure. We investigated the mechanisms, both acute and chronic, by which a synchronously stimulated conditioned muscle wrap affects left ventricular function in a chronic canine model of dilated cardiomyopathy. METHODS: Nineteen dogs underwent rapid ventricular pacing at a rate of 215 beats/min for 4 weeks to create a model of heart failure. Eight dogs were then randomly selected to undergo cardiomyoplasty, and all dogs received 6 additional weeks of rapid ventricular pacing. The cardiomyoplasty group also received a graded muscle conditioning protocol of synchronized burst stimulation to transform the muscle wrap. All dogs were studied with pressure-volume analysis and echocardiography at baseline and after 4 and 10 weeks of rapid ventricular pacing. Data in the cardiomyoplasty group were analyzed with the stimulator off, with it augmenting every beat (1:1), and with it augmenting only every other beat (1:2). RESULTS: Stimulator "of" data at 10 weeks of rapid pacing demonstrated chronic effects by enhanced ventricular function (end-systolic elastance = 1.80 after myoplasty vs 1.17 for controls, p = 0.005) and a stabilization of volumes and composite end-systolic and end-diastolic pressure-volume relations in the cardiomyoplasty group when compared with controls. Myoplasty stimulation increased apparent contractility (preload recruitable stroke work = 31.3 for stimulator "of" vs 40.6 for stimulator 1:2 assisted beats [p < 0.05] and vs 45.4 for stimulator 1:1 [p < 0.05]). CONCLUSIONS: Benefits from dynamic cardiomyoplasty are by at least two mechanisms: (1) the girdling effects of a conditioned muscle wrap, which halts the chronic remodeling of heart failure, and (2) active systolic assistance, which augments the apparent contractility of the failing heart.

Ten weeks of rapid ventricular pacing creates a long-term model of left ventricular dysfunction.

OBJECTIVE: Rapid ventricular pacing produces a reliable model of heart failure. Cessation after 4 weeks of rapid ventricular pacing results in rapid normalization of left ventricular function, but the left ventricle remains persistently dilated. We present novel data that show that prolonged rapid ventricular pacing (10 weeks) creates a model of chronic left ventricular dysfunction. METHODS: In 9 dogs undergoing 10 weeks of rapid ventricular pacing, left ventricular function and volumes were serially assessed by using 2-dimensional echocardiography and pressure-volume analysis for 12 weeks after cessation of pacing. RESULTS: Increased end-diastolic volume and decreased systolic and diastolic function were seen at the end of pacing. By 2 weeks of recovery from rapid ventricular pacing, end-diastolic volume and ejection fraction were partially recovered but did not improve further thereafter. Load-independent and load-sensitive indices of function obtained by pressure-volume analysis at 8 and 12 weeks of recovery confirmed a persistence of both systolic and diastolic dysfunction. In addition, left ventricular mass increased with pacing and remained elevated at 8 and 12 weeks of recovery. Four of these dogs studied at 6 months of recovery showed similar left ventricular abnormalities. CONCLUSION: Ten weeks of rapid ventricular pacing creates a long-term model of left ventricular dysfunction.

Early post-transplant lymphoproliferative disease following heart transplantation in the absence of lymphocytolytic induction therapy.

We report a case of post-transplant lymphoproliferative disease presenting as a disseminated polymorphous B-cell lymphoma involving the cardiac allograft 3 months following transplantation in a recipient who did not receive anti-lymphocyte induction immunosuppression. In situ hybridization for the lytic Epstein-Barr virus marker NOT I was positive within a lymphocytic infiltrate on endomyocardial biopsy. Our case is the third of early post-transplant lymphoproliferative disease (within 6 months of transplantation) involving the heart allograft in the absence of anti-lymphocyte induction immunosuppression. Post-transplant lymphoproliferative disease of the heart allograft should be considered in the presence of an atypical cardiac lymphocytic infiltrate, with possible differentiation from allograft rejection using in situ hybridization for Epstein-Barr virus.

Cortical blindness secondary to cyclosporine after orthotopic heart transplantation: a case report and review of the literature.

Cyclosporine neurotoxicity has been described after liver, kidney, and bone marrow transplantation and has been associated with a number of risk factors, including hypomagnesemia and low serum cholesterol levels. Reports in heart transplant recipients are less common. We present a patient with cortical blindness secondary to cyclosporine after orthotopic heart transplantation. The patient had confusion, focal visual field defects, and bilateral occipital lobe lesions shown on magnetic resonance imaging. Although he had significant clinical improvement with decreasing cyclosporine levels, residual computerized visual field defects and magnetic resonance imaging abnormalities were documented several months later.

Hepatitis C transmission and infection by orthotopic heart transplantation.

BACKGROUND: The transmission and clinical consequences of hepatitis C viral (HCV) infection acquired by orthotopic heart transplantation (OHT) from an HCV-infected donor to an HCV-naive recipient have not been well described. We report our experience in 5 HCV-naive patients who were transplanted with hearts from HCV-positive donors. All transplants occurred within a 1-year period. METHODS: After cardiac transplantation we retrospectively examined the recipients' clinical course, liver-associated enzymes, HCV-antibody serology, quantitative HCV RNA level, and HCV genotype. RESULTS: Five subjects with rapidly deteriorating heart failure and negative serum antibodies to HCV received an emergent OHT from a donor known to be infected with HCV. Liver-associated enzymes peaked at 2 to 6 weeks post-transplant: mean peak alanine aminotransferase was 180 U/L (normal, 9 to 52) and aspartate aminotransferase was 111 U/L (normal, 14 to 36). Liver enzymes had returned to normal limits by 6 and 12 months post-OHT. At a mean 15 months after transplantation, only 1 of 5 patients has developed antibodies to HCV, but 4 of 5 have evidence of infection, as shown by serum HCV RNA. No patient has developed evidence of liver failure. CONCLUSIONS: (1) Transmission of HCV from an HCV-positive donor to an HCV-naive recipient at the time of OHT is likely. (2) Antibodies to HCV post-OHT may remain negative for more than 1 year in these patients. (3) Hepatitis C viral RNA using polymerase chain reaction should be the test of choice for diagnosis of HCV infection post-OHT. (4) Hepatitis C viral donor hearts should be limited to critically ill patients in extremis until the long-term consequences of acquisition of HCV by an OHT recipient are known.

Use of theophylline for treatment of prolonged sinus node dysfunction in human orthotopic heart transplantation.

Sinus node dysfunction may complicate heart transplantation in over 50% of cases, leading to prolonged bradyarrhythmias in 20% of recipients. Permanent pacemaker implantation, the standard treatment for such persistent rhythm disturbances, can result in significant complications in this setting. A protocol with theophylline, a methylxanthine known to reverse the sinus node electrophysiologic abnormalities observed in transplant patients, was initiated at our institution in October 1989 to treat posttransplantation bradyarrhythmias and to reduce the need for pacemaker implantation. Patients with sinus or nodal bradycardia or sinus arrest were given theophylline orally; the drug was initiated in 15 of 38 patients (39.5%), 3 to 24 days after transplantation. Mean duration of treatment was 57.4 days (range, 20 to 105 days). Normal sinus rhythm with a rate of more than 90 beats/min was restored in 14 of 15 patients (93.3%). Permanent pacing was required in one patient. Transplant recipients before October 1989 (group 1, n = 112) were compared with subsequent transplant recipients (group 2, n = 38). These groups did not differ significantly in incidence of bradyarrhythmias or potential risk factors for posttransplantation sinus node dysfunction, though a greater preoperative use of amiodarone occurred in group 2. Permanent pacemaker requirement was significantly reduced from 16.1% in group 1 to 2.6% in group 2 (p < 0.05) with the introduction of theophylline. Theophylline is effective treatment for posttransplantation bradyarrhythmias, thereby resulting in a reduced need for pacemaker implantation.

Auditory and visual memory losses in aging populations.

Seventy-four men and women (age range, 44-77 years) were tested for short-term auditory and visual memory as part of a larger series of memory and cognitive function tests. All test scores for visual memory, including facial photograph recognition when a sequence requirement was adhered to, showed a significant decline (p smaller than .05) in a comparison of subjects aged 44-54 and subjects aged 55-64. This decline was not observed with the two tests of auditory memory. Thus the data indicate that short-term visual memory may be more susceptible to aging than is auditory memory.

Artifactual prolongation of the activated partial thromboplastin time mimicking a coagulopathy. A lesson relearned.

A markedly prolonged activated partial thromboplastin time (APTT) was observed in a 61-year-old woman with bruising and a decreasing hematocrit. Coagulation laboratory evaluation was sought to determine the cause of the prolonged APTT and bleeding. Evaluation demonstrated that, rather than identifying a coagulopathy, the APTT prolongation was most likely artifactual. The APTT was actually very short. With a combination of a relatively strong activating APTT reagent (Dade Actin; Dade, Miami, FL) and a fixed lag phase in the automated coagulation instrument (16 seconds), the clot formed before the instrument began to read. Thus, during the period of observation (120 seconds), no change in optical density was observed. This was interpreted by the laboratory as "> 120 seconds." This case reminds those involved in the performance and interpretation of APTTs of the importance of a manual or visual method of verifying markedly prolonged APTTs.

Vitamin E deficiency due to increased consumption in beta-thalassemia and in Gaucher's disease.

Plasma vitamin E levels were found to be decreased (less than 0.5 mg) in thalassemia and in 17 out of 20 patients with Gaucher's disease, where the levels were two standard deviations below the normal mean value. In the latter, the decrease in vitamin E levels correlated with the severity of the clinical expression of the disease and correlated inversely with the degree of hepatosplenomegaly and serum tartrate-resistant acid phosphatase activity. In both diseases, there was no evidence for intestinal malabsorption of the lipid-soluble vitamin. In spite of the different etiology, pathophysiology, and clinical expression, severe vitamin E deficiency could result in both diseases by a common mechanism. In thalassemia, rapid consumption of vitamin E occurs while neutralizing oxidative damage in the pathological erythrocyte membranes and in other tissues. In Gaucher's disease, lysosomal accumulation of glucocerebroside may stimulate phagocytes into a maintained "respiratory burst" with excessive production of oxygen free radicals, resulting in increased utilization and eventual deficiency of vitamin E. Efficacy of antioxidant therapy was evaluated by administration of vitamin E with and without canthaxanthin, which has similar antioxidant properties to beta-carotene, to patients with beta-thalassemia. The results showed increased serum vitamin E levels and a decrease in the extent of erythrocyte lipid membrane peroxidation, while no significant changes occurred in hemoglobin levels and in transfusion requirements.

Canine diaphragm muscle after 1 yr of continuous electrical stimulation: its potential as a myocardial substitute.

Skeletal muscle has been rendered fatigue resistant by chronic stimulation and therefore has potential as an active substitute for damaged myocardium. It is therefore important to know whether stimulation produces any deleterious effects in the long term. Hemidiaphragm muscles of four dogs were examined after chronic stimulation for 1 yr at either 2 or 4 Hz. The stimulated hemidiaphragms appeared normal on gross inspection and were still contracting vigorously. By histochemical and immunohistochemical criteria, they had acquired a uniformly type I character, in contrast to the mixed fiber type composition of the unstimulated hemidiaphragms. This transformation was also reflected in their complement of myosin isozymes. There was some enzymatic evidence of an associated shift towards aerobic pathways of energy generation. Histological examination revealed no evidence of degenerative changes. Trends, observed in the shorter term (6-8 wk), toward a decrease in fiber area and an increase in connective tissue showed no further progression at 1 yr. Thus hemidiaphragm muscle stimulated at frequencies at or above the normal heart rate does not appear to undergo adverse long-term changes that would constrain its use in a myocardial assist role.