The risk of coronary artery disease after heart transplantation is increased in patients receiving low-dose cyclosporine, regardless of blood cyclosporine levels.

BACKGROUND: Coronary artery disease (CAD) of allografted hearts is the main cause of late mortality after cardiac transplant, but its etiology is still undetermined. HYPOTHESIS: This study was undertaken to evaluate the relevance of several risk factors, including cyclosporine (CsA) dose and blood CsA levels, to the incidence of CAD. METHODS: In 163 heart transplants performed between November 1985 and August 1994 at our Institution, CAD was diagnosed by coronary angiography or at postmortem examination. Patients in whom postmortem examination or coronary angiography was not performed, as well as those < 15 years of age and those who died within 1 month of surgery, were excluded from the study. The following risk factors were analyzed: recipient age, gender, pretransplant diagnosis, donor age, number of human leukocyte antigen (HLA)-AB mismatches, cytomegalovirus serology, mear serum cholesterol and triglyceride levels, the number of treated acute rejections, mean weighted CsA dose (CsA dosew and weighted blood CsA levels (blood CsA levelw). RESULTS: Coronary artery disease was diagnosed in 32 patients (19.6%). A low mean CsA dosew was the only significant predictor for CAD at multivariate analysis (p < 0.01): there was no correlation with blood CsA levelw. In the patients receiving a CsA dosew > 4 mg/kg/day, the 8.9 year probability of their remaining CAD free was 69% [confidence interval (CI) 50-87%] in comparison with 31% (CI 0-65%) in patients receiving a CsA dosew < 4 mg/kg/day. CONCLUSION: In our experience, a low CsA maintenance dose is the main risk factor for CAD, irrespective of blood CsA levels.

A new frontier for cardiac therapy. Principles and practice of aerobic cardiac surgery.

As recently reported in the literature, aerobic cardiac surgery (normothermic total body perfusion + continuous normothermic blood cardioplegia) might achieve optimal heart protection by virtually eliminating myocardial ischemia during aortic cross-clamping. Two-hundred and fifty consecutive patients underwent cardiac surgery by this technique. Mean cross-clamp time was 72.6 +/- 30.7 minutes. Ten patients (4%) died, 20 (8%) needed major inotropic support and 8 (3.2%) required circulatory assistance. Two-hundred and twenty-three patients (89.2%) returned spontaneously to normal sinus rhythm and 8 (3.2%) had evidence of perioperative myocardial infarction. Nineteen patients (7.6%) had a cross-clamp time longer than 120 minutes and no significant difference in mortality was observed with those undergoing a shorter cross-clamping. When comparing 154 patients receiving retrograde continuous normothermic blood cardioplegia induction with 46 receiving antegrade induction, no difference was found in perioperative parameters, mortality and morbidity. By univariate analysis, impaired preoperative LV performance was identified as the only risk factor for operative mortality. In our experience aerobic cardiac surgery appears most suitable for emergency and redo operations, extensive coronary revascularization, complex mitral reconstruction, aortic valve replacement (particularly with unstented biological prostheses), cardiac transplants and whenever two or more valvular and/or coronary procedures are associated. Retrograde induction is as effective as antegrade and simplifies the technique, facilitating unmodified continuous normothermic blood cardioplegia in different anatomical and clinical situations.

Pediatric heart transplantation without chronic maintenance steroids.

From 1986 to February 1993, 40 children aged 2 months to 18 years (average age 10.4 +/- 5.8 years) underwent heart transplantation. Indications for transplantation were idiopathic cardiomyopathy (52%), congenital heart disease (35%) with and without prior repair (71% and 29%, respectively), hypertrophic cardiomyopathy (5%), valvular heart disease (3%), and doxorubicin cardiomyopathy (5%). Patients were managed with cyclosporine and azathioprine. No prophylaxis with antilymphocyte globulin was used. Steroids were given to 39% of patients for refractory rejection, but weaning was always attempted and generally successful (64%). Five patients (14%) received maintenance steroids. Four patients died in the perioperative period and one died 4 months later. There have been no deaths related to rejection or infection. Average follow-up was 36 +/- 19 months (range 1 to 65 months). Cumulative survival is 88% at 5 years. In patients less than 7 years of age, rejection was monitored noninvasively. In the first postoperative month, 89% of patients were treated for rejection. Freedom from serious infections was 83% at 1 month and 65% at 1 year. Cytomegalovirus infections were treated successfully with ganciclovir in 11 patients. No impairment of growth was observed in children who underwent transplantation compared with a control population. Twenty-one patients (60%) have undergone annual catheterizations and no sign of graft atherosclerosis has been observed. Seizures occurred in five patients (14%) and hypertension was treated in 10 patients (28%). No patient was disabled and no lymphoproliferative disorder was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative clinical assessment of a hollow-fibre membrane oxygenator (Capiox II) and a bubble oxygenator (Harvey 1500).

Personal experience is reported on the use of a membrane oxygenator, the Capiox II, which is clinically compared with a bubble oxygenator for medium-term perfusion. The characteristics considered were the efficiency of the heat exchanger, the oxygenating capacity, traumatic effects on the blood and the direct effect on the renal and cardiopulmonary systems. The Capiox II demonstrated a better oxygenating capacity, less platelet damage, a smaller variation in the free plasma haemoglobin, a significant difference in postoperative bleeding and blood transfusion requirements, but showed no variation in renal and cardiopulmonary function. The authors suggest that the Capiox II is to be preferred for extra-corporeal circulation of medium duration, for which it combines the advantages of both bubble and membrane oxygenators, while being less complex and costly than previously marketed membrane devices.

Macromolecular requirements for abrogation of Fv-1 restriction by murine leukemia viruses.

The molecular basis of abrogation of Fv-1 restriction in mouse cells by murine leukemia virus was investigated. Two different lines of experimentation indicated that high-molecular-weight viral RNA is required for abrogation. First, the decay of abrogating ability of virus stocks heated at 43 degrees C was quantitatively correlated with a loss of intact virion 35S RNA. Second, Act D virions, which lack such RNA although they contain normal structural proteins, failed to abrogate. These findings imply that abrogation does not result from the mere entry of virion structural proteins into a cell. Additional data indicate that the role of viral RNA in abrogation is not that of a template for DNA synthesis. Virus particles lacking reverse transcriptase activity as a result of either mutation or heat inactivation exhibit abrogating activity even though they do not synthesize detectable viral DNA. In addition, abrogation was shown to take place in the presence of cytosine arabinoside, an inhibitor of DNA synthesis. Thus, abrogation does not depend on viral or cellular DNA synthesis, and the role of viral RNA in this process must involve some other function. The nature of this viral function and its occurrence in Fv-1 permissive cells are discussed.

Abrogation of Fv-1b restriction with murine leukemia viruses inactivated by heat or by gamma irradiation.

Fv-1b restriction in BALB/3T3 cells is temporarily abrogated following infection with N-tropic murine leukemia virus. The mechanism of this phenomenon was investigated by comparing the inactivation rates for viral infectivity and for the ability of the same virus to abrogate Fv-1 restriction. Inactivation of the abrogating ability of N-tropic murine leukemia virus following graduated doses of gamma radiation proceeded at half the rate of that for viral infectivity. This result indicates that viral RNA must function in abrogating Fv-1b restriction but that only a portion of the viral genome is required. The inactivation kinetics of N-tropic murine leukemia virus were also determined following incubation of virus at 43 degrees C. Abrogating ability of N-tropic murine leukemia virus was found to be about six times as stable under these conditions as was viral infectivity. Interestingly, virion-associated reverse transcriptase activity was inactivated at the same rate as was viral infectivity, indicating that this enzyme may not need to function during abrogation. Virus heated at 43 degrees C was used to study the kinetics of the abrogation phenomenon itself. Abrogation was shown to be transient, requiring 6 to 9 h after virus infection to become maximally effective and beginning to disappear after about 18 h. The data reported here confirm the idea that abrogation of Fv-1 restriction can be separated experimentally from virus replication, and they raise the possibility that a separate biochemical pathway exists for incoming viral RNA in Fv-1 restrictive cells.

Loss of Fv-1 restriction in Balb/3T3 cells following infection with a single N tropic murine leukemia virus particle.

The ability of various murine leukemia viruses (MuLVs) to replicate in mouse cells exhibiting Fv-1 restriction was analyzed by quantitative dose-response assays. In particular, the effect of infection with N, B, or NB tropic MuLVs on Fv-1b restriction in Balb/3T3 cells was measured with an infection center technique in which pseudotypes of murine sarcoma virus (MSV), which have been shown to exhibit Fv-1 dependence of expression, were used to quantitate the degree of restriction. The resulting dose-response curves indicate that productive infection of a single Balb/3T3 cell with N tropic MSV requires co-infection with two MuLV particles. These two MuLV particles are functionally distinguishable. One of them must be N tropic and must be added less than 18 hr after infection with N tropic MSV. The second MuLV particle, on the other hand, need not be N tropic and may be added at any time. Balb/3T3 cultures infected with sufficient N tropic MuLV become fully permissive to transformation by N tropic MSV and to productive infection by N tropic MuLV. This effect, termed "abrogation" of Fv-1 restriction, results from infection of a Balb/3T3 cell with a single N tropic MuLV particle, but apparently occurs without viral replication. It seems probable that a requirement for abrogation of Fv-1b restriction by a single infectious particle of N tropic MuLV, which does not itself replicate, is responsible for the two-hit dose-response relationship observed in infectivity titrations of N tropic MuLV in Balb/3T3 cells. The requirements that N tropic MuLV be added within a specified time period with regard to N tropic MSV in order for abrogation to occur suggests that in the absence of N tropic MuLV, the cellular Fv-1b restriction mechanism inactivates N tropic MSV by 9 hr after infection.

Phenotypic mixing between N- and B-tropic murine leukemia viruses: infectious particles with dual sensitivity to Fv-1 restriction.

In effort to understand how N or B tropism is determined in murine leukemia virus (MuLV) particles, we analyzed the MuLV produced after dual infection of mouse cells by N- and B-tropic MuLV. The progeny MuLV from such a mixed infection are sensitive to Fv-1 restriction in both N- and B-type cells, but are still highly infectious for mouse cells which do not exhibit Fv-1 restriction. This dual sensitivity to Fv-1 restriction is a phenotypic property of MuLV produced by mixedly infected cells, since individual virus clones derived from this MuLV are either N- or B-tropic. In further experiments, we superinfected murine sarcoma virus (MSV)-transformed cells with mixtures of N- and B-tropic MuLVs. The rescued MSV is restricted in its ability to transforms both N- and B-type cells. The results suggest that N- and B-tropic MuLVs specify different determinants, which are incorporated into virions along with the viral genome and which are the recognition sites for Fv-1 restriction. The presence of a given determinant in a virion renders the virus sensitive to restriction in cells of the opposite Fv-1 type.