Congenital diverticulum of the ventricle.

Ten cases of ventricular diverticula were seen at the Texas Heart Institute between 1965 and 1984. Operations were performed on nine of the 10 patients with no operative mortality. The tenth patient, a 3-month-old infant with multiple abnormalities, was not returned after the initial evaluation. Most diverticular in our series were unsuspected and diagnosed during cardiac catheterization. Symptoms were related mainly to associated malformations, including intracardiac, midline thoracic, diaphragmatic, and abdominal wall defects. The surgical techniques employed in each case varied according to the size and site of the diverticulum and the associated cardiac defects. We recommend surgery for all diagnosed ventricular diverticula, especially when associated with other intracardiac defects.

Cardiac transplantation at the Texas Heart Institute: comparative analysis of two groups of patients (1968-1969 and 1982-1983).

Two groups of heart transplant recipients were studied. Patients in Group 1 underwent heart transplantation from May, 1968, to November, 1969. They were compared with Group 2, a series begun in July, 1982, when the current cardiac transplantation program was renewed at the Texas Heart Institute, and terminated in December, 1983. Patient selection, management, and results were compared. With a cumulative follow-up of 64 patient-months (Group 1) versus 93 patient-months (Group 2), the actuarial 18-month survival was 0 in Group 1 versus 70% in Group 2. Nine of the 18 patients in Group 1 died of rejection versus 4 of the 18 patients in Group 2. There were 6 infection-related deaths in Group 1 and none in Group 2. Using linearized rates based on 100 patient-months, the incidences of rejection and infection were, respectively, 23 versus 10.7 (p less than 0.05) and 64 versus 34 (p less than 0.05) between Groups 1 and 2. Incidence, pattern, and severity of these major complications have been reduced significantly. Over the last decade, there have been improvements in the selection of potential candidates, better management of donors, improved graft preservation, and the introduction of more selective immunosuppression.

Surgical treatment of mitral systolic click syndrome: results in 37 patients.

From 1974 to 1983, 37 symptomatic patients with mitral systolic click (Barlow's syndrome) underwent mitral valve repair. In 11 patients (30%), the click syndrome was associated with minor mitral regurgitation. Thirty-two patients (86%) had chest pain, 20 had arrhythmia (54%), and 20 had dyspnea as a major complaint. In 5 patients, the arrhythmia was serious, and in 2 of them, it was potentially life threatening. Mitral annuloplasty using a collar prosthesis was performed in 33 patients with posterior leaflet plication in 2, shortening of the chordae in 1, and commissural plication in 2. In 4 patients, commissural plication was performed. One of these patients also required cusp plication and shortening of the chordae, and another required repair of ruptured chordae. There were no operative or late cardiac-related deaths at a mean follow-up of 4.7 years (range, 1 to 10 years). Sixty-two percent of patients with prolapse alone and 91% of those with associated regurgitation were improved by at least one New York Heart Association Functional Class, with 60% of patients obtaining relief of one or more symptoms. In the presence of major symptoms, mitral annuloplasty offers symptomatic relief for some patients with mitral systolic click syndrome without valve incompetence, but it gives substantially better results in patients with mitral regurgitation.

Occlusive coronary arteritis: a cause of early death in a cardiac transplant patient.

A patient died 5 months after undergoing cardiac transplantation. Endomyocardial biopsies performed prior to death showed no evidence of severe rejection. At autopsy, nonnecrotizing occlusive coronary arteritis was present. The intima of the coronary arteries contained numerous lymphocytes and plasma cells. Chronic rejection appeared to be responsible for the arteritis. The onset of coronary occlusive disease is insidious, and recognition depends on the performance of coronary arteriography, which is usually not done until the one-year follow-up. Early coronary arteriography is suggested to rule out occlusive coronary arteritis when cardiac allograft function is not satisfactory, even when the endomyocardial biopsy shows no evidence of rejection.

Radical excision of invasive thymoma with intracardiac extension.

A patient with a low grade malignant thymoma who also had pleural, pericardial and cardiac invasion with intracardiac extension, presented with signs of superior vena cava obstruction, moderate hepatosplenomegaly and a mediastinal mass on a plain chest radiograph. Radical excision requiring cardiopulmonary bypass for the removal of the intracardiac extension into the right atrium was performed. Despite the patient's failure to receive radiotherapy treatment, he was alive one year after surgery. This case is reported because this mode of presentation of intracardiac extension of a thymoma is uncommon and because only this method of radical excision could ensure near-total removal of the mass and prevent early death from cardiovascular complications.

Cardiac transplantation: current results at the Texas heart institute.

The first series of cardiac transplants at the Texas Heart Institute began in May of 1968 but was discontinued because of the complications of infection and rejection. A second series of cardiac transplants was initiated in July of 1982 after the introduction of the immunosuppressant drug, cyclosporine. By August of 1984, 30 patients had undergone orthotopic cardiac transplantation for end-stage cardiac disease. Of the patients in this series, four have died of rejection, two of infectious complications, and one of an unknown cause. The remainder have all returned to Class I New York Heart Association (NYHA) cardiac status. All patients were reviewed in detail for suitability of cardiac transplantation and presented to a cardiac transplant review board. All transplanted patients were functional Class IV. Donor hearts were obtained locally or by long-distance procurement. Ten of the hearts were obtained from an average distance of 250 miles from Houston. Donors ranged in age from 16 to 37 years. Requirements were normal cardiac function with minimal use of inotropic support, no history of cardiac disease, absence of cardiac arrest and absence of active infection. Although only one of the patients in the initial group of transplants survived 1 year, to date there have been 11 survivors for more than 1 year in the current series. Advances in cardiac transplantation have resulted in an improved prognosis for the terminal cardiomyopathic patients requiring transplantation. The use of cyclosporine, an immunosuppressant that spares the nonspecific immune system, has been helpful in allowing patients to survive infections. The use of the drug must be carefully monitored, however, because of its numerous toxicities.

Successful treatment of invasive aspergillosis in a heart transplant patient.

Infection continues to be a major cause of mortality in cardiac transplant patients, and even though there has been significant progress in diagnosing and treating many infectious disease problems, invasive aspergillosis in the transplant patient represents a serious and usually fatal complication. Even with successful early diagnosis, the use of free amphotericin B (a polyene antibiotic) has failed to cure disseminated infection. We report the case of a 46-year-old transplant patient who failed to respond to treatment with free amphotericin B after a 7-day period of treatment for biopsy-proven pulmonary aspergillosis. However, a subsequent substitution of a liposomal form of amphotericin B was used, and the patient responded well to a total dose of 1.5 mg. After 7 months, the patient continues free of infection. This experience suggests that the introduction of liposomal amphotericin B may give new hope for treating an otherwise lethal infection.

Cardiac transplantation in a patient with septicemia after prolonged intraaortic balloon pump support: implications for staged transplantation.

After initial support with an intraaortic balloon pump, and since the introduction of cyclosporine for immunosuppression, five patients have undergone cardiac transplantation in our institution with good results. Not one of these patients died of sepsis in the immediate postoperative period. We report the clinical course of one such patient to show the advantage of cyclosporine immunosuppression and the value of circulatory support devices in patients awaiting suitable cardiac donors. A 22-year-old mother of two children was transferred to our institution with progressive cardiac failure. An intraaortic balloon (IABP) was inserted after she had become hypotensive, obtunded and acidotic, with severe congestive heart failure. However, she failed to improve and we performed a cardiac transplantation. After major problems with infections-a leading cause of death among cardiac transplant recipients-and episodes of convulsions that were controlled with Dilantin, along with other complications, she slowly but progressively improved and was discharged 7 weeks post-transplantation. She had one episode of allograft rejection, which was reversed with a short course of Solu Medrol. She is alive and well 18 months post-transplantation. In conclusion, cardiac transplantation in patients with sepsis can be expected to have a favorable outcome if cyclosporine is used for immunosuppression. When IABP or any other circulatory assist device is used as a bridge to cardiac transplantation, it is still possible to control infection in such patients, especially when cyclosporine is used as the major immunosuppressive.

Infection after cardiac transplantation: treatment and prognosis.

Since July 1982, 18 patients have undergone orthotopic cardiac transplantation at the Texas Heart Institute with steroid and cyclosporine immunosuppression. There have been no deaths from infection despite 15 bacterial, 8 viral, 6 fungal and 1 protozoal infection episodes. With a total follow-up of 90 patient months (mean follow-up, 5.0 months; range 0.1 to 18 months), the incidence of infection is 33 episodes per 100 patient months (1.7 episodes per patient). Only 23 episodes (77%) required drug treatment. Compared to conventional immunosuppressive regimes, cyclosporine treatment is associated with a substantial reduction in the incidence and severity of infection in cardiac allograft recipients.

Evolution of the Texas Heart Institute Distant Organ Procurement Program.

Between August and December 1983, the Texas Heart Institute Transplantation Service performed 10 cardiac transplants. All hearts were removed at outside hospitals and transported to the Heart Institute. Adequate return of cardiac function occurred in all groups after ischemic times of 58.5 minutes for hearts procured within Houston (range, 56-62 minutes) and 152 minutes for those procured in other cities (range, 130-179 minutes). Eight of the transplant patients are alive and well following operation. Distal procurement has more than doubled the number of suitable organs, and offers considerable potential for expansion of the transplant program.

Legionella infections in cyclosporine-immunosuppressed cardiac transplants.

Pulmonary infections from bacterial or viral agents, as well as rare infectious agents, such as Toxoplasma gondii, Aspergillus, and Pneumocystis carinii, have been a bane to the clinician in charge of the care of transplant patients. One such opportunistic Organism, Legionella pneumophila, was responsible for four episodes of infection in three of our patients who survived due to better management of immunosuppression, together with aggressive therapy and early diagnosis of the infectious complications.

Heart transplantation in an 8-month-old girl. 10th anniversary report.

In 1984, Dr. Denton A. Cooley led a surgical team that implanted a cardiac allograft in an 8-month-old girl who had end-stage cardiac disease secondary to endocardial fibroelastosis. At that time, experience with cardiac transplantation in infants was limited, and the long-term effects of the procedure were cause for concern. Ten years later, our patient is a healthy 4th-grade student who enjoys a remarkably normal life. She has grown and developed quite satisfactorily, and her heart has enlarged in proportion to her overall somatic growth. Long-term immunosuppression has produced no adverse effects, and the child's medical problems have differed little from those of her peers. This landmark case has yielded preliminary answers to a number of important questions about cardiac transplantation in infants and has confirmed our original opinion that the procedure is well warranted in selected patients.

Heart transplantation: a therapeutic alternative for patients with end-stage cardiac disease; the Texas Heart Institute experience

El transplante del corazón es una modalidad terapéutica aceptada para aquellos pacientes que sufren de enfermedad cardíaca terminal y cuya condición no es corregible mediante los tratamientos médicos o quirúrgicos convencionales. Desde julio de 1982, el "Texas Heart Institute" ha llevado a cabo 74 transplantes cardíacos usando la Ciclosporina como agente inmunosupresivo con una sobrevivencia de 73%. Los diagnósticos antes del transplante incluyeron cardiomiopatía idiopática (36.4%), miocarditis viral (8.1%). La fibroelastosis endocárdica, las enfermedades congénitas y reumática cardíaca completaron el restante 15% de los casos. En nuestra serie, las infecciones y episodios de rechazo constituyeron las mayores causas de mortalidad y morbilidad. Las mejoras y avances en los criterios de selección de donantes y recipientes, en la preservación de órganos y en la inmunosuperión postoperatoria han contibuido a mejores resultados y mayor sobrevivencia