Comparison between a liquid chromatography-tandem mass spectrometry assay and a fluorescent polarization immunoassay to measure whole blood everolimus concentration in heart and renal transplantations.

Various methods [fluorescent polarization immunoassay (FPIA) and liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay] are used for therapeutic drug monitoring of everolimus. The aim of this study is to compare these assays in renal and heart transplantation. The correlation between results was investigated by linear regression in 44 patients (24 heart recipients and 20 renal recipients--137 samples). The comparison between assays was performed by a paired t-test. A highly significant correlation was found between FPIA and LC-MS/MS in heart and renal recipients [FPIA=0.851 x LC-MS/MS+1.773r(2)=0.8738 (P<0.001)]. Paired t-tests did not show a significant difference between everolimus whole blood concentrations in the populations of heart and renal recipients or heart recipients or renal recipients. FPIA and LC-MS/MS assays gave consistent overall results although some significant differences were observed in some samples between these methods indicating that FPIA assay has limitations that deserve further investigations.

[Body mass index and albuminemia in patients under mechanical circulatory assistance before cardiac transplantation]. / Indice de masse corporelle et albuminémie péri-implantatoires de patients sous assistance circulatoire mécanique (ACM) en attente d'une transplantation cardiaque.

OBJECTIVE: To evaluate the prognostic influence of peri-implantation nutritional status of patients under mechanical circulatory assist (MCA) prior to cardiac transplantation (CT). STUDY DESIGN: Retrospective analysis of patients with cardiogenic shock included from June 1997 to December 2002. PATIENTS AND METHODS: Evaluation at MCA's implantation, at day (D) 30 and at CT or patient's death (D) of body mass index (BMI=body weight (kg)/size (m(2)), albuminemia (Alb g/l), expressed as median values (med) and range (min-max). Odds ratio (OR) and CI 95%) were calculated. A multivariate analysis was performed to determine variables related to D or CT success. RESULTS: Thirty-four patients (30 men), median age 40.5 years (10-63), were included. MCA types were cardiac pumps (N=3); pneumatic (N=18) or electric (N=5) ventricular assist devices and artificial heart (N=8). Global mortality was 56% (19 over 34 patients) and at implantation in the global population (N=34) BMI was 19.4 (9.3-28.1) and Alb 24.6 g/l (15-37.5). At MCA's implantation and D30 respectively, 38 and 42% of the patients had a severe hypoAlb (Alb<30 g/l) and a BMI<19 attesting of a seriously deteriorated nutritional status. No significant statistical difference was observed on median BMI of transplanted patients T (N=15) and expired patients D (N=19). Alb was significantly different (p<10(-4)) between T and D patients: median Alb: 30 g/l (20-37.5) in T patients, 20 g/l (15-31) in D patients. HypoAlb<21 g/l was an independent prognostic factor of death (p=0.004; OR: 0.541; IC95% : 0.36-0.82) and Alb>33 g/l an independent prognostic factor of CT success (p=0.003; OR:1.38; IC95% : 1.12-1.71). CONCLUSION: These results seem to demonstrate that at MCA implantation, a seriously deteriorated albuminemia level (<30 g/l) negatively impacts patients overall survival after CT.

[Anthracycline-induced heart failure aggravated by pregnancy. Survival after cardiac assistance with artificial heart device and heart transplantation]. / Myocardiopathie aux anthracyclines décompensée par une grossesse. Guérison par transplantation cardiaque après assistance temporaire par coeur artificiel.

We report a case of a young woman suffering from a steady anthracycline-induced myocardiopathy with a decreased left ventricular function on echocardiography. A pregnancy was initiated, without worsening of the cardiopathy until 34 weeks. Nine days after delivery, an acute heart failure was observed leading to heart transplantation after cardiac assistance with heart cardiac device. As pregnancy is an extended stress test for a chronic failing heart, a multidisciplinary decision of pregnancy initiation and follow up should be preferred in pre and postpartum period, when such a cardiopathy exists.

Right ventricular function early after total or standard orthotopic heart transplantation.

Right ventricular failure after orthotopic heart transplantation (OHT) is classically related to preoperative pulmonary hypertension. However, the role of the enlarged atria in right ventricular dysfunction after OHT remains unclear. For that purpose, the right ventricular function in the first 2 days after OHT was compared in two groups of transplant recipients: 11 patients who underwent standard OHT (group I) and 9 patients who underwent total OHT, which consisted of total excision of both the left and right atria and OHT of an intact donor heart with its atria as well as its ventricle (group II). Right ventricular ejection fraction, cardiac index, and right-sided pressures were recorded at baseline and 4, 8, 12, 24, and 48 hours after OHT using a Swan-Ganz catheter with a rapid-response thermistor. Right ventricular function parameters did not differ between groups; they were characterized by a decrease in right ventricular ejection fraction and an increase in right ventricular end-diastolic volume index whereas cardiac index and right-sided pressures remained normal or slightly increased. Ischemic time (177 +/- 41 minutes in group I versus 178 +/- 39 minutes in group II) and preoperative pulmonary vascular resistance (1.9 +/- 0.7 Wood units in group I versus 3.0 +/- 1.5 Wood units in group II) were not different between groups. These results suggest that the anatomic and physiologic advantages offered by the modified technique of OHT had no clinical relevance in this group of patients with low preoperative pulmonary vascular resistances when compared with a group of patients who underwent transplantation with the standard technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrospective clinical comparison of Celsior solution to modified blood Wallwork solution in lung transplantation for cystic fibrosis.

OBJECTIVE: To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation. METHODS: From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution. RESULTS: Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant). CONCLUSION: Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.

[Surgery in heart failure (without transplantation)]. / Chirurgie dans l'insuffisance cardiaque (hors transplantation).

Cardiac transplant remains the treatment of reference for end-stage cardiac insufficiency. The very great disparity between the number of grafts available and the number of patients eligible to be included on the transplant list drives some of them to contemplate a surgical alternative in order to improve their clinical condition and to delay as much as possible the date of transplant. The objective is to treat surgically one or several of the lesions causing the cardiac insufficiency. It could be valvular surgery, coronary surgery or a combination of both, ventricular remodelling or cardiomyoplasty. It is coronary revascularisation surgery which gives the most spectacular results on condition that it is aimed at the myocardial zones for which viability has been demonstrated by stress echocardiography or a PET scan.

[Cure of superacute eosinophilic myocarditis treated by temporary circulatory assistance]. / Guérison d'une myocardite suraiguë à éosinophiles traitée par assistance circulatoire temporaire.

The authors report the case of a 31 year old woman, admitted as an emergency for acute myopericarditis, in cardiogenic shock. Echocardiography showed severe left ventricular dysfunction associated with concentric biventricular hypertrophy with increased echogenicity of the myocardial walls. Poor response to treatment with intravenous inotropic drugs led to referral for biventricular circulatory assistance with a Biomedicus pump, which was withdrawn on the 9th day after recovery of normal left ventricular function. Myocardial biopsies showed massive interstitial inflammation with a predominance of eosinophilic cells suggesting a hypersensitivity reaction. Steroid therapy was prescribed when the results of biopsy were known and stopped after 6 months. This case emphasises the value of echocardiography and myocardial biopsy in diagnosis and treatment of acute myocarditis with cardiogenic shock.

[Cardiac transplantation at the University Hospital Center of Nantes. 2 years' experience]. / Transplantation cardiaque au CHU de Nantes. Deux ans d'expérience.

Between March, 1985 and April, 1987, 25 orthotopic heart transplantations were performed in 20 men and 5 women aged from 17 to 58 years (mean 42 years) on account of cardiomyopathy (n = 15), ischaemic heart disease (n = 6) or miscellaneous lesions (n = 4). The immunosuppressive treatment consisted of antilymphocyte serum and corticosteroids during 10 days; cyclosporine was introduced on the 7th day and continued thereafter in association with low-dose corticosteroid therapy. Endomyocardial biopsies were performed. Acute rejection, responsible for 2 deaths (one on the 10th day, the other in the 10th week), usually occurred within the first 3 months. Infections were frequent and often serious, resulting in one death in the 7th week. One out of patients had to be treated for arterial hypertension, and 3 patients presented with renal impairment (blood creatinine over 200 mumoles/l). The actuarial survival rate at 2 years is 84 p. 100. More than one-half of the patients have resumed social and occupational activities.

[Late cerebrovascular complications of cardiac transplantation]. / Les complications cérébro-vasculaires tardives de la transplantation cardiaque.

The occurrence of stroke after the post-operative period of cardiac transplantation is a rare event, and the role of the cardiac transplant in these patients, who often have various vascular risk factors, is unclear. We reviewed the clinical records of 303 consecutive patients with orthotopic cardiac transplantation performed from March 1985 to December 1996 and selected those who developed a stroke over the first 2 months postoperatively, in order to evaluate the frequency and the mechanisms of late cerebrovascular complications. Four patients had presented cerebral infarct and two intracranial hemorrhage. The overall risk of late cerebrovascular complications was 2.6p.100 at 5 years. Ischemic stroke was related to cardiac embolus in one patient, lacunar infarction in another, and was of undetermined etiology in two cases. In addition to vascular risk factors prior to transplantation and the development of intracardiac thrombus, immunosuppressive therapy, the surgical procedure and cardiac rejection may play a role in the occurrence of stroke in such patients.

[Posterior reversible encephalopathy syndrome: about 2 cases related to the cyclosporine]. / Syndrome d'encéphalopathie postérieure réversible: à propos de 2 cas liés à la ciclosporine.

Following a pulmonary transplantation for cystic fibrosis, 2 patients exhibited a syndrome associating arterial hypertension, headache, visual trouble and generalized seizures. Cerebral magnetic resonance imaging revealed diffuse cortical and subcortical lesions predominantly in posterior regions. The exclusion of alternate diagnoses and the disappearance of the symptoms when the cyclosporine treatment was stopped confirmed the diagnosis of cyclosporine-related reversible posterior encephalopathy syndrome (PRES). Immediate appropriate management resulted in symptom disappearance and regression of radiological images.

[Mucoviscidosis: lung transplantation is always in order]. / Mucoviscidose: la transplantation pulmonaire toujours d'actualité.

THE ONLY SOLUTION: Despite significant progress in the management of patients with multiple sclerosis, lung transplantation remains the only chance for survival in those with severe respiratory failure. WAITING LIST INCLUSION CRITERIA: Lung function tests, the patientís general states and psychological and familial factors all contribute to determining inscription on lung transplantation waiting lists. TECHNICAL ASPECTS: Heart-lung, monoblock two-lung and sequential two-lung transplantations are detailed according to the respective advantages and disadvantages. RESULTS: Hospital mortality is about 5% and 5-year survival about 50%. However, only 10% of the patients on waiting lists due to the lack of organs survive for 2 years. PERSPECTIVES: The number of grafts must be increased by developing lobular grafts from live donors using the bipartition technique. Nevertheless, xenografts remain the most promising perspective for increasing the number of patients who can benefit from this therapy.

[Pulmonary and cardiopulmonary transplantation in mucoviscidosis]. / Transplantation pulmonaire et cardiopulmonaire au cours de la mucoviscidose.

As early as 1987, several teams in France began lung transplantation for patients with cystic fibrosis. Most of these teams propose transplantation when the life expectancy is under 2 years. The major functional criteria are VEMS < 30%, PaC02 > 50 mmHg and PaO2 < 55 mmHg. This contribution focuses on psychologic, nutritional and infectious aspects required in preparing the patients for transplantation and on graft selection. Surgical techniques and patient care after transplantation are also reported. The overall probability of survival after transplantation for cystic fibrosis is 48, 35 and 29% at 1, 2 and 3 years respectively with wide intercentre variation. The lack of sufficient graft supply and the risk of post-transplantation degradation remain the two principal problems for transplantation in cystic fibrosis.

[Intra-aortic balloon pumping and heparin-induced thrombocytopenia]. / Contre-pulsion par ballonnet intra-aortique et thrombopénie induite par l'héparine non fractionnée.

Thrombocytopenia is frequently reported in the presence of intra-aortic balloon pumping (IABP) after cardiac surgery and in cardiology, but heparin-induced thrombocytopenia (HIT) is rarely responsible of it in this circumstance. A case-report if HIT in a patient with IABP is presented. This case emphasised the difficulty in diagnosis of HIT in this situation. An acute decrease in platelet count lasting after removal of IABP could suggest the diagnosis of HIT when other origins for thrombocytopenia are excluded.