Prevention of bone loss in cardiac transplant recipients. A comparison of biphosphonates and vitamin D.

Bone mineral density is already abnormally reduced at the moment of cardiac transplantation and bone loss occurs at an impressive rate in the first postoperative year. The aim of the study was to compare two prophylactic medical regimens as to their efficacy in mitigating bone loss after transplantation. Forty-eight consecutive recipients were randomized to receive either alternating calcium carbonate and disodium etidronate (group A) or a daily supplement of calcium carbonate and alphacalcidol (group B). Bone mineral density measurements were performed immediately before hospital discharge and 6, 12, and 24 months after surgery using dual energy X-ray absorptiometry. Clinical events were recorded and roentgenograms of the spine were performed postoperatively and 1 and 2 years later. In both treatment groups bone loss remained significant at the level of the lumbar spine in the first postoperative year (P<0.005) and at the level of the femoral neck in the first (P<0.005) and the second (P<0.06) year after transplantation. Six months after transplantation, however, patients receiving alphacalcidol had a significant reduction in bone loss at the level of the lumbar spine (P=0.047) and at the level of the femoral neck (P=0.043). At the level of the femoral neck this decrease in bone loss was even more pronounced in the second postoperative year (P<0.001). In the group of patients treated with disodium etidronate, 4 recipients needed additional hospitalizations for treatment of symptomatic fractures at the level of the lumbar spine or the femoral neck. No such events happened in recipients receiving vitamin D supplements. Prophylactic administration of calcium carbonate and alphacalcidol after cardiac transplantation reduces bone loss and seems to decrease osteoporotic complications.

Surgical treatment of acute, massive lung embolism. Results and follow-up.

Between 1970 and 1984 the diagnosis of acute, massive lung embolism was made 30 times in our department. In 29 patients the clinical diagnosis was correct and a Trendelenburg operation under extra-corporeal circulation was performed. In 18 cases there was an operation in the immediate preoperative course. In 1 case there was a combination of operation and the use of contraceptives. 3 cases were immobilized by a plaster of Paris cast. In 4 cases the use of oral contraceptives and in 3 patients the history of chronic recurrent lung embolism were evident. The mean immobilisation time was 15 days. In 24 cases the diagnosis was made only on the base of the clinical anamnesis, and examination, E.C.G. and chest radiography. In 4 cases angiography and in 1 patient the scintigraphy confirmed the diagnosis. Preoperatively 28 patients were in severe shock. One patient was operated electively. 14 patients needed external cardiac massage. In all cases clots were found in the left pulmonary artery, 28 in the right pulmonary artery, in 3 cases clots in the right atrium, 3 in the right ventricle and three in the inferior caval vein. Nine De Weese caval vein clips were inserted and one Mobin-Uddin filter. Postoperatively 18 patients were alive and well without sequelae. Two patients developed a cerebro-vascular accident (CVA) with one complete recovery. Ten patients died. Postoperative treatment consisted of I.V. heparin administration immediately after surgery and 6 months of oral anticoagulants. Except for chronic recurrent lung embolism the pulmonary function tests were excellent postoperatively without recurrence of the disease.