Declining need for permanent pacemaker insertion with the bicaval technique of orthotopic heart transplantation.

BACKGROUND: The bicaval technique of orthotopic heart transplantation, in contrast to the standard biatrial technique, may better preserve right atrial anatomy and, thus, may be associated with less sinus node dysfunction and less atrioventricular valve dysfunction. OBJECTIVES: To compare the requirement for permanent pacemaker insertion and the incidence of atrioventricular valve dysfunction following heart transplantation with either the standard or the bicaval technique. PATIENTS AND METHODS: A retrospective analysis was conducted of a consecutive cohort of 105 patients, older than 18 years of age, undergoing heart transplantation with either the standard (n=48) or the bicaval (n=57) technique from December 1998 to December 2001. RESULTS: Cross-clamp (100 min versus 112 min; P=0.012) and donor ischemic (222 min versus 276 min; P=0.005) times were significantly prolonged in the bicaval group. Perioperative morbidity and mortality were statistically similar between the groups. Bicaval transplantation resulted in a significant decrease in the requirement for permanent pacemaker insertion at 30 days (13% versus 0%; P=0.008) and 90 days (17% versus 1.8%; P=0.01) after transplantation. There was a nonsignificant trend toward a decreased degree of tricuspid valve regurgitation (mean 1.81 versus 1.36; P=0.141) and mitral valve regurgitation (mean 1.04 versus 0.79; P=0.348) with the bicaval technique. CONCLUSIONS: Although associated with longer cross-clamp and donor ischemic times, the data demonstrated a significant reduction in the need for permanent pacemaker insertion at 30 and 90 days post-transplantation with the bicaval technique. There was no statistically significant difference in the degree of mitral and tricuspid valve regurgitation between the two groups.

A randomized, controlled trial of daclizumab vs anti-thymocyte globulin induction for lung transplantation.

BACKGROUND: Rejection remains a significant cause of morbidity and mortality after lung transplantation. The purpose of this study was to test the efficacy and safety of daclizumab (DZM) vs anti-thymocyte globulin (ATG) as a component of induction therapy. METHODS: Fifty adults undergoing lung transplantation were randomized to receive either ATG or DZM during induction therapy. Patients were followed for 1 year after transplant. RESULTS: Although there was no significant difference in the number of acute or chronic rejections between groups, there was a trend toward a delay in time to first acute rejection with DZM induction. Average absolute lymphocytes and average platelet count were significantly higher in the DZM group. Cytomegalovirus (CMV) serology mismatch was higher in the DZM group (7 vs 1, p = 0.05). The DZM group had a greater number of infections (83 vs 47, p = 0.02); however, the number of CMV infections was also significantly greater (18 vs 6, p = 0.03), corresponding to a higher incidence of CMV mismatch. A cost analysis revealed no difference between total drug costs, intensive-care unit (ICU) costs and total hospital costs. One-year survival was 96% in the DZM group and 88% in the ATG group. CONCLUSIONS: DZM is a safe component of induction therapy in lung transplantation. In addition, DZM may prolong freedom from acute rejection. Significant infections were more frequent in the DZM group, but this was likely due to a higher incidence of CMV mismatch. Both methods of induction therapy worked well, with excellent 1-year survival.

Pretransplant diabetes, not donor age, predicts long-term outcomes in cardiac transplantation.

BACKGROUND AND AIM: Accepting donors of advanced age may increase the number of hearts available for transplantation. Objectives were to review the outcomes of using cardiac donors 50 years of age and older and to identify predictors of outcome at a single institution. METHODS: A retrospective analysis of all adult cardiac transplants (n = 338) performed at our institution between 1988 and 2002 was conducted. RESULTS: Of these, 284 patients received hearts from donors <50 years old and 54 received hearts from donors > or =50 years old. Recipients of hearts from older donors had a greater frequency of pretransplant diabetes (19% vs 33%), renal failure (16% vs 30%), and dialysis (3% vs 9%). There were no differences in ICU or postoperative length of stay, days ventilated, or early rejection episodes. Recipients of older donor hearts, however, had increased perioperative mortality (7% vs 17%; p = 0.03). Multivariate analysis identified older donors (OR 2.599; p = 0.03) and donor ischemia time (OR 1.006; p = 0.002) as significant predictors of perioperative mortality. Actuarial survival at 1 (87% vs 74%), 5 (76% vs 69%), and 10 (59% vs 58%) years was similar (p = 0.08) for the two groups. Separate multivariate analyses identified pretransplant diabetes as the sole predictor of long-term survival (HR 1.659; p = 0.02) and transplant coronary disease (HR 2.486; p = 0.003). CONCLUSIONS: Despite increased perioperative mortality, donors > or =50 years old may be used with long-term outcomes similar to those of younger donor hearts. This has potential to expand the donor pool. Pretransplant diabetes has a significant impact on long-term outcomes in cardiac transplantation and requires further investigation.

Saphenous vein harvest with SaphLITE system versus conventional technique: a prospective, randomized study.

BACKGROUND: Minimally invasive saphenous vein harvest (MIVH) techniques have been evaluated and reported with heterogeneous results. The aim of this study was to evaluate the efficacy of MIVH on the outcomes of postoperative leg wound healing and pain using the SaphLITE retractor system. METHODS: Two hundred twenty-five patients undergoing elective coronary artery bypass grafting surgery were randomized to receive either SaphLITE vein harvest (SVH) or conventional open vein harvest (OVH). RESULTS: There were no significant differences between the two groups in demographics, postoperative mortalities and major complications. For SVH group and OVH group, total leg wound length was 18.33 +/- 7.93 cm vs 46.10 +/- 15.63 cm (p < 0.001), and vein harvest time was 50.70 +/- 16.55 minutes vs 40.35 +/- 16.43 minutes (p < 0.001). In-hospital leg wound healing disturbance (LWHD) rate was 4.7% for SVH group and 1.7% for OVH group (p = 0.190). Delayed LWHD rate was 16.0% for SVH group and 39.5% for OVH group (p < 0.001). Combined, LWHD rate was 20.8% for SVH group and 41.2% for OVH group (p = 0.001). There was no significant difference in the worst postoperative leg wound pain or length of hospital stay between the 2 groups. Double-blinded histologic examinations revealed normal vascular structure in the harvested veins from both groups. CONCLUSIONS: Our study demonstrated that harvesting saphenous vein with SaphLITE retractor system is a good technique which is associated with reduced rate of delayed LWHD, preserved venous structural integrity, and acceptable harvest speed.

Coronary artery bypass surgery with heparin-coated perfusion circuits and low-dose heparinization.

OBJECTIVE: To evaluate the safety and efficacy of heparin-coated perfusion circuits with low-dose heparinization and centrifugal pumping compared with the standard method during coronary artery bypass grafting. DESIGN: Prospective, randomized, single-blind clinical trial. SETTING: A primary care institution. PATIENTS: Ninety patients who underwent first-time elective coronary artery bypass grafting were eligible for the study. After giving informed consent, they were randomly assigned to 1 of 3 groups (30/group). INTERVENTIONS: Perfusion on regular uncoated bypass equipment with a roller pump and full-dose heparinization (300 IU/kg bolus, activated clotting time [ACT] > 400 s) (group 1), on a heparin-coated oxygenator with a centrifugal pump and full-dose heparinization (group 2) and on fully heparin-coated bypass equipment with a centrifugal pump and low-dose heparinization (100 IU/kg bolus, ACT of 180-400 s) (group 3). Standard coronary artery bypass grafting was performed. OUTCOME MEASURES: Postoperative bleeding, transfusion requirements and clinical outcomes. RESULTS: There were no complications related to the study protocol. Study groups were similar in terms of postoperative bleeding, transfusion requirements and clinical outcomes. CONCLUSIONS: Heparin-coated cardiopulmonary bypass with low-dose heparinization and centrifugal pumping is a safe practice but showed no advantages over the use of regular uncoated bypass circuits for coronary bypass surgery.