Ventral incisional hernia (VIH) repair after liver transplantation (OLT) with a biological mesh: experience in 3 cases.

BACKGROUND: Hernias after orthotopic liver transplant (OLT) occur in about 30 % of cases. Predisposing factors in liver cirrhotic patients of cases are ascites, low abdominal muscle mass and cachexia before and immunosuppression after OLT. Standard operative transplant-technique even in small hernias is to implant a mesh. For patients after liver transplantation a porcine non-cross linked biological patch being less immunogenic than synthetic and cross-linked meshes is chosen for ventral incisional hernia repair. METHODS: 3 patients (1 female, 2 male), OLT indications Hepatitis C, exogenous- toxic cirrhosis, median-age 53 (51 - 56) and median time to hernia occurrence after OLT were 10 month (6 - 18 m) are documented. 2 patients suffered from diabetes, 2 from chronic-obstructive lung disease. Maintenance immunosuppressions were Everolimus in 1 patient, Everolimus + MMF in the second and Everolimus +Tacrolimus in the third patient. The biological was chosen for hernia repair due to the preexisting risk- factors. Meshes, 10 × 16 cm were placed, in IPOM (Intra-Peritonel-Onlay-Mesh) -position by relaparatomy. Insolvable, monofile, interrupted sutures were used. RESULTS: All patients recovered primarily, and were dismissed within 10 d post OP. No wound healing disorders or signs of postoperative infections occurred. All are free of hernia recurrence in a mean observation time of 22 month (10 - 36). CONCLUSION: The usage of porcine non-cross-linked biological patches seems feasible for incisional hernia repair after OLT. Wound infections in these patients have been observed with other meshes. Further investigation is needed to prove potential superiority of this biological to the other meshes.

Low incidence of coronary angiography in the evaluation process of the potential heart donor.

INTRODUCTION: We investigated the practice of coronary angiography (CA) on donor hearts. PATIENTS AND METHODS: Between January 1, 2000, and December 31, 2010, all reported organ donors aged <66 years were analyzed retrospectively. Donor charts were evaluated regarding a performed CA, its outcome, the timing of CA during the evaluation process, and reasons for organ refusal. The percentage of positive CA studies in organ donors aged ≥45 years was also evaluated. RESULTS: Of 292 reported organ donors, 152 organ donor hearts were declined (group 1), and 140 hearts (group 2) were transplanted. Of the 152 declined hearts, 91 hearts were found not suitable for organ offer, and 61 were not successfully allocated or were refused by Eurotransplant. CA was conducted in 17 organ donors (5.8%). In 6 donors, a previous CA was reported (all had pathologic findings), and in 11 donors, a donor CA was performed, indicating 4 pathologic and 7 negative findings (54.5% of the hearts evaluated by donor CA were transplanted). No complication or delay of the donation process was reportedly related to donor CA. CONCLUSIONS: Special emphasis and implementation of recommendations for CA to be part of the evaluation of donor organs seem necessary.

[Successful preclinical thoracotomy in a 17-year-old man]. / Erfolgreiche präklinische Thorakotomie bei einem 17-jährigen Mann.

We report the case of a 17-year-old man who sustained multiple stab wounds after a knife attack. After arrival of the emergency medical team the patient suffered a cardiac arrest caused by cardiac tamponade. After emergency thoracotomy and open heart massage the patient developed ROSC and could be discharged 13 days later without neurological deficits. Prehospital thoracotomy is rarely performed in Austria but is the only realistic chance for survival in cases of hematopericardium and tamponade. Better training of emergency physicians in Austria concerning surgical resuscitation could increase survival rates especially after penetrating thoracic trauma.

Socio-economic effects and cost saving potential of remote patient monitoring (SAVE-HM trial).

OBJECTIVE: In the SAVE-trial we evaluated the safety, reliability and improvements of patient management using the BIOTRONIK Home Monitoring®-System (HM) in pacemaker (PM) and implanted cardioverter defibrillator (ICD) patients. DESIGN: 115 PM (Module A) and 36 ICD-patients (Module B) were recruited 3 months after implantation. PATIENTS: 65 patients in Module A were randomised to HM-OFF and had one scheduled outpatient clinic follow-up(FU) per year, whereas patients randomised to HM-ON were equipped with the mobile transmitter and discharged without any further scheduled in-office FU. In Module B 18 patients were randomised to HM-OFF and followed by standard outpatient clinic controls every 6 months; 18 patients were randomised to HM-ON receiving remote monitoring plus one outpatient clinic visit per year; unscheduled follow-ups were performed when necessary. RESULTS: The average follow-up period was 17.1 ± 9.2 months in Module A and 26.3 ± 8.6 months in Module B. In both modules, the number of FUs per year was significantly reduced (Module A HM-ON 0.29 ± 0.6 FUs/year vs HM-OFF 0.53 ± 0.5 FUs/year; p b 0.001; Module B HM-ON 0.87 ± 0.25 vs HM-OFF 1.73 ± 0.53 FU/year,p b 0.001). Cost analysis was significantly lower in the HM-ON group compared to the HM-OFF group (18.0 ± 41.3 and 22.4 ± 26.9 € respectively; p b 0.003). 93% of the unscheduled visits in Module B were clinically indicated,whereas 55% of the routine FUs were classified as clinically unnecessary. CONCLUSION: Remote home monitoring of pacemaker and ICD devices was safe, reduced overall hospital visits, and detected events that mandated unscheduled visits.

Establishing a brain-death donor model in pigs.

INTRODUCTION: An animal model that imitates human conditions might be useful not only to monitor pathomechanisms of brain death and biochemical cascades but also to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. METHODS: Brain death was induced in 15 pigs by inserting a catheter into the intracranial space after trephination of the skull and augmenting intracranial pressure until brain stem herniation. Intracranial pressure was monitored continuously; after 60 minutes, brain death diagnostics were performed by a neurologist including electroencephalogram (EEG) and clinical examinations. Clinical examinations included testing of brain stem reflexes as well as apnoe testing; then intensive donor care was performed according to standard guidelines until 24 hours after confirmation of brain death. Intensive donor care was performed according to standard guidelines for 24 hours after brain death. RESULTS: Sixty minutes after brain-death induction, neurological examination and EEG examination confirmed brain death. Intracranial pressure increased continuously, remaining stable after the occurrence of brain death. All 15 animals showed typical signs of brain death such as diabetes insipidus, hypertensive and hypotensive periods, as well as tachycardia. All symptoms were treated with standard medications. After 24 hours of brain death we performed successful multiorgan retrieval. DISCUSSION: Brain death can be induced in a pig model by inserting a catheter after trephination of the skull. According to standard guidelines the brain-death diagnosis was established by a flat-line EEG, which occurred in all animals at 60 minutes after induction.

Establishing a donation after cardiac death model in pigs.

INTRODUCTION: Due to the lack of human donors, several strategies have sought to expand the organ pool. Efforts to characterize donation after cardiac death (DCD) have included studies of cell viability, histological and immunohistochemical changes, and oxidative stress, which is known to negatively impact graft survival. A large animal model would be useful for these inquiries. Therefore, we sought to establish a DCD animal model in pigs. METHODS: We simulated non-heart-beating donation Maastricht II and III conditions in 24 pigs. Cardiac fibrillation was induced using 9-V direct current. After various times of ventricular fibrillation (1-10 minutes) with no mechanical and/or medical treatment to achieve cardiac output, reanimation was performed for 30 minutes prior to multiorgan donation. Then, a neurological status was performed. Blood samples were obtained at defined times tissue samples were stored in liquid nitrogen and subsequently embedded in paraffin and subjected to further analysis. RESULTS: We established a DCD pig model in our laboratory by inducing cardiac fibrillation. Up to now, only DCD donation according to the Maastricht criteria II and III has been performed, but establishing all Maastricht criteria of DCDs seems to be feasible. CONCLUSION: A DCD model in pigs enables us to characterize organ quality more precisely as well as evaluate amelioration of storage conditions and donor treatments in a large-animal model.

JTV519 (K201) reduces sarcoplasmic reticulum Ca²âº leak and improves diastolic function in vitro in murine and human non-failing myocardium.

BACKGROUND AND PURPOSE: Ca²âº leak from the sarcoplasmic reticulum (SR) via ryanodine receptors (RyR2s) contributes to cardiomyocyte dysfunction. RyR2 Ca²âº leak has been related to RyR2 phosphorylation. In these conditions, JTV519 (K201), a 1,4-benzothiazepine derivative and multi-channel blocker, stabilizes RyR2s and decrease SR Ca²âº leak. We investigated whether JTV519 stabilizes RyR2s without increasing RyR2 phosphorylation in mice and in non-failing human myocardium and explored underlying mechanisms. EXPERIMENTAL APPROACH: SR Ca²âº leak was induced by ouabain in murine cardiomyocytes. [Ca²âº]-transients, SR Ca²âº load and RyR2-mediated Ca²âº leak (sparks/waves) were quantified, with or without JTV519 (1 µmol·L⁻¹). Contribution of Ca²âº -/calmodulin-dependent kinase II (CaMKII) was assessed by KN-93 and Western blot (RyR2-Ser(2814) phosphorylation). Effects of JTV519 on contractile force were investigated in non-failing human ventricular trabeculae. KEY RESULTS: Ouabain increased systolic and diastolic cytosolic [Ca²âº](i) , SR [Ca²âº], and SR Ca²âº leak (Ca²âº spark (SparkF) and Ca²âº wave frequency), independently of CaMKII and RyR-Ser(2814) phosphorylation. JTV519 decreased SparkF but also SR Ca²âº load. At matched SR [Ca²âº], Ca²âº leak was significantly reduced by JTV519, but it had no effect on fractional Ca²âº release or Ca²âº wave propagation velocity. In human muscle, JTV519 was negatively inotropic at baseline but significantly enhanced ouabain-induced force and reduced its deleterious effects on diastolic function. CONCLUSIONS AND IMPLICATIONS: JTV519 was effective in reducing SR Ca²âº leak by specifically regulating RyR2 opening at diastolic [Ca²âº](i) in the absence of increased RyR2 phosphorylation at Ser(2814) , extending the potential use of JTV519 to conditions of acute cellular Ca²âº overload.

Case of Paracoccus yeei infection documented in a transplanted heart.

After a successful cardiac transplantation, routine endomyocardial biopsies showed severe infiltrates comparable with myocarditis. Polymerase chain reaction analysis of native myocardial samples revealed infection with Paracoccus yeei, and the clinical condition of the patient deteriorated. After administration of ciprofloxacin, his clinical condition improved, and further biopsies showed no infiltrates in the cardiac specimens. To our knowledge this is the first documented case of P. yeei infection in a heart transplant patient.