Renal function and safety of heart transplant recipients switched to mycophenolate mofetil and low-dose cyclosporine.

BACKGROUND: We evaluated cyclosporine (CSA) dose reduction and mycophenolate mofetil (MMF) treatment versus maintained CSA dosage and azathioprine (AZA) in HTX regarding renal function and safety from CSA nephrotoxicity (creatinine > 1.7 mg/dL). METHODS: Fourteen recipients (group 1: 12 men, 2 women) with CSA-based immunosuppression (plus azathioprine and/or steroids) were started on 2000 mg MMF/d. Azathioprine was discontinued and CSA tapered to trough whole blood levels of 70 to 120 microg/L. Ten recipients (group 2: seven men, three women) were maintained on their CSA dosages. Creatinine clearance, serum creatinine, uric acid, urea nitrogen, and rejection were monitored. RESULTS: Mean age was 58 (range 44 to 69 years) and 48 years (range 24 to 61 years) in groups 1 and 2, respectively. In group 1 creatinine fell from 2.7 +/- 0.8 to 1.9 +/- 0.5 mg/dL (baseline vs control 2: P =.001); uric acid and urea nitrogen remained constant. CSA levels decreased from 173 +/- 56 to 110 +/- 33 microg/L (P =.02). In group 2 creatinine (2.4 +/- 0.7 vs 2.3 +/- 0.5 mg/dL), uric acid, urea nitrogen, and CSA levels remained constant. Comparison between groups showed higher creatinine clearance (50 +/- 18 vs 29 +/- 14 mL/min; group 1 vs group 2: P =.02), lower CSA levels (110 +/- 33 vs 161 +/- 35 microg/L; P <.001) and a trend toward lower serum creatinine (1.9 +/- 0.5 vs 2.3 +/- 0.5 mg/dL, P =.077). There were two rejections >/= 1B according to ISHLT in the study and four in the control group. Two deaths occurred in each group. CONCLUSIONS: Conversion from AZA to MMF after CSA reduction improves creatinine clearance in HTX recipients and reduces serum creatinine. No negative effect on patient safety was identified by rejection rate or survival.

Single atriocaval cannulation is associated with increased incidence of hypercirculatory failure after cardiopulmonary bypass.

UNLABELLED: Cardiopulmonary bypass (CPB) can lead to hypercirculatory cardiac failure (HCF). Despite the activation of inflammatory mediators, the infusion of cardioplegic solution into the systemic circulation may result in decreased systemic vascular resistance and thus may cause HCF. The present prospective study was conducted to investigate in cardiac surgical patients the effects of single atrial versus bi-caval venous drainage and intraoperative hemofiltration on the incidence of HCF. METHODS AND RESULTS: 120 patients undergoing coronary artery bypass surgery (CABG) were randomized in 3 groups: A- single atrial cannulation; B- single atrial cannulation and intraoperative zero fluid balance hemofiltration; C- bi-caval cannulation. Myocardial protection was performed using cold crystalloid cardioplegia (Bretschneider's HTK) administrated into the aortic root and moderate hypothermia (32 degree C). Hemodynamics, fluid balance, vasoactive drugs, body temperature, and hemoglobin/hematocrit ratio were recorded during and up to 12 hours after surgery. We noted a significantly increased incidence of HCF in-group A (32%, n=13) and B (40%, n=16) when compared to group C (10%, n=4, p<0.05), with significantly increased requirements for vasoactive medication in patients developing HCF. CONCLUSION: The present study results demonstrate that single atrial cannulation is associated with a significantly higher incidence of HCF. This is presumably caused by infusion of cardioplegic solution into the systemic circulation.

Pneumonectomy for lung cancer in heart transplant recipient.

Prolonged nonspecific immunosuppression after solid-organ transplantation is associated with an increased risk of certain cancers. Review of the medical literature reveals that the combination of profound immunossuppression (triple-drug immunosuppression), a heavy smoking history, advanced age and a working exposition puts cardiac transplant recipients at increased risk for the development of aggressive lung cancer. These tumors in cardiac transplant recipients carry a poor prognosis. We present one case of bronchogenic carcinoma in a cardiac transplant patient. The patient was operated to resect the tumor and a long-term cure and a good quality of life should, however, be offered.

Dilated coronary sinus mimicking posterior left ventricular aneurysm.

Dilation of the coronary sinus is mostly a congenital lesion. As acquired lesion it was found to be associated with poor left ventricular function. In the present case an angiographic diagnosed posterior left ventricular aneurysm was during surgery found to be a dilated coronary sinus. Preoperative left ventricular function was normal.

Anaphylactic reactions to aprotinin reexposure in cardiac surgery: relation to antiaprotinin immunoglobulin G and E antibodies.

BACKGROUND: Aprotinin, a serine proteinase inhibitor, reduces bleeding during cardiac surgery. As aprotinin is derived from bovine lung, it has antigenic properties. This investigation examined the incidence of anaphylactic reactions in patients reexposed to aprotinin and the relation to preformed antiaprotinin immunoglobulin (Ig)G and IgE antibodies. METHODS: This prospective observational study conducted at five centers in Germany evaluated patients undergoing repeat cardiac surgery reexposed to aprotinin between 1995 and 1996. Antiaprotinin IgG and IgE antibody measurements, using a noncommercial enzyme-linked immunosorbent assay and an immunofluorescence assay, respectively, were performed preoperatively and postoperatively. An anaphylactic reaction was defined as major changes from baseline within 10 min of aprotinin administration of systolic pressure 20% or greater, heart rate 20% or greater, inspiratory pressure greater than 5 cm H2O, or a skin reaction. RESULTS: In 121 cases (71 adults, 46 children), a mean aprotinin reexposure interval of 1,654 days (range, 16-7,136 days) was observed. Preoperative antiaprotinin IgG (optical density ratio > 3) and IgE antibodies (radioallergosorbent test [RAST] score < 3) were detected in 18 and 9 patients, respectively. High concentrations of each (IgG, optical density ratio > 10; IgE, RAST score > or = 3) were detected in five patients. Three patients (2.5%; 95% confidence interval, 0.51-7.1%) experienced an anaphylactic reaction after aprotinin exposure, followed by full recovery; these patients had reexposure intervals less than 6 months (22, 25, and 25 days) and the highest preoperative IgG concentrations of all patients (P < 0.05). Assay sensitivity was 100%, as no anaphylactic reactions occurred in IgG-negative patients (95% confidence interval, 0.0-3.1%); assay specificity was 98%. Preoperative IgE measurements were quantifiable in two of three reactive patients and in three nonreacting patients. CONCLUSIONS: Quantitative detection of antiaprotinin IgE and IgG lacks specificity for predictive purposes; however, quantitation of antiaprotinin IgG may identify patients at risk for developing an anaphylactic reaction to aprotinin reexposure.

Successful reconstruction of stripped superficial femoral vein.

A 69-year-old man who had hemorrhagic shock after inadvertent stripping of the right superficial femoral-popliteal vein during surgery for greater saphenous vein varicosis in another hospital was referred to us. Phlebography revealed a ruptured popliteal vein with intact profunda femoris and common femoral veins. The stripped superficial femoral-popliteal vein brought in a jar was reimplanted. Phlebography performed during the patient's follow-up visits in our outpatient clinic 11 months postoperatively showed a patent femoral vein.

Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management.

BACKGROUND: The incidence of a bronchopleural fistula (BPF) as a major complication after non-small cell lung carcinoma (NSCLC) surgery has decreased in recent years, due to new surgical refinements and a better understanding of the bronchial healing process. We reviewed our most recent experience with BPFs and tried to determine methods which may effectively reduce its occurrence. METHODS: Data on 490 patients with lung resections for NSCLC over a period from 1990 to 1999 were retrospectively reviewed. Details regarding surgery and the subsequent treatment were carefully reviewed. Particular attention was paid to factors possibly affecting the occurrence of BPFs: the technique of the initial bronchial closure, previous radiation and/or chemotherapy, need for postoperative ventilation and presence of residual carcinomatous tissue at the bronchial suture line. Information about age, sex, clinical diagnosis, associated conditions, TNM stage, period between primary operation and rethoracotomy and postoperative outcome was also recorded. RESULTS: The overall BPF incidence was 4.4% (22/490). There were 21 (95.5%) males and 1 (4.5%) female, mean age was 57.8 years. BPFs occurred after pneumonectomy in 12 (54.6%), after lobectomy in 9 (40.9%) patients and after sleeve resections in 1 (4.5%) patient. Mortality rate was 27.2% (6/22). Right-sided pneumonectomy and postoperative mechanical ventilation were identified as risk factors for BPFs (p<0.05). Initial chest re-exploration was performed in 20 (90.9%) patients. After debridement, the bronchial stump was reclosed by hand suture in 10 (45.4%) patients. All 10 (45.4%) patients with a post-lobectomy- and sleeve resection BPF necessitated completion surgery. The BPF was additionally covered with a vascularized flap in 20 (90.9%) patients. In 2 (9%) patients with small BPFs and poor overall condition the initial treatment was endoscopic. In both the fistula persisted and the stump had to be surgically resutured. CONCLUSIONS: A BPF remains a major complication in the surgery of NSCLC because of its high mortality and morbidity rate. A BPF is more common after right-sided pneumonectomy and is frequently associated with postoperative mechanical ventilation. The management varies according to the initial type of surgery, the size of the BPF, the overall patient condition and that of the remaining lung. Endoscopic treatment is reserved only for small fistulas associated with poor general condition.

Giant localized fibrous mesothelioma: an unusual large intrathoracic tumor.

BACKGROUND: Localized fibrous mesotheliomas are rare intrathoracic tumors arising from the pleural tissue. They are mostly benign tumors, with dimensions ranging from a small nodule to a large intrathoracic tumor. CASE: This paper describes the presence of giant localized fibrous mesothelioma filling the lower left pleural cavity, which developed over a 20-year period. Surgical resection of the tumor showed a large, localized fibrous mesothelioma 14 cm in diameter. CONCLUSIONS: The clinical manifestations of localized fibrous mesotheliomas are very variable. Small tumors may be asymptotic, while large tumors may cause respiratory, cardiac or metabolic symptoms. Complete surgical resection is the preferred treatment and is usually curative. Careful follow-up is indicated because recurrence may occur, even many years after the initial operation.

Chyloperitoneum. A rare complication after abdominal aortic aneurysm repair.

We report a case of chylous ascites as a rare complication following elective aortic aneurysm repair in a 66-year-old male. After its early development on the second post-operative day, re-laparotomy was performed with ligation of fistulas and omentumplasty. After recurrence of chylous ascites, conservative treatment for three months including parenteral nutrition and low-fat diet under continuous peritoneal drainage led finally to success.

Retrocardiac arteriovenous malformation causing recurrent cerebral ischemia.

A 28-year-old woman had been suffering from recurrent cerebral embolizations for almost 9 years. A retrocardiac arteriovenous malformation was identified as the source of emboli. It was supplied by chest wall veins and the right upper pulmonary vein, connected to the back wall of the left atrium and a possibly aberrant hepatic vein originating from the abdomen. The aneurysm was resected and all supplying veins ligated. The vein from below the diaphragm was implanted into the right atrium. Her postoperative course was uncomplicated. Long-term follow-up free from cerebrovascular events.

Preimplant ultrastructure and calcification tendency of various biological aortic valves.

BACKGROUND AND AIM OF THE STUDY: In recent years a number of fixation and anti-calcification methods have been developed, but little is yet known about the calcification process of biological valves. The aims of this study were to: (i) perform a systematic ultrastructural investigation on various biological valves; and (ii) determine the extent of calcification of these valves in a subcutaneous rat model. METHODS: The following porcine aortic prostheses were investigated: Toronto-SPV, Intact, Freestyle, Mosaic and Hancock-II. Samples taken from the valve leaflets, and in the case of the Freestyle and Toronto-SPV valves also from the aortic wall, were examined ultrastructurally using scanning and transmission electron microscopy. Other samples were implanted subcutaneously in Wistar rats for 12 weeks. The calcium content of the samples was measured using atomic absorption spectrophotometry. RESULTS: All valves examined showed a considerable loss of the endothelial cover. Significant changes in valve ultrastructure were also detected. With regard to calcium content, two valve groups could be distinguished (p <0.05): (i) those with high calcium content, e.g. Toronto-SPV and Intact (>40 mg/g dry tissue); and (ii) those with low calcium content, e.g. Mosaic, Freestyle and Hancock-II (<5 mg/g). CONCLUSION: Fixation methods have pronounced effects on the ultrastructural integrity of bioprostheses. The degenerative calcification of bioprostheses can be effectively inhibited by glutaraldehyde-free fixation and anti-calcification treatments.

Improvement of impaired renal function in heart transplant recipients treated with mycophenolate mofetil and low-dose cyclosporine.

BACKGROUND: Cyclosporine (CsA) nephrotoxicity is a common problem after cardiac transplantation. We have studied the impact of CsA dose reduction in association with mycophenolate mofetil (MMF) treatment on renal function in heart transplant recipients with suspected CsA nephrotoxicity (serum creatinine level >2 mg/dl). METHODS: Twelve heart transplant recipients (11 men, 1 woman; 111 to 1813 days after transplantation) with CsA-based immunosuppression (plus azathioprine and/or steroids) and a serum creatinine level >2.0 mg/dl were started on a daily dose of 2000 mg of MMF. Dilated cardiomyopathy was the underlying disease in nine patients, ischemic cardiomyopathy in three patients. Mean patient age was 57 years (range 44-69 years). Azathioprine was discontinued and CsA slowly tapered. Creatinine clearance, serum creatinine level, urea nitrogen, and uric acid were monitored. CsA levels were measured, and CsA dose was adjusted for whole blood levels of 70-120 microg/L. Ten patients still had endomyocardial biopsies, whereas one had echocardiographic controls only. RESULTS: One grade 1B rejection episode according to ISHLT (International Society for Heart and Lung Transplantation) was observed until 1 year after the switch to MMF. One patient was excluded due to gastrointestinal side effects. CONCLUSIONS: Conversion from azathioprine to MMF with consecutive reduction of CsA in heart transplant recipients with CsA-impaired renal function improves renal function as evidenced by lower serum creatinine, urea nitrogen, uric acid, and higher creatinine clearance.

Haemodynamic changes during minimally invasive coronary artery bypass surgery using high-dose esmolol.

UNLABELLED: We aimed to investigate the effects of high-dose esmolol on haemodynamics and oxygen extraction in minimally invasive direct coronary artery bypass (MIDCAB) surgery patients. METHODS: In 18 patients, heart rate (HR), mean arterial (MAP), central venous (CVP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and mixed venous oxygen saturation (Sv0(2)) were prospectively measured after induction of anaesthesia (T1), start of surgery (T2), during bypass grafting with beta-blockade (T3), and at the end of surgery (T4). RESULTS: Mean esmolol dose at T3 was 0.44+/-0.2mgkg(-1)min(-1). HR was unchanged, whereas significant decreases in mean CO (3.1+/-0. 8 vs 4.8+/-1.0lmin(-1)m(-2), pre-esmolol), MAP (53+/-10 vs 89+/-14mmHg), and SvO(2) (65+/-10 vs 81+/-4%) were observed during esmolol administration. All haemodynamic parameters normalized immediately after termination of esmolol (T4). CONCLUSIONS: Despite unchanged HR esmolol reduced CO and MAP suggesting a favorable reduction of myocardial oxygen consumption. Mean Sv0(2) during esmolol administration reflects an acceptable ratio of whole-body oxygen delivery and consumption. Haemodynamic changes with high-dose esmolol during MIDCAB surgery remain within safety margins.

Pulmonary arteriovenous fistula drainage into the left atrium.

Arteriovenous fistulas with venous drainage into the left atrium are a rare anomaly. Although the etiology of pulmonary arteriovenous fistulas is unknown, these abnormalities are considered to have occurred during early fetal development. A case of this malformation in a 72-year-old woman successfully treated by surgery is described.

Chyloperitoneum: a rare complication after abdominal aortic aneurysm repair.

We report a case of chylous ascites as a rare complication following elective aortic aneurysm repair in a 66-year-old male. After early development of this condition on the second postoperative day, relaparotomy was performed with ligation of fistulae as well as omentoplasty. After recurrence of chylous ascites, conservative treatment consisting of parenteral nutrition and a low-fat diet for 3 months along with continuous peritoneal drainage finally led to successful resolution of this complication.

Intraoperative acute occlusion of aortic bifurcation during extracorporeal circulation.

A 36-year-old male patient showed a significant decrease of arterial pressure in the lower extremities during coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC). Arterial pressure measured in the femoral artery fell to 10-20 mmHg at the end of ECC, whereas in the upper extremities arterial pressure levels were normal. At the end of the surgery a complete ischemia of both lower extremities was observed. We suspected Leriche's syndrome and performed a successful aortic embolectomy through bilateral femoral arteriotomies immediately. An insufficient anticoagulation could be excluded by prolonged "activated clotting time" (ACT), therefore we presumed that the source of embolus was a small aneurysm of the left ventricle. The shape and superficial structure of the extracted embolus, which was partly covered with endocardium, confirmed our suspicion. No complications occurred throughout the postoperative period. On the 10th postoperative day, the patient left our department for postoperative rehabilitation with a normal perfusion of the lower extremities.

Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms.

Preoperative screening, and interventional and surgical therapy of cardiovascular diseases are of pivotal importance for successful outcome after abdominal aortic aneurysm surgery. In a retrospective study, all patients who underwent surgery for abdominal aortic aneurysm were reevaluated by preoperative diagnostic and therapeutic interventions for cardiovascular disease. Two study periods (1980-1989 and 1990-1996) were compared. Of 603 patients operated upon for abdominal aortic aneurysm between 1980 and 1996, 449 had surgery on an elective basis and 154 as an emergency. Preoperative diagnostic studies for coronary artery disease were performed on elective patients and were positive in 76.8% (1980-1989, 76.1%, 1990-1996, 77.5%). Coronary angiography was performed in 108 patients (29.6%). Medical therapy of coronary artery disease declined by 2.3%, and interventional procedures by 18.8%. In contrast, myocardial revascularization with subsequent aneurysm resection increased by 26.6% and 12 patients (16%) required urgent simultaneous cardiac and aortic surgery. Early mortality after abdominal aortic aneurysm surgery decreased from 4.2 to 2.9%, and the frequency of primary cardiac failure as the cause of death was reduced from 33.3 to 22.2% (P < 0.05). It was concluded that 42.6% more cardiac surgical procedures were performed before abdominal aortic aneurysm surgery since 1990 compared with the period 1980-1989. In contrast, the number of interventional procedures fell by 18.8%. Surgical therapy of cardiac disease reduces early mortality after elective abdominal aortic aneurysm surgery.

Complex traumatic dissection of right vertebral and bilateral carotid arteries: a case report and literature review.

A 27-year-old female motorcycle passenger was admitted with bruises and concussion after a motor-vehicle accident. After a lucid interval of several hours she became stuporous and progressed to an acute comatose state. Computed tomography demonstrated extensive cerebral ischaemia in the territory of the right middle cerebral artery. Angiography after transfer to the authors' hospital revealed dissections of both carotid arteries and of the right vertebral artery. The patient underwent surgical reconstruction of the left internal carotid artery with saphenous vein. The management of this patient is discussed and the literature reviewed.

Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management.

The most important limitation of the use of the intra-aortic balloon pump is the risk of vascular complications. The aim of this study was to identify risk factors and aspects of diagnosis and management that may decrease the risk of vascular morbidity associated with intra-aortic balloon pumps. Risk factors, surgical techniques, complications and other variables were retrospectively evaluated in 524 patients who had an intra-aortic balloon pump inserted between January 1988 and December 1998. Of the total, 140 (26.7%) patients with an intra-aortic balloon pump had ischaemic complications that needed surgery. The mean age was 65.2 +/-12.3 years (66.7% men and 27.5% women). The mortality rate was 28.1%. The mortality for patients with ischaemic vascular complications was significantly higher than in those patients without (59.6 versus 30.1%, P = 0.001). One-hundred and eight (77.2%) ischaemic complications occurred during therapy with an intra-aortic balloon pump and 32 (22.8%) complications after intra-aortic balloon pumping had been stopped. Thromboembolectomy was required in 71 (50.7%) patients. Associated surgical procedures were performed in 69 (49.3%) patients. A history of peripheral vascular disease (43.6 versus 23.6%, P < 0.05) and the presence of diabetes mellitus (49.2 versus 16.9%, P < 0.05) increased the risk of limb ischaemia significantly. Limb ischaemia remains the major complication after intra-aortic balloon pump insertion. Independent predictors for vascular complications included peripheral vascular disease and diabetes. Intra-aortic balloon pump removal and thrombectomy is usually sufficient to provide revascularization. Identification of subclinical disease may aid in the management of subsequent acute limb ischaemia.

Influence of glutaraldehyde fixation on the detection of SLA-I and II antigens and calcification tendency in porcine cardiac tissue.

OBJECTIVE: Immunological effects have been addressed as key factors for the long-term results of biological porcine aortic prostheses. In this study we investigated the influence of glutaraldehyde fixation on the expression of SLA (swine leucocyte antigens) and the calcification of porcine cardiac tissue. DESIGN: Deparaffinized sections obtained from porcine aortic tissue were fixed in a buffered glutaraldehyde solution for 1, 2, 3, 24 and 72 hours, respectively, and finally immunostained with monoclonal anti-SLA class I antibody 2.27-3a and anti-SLA-II antibody MSA3. Sixteen samples from fixed porcine cardiac tissue and, for comparison, 8 samples from leaflets of Toronto-SPV and Freestyle valves were implanted subcutaneously in 10 Wistar rats for 12 weeks and their calcium content was measured by atomic absorption spectrophotometry. RESULTS: SLA-I epitopes were no longer detectable using anti-SLA-I antibodies after fixation for 3 h. The SLA-II antigens remained detectable after longer fixation period. Short-time fixation resulted in marked calcification of the porcine cardiac tissue and to destruction of the SLA-I epitopes, whereas, even after longer fixation time, the epitopes of the SLA-II antigen remain unaffected. CONCLUSION: Chelate formation due to glutaraldehyde treatment provides protection against calcification. Short-time fixed porcine cardiac tissue has a tendency towards a greater degree of calcification than longer fixation periods. Based on the present results, it is pointless to set the length of fixation to switch off the immunogenicity.