Heart-lung transplantation: the initial Arizona experience.

Since November 1985, cardiopulmonary transplantation has been performed at the University of Arizona heart transplant program. Seven patients, five women and two men, have undergone heart-lung transplantation. Five patients had primary pulmonary hypertension, and two patients had Eisenmenger's complex. The mean age was 31 years (range, 17 to 43 years). Average follow-up was 15 months (range, 3 to 34 months), with a total of 115 patient-months. There have been no operative or late deaths. Immunosuppression consisted of rabbit antithymocyte globulin, cyclosporine (Cyclosporin A), azathioprine, methylprednisolone, and prednisone. Our first five patients were aggressively diagnosed and treated for rejection by endomyocardial biopsy, with each patient having one or several treatments for acute rejection. These five patients had one or several episodes of severe infection, particularly cytomegalovirus. In our last two patients we omitted routine heart biopsies. Only those rejection episodes diagnosed by chest x-ray films are considered significant. Our last two patients have not been treated for acute rejection and have had no infections. Presently our immunologic surveillance consists only of careful clinical examination and frequent chest x-ray films. Any changes in the patient's condition are aggressively investigated, searching for infection or rejection. Two patients have been used as domino donors of their native heart.

Extracorporeal pulsatile biventricular support after cardiac transplantation.

A donor heart failed to adequately sustain hemodynamic function after cardiac transplantation. The cause of the donor heart dysfunction was unknown, and there were no definite risk factors identified to suggest the heart would not recover. A Symbion Acute Ventricular Assist Device System was used to support both ventricles. The heart gradually recovered and the system was explanted after 1 week of support. The patient recuperated and has been discharged from the hospital.

Orthotopic total artificial heart bridge to transplantation: preliminary results.

A detailed summary of seven patients who received eight total artificial heart implants, including one Phoenix heart, two Jarvik 7-100 ml hearts, and five Jarvik 7-70 ml hearts, and nine heart transplants, reveals that bleeding, hemolysis, and thromboembolic and infectious problems are not the limiting factors. Size of the patient and the requirement for adequate space to permit adequate systemic and pulmonary venous filling seem to be the major limitations. Patients with a reasonable expectation of receiving a transplantation within 3 weeks are the best candidates for a bridge to transplantation. After this adhesions were found to cause severe technical problems at reoperation.

Transtracheal aspiration and fine needle aspiration biopsy for the diagnosis of pulmonary infection in heart transplant patients.

A total of 129 transtracheal aspirations or fine needle aspirations, or both, were performed in 65 heart and heart-lung transplant patients to identify the causative pathogen in suspected pulmonary infection. Transtracheal aspiration was performed in 82 instances, fine needle aspiration in 47, and both procedures in 23. Both transtracheal and fine needle aspiration were highly specific, 96% and 100%, respectively. Sensitivity for transtracheal aspiration was lower than for fine needle aspiration, 70% and 89%, respectively. The lower sensitivity of transtracheal aspiration is attributed to its performance in all patients with suspected infection regardless of chest radiographic findings. Fine needle aspiration was performed when identifiable lesions could be used as a "target." Overall accuracy of transtracheal aspiration was 78% compared to 91% for fine needle aspiration both alone and combined with transtracheal aspiration. More invasive procedures such as bronchoalveolar lavage and open lung biopsy were required in only three patients (2%). Transtracheal aspiration resulted in one minor complication (1%). The commonest complication of fine needle aspiration was pneumothorax (21%). There were no deaths associated with either procedure. We conclude that in heart and heart-lung transplant patients with suspected pulmonary infection, transtracheal aspiration and fine needle aspiration are safe and accurate methods to identify the causative organism. More invasive techniques may be required in a small minority of patients.

Diabetes and heart transplantation.

Diabetes mellitus remains a relative contraindication to heart transplantation. From June 1985 to December 1987, 71 patients underwent heart transplantation. Fifty-seven patients were nondiabetic, and nine had preexisting diabetes mellitus. Four patients were insulin dependent and three were not. All operative survivors (66) from these two groups were compared for survival and numbers of rejection and infection. Actuarial survival in the group with diabetes mellitus was 100% and 97.7% in the group without diabetes. Immunosuppression was maintained with cyclosporine, azathioprine, and low-dosage prednisone. In the group with diabetes two patients were maintained without prednisone. Selected diabetic patients can have successful transplantations. There is no significant difference in survival between the diabetic and nondiabetic patient. There is a tendency toward more rejections and fewer infections among the diabetic patients. In our experience diabetes mellitus is not a contraindication to heart transplantation.

Early experience with the total artificial heart as a bridge to cardiac transplantation.

There is no doubt that currently available biventricular pneumatic pulsatile devices placed orthotopically with transcutaneous drive lines can support life in patients who may then be successfully transplanted. For the most part, the world experience is with the Jarvik hearts. The current model of choice is the 70-cc device because it is smaller and may be implanted with less fear of "fit problems" than the 100-cc model. As Case 4 illustrates, a fit problem may cause a fatal outcome. But if special precautions in implantation are taken, these may be avoided (Case 6). The fears of excessive bleeding, hemolysis, embolism, and infection with the use of these devices are not as prohibitive as we suspected. Bleeding is always a threat in complex cardiac surgery with grafting. Hemolysis is not a problem if excessive transfusion can be avoided. Embolism and infection may be inevitable, but as our patient B.C. has proven, there is no need to rush immediately to transplantation. And if the implanted patient does not meet local transplant selection criteria, we have enough information now to recommend that they not be accepted for transplantation. Bleeding may be anticipated to be a major problem in any patient with dense reactive scar tissue. To avoid this, transplantation should be done within 3 weeks. We recommend patients who have previously been selected for orthotopic transplantation and begin an accelerated decompensation (our Cases 2 and 7) as the best candidates for temporary orthotopic mechanical support. In these patients, there is no question about whether recovery of the native heart is possible or whether a reversible myocardial insult is present. The plan to do an orthotopic transplant indicates that a cardiectomy is necessary. Case 5, who was in reasonable shape for transplantation, was also favorable. In cases of anticipated graft failure, early use of the Jarvik 7-70 is recommended. This type of device, when suitably placed, provides excellent control of the circulation. There is no requirement for intensive care of the native heart, since it is gone, along with toxic antiarrhythmic medications, risk of embolizing a mural thrombus, and the constant balancing of a univentricular device vis-á-vis the native heart. Further, if pulmonary edema is present with accompanying elevation in pulmonary vascular resistance, the biventricular device requires only an upward adjustment in right drive pressure. With a univentricular device one must worry not only about the pulmonary vascular resistance but also about the capacity of the right heart to pump at a normal output.(ABSTRACT TRUNCATED AT 400 WORDS)

The mechanism of hepatoprotection by epsilon aminocaproic acid and putrescine.

Hepatic neutral serine proteases (including plasminogen activator) and ornithine decarboxylase (ODC) are induced by the hepatotoxin galactosamine (GALN). We examined the hepatoprotection conferred by epsilon-aminocaproic acid (EACA), a fibrinolytic inhibitor, putrescine (PUTR), the polyamine generated from ornithine by ODC, and alpha-difluoromethylornithine (DFMO), an irreversible inhibitor of ODC. GALN, 450 mg/kg, was administered intraperitoneally to Wistar-Lewis rats (group I). Groups II, III, and IV were also given EACA (80 mg/kg), PUTR (0.3 mmol/kg), or DFMO (0.3 mmol/kg), respectively, 1 hour before and 3, 7, and 12 hours after GALN. Rats were killed 2 hours after an intraperitoneal dose of 3H-thymidine was administered, 30 or 45 hours after GALN. EACA and PUTR were effective protectants against necrosis as judged by enzymes and histologic findings. Neither increased thymidine incorporation above the levels seen with GALN only. DFMO offered no protection even though thymidine incorporation at 45 hours was increased. Both EACA and PUTR, which have similar chemical structures, possessed significant antiprotease activity in vitro, suggesting that they act by inhibiting toxin-induced neutral serine protease activity and not by accelerating regeneration.