Successful use of the total artificial heart as a bridge to transplantation with no mediastinitis.

UNLABELLED: High rates of infection, especially mediastinitis, have been reported with the use of the total artificial heart (TAH), thereby limiting its usefulness. We have used the TAH as a bridge to transplantation with only minor infectious complications and a zero incidence of mediastinitis. Between February 1988 and August 1990, the TAH was inserted at Loyola University Medical Center in 19 patients, ages 16 to 64 years (mean, 44 years). Seventeen patients (89%) underwent transplantation within 1 to 34 days (mean, 9.8 days). Of the patients who did not undergo transplantation, one was brain dead and the other died of bleeding diathesis. Early (30-day) deaths occurred in two patients (11.7%): acute rejection at 18 days and multiple cerebral infarcts at 14 days. Three late deaths (17.6%) occurred: one patient, cytomegalovirus and pneumocystis pneumonia at 4 months; one patient, bronchopneumonia and multisystem failure at 9 months; and one patient, chronic rejection at 14 months. Minor infectious complications during the TAH implantation included Enterobacter pneumonia treated with antibiotics and positive sputum cultures (Escherichia coli; Candida), with no clinical evidence of infection in two patients. No cases of mediastinitis occurred either while the TAH was implanted or after transplantation. All patients were on antibiotics while the device was in place. CONCLUSION: Our experience with the TAH shows this to be an excellent device for successful bridging of patients for heart transplantation. We have had minimal infectious complications and none directly attributed to the use of this device. This device should continue to be used safely as a bridge to transplantation.

Comparison of results after heart transplantation: mechanically supported versus nonsupported patients.

Between March 1984 and July 1990 our team transplanted 168 hearts. One hundred twelve patients did not require mechanical support (group I). Fifty-six patients required mechanical support (group II). Intraaortic balloon counterpulsation was used in 37 patients (66%). The total artificial heart (TAH) was used in 16 patients (29%), and the ventricular assist device (VAD) was used in three patients (5%). The time spent on the device ranged from 1 to 35 days. No statistical difference was noted on the survival between the two groups. The 30-day and 1-year survival rate was 95% (106 patients) and 71% (79 patients) in group I and 91% (51 patients) and 68% (38 patients) in group II. As of July 31, 1990, 70% in group I and 68% in group II are alive. No significant differences were found between the two groups for the following variables (after heart transplantation): length of stay, 30-day survival, 1-year survival, and complications. The only significant difference found between the two groups was the incidence of infections: group I, 23%; group II, 51.7% (p = 0.001). Mechanical support as a bridge to transplantation provides excellent support until a donor becomes available. No difference was found in the 30-day and 1-year survival between the two groups.

Use of the total artificial heart and ventricular assist device as a bridge to transplantation.

The proliferation of transplant programs has not been paralleled by a similar increase in the availability of organ donors. This has significantly prolonged the waiting period and consequently has resulted in increased mortality of the patients with end-stage heart disease who are awaiting transplantation. Between 1984 and 1987, 104 orthotopic heart transplants were performed at Loyola University Medical Center. During the same period, 25 patients died while waiting for a suitable donor. To reduce the mortality of our patients waiting for transplantation, we began using the total artificial heart and a ventricular assist device as a bridge to transplantation in 1988. Of 29 patients who underwent transplant procedures in 1988, 18 required either a total artificial heart (15) or a ventricular assist device (3) as a bridge to transplantation. The underlying heart conditions were ischemic cardiomyopathy (11), dilated cardiomyopathy (5), giant cell myocarditis (1), and allograft failure (1). The average duration of mechanical support was 10 days (range, 1 to 35 days). Seventeen of the supported patients had successful transplants. One patient had brain death and did not receive a heart transplant. Of the 17 patients who survived surgery, two died within 30 days: one at 17 days because of acute rejection, the other at 14 days because of a cerebral vascular event. Fifteen patients (83%) were long-term survivors. Nine of the supported patients required reoperation because of bleeding after device implantation. There was no mediastinal or incisional infection. While the mechanical device was in place, the activated clotting time was maintained between 170 and 200 seconds with the administration of heparin (400 to 1000 units per hour).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of the Jarvik-7 total artificial heart and the Symbion ventricular assist device as a bridge to transplantation.

The proliferation of transplantation programs has not been paralleled by a similar increase in the availability of organ donors. Between 1984 and 1987, 104 orthotopic heart transplantations were performed at Loyola University Medical Center. During the same period, 25 patients died while awaiting a donor organ. To reduce the mortality, we began using the total artificial heart (TAH) and a ventricular assist device (VAD) as a bridge to transplantation in 1988. Of 29 patients who underwent transplantation, 15 patients required a TAH and three patients required a VAD as a bridge. The underlying heart conditions were ischemic cardiomyopathy (11 patients), dilated cardiomyopathy (5 patients), giant cell myocarditis (1 patient), and allograft failure (1 patient). The average duration of mechanical support was 10 days (range, 1 to 35 days). Of the 17 patients who successfully underwent transplantation, 1 patient died at 17 days because of acute rejection of the transplanted heart, and another patient died at 14 days because of a cerebral vascular event. Fifteen patients (83%) were long-term survivors. Nine patients required reoperation for bleeding. While the mechanical device was in place, the activated clotting time was maintained between 170 and 200 seconds with heparin. Dipyridamole was given. We conclude that the TAH and VAD are excellent mechanical bridges to transplantation.

Calcified pancreatic pseudocysts.

Extensive calcification of a pancreatic pseudocyst that permits visualization on plain abdominal radiographs is unusual. When such x-ray findings are encountered, a broad differential diagnosis can be made, which includes tumors, cysts, abscesses, or malformations of the adjacent structures. Two cases of calcified pancreatic pseudocysts are discussed. Calcified pancreatic pseudocysts may be a potential source of complications such as pain, bleeding, or infection. Because the cyst wall is mature and spontaneous resolution is unlikely, proper treatment of calcified pseudocysts consists of timely resection or internal drainage.

Spectrum of catecholamine-secreting tumors of the organ of Zuckerkandl.

In a series of 24 pheochromocytomas, four were tumors in the organ of Zuckerkandl. Their presenting symptoms of headache, palpitation, diaphoresis, and anxiety were similar to symptoms of adrenal pheochromocytomas. Two patients had paroxysmal and two patients sustained hypertension. All four had elevated urinary vanillylmandelic acid, metanephrine or catecholamine levels. Two of the tumors were localized with angiography before the availability of computerized tomography. Two patients underwent initial computerized tomography, which was nondiagnostic. Later scans looking specifically for organ of Zuckerkandl tumors were positive. Organ of Zuckerkandl tumors, like other ectopic pheochromocytomas, have a higher rate of malignancy. Two of the four were malignant tumors. One patient died 4 years after operation, but the other patient remains stable despite metastatic disease 8 years after operation. The two patients with benign tumors remain well 2 and 3 years after resection and treatment with alpha-blockade.

An integrated university emergency medicine - trauma program.

UNLABELLED: Systems for prehospital care, emergency medical care, and trauma care clearly overlap educationally, medically, financially, and politically. Most systems have not accomplished separation of this interdisciplinary tangle. To solve this dilemma we have customized an Emergency Medicine and Trauma Service (EM & TS) at a regional trauma medical center. The program (annually): 1)treats 32,000 patients (11,330 are trauma); 2) educates 140 paramedics, residents, students. Physician personnel: Members are fully trained in Internal Medicine, Surgery, or Pediatrics; are members of other academic departments. Each is approved by three chairman: Emergency Department, The physician's specialty, and Surgery, Structure: Board-qualified trauma surgeon always present; other faculty supplement surgical manpower; physicians are salaried; each is responsible to Director of EM & TS; trainees are not included as patient-care manpower. Organization: Academically, EM & TS is a Section of the Department of Surgery; the Section Chief is Director of EM & TS, and is responsible for Emergency Department, prehospital care, and trauma admissions. THE SOLUTION: A vertical responsibility structure to this multidisciplinary system has provided a successful solution and may be tailored to other systems.