Pseudomyxoma originating from the interatrial septum in a heart transplant patient.

This report describes the echocardiographic diagnosis of an intracardiac mass in a heart transplant patient. The typical morphology of the lesions, its attachment to the interatrial septum, and the absence of a nidus focus for thrombus formation led to the preoperative assumption that it was a myxoma. The mass was successfully excised at the time of operation and the patient had an uneventful recovery. Pathology findings revealed a thrombus. Thus, echocardiography may have limited specificity for the differentiation of intracardiac tumors and thrombus.

In the current era, complete revascularization improves survival after coronary artery bypass surgery.

BACKGROUND: Complete revascularization has been the standard for coronary bypass grafting. However, surgical intervention has evolved with increasing use of arterial conduits and off-pump techniques. METHODS: Patients undergoing non-redo bypass surgery from January 1998 through December 2000 were followed up with questionnaires and telephone contact. Incomplete revascularization was defined as absence of bypass grafts placed to a coronary territory supplied by a vessel with 50% or greater stenosis. RESULTS: One thousand thirty-four patients were followed for a mean of 3.3 +/- 1.6 years. Complete revascularization was found in 937 (90.6%) patients, and incomplete revascularization was found in 97 (9.4%) patients. Eight hundred twenty-seven (80.4%) patients underwent on-pump operations, and 207 (19.6%) underwent off-pump operations. Incomplete revascularization was more prevalent in off-pump versus on-pump operations (21.7% vs 6.3%, P < .001). Multivariable Cox regression analysis indicated that in-hospital cerebrovascular accidents (hazard ratio, 5.49; P < .001), chronic obstructive pulmonary disease (hazard ratio, 1.97; P = .019), and incomplete revascularization (hazard ratio, 1.85; P = .040) predicted an increased hazard (risk) of cardiac death. Left internal thoracic artery (hazard ratio, 0.38; P = .047), right internal thoracic artery (hazard ratio, 0.25; P = .019), and radial artery (hazard ratio, 0.36; P < .001) grafting reduced the risk of cardiac death. The 5-year unadjusted survival rate was 52.6% versus 82.4% in patients undergoing incomplete and complete revascularization ( P < .001), with cardiac survival rates of 74.5% versus 93.1%, respectively ( P < .001). However, this difference in cardiac survival was smaller in octogenarians with incomplete versus complete revascularizations (77.4% vs 87.6%, P = .101) and was essentially absent in off-pump versus on-pump operations if complete revascularization was achieved in both cases (93.6% vs 93.1%, P > .200). CONCLUSIONS: Complete revascularization and arterial grafting improve 5-year survival. Off-pump techniques do not affect survival. Complete revascularization should be performed whenever possible.

Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair.

BACKGROUND: In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair. METHODS: We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group. RESULTS: No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (< or = 30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (> 30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure. CONCLUSIONS: In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.

Hemodynamics during humoral rejection events with total versus standard orthotopic heart transplantation.

PURPOSE: We hypothesized that total orthotopic heart transplantation (TOHT) improves humoral rejection hemodynamics compared with biatrial transplantation or standard orthotopic heart transplantation (SOHT). METHODS: We reviewed 1942 biopsies from 134 patients (pts) and right heart catheterization data obtained at endomyocardial biopsy. Biopsies that displayed humoral rejection by histological findings and positive immunofluorescence for immunoglobulins and complement were analyzed. Patients with pacemakers, atrial fibrillation or beta-blocker therapy at the time of biopsy were excluded. Thirty-two pts after TOHT and 22 after SOHT matching these criteria were identified. RESULTS: Demographic data, underlying disease, pretransplant hemodynamics, and donor demographics were similar. Cardiac output and index were higher in the total orthotopic group (5.9+/-1.1 vs 5.1+/-1.4 L/min, p=0.027; 3.3+/-0.5 vs 2.8+/-0.6 L/min/m2, p=0.016). Right atrial and pulmonary capillary wedge pressure were lower after TOHT (7+/-3 vs 11+/-5 mmHg, p<0.001; 13+/-4 vs 16+/-5 mmHg, p=0.035). Pulmonary pressures, pulmonary vascular resistance and heart rate were similar. CONCLUSION: TOHT offers improved hemodynamics during humoral rejection as evidenced by higher cardiac output and index with lower right atrial and pulmonary capillary wedge pressures. Future studies must examine the potential benefits of TOHT during combined cellular and humoral rejection events.

Eosinophilic myocarditis in patients awaiting heart transplantation.

OBJECTIVE: To determine the possible causative agents of eosinophilic or hypersensitivity myocarditis in patients awaiting heart transplantation. DESIGN: Consecutive patient series. SETTING: Large university-affiliated hospital. PATIENTS: A total of 190 consecutive patients who had heart transplantation at our center. INTERVENTIONS: The myocardium of the explanted heart was examined for a mixed inflammatory cell infiltrate containing an identifiable component of eosinophils. The relative quantity of each cell type was evaluated by a semiquantitative grading system (scored 0 to 3). The clinical findings and medications were reviewed, and patients were followed after heart transplantation. MEASUREMENTS AND MAIN RESULTS: Eosinophilic myocarditis (EM) was found in the explanted heart in 14 patients (7.4%). Myocardial infiltration by eosinophils ranged from mild (n = 6), often focal involvement to marked (n = 8), usually multifocal or widespread involvement. Twelve patients (86%) had peripheral blood eosinophilia before transplant, and in ten (71%), the eosinophil count at least doubled. Loop or thiazide diuretics were used in all 14 patients, and angiotensin-converting enzyme inhibitors were used in 12. Preoperative characteristics were similar in patients with and without EM, except for a higher frequency of inotropic support and assist devices in EM patients. Dobutamine was used in 12 (86%) and dopamine in seven (50%; one with dopamine alone), and one patient (7%) received neither dopamine nor dobutamine. In two patients receiving dobutamine and one receiving dopamine, tapering or discontinuation of the inotropic infusion resulted in a significant diminution of the peripheral eosinophilia and the EM before transplantation. Postoperative survival in patients with and without EM was similar at 8 yrs (50% +/- 13% and 54% +/- 4%, p =.34). No patient in this study has had EM on biopsy after transplant. CONCLUSIONS: EM is a complication of multiple drug therapy in patients awaiting heart transplantation, and should be suspected when peripheral blood eosinophilia is present or the eosinophil count increases by at least two-fold. EM may be related to intravenous inotropic therapy, and this is the first study to document improvement in myocardial pathology after inotropic drug withdrawal. Hypersensitivity to thiazide and loop diuretics, angiotensin-converting enzyme inhibitors, and antibiotics must also be considered. Survival after heart transplantation is not impaired, and postoperative steroid therapy may prevent EM.

Biventricular support in patients with profound cardiogenic shock: a single center experience.

Options for managing heart failure patients with cardiogenic shock refractory to inotropic and intra-aortic balloon pump (IABP) therapy are limited. Ventricular assist devices (VADs) can bridge these patients to heart transplantation. However, controversy exists over whether extracorporeal membrane oxygenation (ECMO) before VAD placement is beneficial. We report our use of biventricular assist devices (BiVADs) as a direct bridge to transplant. Since July 1999, 19 Thoratec BiVADs were implanted for heart failure unresponsive to medical therapy. Patient ages ranged from 20 to 67 years. Causes of heart failure included idiopathic 32%, ischemic 26%, postcardiotomy 21%, and other 21%. All patients were in cardiogenic shock, and three were receiving cardiopulmonary resuscitation (CPR) before implant. Preimplant conditions included IABP 89%, mechanical ventilation 68%, three or more inotropes 84%, hyperbilirubinemia 59%, acute renal failure 63%, and hemodialysis 16%. Fifty-nine percent of patients bridged successfully to transplantation, with 90% posttransplant survival. Duration of BiVAD support ranged from 0 to 91 days, with two patients currently on support awaiting transplantation. Complications included bleeding requiring reoperation 26%, stroke 11%, infection (any positive culture) 68%, and cannula site infection 5%. The Thoratec BiVAD can successfully be used as a direct bridge to transplantation in heart failure patients with cardiogenic shock.

Off-pump coronary surgery: effect on early mortality and stroke.

BACKGROUND: Avoiding cardiopulmonary bypass in coronary artery bypass grafting is thought to reduce early mortality and morbidity. METHODS: We used our prospective database to compare all patients having off-pump coronary surgery (n = 389) with those having on-pump coronary surgery (n = 2412) between March 15, 1995, and November 1, 2000. Patients were grouped by age (years) in decades (>90, 80-89, 70-79, 60-69, <60 years). The Northern New England risk model was applied. Thirty-two independent variables were entered into a stepwise logistic regression analysis with the end points being surgical mortality and postoperative stroke. RESULTS: Patients undergoing off-pump operations were older (70.9 +/- 12 vs 68.1 +/- 11 years; P <.001), and their Northern New England predicted risk was higher (11.9% +/- 13% vs 9.2% +/- 10%; P <.001). However, patients having on-pump bypass had significantly more bypass grafts constructed (3.3 +/- 0.8 vs 1.9 +/- 0.8; P <.001) and triple-vessel coronary artery disease (58% vs 28%; P <.001). There were no significant differences in postoperative mortality, stroke rate, complications, and length of stay between the groups. Logistic regression analysis did not show that cardiopulmonary bypass was a risk factor for either surgical mortality (odds ratio, 1.08; P =.83) or stroke (odds ratio, 1.59; P =.27). CONCLUSION: Off-pump coronary bypass did not reduce early mortality and morbidity. Early and late results should be compared in a prospective randomized study.

Cardiac surgery in patients aged at least 80 years.

Cardiac surgery in patients aged 80 years and over has become more acceptable with improvements in health care services and the steady increase in the number of octogenarians in the population. These demographic changes are reflected in an increasing number of octogenarians with advanced symptomatic disease undergoing complex cardiac intervention. We reviewed data from 62 articles on cardiac surgery in octogenarians. The medical and ethical issues involved in making the decision are complex. Long-term results of cardiac surgery in octogenarians show that these patients can withstand heart surgery with improved functional benefit and quality of life. Surgery is beneficial especially for patients undergoing coronary artery revascularization or isolated aortic valve surgery. The operative course in octogenarians is more complicated, which is reflected in longer postoperative hospitalization. In refutation of the assumption that mortality in octogenarians is related to multisystem failure, most deaths are cardiac in nature. Highly selective criteria (identifying risks and benefits individually) should be applied to octogenarians undergoing cardiac surgery to achieve a satisfactory result.

Simultaneous biatrial computerized mapping during permanent atrial fibrillation in patients with organic heart disease.

INTRODUCTION: Activation patterns during permanent atrial fibrillation (AF) in patients with organic heart diseases are unclear. METHODS AND RESULTS: We studied six patients with permanent AF and organic heart diseases undergoing surgery. The duration of AF averaged 4.9+/-7.6 years. Computerized epicardial mappings of the right atrial (RA) free wall and the left atrial (LA) posterior wall were simultaneously performed with 224 bipolar electrodes at 3-mm spatial resolution. In the RA, large wavefronts and conduction blocks were frequently observed. The lines of block correlated with the crista terminalis and large pectinate muscles. In contrast, the LA had rapid repetitive activities originated from corners of the electrode plaque, near the four pulmonary veins (PVs). On average, 2.8+/-1.2 sites of rapid repetitive activities were identified per patient. They activated continuously, intermittently, or alternately during AF. The mean activation cycle length in the RA (196+/-22 msec) was significantly longer than that in the LA (179+/-26 msec; P = 0.004). The maximum dominant frequency in the LA was higher than that in the RA (6.41+/-1.18 Hz vs 5.66+/-0.55 Hz; P = 0.049). The maximum dominant frequency was consistently located in areas with rapid repetitive activations near the PVs. CONCLUSION: During human permanent AF associated with organic heart diseases, the activation cycle length was shorter in the LA posterior wall than in the RA free wall. Rapid repetitive activities are consistently observed in the LA posterior wall, at or near the PVs.

Heart transplantation with donors fifty years of age and older.

OBJECTIVE: Limited availability of donor organs has led to the progressive expansion of the criteria for donor selection, particularly a higher age limit of potential donors. We retrospectively reviewed the outcomes of patients who underwent heart transplantation using cardiac allografts 50 years of age and older and compared them with patients who had donor organs younger than 50 years. METHOD: Between September 1989 and May 2000, 20 patients underwent orthotopic heart transplantation using donor hearts 50 years of age and older (range 50-56 years, mean 52.7 +/- 1.8 years) and were compared with 267 patients who received donor organs less than 50 years of age (range 9-49.9 years, mean 27.2 +/- 8.6 years). Patient and donor criteria were identical in both groups. Follow-up was 4 to 128 months with a mean of 37.4 +/- 2.8 months in the older donor group and 52.6 +/- 2.4 months in the younger donor group. RESULTS: There were no differences between these 2 cohorts of patients regarding age, sex, cardiomyopathy, preoperative cytomegalovirus status, New York Heart Association class, and transplant status at transplantation. Donor characteristics, including sex, left ventricular ejection fraction, diabetes, cytomegalovirus status, and allograft ischemic times, were also similar in the 2 groups. Donor/recipient cytomegalovirus matching showed no differences as well. Thirty-day or to discharge operative mortality was similar in the older and younger donor groups (5% +/- 4.8% vs 3.5% +/- 1.1%; P =.84). Actuarial survival at 1 and 5 years was also similar in both groups (89.7% +/- 6.9% vs 91% +/- 1.8% and 53.1% +/- 14.7% vs 71.0% +/- 3.1%, respectively; P =.59). No patient in the older donor group required coronary artery bypass grafting or retransplantation during the follow-up period, whereas 2 patients in the younger donor group required coronary artery bypass, and 5 patients underwent retransplantation (P > or =.50). Two patients in the older donor group died of nonspecific allograft failure, whereas 3 patients in the younger donor group experienced similar posttransplant complication (P > or =.50). CONCLUSIONS: Carefully selected donor hearts 50 years of age and older can be used for heart transplantation with long-term survival and related outcomes similar to those of younger donor organs. This use of selective cardiac allografts maximizes donor organ usage and expands the donor pool effectively without an adverse impact on long-term results.

Transplante cardíaco ortotópico bicaval: novos horizontes no transplante cardíaco / Cardiac transplantation using bicaval technique: new horizons for cardiac tranplants

A técnica do transplante cardíaco, ou biatrial, foi introduzida por Lower e Shumway em 1960, em trabalho experimental com cäes. Estima-se que mais de vinte mil cirurgias foram realizadas nestas três décadas, porém desde os primeiros pacientes, as arritmias atriais e os distúrbios da conduçäo átrio-ventricular foram sempre os efeitos indesejáveis da técnica. Mesmo com as modificações introduzidas por Barnard estas complicaçöes continuaram. Com o desenvolvimento de métodos diagnósticos mais sofisticados, como o ecocardiograma transesofágico, outras anormalidades foram detectadas: insuficiência das valvas átrio-ventriculares mitral e tricúspide, aumento dos átrios com formaçäo de trombos nas linhas de sutura, assincronia de contraçäo do átrio do doador com o receptor e insuficiência ventricular direita no pós-operatório imediato. Com o objetivo de contornar estes problemas, Yacoub e Dreyfus apresentaram, em 1990, a técnica do transplante cardíaco ortotópico bicaval, onde o coraçäo do receptor é retirado totalmente e o coraçäo do doador é implantado com suturas individuais das veias pulmonares e das veias cavas. A técnica bicaval, segundo estudos preliminares, parece solucionar os efeitos adversos do procedimento biatrial