A fetally expressed immunoglobulin VH1 gene belongs to a complex set of alleles.

The immunoglobulin VH gene 51p1, a member of the large VH1 gene family, is preferentially expressed by B cells in the fetus and in chronic lymphocytic leukemia (CLL) and appears to be the source for many cryoglobulin rheumatoid factors. Polymorphism of 51p1 may therefore be functionally important. We have studied the germline representation of 51p1 and closely related VH elements to establish their prevalence and allelic relationship. A panel of oligonucleotide probes directed to the complementarity determining regions (CDR1 and CDR2) of 51p1 and a similar gene, hv1263, was used in restriction fragment polymorphism analysis of 48 unrelated individuals and six families. 13 VH alleles to the 51p1 locus were identified, each distinguished by its restriction fragment size, hybridization profile, or both. On some haplotypes the locus was duplicated. Null alleles were not seen. The 13 alleles were cloned, yielding nine distinct nucleotide sequences that were > 98.2% identical and included 51p1 and hv1263. These germline variations could influence specificity for antigen, because the corresponding protein sequences differed by up to five amino acids, including three nonconservative changes in the CDR. Two of the most prevalent variants contained 51p1. These findings expand the spectrum of polymorphism seen among human VH genes and elucidate the germline origin of VH1 sequences frequently expressed in autoantibodies and CLL. We conclude that the 51p1 locus is polymorphic, and that the 51p1 element is the predominant member of a complex set of alleles.

Independent plasma levels of sodium and glycine during transurethral resection of the prostate.

This study was done to evaluate the potential role of plasma glycine levels as an indicator of the biochemical changes occurring during or shortly after transurethral resection of the prostate ( TURP ). Seventeen patients undergoing TURP were studied to determine the fate of the absorbed glycine and its effects on other amino acids and their relationship to changes in serum sodium and osmolarity. Twelve patients showed more than 100 per cent increase in plasma glycine levels with values ranging to more than 100-fold elevation. Only two patients showed a change in serum sodium of greater than 10 mEq/l with corresponding change in osmolarity. In one such patient there was no accompanying change in plasma glycine. Thus, major changes in plasma glycine and serum sodium may occur independently of one another, and may separately account for manifestations of the reactions following TURP .

Survival and complications following ventricular assist pumping for cardiogenic shock.

Thirty patients (pts) have undergone ventricular assist pumping for up to 25.4 days (mean 6.8 days). Twenty-eight pts could not be weaned from cardiopulmonary bypass (CPB) after open heart operations and two pts sustained myocardial infarctions (MI), with cardiogenic shock unresponsive to medical therapy previous to surgery. Twenty-two pts required left ventricular assistance (LVA); 55% (12/22) were weaned from the pump and 32% (7/22) survived. Two pts required right ventricular assistance (RVA); both were weaned from the pump and survived. Six pts required right and left ventricular assistance (BVA) and none survived. Postoperative survival for program years 1976 through 1979 (14 pts) was 14% (2/14). Postoperative survival for program years 1980 through 1982 (16 pts) was 44% (7/16), reflecting improved pump insertion techniques (left atrial cannulation) and pt management. Since 1980, 12 pts have required LVA, nine have been weaned from the pump, and six pts have survived (50%). One pt has required RVA and has survived, and three pts requiring BVA did not survive. Seven pts have been alive and well 5, 9, 14, 19, 24, 30 and 36 months after surgery. Five are NYHA functional Class I status and two pts are NYHA Class II status. Current data indicates that single ventricular assistance in pts who cannot be weaned from CPB is "reasonable and therapeutic treatment to extend life."

The anesthetic evaluation and management of the surgical patient with heart disease.

Successful management of a patient with heart disease requires an understanding not only of the pharmacology of anesthesia but also of the pathophysiology of heart disease. Both of these factors as well as the choice and conduct of anesthesia by the anesthesiologist are thoroughly explored in this article.

Clinical effectiveness of mechanical ventricular bypass in treating postoperative heart failure.

Our group has designed an air-powered, sac-type ventricular assist pump (VAP) that has a smooth polyurethane surface and Bjork-Shiley-type valves. This VAP has undergone extensive testing in calves and has been available for clinical use during the last 5 years. When properly employed, the circulatory support permitted immediate separation of the patient from bypass. Definite hemodynamic evidence of improved ventricular function has been observed during the period of unloading of the deranged ventricle by the VAP. However, during the first 3 years of our experience, the VAP was used in 11 patients with 1 survivor. During the last 2 years, specific attention has been directed to use of right, left, or biventricular assistance as indicated, to prompt application of the VAP when required, and to use of atrial rather than ventricular cannulation for VAP inflow. Accordingly, the survival rate over this 2-year period has increased to 50% (four of eight patients). The short-term assist pump is an important adjuvant for the surgeon who operates on seriously ill cardiac patients.

Hetastarch as a prime for cardiopulmonary bypass.

Hetastarch, a synthetic colloid osmotic plasma volume expander, was employed in a prime for cardiopulmonary bypass in 37 patients undergoing myocardial revascularization. Comparison of laboratory values to those of 42 patients undergoing myocardial revascularization using an albumin-containing prime showed lower postoperative platelet counts (p less than 0.02) with hetastarch. There were no differences in chest tube drainage, blood use, plasma hemoglobin, fibrinogen levels, of coagulation times. The hetastarch prime cost $119.50 per patient, whereas the albumin-containing prime cost $321.35 per patient.

Ventricular-assist pumping in patients with cardiogenic shock after cardiac operations.

A ventricular-assist pump was used to support the circulation in eight patients who could not be separated from cardiopulmonary bypass after open-heart operations. In five patients with left ventricular failure, the systemic circulation was maintained with pumping from the left atrium to the aorta for 7.0 +/- 1.8 days (mean +/- S.E.M.); three of these patients were well four to 17 months after surgery. In two patients with biventricular failure, right and left ventricular bypass supported the circulation, but neither patient survived. One other patient had isolated right ventricular failure; pumping from the right atrium to the pulmonary artery maintained the pulmonary circulation for 2.2 days. This patient lived for 18 months. Use of the ventricular-assist pump in our patients provided complete support of the systemic or pulmonary circulation or both. Profoundly depressed ventricular function is potentially reversible if technical problems in employing the pump can be avoided.