Low-dose valganciclovir for cytomegalovirus prophylaxis in heart transplant recipients.

We retrospectively assessed our center's experience with a protocol of low-dose (450 mg once daily) valganciclovir administered for 3-6 months (median 5 months) in a cohort of of 55 cytomegalovirus (CMV) donor-positive (D+) and/or recipient-positive (R+) heart transplant recipients. Although no CMV disease occurred in patients while receiving low-dose valganciclovir, during the 12-month post-transplantation observation period of this study, 4 (22.2%) of the 18 D+/R- patients and 1 (2.7%) of the 37 R+ patients developed symptomatic CMV viremia. Leukopenia was frequent, including neutropenia [absolute neutrophil count (ANC), <1,000 cells/µL] that occurred in 21.8% and severe neutropenia (ANC <500 cells/µL) in 7.3%. Among CMV R+ heart transplant recipients, low-dose valganciclovir appeared to be an effective, less expensive strategy for CMV prophylaxis; however, caution may be necessary among D+/R- recipients.

Cervical adult rhabdomyoma presenting as a rapidly growing mass in a patient with diffuse large B-cell non-Hodgkin's lymphoma.

BACKGROUND: Adult rhabdomyoma is a rare mesenchymal tumor, which generally grows slowly and is mainly localized in the head and neck area. PATIENT AND METHODS: We report the extraordinary case of a rapidly growing adult rhabdomyoma in a 73-year-old man. The patient was treated for diffuse large B-cell non-Hodgkin's lymphoma with CHOP therapy (doxorubicin, cyclophosphamide, vincristine, and prednisone). Comparison of the respective computed tomography scans showed prominent enlargement of 35% in the tumor mass volume on the right side of the neck within 3 months. The tumor was highly suspicious for lymphoma. Surgical resection was performed. RESULTS: Histological examination revealed a tumor which was composed of tightly packed polygonal cells with a PAS-positive granular or vacuolated cytoplasm, occasionally with cross-striations. Immunohistochemically, the cells were positive for desmin, myogenin, Myo-D1, but negative for S-100. Due to these characteristic morphologies, adult rhabdomyoma was diagnosed. CONCLUSION: This is the first report on an adult rhabdomyoma with a proven rapid enlargement. The possible pathomechanisms are discussed.

Cholecystectomy in the potential heart transplant patient.

The management of cholelithiasis with gallstone pancreatitis in the heart transplant candidate is a difficult problem. Biliary tract surgery in the heart transplant candidate presents an additional set of clinical risks in view of extensive heart disease. We report the cases of three patients with symptomatic cholelithiasis with gallstone pancreatitis who were successfully operated on while awaiting cardiac allografts. Each patient was preoperatively prepared with (1) a lumbar epidural catheter for postoperative pain control with epidural opioids, (2) a balloon-tipped (Swan-Ganz) catheter and arterial line for perioperative monitoring, and (3) an intraaortic balloon pump for circulatory support with full heparinization after epidural catheter placement. In addition, preoperative optimization of cardiovascular function with pharmacologic agents was carefully achieved for 6 to 12 hours before surgery. All three patients had stable intraoperative courses, with less than a 300 ml blood loss. Their postoperative outcomes were without surgical complication. We think that biliary tract surgery may be safely accomplished in the heart transplant candidate with careful, appropriate preparation and meticulous surgical technique. We also present our management algorithm for heart transplant patients with cholelithiasis before and after operation.

Extracardiac surgical complications in heart transplant recipients.

As the population of patients undergoing orthotopic heart transplantation increases, more patients are likely to develop surgical complications unrelated to the transplant procedure. This article reviews 38 extracardiac surgical complications sustained in 18 of 48 patients undergoing orthotopic heart transplantation at our institution over a 4-year period. Twenty-seven complications (71.1%) required operative intervention most commonly in an urgent or emergent manner (59.3%). Three patients underwent six laparotomies. Infection was the cause in almost half of all complications and in 65% of those requiring surgery. Gastrointestinal hemorrhage was common and successfully managed nonoperatively in all cases. The overall operative mortality was 11% with only two deaths related to a surgical complication. The satisfactory outcome in these patients can be attributed to the early diagnosis of complications, timely therapeutic intervention, careful adjustment of immunosuppressive agents, and close patient follow-up with the transplant institution.

Delayed reversal of impaired vasodilation in congestive heart failure after heart transplantation.

The effects of changes in central cardiovascular function on peripheral vasodilation were investigated. Strain gauge plethysmography was used to measure the maximal blood flow response following release of forearm arterial occlusion and the peak reactive hyperemic blood flow response (ml/min.100 ml) before and twice after orthotopic heart transplantation in 10 subjects with severe congestive heart failure. The 2 posttransplantation studies were done before hospital discharge (mean 18 days after transplantation) and again after discharge (mean 114 days after transplantation). Transplantation led to a significant but delayed increase in maximal vasodilation (reactive hyperemic blood flow: pretransplant 21 +/- 3; predischarge 25 +/- 2; postdischarge 43 +/- 5) and a concurrent significant reduction in minimal forearm resistance. Although the improvement in peripheral vasodilator function may be linked to improvement in cardiac function, this linkage is not direct, nor is it immediate. If the normalization of maximal metabolic blood flow is related to resumption of normal physical activity postdischarge, then much of the basic abnormality in vasodilator capacity in congestive heart failure may be related to physical deconditioning.

Atrial natriuretic peptide in recipients of human orthotopic heart transplants.

Atrial natriuretic peptide (ANP) has been proposed to play a role in the maintenance of fluid and electrolyte homeostasis. ANP can be secreted in response to atrial stretch, and right atrial pressure has been proposed to control its secretion in vivo. This study was designed to characterize plasma immunoreactive (IR)-ANP in heart transplant recipients and to determine if IR-ANP levels in these patients correlate with cardiac filling pressures. Nineteen heart transplant recipients were studied during endomyocardial biopsy (group 1), and 20 patients with symptoms of coronary artery disease were studied during cardiac catheterization (group 2). Central venous blood samples and right heart catheterization data were obtained in each patient. IR-ANP levels were measured with a radioimmunoassay for alpha human ANP in extracted plasma samples. There were no differences between groups 1 and 2 in right atrial pressure (6.5 +/- 0.8 versus 6.1 +/- 0.6), pulmonary capillary wedge pressure (13.3 +/- 1.2 versus 11.2 +/- 1.3), mean pulmonary artery pressure (18.0 +/- 1.2 versus 18.2 +/- 1.3), or cardiac index (2.8 +/- 0.0 versus 2.8 +/- 0.1), but patients in group 1 had a higher mean blood pressure (110.6 +/- 2.4 versus 98.3 +/- 3.1, p less than 0.001). Plasma IR-ANP levels in heart transplant recipients were higher than normal (217.0 +/- 28.1 versus 19.2 +/- 2.1 pg/ml, p less than 0.001) and higher than in cardiac catheterization patients (217.0 +/- 28.1 verus 71.1 +/- 11.5 pg/ml, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid hormone levels in heart and kidney cadaver donors.

Experimental animal work has shown that thyroid hormone levels become undetectable 9 hours after brain death. It is unknown whether such an acutely hypothyroid state contributes to the hemodynamic instability of brain-dead donors or whether these donors should be resuscitated with thyroid hormone. No previous clinical study has examined thyroid hormone levels in human brain-dead organ donors. We retrospectively examined the thyroid hormone levels as measured by triiodothyronine and thyroxine in 22 human cadaver donors. Eight donors provided heart and kidney allografts, and the remaining 12 were kidney donors only. No donor had a normal triiodothyronine level and 10 were below normal, with undetectable levels in 12. Thyroxine levels were normal in 10 and below normal in 12. In comparing donors with below normal to undetectable triiodothyronine levels and donors with normal to below normal thyroxine levels, no statistically significant differences were found regarding blood pressure during harvest, duration of harvest, or dopamine requirements during harvest. Donors with a closed-head injury plus multiple injuries had statistically lower thyroxine values than donors with only a closed-head injury. For the heart donors, no correlation was found between thyroid hormone levels and the duration or dose of dopamine required for the heart allograft recipients after transplant. The incidence of acute tubular necrosis in the kidney transplants did not correlate with the donor thyroid hormone levels.(ABSTRACT TRUNCATED AT 250 WORDS)