Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis.

Talc lung granulomatosis results from the intravenous use of medication intended for oral use. Talc (magnesium silicate) acts as filler in some oral medications; when injected intravenously, it deposits in the lungs leading to airflow obstruction and impaired gas exchange. Allocation of donor lungs to previous intravenous drug users is controversial. After a careful selection process, 19 patients with talc lung granulomatosis have received lung allografts in our program. Long-term survival for these patients is excellent and our results suggest the previous use of intravenous drugs should not necessarily preclude lung transplantation.

Troponin T and I are not reliable markers of cardiac transplant rejection.

OBJECTIVE: Heart transplant recipients undergo a number of invasive endomyocardial biopsies to screen for rejection. Serum assays of troponin T and/or I may provide a less invasive alternative. The purpose of this study was to evaluate troponin T and I as markers of cardiac transplant rejection. METHODS: We conducted a prospective analysis comparing troponin T and I levels to biopsy results in heart transplant recipients. Plasma was assayed for troponin T and I preoperatively, on the first 3 postoperative days, and with each subsequent biopsy. RESULTS: Twenty-nine patients entered the study. A total of 173 biopsies were performed at a mean follow-up of 129+/-9 days (range: 12-564 days). There were two rejection episodes (> or = grade 3), one in each of two patients. There were no significant relationships between troponin T or I and biopsy-proven rejection (> or = grade 3; P=0.59 and 0.54, respectively). There were also no correlations between troponin T or I levels and biopsy grade (P=0.40 and 0.92, respectively). Troponin T and I levels peaked on postoperative day 1 and fell to baseline over long-term follow-up with no peak in serum markers associated with rejection episodes. Donor ischemic time was significantly correlated to troponin T on postoperative days 1-3 (r=0.58, P=0.005; r=0.61, P=0.004; and r=0.61, P=0.003, respectively). CONCLUSIONS: Troponin T and I are not useful indicators of cardiac rejection, but do correlate with donor heart ischemic injury.

A multicenter, randomized, controlled trial of Celsior for flush and hypothermic storage of cardiac allografts.

BACKGROUND: A multicenter, randomized, controlled, open-label trial was conducted to evaluate the safety and efficacy of Celsior when used for flush and hypothermic storage of donor hearts before transplantation. METHODS: Heart transplant recipients were randomized to one of two treatment groups in which donor hearts were flushed and stored in either Celsior or conventional preservation solution(s) (control). Study subjects were followed for 30 days after transplantation. RESULTS: A total of 131 heart transplant recipients were enrolled (Celsior, n = 64; control, n = 67). The treatment groups were evenly distributed in donor and recipient base line characteristics. Graft loss rate was lower in the Celsior group on day 7 (3% versus 9%) and on day 30 (6% versus 13%), but the difference was not statistically significant based on 95% confidence interval analysis. No significant difference was measured between the Celsior and control groups in 7-day patient survival (97% versus 94%) and the proportion of patients with one or more adverse events (Celsior, 88%; control 87%) or serious adverse events (Celsior, 38%; control, 46%). Significantly fewer patients in the Celsior group developed at least one cardiac-related serious adverse event (13% versus 25%). CONCLUSIONS: Celsior was demonstrated to be as safe and effective as conventional solutions for flush and cold storage of cardiac allografts before transplantation.

Extended donor ischemic times and recipient outcome after orthotopic cardiac transplantation.

BACKGROUND: The effect of extended donor ischemic times on mortality following heart transplantation is a matter of considerable debate. PATIENTS AND METHODS: A retrospective study of the 261 consecutive heart transplantations performed at the centre (University of Alberta, Edmonton, Alberta) between July 1985 and June 1999 was conducted. Patients were divided into the following two groups based on donor ischemic time: 4 h or less and longer than 4 h. Donor and recipient factors were analyzed for their effects on 30-day and 90-day survival. RESULTS: Thirty-day mortality was not significantly greater with prolonged donor ischemic times (13%) than with shorter ischemic times (7%, P=0.14). There was also no significant increase in 90-day mortality with longer ischemic times (16%) than with shorter ischemic times (10%, P=0.27). Actuarial survival (10 years) was similar between the groups (P=0.33). Predictors of 30-day and 90-day mortality were cardiopulmonary bypass time (P<0.001 and P<0.001, respectively) and lower donor weight (P=0.008 and P=0.02, respectively). CONCLUSIONS: Longer donor ischemic times were not significantly related to decreased 30-day, 90-day or 10-year actuarial survival.

Successful cardiac transplantation with methanol or carbon monoxide-poisoned donors.

BACKGROUND: Patients succumbing to methanol or carbon monoxide poisoning are usually rejected for heart donation. Increasing demand for donors has lead to the expansion of acceptance criteria and increased use of the marginal donor. METHODS: We transplanted hearts from donors who had had methanol intoxication in three cases and carbon monoxide exposure in two cases. Standard donor evaluation criteria and transplantation techniques were used. RESULTS: All of the transplants were successful. Three of the recipients required significant inotropic support for a few days postoperatively; however, all of the hearts functioned well over the intermediate and long term. Two recipients (1 from each group) died of complications other than heart failure (1.5 and 2 years postoperatively). CONCLUSIONS: Successful heart transplantation can be achieved using the hearts from patients succumbing to methanol or carbon monoxide poisoning. Routine evaluation of cardiac function and myocardial damage is adequate for screening these donors. Hearts from methanol-poisoning victims may require longer inotropic support postoperatively before complete recovery, but can provide excellent long-term function and results.

Reduction of leg wound infections following coronary artery bypass surgery.

OBJECTIVE: To reduce the rate of infection at the saphenous vein harvest site after coronary artery bypass surgery, to identify predictors of infection and to determine the best method for leg wound closure. DESIGN: A randomized clinical trial was undertaken to determine the best technique for reducing the postoperative leg wound infection rate. Patients were allocated to one of four leg wound closure methods: staples, close immediately; staples, close after protamine administration; subcuticular sutures, close immediately; and subcuticular sutures, close after protamine. Risk factors evaluated were age, sex, diabetes, obesity, peripheral vascular disease, reoperation, time in surgery, wound length, wound depth, time that the wound was open, wound quality and harvest site. SETTING: The Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta. PATIENTS: All consenting patients undergoing elective coronary artery bypass surgery involving saphenous vein harvesting were considered for the study. Exclusion criteria were insertion of a drain, insertion of an intra-aortic balloon pump in the index limb and inability to complete follow-up at the authors' centre. Eighty patients were initially enrolled, with 77 completing the study. INTERVENTIONS: Patients underwent standard saphenous vein harvesting followed by wound closure as indicated by the study group. MAIN RESULTS: The major infection rate was reduced from 13% to 3% (P = 0.02). Each closure method was equally effective, and wound depth was the only factor related to infection. CONCLUSIONS: Leg wound infections continue to be a major source of morbidity after coronary bypass surgery.

Quality of life of candidates for and recipients of heart transplants.

OBJECTIVE: To describe the quality of life (QOL) of candidates for and recipients of heart transplants over a five-year period. DESIGN: Descriptive, longitudinal. SETTING: Canadian university-affiliated tertiary care medical centre. PATIENTS: Sixty-five candidates for heart transplantation; after one year, six candidates were still awaiting transplantation; 42 patients received transplants and were included in the study six months post-transplant. OUTCOME MEASURES: Three measures of QOL were used: the Index of Well-Being, Cantril's Self-Anchoring Striving Scale and the "time-trade-off technique'. INTERVENTION: Data were collected before transplantation, six months post-transplantation, one year post-transplantation and annually for the next four years; for individuals who did not receive transplants, data were collected six months and one year after the first interview. MAIN RESULTS: QOL scores were considerably higher after than before transplantation, and compared favourably with norms for the general population. For 11 individuals who did not receive transplants, QOL remained low. QOL for heart transplant recipients was remarkably stable over the five-year study period. The major predictors of QOL for candidates awaiting transplantation were health status, outlook and ability to work. After transplantation, the major predictors of QOL were outlook, health status and employment status. CONCLUSIONS: There is evidence to suggest that QOL improves after heart transplantation, and that improvement is relatively stable over time. Further work is needed to identify the factors that could result in improvements in QOL.

Endoscopic diagnosis and treatment of postoperative bronchopleural fistula.

The diagnosis and closure of small postresection bronchopleural fistulae can be accomplished with selective bronchography and placement of fibrin sealant through the flexible fiberoptic bronchoscope. This method of diagnosis and closure of the bronchopleural fistula avoids both general anesthesia and a thoracotomy. This technique is successful in small bronchopleural fistulae and patients with multiple postresection bronchial stumps.

Heart and heart-lung transplantation: the Canadian and world experience from December 1967 to September 1985.

By Sept. 1, 1985, 62 centres around the world were identified as having participated in heart transplantation; of these 14 had also performed combined heart-lung transplantation. Between December 1967 and December 1984, 1599 recipients had undergone 1644 transplant procedures. By September 1985, 112 heart-lung transplant procedures had been performed in 110 patients. Overall survival at 1 and 3 years respectively, excluding perioperative mortality, averaged 80% and 65%; for heart transplantation alone survival rates were 85% and 75%, respectively. In Canada, of 81 heart and 5 heart-lung transplant procedures that were performed in nine centres between April 1981 and September 1985, 38 heart and 2 heart-lung transplants were carried out in the first 9 months of 1985. Sixty-four of the heart and 2 of the heart-lung transplant recipient were alive from 20 days to 4.42 years postoperatively.

Timing of abnormal interventricular septal motion after cardiopulmonary bypass operations. Lack of injury proved by preoperative, intraoperative, and postoperative echocardiography.

Abnormal interventricular septal motion after cardiopulmonary bypass is a widely known occurrence. The cause and exact timing of this phenomenon remain unclear. We have studied 21 patients prospectively with preoperative, intraoperative, and postoperative two-dimensional and M-mode echocardiograms. Intraoperative studies were obtained with the pericardium closed and open and after completion of procedures performed with cardiopulmonary bypass. Fourteen patients had coronary artery bypass graft operations alone. Six patients had valve replacement with or without coronary bypass, and one patient had removal of a left atrial myxoma. All patients had normal interventricular septal motion before the operation, and none had abnormal septal motion intraoperatively. Four to eight days postoperatively, the septum still thickened normally in all patients, with five patients having normal, nine patients abnormal, and seven patients paradoxical interventricular septal motion. Studies in 11 patients 1 to 4 months postoperatively showed no change from the early postoperative study. The pericardium was left open postoperatively in all patients. Six patients were studied a few hours after sternal closure and all had abnormal interventricular septal motion. We conclude that abnormal interventricular septal motion after cardiac operations is not due to injury of the septum, adhesion formation, or loss of pericardial constraint. Closure of the chest wall itself, with the pericardium left open, is associated with this abnormality.

Cyclosporine in heart and heart-lung transplantation.

At Stanford University Medical Center from January 1968 until January 1984, 288 patients received 313 heart transplants. The immunosuppressive regimen before December 1980 consisted of azathioprine and prednisone, with or without rabbit antithymocyte globulin. After that time cyclosporine replaced azathioprine. In 92 recipients of 95 heart allografts, the 1- and 3-year survival rates were 82% and 65% to 70% respectively. In the 3 years from March 1981 to March 1984, successful heart-lung transplantation was accomplished in 13 of 19 recipients, using cyclosporine-based immunosuppression. Survival ranged from 1 to 38 months. While it is true that cyclosporine has improved survival in heart transplant recipients, has allowed successful heart-lung transplantation to be performed, has shortened intensive care unit and total hospital stays and therefore hospital costs, and has allowed easier management of rejection and infection, several disconcerting problems have not yet been resolved. These include hypertension that is difficult to control and renal dysfunction in all patients, and the fact that cellular and humoral rejection still occurs, as manifested by graft atherosclerosis, bronchiolitis obliterans and classic acute rejection. Better understanding and application of cyclosporine immunosuppression will undoubtedly minimize both cyclosporine- and non-cyclosporine-related postoperative complications and will improve survival even further.

Induction of specific unresponsiveness to heart allografts in mongrel dogs treated with total lymphoid irradiation and antithymocyte globulin.

The survival of heterotopic heart allografts was determined in mongrel dogs treated with total lymphoid irradiation (TLI) alone or in combination with other immunosuppressive agents. TLI alone (total dose, 1800 rad) minimally prolonged graft survival as compared with untreated controls. However, marked synergy was observed when TLI was combined with a 10-day post-transplant course of rabbit anti-dog thymocyte globulin (ATG). Approximately 40% of recipients given TLI and ATG showed specific unresponsiveness, as judged by the lack of rejection on serial biopsies for more than 1 yr and the prompt rejection of third party hearts. The addition of post-transplant azathioprine (90 to 180 days) to the TLI and ATG regimen increased the mortality of recipients and reduced the fraction of dogs showing specific unresponsiveness. Infusion of donor bone marrow cells at the time of heart transplantation failed to induce specific unresponsiveness in recipients given TLI alone or TLI in combination with post-transplant methotrexate, cyclosporine A, or ATG. The results indicate that the combination of TLI and a brief course of ATG without marrow transplantation was the most effective regimen for the induction of specific unresponsiveness in mongrel dogs.

Surgical treatment of the dilated aortic root in a child with Marfan's syndrome.

Life-threatening cardiovascular manifestations of Marfan's syndrome are rare in young children. The authors report the case of a 4 1/2-year-old girl with Marfan's syndrome who had a large aneurysm of the ascending aortic valve replaced and both coronary arteries implanted into a prosthetic graft (Bentall's procedure). Other published reports of children with aortic aneurysms due to Marfan's syndrome are reviewed.

Congenital saccular aneurysm of the superior vena cava.

It is important to recognize the true nature of the rare superior vena caval aneurysm with nonoperative techniques, in order to avoid needless diagnostic thoracotomy. Two distinct types exist--the fusiform and the saccular. The presence of such an aneurysm should be suspected if there is size variation during respiration on roentgenographic evaluation, and can be confirmed venographically. That these aneurysms do not enlarge, rupture, or thrombose argues for conservative management.

Pulmonary reperfusion syndrome.

"Reperfusion syndrome" of the lung may play a role in the pulmonary edema and hemorrhage that occur following pulmonary embolectomy, cardiopulmonary bypass, and shock. Bioenergetic, metabolic, and ultrastructural studies of canine lungs indicate that ventilated lung tissue could tolerate 5 hours of pulmonary arterial occlusion with minimal damage. However, a 24-hour interruption of pulmonary arterial blood flow produced a significant decrease in the ratio of adenosine triphosphate to adenosine disphosphate, and glycogen, and an increase in tissue lactate. Reperfusion of these lungs resulted in even more pronounced biochemical and ultrastructural deterioration, as well as gross pulmonary edema and hemorrhage. The lesion appears to be similar to the reperfusion damage that occurs in other organs, such as the kidney, and the skeletal and cardiac muscles.