Combined heart and kidney transplantation: long-term analysis of renal function and major adverse events at 20 years.

BACKGROUND: Combined heart-kidney transplantation (HKTx) is an accepted therapeutic option for patients with end-stage heart disease associated with severely impaired renal function. We report our long-term follow-up with this combined procedure. PATIENTS AND METHODS: Between April 1989 to November 2009, nine patients underwent combined simultaneous (HKTx) at our center. Seven patients were males (mean age 45.2 +/- 10.12 years); seven patients were on dialysis at the time of transplantation. RESULTS: Surgical procedures were uneventful in all patients. One patient died in the intensive care unit 41 days after transplantation. During long-term follow-up, three patients died: one due to infection and multiorgan failure 148 months after HKTx, one due to a lung neoplasm after 6 years, and one, a cerebral stroke at 34 months after transplantation. Only one patient experience renal allograft failure secondary to hypertension and cyclosporine nephrotoxicity at 10 years after HKTx with the need for renal replacement therapy. Last estimated glomerular filtration rates of all other patients was 61.3 +/- 17.4 mL/min. CONCLUSIONS: In selected patients, with coexisting end-stage cardiac and renal failure, combined HKTx with an allograft from the same donor proved to give satisfactory short- and long-term results, with a low incidence of both cardiac and renal allograft complications.

[Thoracic epidural analgesia (TEA) in clinical practice: effects, technique, complications and suggestions during anticoagulant treatment]. / Analgesia epidurale toracica (TEA) nella pratica clinica: effetti, tecnica, complicanze e suggerimenti in corso di terapia anticoagulante.

The effects of thoracic peridural analgesia (TEA) on the neuroendocrine response to surgery are well known, but, at the present this technique is not widely used especially in Italy. The aim of this paper is to give information and suggestions on thoracic epidural analgesia in thoracic and cardiac surgery, and to discuss how anticoagulant therapy may interfere on this technique.

[Hemodynamic effects of propofol in patients undergoing pulmonary excision and in patients undergoing closed heart mitral valve surgery]. / Effetti emodinamici del propofol in pazienti operati di exeresi polmonare e in pazienti operati di commissurolisi mitralica a cuore chiuso.

The effects of propofol on cardiovascular dynamics were studied, by means of SO2 Swan-Ganz catheter, in 12 patients scheduled for elective pulmonary resection and in 10 patients undergoing closed heart mitral valve commissurotomy. Myocardial contractility was also investigated in 10 patients (5 pulmonary and 5 mitral valve patients) by means of transthoracic echocardiography. The patients were premedicated with morphine (0.1 mg/kg i.m.), scopolamine (0.005 mg/kg i.m.) and diazepam (0.1 mg/kg p.o.). Anaesthesia was induced with propofol (2 mg/kg i.v.) and fentanyl (0.005 mg/kg i.v.) and maintained with propofol (6 mg/kg/h) plus fentanyl (0.005 mg/kg/h) infusion. Muscle relaxation was assured by pancuronium bromide (0.1 mg/kg). Ventilation (O2-N2O 50%) was controlled to maintain ETCO2 between 30 and 40 mmHg. All the patients undergoing pulmonary resection were intubated with double lumen endotracheal tube. Measurements were performed with the patients awake, after induction, during steady state anaesthesia, before and after thoracotomy. Propofol together with fentanyl significantly decreased arterial pressure (more than 35%) and cardiac index (more than 40%) in both groups of patients; heart rate showed no significant changes even after intubation. Right atrial pressure didn't change meanwhile wedge pressure showed a reduction, with statistical significance only in pulmonary patients. Total systemic resistances didn't show any variation in both groups of patients. The echocardiographic data revealed an important impairment of myocardial contractility after bolus of propofol, mainly in cardiac patients, as evidenced by decrease of ejection fraction values (20%) and by increase of left ventricle end systolic volume index (10%) from baseline. SVO2 and DO2/VO2 ratio values were stable, according with deep anaesthesia level and adequate metabolic balance. In pulmonary patients, during one lung ventilation, the intrapulmonary shunt values did not differed either during or without propofol infusion, thus suggesting that propofol doesn't interfere with pulmonary hypoxic vasoconstrictor response. In conclusion an aware use of propofol and a careful haemodynamic monitoring would be advisable primarily in patients with a well known or supposed cardiovascular disease.

Direct measurement of pulmonary and systemic flow during assisted circulation.

During biventricular assistance as a bridge to cardiac transplantation, the flow data provided by the pumping systems were compared with flow data obtained with the Fick method. There was a difference between the data sets only in the first 20 hr of observation, with the Fick method giving higher values. During the same period, analysis of the arterial and pulmonary pressure traces showed pulsatile activity to be related with the electrocardiogram's T waves. In the long run, the flow data provided by both methods were no different and the T wave-related pulsatile activity disappeared. The authors concluded that the Fick method represents a useful tool when measuring total flow during biventricular support.