Hemodynamic response to OKT3 in orthotopic heart transplant recipients: evidence for reversible myocardial dysfunction.

The murine-derived monoclonal antibody OKT3 has been shown to be a useful immunosuppressive agent in transplant recipients; but it may cause cardiac instability and hemodynamic findings similar to those seen in septic shock after a first dose. Eight patients who received orthotopic heart transplants and were randomized to OKT3 therapy for immunosuppression were evaluated with serial hemodynamic and radionuclide monitoring for an 8-hour period during the first dose of OKT3. Cytokines including tumor necrosis factor-alpha, interleukin-1 and -2, and interferon-gamma were measured hourly to determine the potential mechanism of action of OKT3. All patients tolerated OKT3, although most had symptoms--pyrexia, chills, dyspnea, nausea and vomiting, and fever--within an hour after the dose. All patients exhibited a biphasic hemodynamic response to the first dose of OKT3. The initial hemodynamic response was characterized by a hyperdynamic phase with involvement in cardiac function as measured by cardiac output and ejection fraction. Left ventricular ejection fraction increased from 68% +/- 10% to 79 +/- 11% and was accompanied by increases in right ventricular ejection fraction and increases in cardiac index from 2.1 +/- 1.1 to 3.8 +/- 1.3 L/min/m2. The increase in ejection fraction was accompanied by a significant decrease in systemic vascular resistance index, from 2190 +/- 740 to 1608 +/- 573 dyne.sec.cm-5. The improvement in left ventricular ejection was caused by a significant decrease in end-systolic volume index (18 +/- 9.5 to 11 +/- 7 ml/m2). This occurred within the first 2 hours after OKT3 and was followed by cardiac index and ejection fraction returning to baseline in the next 2 to 3 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical care management of lung transplant recipients.

In the last 10 years, lung transplantation has become an increasingly common procedure for patients with end-stage respiratory disease. Although long-term survival can be achieved, there is still significant morbidity within the first year. Early postoperative problems that may be anticipated include respiratory insufficiency, airway anastomotic problems, hemorrhage, infection, and episodes of acute rejection. These problems and others make the immediate perioperative period particularly challenging. With aggressive management, however, the probability of a successful outcome can be enhanced.

Evolution of human cardiac myocyte dimension during prolonged mechanical support.

In animal models using left ventricular assist systems over long time periods, myocardial cellular atrophy has been reported, raising concern that prolonged clinical use of such systems might lead to deterioration in left ventricular function. At the University of Pittsburgh, long-term clinical use of the Novacor (Baxter Healthcare Corp., Novacor Div., Oakland, Calif.) left ventricular support system for patients awaiting heart transplants has allowed study of the effects of long-term mechanical support on human subjects. This study determined that cardiac myocyte dimension is initially greater in patients with end-stage cardiac disease who require support rather than in patients with the same disease who do not require such support. Although myocyte dimension does decrease within a few days of the inception of support, this decrease merely brings cell size closer to the values usual in patients with chronic end-stage cardiac disease, and no further shrinkage is observed. Thus the Novacor left ventricular assist system does not appear associated with left ventricular atrophy, and its long-term use may not be detrimental to left ventricular function.

Depression and recovery of right ventricular function after cardiopulmonary bypass.

Transient left ventricular dysfunction is commonly described in association with cardiopulmonary bypass (CPB). We evaluated changes in right ventricular (RV) function after elective cardiac surgery in 24 patients with normal preoperative cardiac function. In all, irrespective of distribution of coronary artery disease or use of pharmacologic support, a transient depression of RV systolic function with respect to both preinduction and initial postoperative (Postop) values occurred 262 +/- 116 min post-CPB as represented by a decrease in RV stroke volume index (25.0 +/- 1.7 vs. 33.4 +/- 1.9 ml/m2 Postop) and RV ejection fraction (31.0 +/- 2.2 vs. 45.6 +/- 2.5% Postop), and an increase in RV end-systolic and end-diastolic volume indices. This depression responded readily to pharmacologic therapy within 2 h, resolved within 24 h, and had no adverse consequences in these otherwise healthy patients. Further studies are needed to identify the cause of this phenomenon and its importance in patients with preexisting cardiac dysfunction.

Approach to management of the heartbeating 'brain dead' organ donor.

In recent years, transplantation has assumed an important role in the treatment of patients with end-stage diseases of most major organ systems. However, the greatest limitation in organ transplantation today is organ supply. Among factors that can affect the organ supply favorably, donor management has received the least attention. This review addresses management of the multi-organ donor within the intensive care unit. With an increased awareness of donor management issues and the application of a rational physiological approach, the supply of functional organs for transplantation can be increased.

KIE: Clinical management of the brain dead, potential multi-organ donor within the intensive care unit is reviewed. The emphasis is on physiological maintenance until organ procurement. Among the topics discussed are donor recognition and evaluation, declaration of brain death, medical management, and organ procurement and coordination.