Implantation of the implantable cardioverter defibrillator in the heart transplant candidate.

Because the major cause of death in patients awaiting heart transplantation results from out-of-hospital sudden cardiac arrest, the use of the implantable cardioverter defibrillator has been proposed as a bridge to transplantation. To provide a safe and simple implantation procedure that also easily allows access to cardiopulmonary bypass at the time of transplantation, a modified subxiphoid approach is reported.

Emergency cardiopulmonary bypass support in patients with cardiac arrest.

Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.

Treatment of end-stage chronic obstructive pulmonary disease with double lung transplantation.

Six patients with end-stage emphysema (age 44 +/- 2 years) underwent double lung transplantation (Tx) from June 1988 through May 1990. All suffered from severe inanition and required oxygen therapy. The ischemic time was 193 +/- 28 minutes. Post-Tx immune suppression was OKT3 (14 days), cyclosporine (trough levels of 150 +/- 25 ng/ml), azathioprine to keep WBC at 3,000 to 5,000/cu mm (1 to 3.0 mg/kg/day) and following OKT3, a tapering prednisone regimen. Two rejection episodes that occurred in two patients on post-Tx day 5 and 10 were treated with bolus doses of methylprednisolone. The mean hospital stay was 32 +/- 7 days (range, 20 to 69 days). Four patients required treatment of cytomegalovirus (CMV) infection: gastritis (+donor, +recipient) in one and CMV pneumonia in two (+donor, -recipient). A fourth (+donor, -recipient) had right-sided Candida empyema six weeks post-Tx, developed CMV and staphylococcal sepsis, and died 64 days post-Tx. One patient required pyloroplasty eight weeks post-Tx and one patient underwent tracheal suture line repair at eight weeks. During a follow-up of 81 patients months (range, 8 to 24 months), one patient had developed Epstein-Barr viral (EBV) induced lymphoproliferative disease in the lung and one patient had developed EBV lymphoma. Three patients are at work, one is continuing rehabilitation, and one is at home. Double lung Tx offers a definitive benefit to patients with emphysema; however, a prolonged postoperative course can be expected. Viral infections remain serious but treatable problems.

Mechanical circulatory assistance after heart transplantation.

From October 1985 through December 1989, 92 heart transplant procedures were performed in 89 patients. Nine patients (aged 19 to 66 years; 7 male, 2 female) required mechanical circulatory support after transplantation because of primary idiopathic organ failure (n = 2), implant difficulty (2), poor organ quality (2), or acute right heart failure (3). Devices used included the intraaortic balloon pump (6), centrifugal right ventricular assist device (2), left ventricular assist (1), biventricular assists (2), and total artificial heart (1). Two patients required multiple devices. One patient underwent retransplantation. Implant time ranged from 1 to 18 days. One early death occurred owing to right heart failure 6 days after transplantation, 7 hours after removal of a right ventricular assist device, for an overall mortality of 11%. The remaining 8 patients are alive 4 months to 28 months after transplantation. The actuarial 1-year survival of 89% +/- 10% compares well with the survival of 87% +/- 4% for the entire transplant group. All surviving patients are in functional class I. Echocardiographic examination in all patients revealed left ventricular ejection fraction to be normal in 7 and depressed in 1. Extending the criteria for organ donors or difficulty with the implant procedure can lead to early organ failure, which may be reversible with circulatory assistance allowing excellent survival.

Mechanical circulatory support as a bridge to transplantation.

From December 1985 through April 1988, 11 patients (three female and eight males), 33.1 +/- 3.9 (+/- SEM) years of age (range, 15 to 50 years), underwent heart transplantation preceded by the use of mechanical circulatory support. The causes of cardiac failure were ischemic (four), viral cardiomyopathy (three), idiopathic cardiomyopathy (two), congenital heart disease (one), and valvular heart disease (one). All patients were preterminal. Mechanical circulatory support consisted of intra-aortic balloon pump (eight), the total artificial heart (seven), biventricular assist (three), and left ventricular assist (two). Seven patients had more than one form of support. The duration of mechanical circulatory support was 12.2 +/- 4.1 days (range, 1 to 44 days). Once listed for transplantation, patients waited for 8.1 +/- 2.4 days for a donor. Seven patients received OKT3 monoclonal antibody as prophylaxis, in addition to triple-drug immunosuppression. There were four rejection episodes and 12 serious infections. In addition, eight patients suffered a major posttransplant complication of a distant organ system: central nervous system (three), renal (two), and respiratory (three). Post transplant hospitalization was 48 +/- 22 days (range, 15 to 248 days). Two patients (18%) died after transplant, one of severe acute rejection (29 days) and one of multisystem failure (248 days). All patients surviving transplant hospitalization are alive 6 to 34 months after the transplant procedure. Eight patients are in functional class I and 1 patient class II. This patient attends school full-time but has a premechanical support system neurologic defect. In follow-up of 163 patient-months except for yearly catheterization, these nine patients required only 5 hospital days. Although the use of the mechanical circulatory support as a bridge to transplantation can result in a prolonged, complicated hospitalization after transplant, the long-term results are gratifying.

Use of the mini Jarvik-7 total artificial heart as a bridge to transplantation.

A 40-year-old woman was maintained on a mini Jarvik-7 total artificial heart for 45 days, during which time she recovered from a viral cardiomyopathy and multiple organ failure. The total artificial heart and driver were free of mechanical dysfunction, and there was no evidence of thromboembolic complications. The patient was maintained on hemodialysis for 26 days, at which time kidney function returned to near normal. The patient underwent an uneventful heart transplant and is now alive at 4 months after transplantation.

The electrocardiogram in aortic valvular atresia.

In a review of the electrocardiograms of 27 patients with aortic valvular atresia, several showed an unusual pattern. In two, the Wolff-Parkinson-White syndrome was present, and in the third, complete right bundle-branch block was seen. The study also confirms that left axis deviation and left ventricular hypertrophy can occur rarely. No patient showed a Q wave in lead V6.

Coarctation of the aorta associated with aortic valvular atresia.

The aortas in 41 specimeans of aortic atresia (ten with associated mitral atresia) were studied for the presence of coarctation of the aorta. The basic lesion, causing varying degrees of obstruction, was observed in 31 instances (75%), 24 minor, seven with major degrees of obstruction. In half, the aortic lesion lay proximal to the ductus, and in the majority of the remainder, opposite the ductus arteriosus. The location of lesion and degree of obstruction was essentially the same whether aortic atresia occurred alone or in association with mitral atresia. Angiography is a fairly reliable method of identifying coarctation associated with aortic atresia. An additional point of interest was that in aortic atresia alone there was strong dominance of the male sex, while this tendency was not observed when mitral atresia was associated with aortic atresia.