Heart transplantation after mechanical circulatory support: four years' experience.

To determine the effect of mechanical circulatory support before heart transplantation, we conducted a retrospective analysis of 207 men who underwent staged orthotopic transplantations. Of these patients, 185 (group I) required pharmacologic support before transplantation; 14 (group II) required mechanical circulatory support with an intraaortic balloon pump (duration of support, 1 to 26 days); and eight (group III) required advanced mechanical circulatory support with an implantable left ventricular assist device (duration of support, 19 to 132 days). A comparison of complications after transplantation (infection and rejection), hospitalization, and survival showed that no significant differences existed among the three groups. In each group, respectively, 1-year survival was 80.9%, 77.3%, and 75%, and 2-year survival was 75.7%, 67.7%, and 75%. Based on our experience, patients receiving mechanical circulatory support before transplantation can be expected to have a good outcome. In fact, such support can help to improve their end-organ perfusion, and, thus, their status as heart transplantation candidates. Furthermore, this study shows that advanced mechanical circulatory support is possible even for prolonged periods, with low risk of sudden death. This finding is an important step toward development of a permanent assist device.

Reevaluation of steroid tapering after steroid pulse therapy for heart rejection.

A retrospective analysis was conducted to determine the efficacy and complications resulting from steroid pulse therapy, with or without a steroid taper, in 93 episodes of heart transplant rejection that occurred in 72 patients (58 men, 14 women; mean age, 47.6 years). Each rejection episode was classified according to severity (Texas Heart Institute endomyocardial biopsy scale) and the treatment. Group 1 included 25 episodes of grade 7, 8, 9, or 10 rejection (International Society for Heart Transplantation [ISHT] grade IIIB or IV) that were treated with high-dose methylprednisolone (2.5 to 3.0 gm) and a steroid taper of 1.75 gm over 30 days. Group 2 included 16 episodes of rejection, with the severity of rejection and methylprednisolone pulse therapy being similar to that in group 1, but without a steroid taper. The results of treatment in group 1 were compared with those in group 2. Group 3 included 12 episodes of grade 5, 6, or 7 rejection (ISHT grade IIIA or IIIB) that were treated with moderate-dose methylprednisolone (1.0 to 2.0 gm) and a steroid taper, as described. Group 4 included 40 episodes of rejection, with the severity of rejection and methylprednisolone therapy being similar to that of group 3, but without a steroid taper. The results of treatment in group 3 were compared with those in group 4. No statistically significant differences were found among the groups regarding subsequent episodes of rejection or infection within 3 months of treatment. No statistically significant difference was noted among the groups in the number of rejection episodes requiring additional therapy to control the rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Adjuvant native heart surgery during heterotopic heart transplantation: two case reports.

The results of heterotopic heart transplantation may be further improved if repairs on native heart abnormalities are performed just before implantation of the allograft. Such procedures increase the potential for the recipient's own heart to recover function and, thus, to maintain circulation if the heterotopic heart malfunctions or fails. The native hearts of two of our patients, both women, showed signs of greater contractility and ejection after repair and were able to provide adequate circulatory support during periods of donor heart failure. The first patient required ventricular aneurysmectomy and coronary artery bypass grafting, and the second, native mitral valve repair. Moreover, when persistent ventricular fibrillation occurred in the donor heart of the first patient, a donor cardiectomy was performed, and the recipient heart functioned well thereafter. As more adjuvant operations are performed and the results evaluated, we may find that heterotopic operations would be suitable in a greater variety of heart transplant candidates.

Coronary artery bypass two years after orthotopic heart transplantation: a case report.

Complete occlusion of the left anterior descending and right coronary arteries developed in a 58-year-old man 2 years after orthotopic heart transplantation. Because of his progressive shortness of breath, reversible myocardial ischemia, and decreasing ejection fraction, aortocoronary bypass was recommended. The operation was performed without complications, and his postoperative ejection fraction improved by more than 58%. In the past, when coronary artery disease developed in cardiac allografts, another transplant procedure was the only treatment option. Because of the limited donor hearts available today, new strategies are necessary for the treatment of cardiac allograft atherosclerosis.

Rapid placement of the Hemopump and hemofiltration cannula.

Hypervolemia, a potential complication in patients on ventricular assist device support, can be managed by use of continuous arteriovenous hemofiltration. The Hemopump, a new catheter-mounted, transaortic axial-flow ventricular assist device, and the vascular access catheter for the Diafilter-30 Hemofilter system, used in continuous arteriovenous hemofiltration, are both usually inserted by way of the femoral artery. Because placing two large catheters in the femoral artery of a patient with peripheral vascular disease can compromise circulation, a technique for placing them in the abdominal aorta was developed. Two patients have undergone combined Hemopump and hemofiltration treatment, and neither experienced complications. Such techniques may benefit more patients in the future, as the usefulness of the Hemopump is proved.

Risk factors for development of accelerated coronary artery disease in cardiac transplant recipients.

Allograft coronary artery disease (CAD) is the major determinant of long-term survival following heart transplantation (HTx). In a group of 210 heart transplant recipients, we diagnosed CAD in 54 (27.1%) by coronary angiography, postmortem examination or examination of the transplanted heart at the time of retransplantation. Retrospective analysis of potential risk factors for the development of CAD was performed for both immunological (rejection pattern, immunosuppressive therapy, cytomegalovirus [CMV] infection), and nonimmunological (hyperlipidemia, smoking, hypertension, diabetes mellitus, obesity) risk factors. The total number of rejection episodes correlated significantly with the occurrence of CAD (P less than 0.05), showing that patients who experienced two or more rejection episodes had an incidence of CAD of 40%, as opposed to a 23% incidence in patients who experienced no rejection. A composite rejection score derived from multivariate regression analysis of the severity, frequency, and timing of acute cardiac rejection episodes was found to correlate with the development of CAD (P less than 0.05). Postoperative arterial hypertension also correlated significantly with the onset of CAD (P less than 0.01), with a 92.6% incidence of hypertension in the group with CAD versus 76.3% in the group without CAD. Smoking after transplantation correlated significantly with the occurrence of CAD (P less than 0.05). There was no significant correlation with other analyzed factors in this group of patients. In this review, the development of CAD after heart transplantation correlated with treated allograft rejection. Aggressive treatment of hypertension and cessation of smoking may contribute to alleviation of this serious complication.

Cefuroxime prophylaxis in cardiovascular surgery: clinical, microbiological, and ecological impact.

To determine the efficacy of cefuroxime as a prophylactic agent against infection, we retrospectively evaluated patients who had undergone cefuroxime therapy for cardiovascular surgery procedures in the years 1987 and 1990. In the 403 evaluable patients (203 in 1987 and 200 in 1990), we noted a postoperative surgical wound infection rate of 3% and a nosocomial infection rate of 3%. These rates have remained constant in 1987 and 1990. Despite more than a 6-fold increase in cefuroxime consumption during this same period, we have not observed a selection for staphylococcal infections in cardiovascular surgery patients, nor have we detected a selection for resistant staphylococci in our institution. Our original criteria that caused us to select cefuroxime for routine prophylaxis-notably its equivalent efficacy and safety as compared with other cephalosporins, and its lack of an adverse impact on the hospital flora-remain valid.

Concomitant donor heart coronary artery bypass grafting during orthotopic heart transplantation.

A 54-year-old diabetic woman with severe cardiomyopathy was placed on our heart transplant candidate list. The patient's condition rapidly worsened and a potential donor-a 45-year-old man whose blood was compatible with that of our patient-was located. Because of the donor's age, coronary arteriography was done, and stenosis in the midleft anterior descending coronary artery was identified. Since the patient's status was critical, the donor heart was accepted despite the presence of stenosis. We used the recipient's internal mammary artery to bypass the stenosis in the left anterior descending artery of the donor heart after performing a standard orthotopic heart transplant. The patient's postoperative course has been relatively free of complications, and the cardiac allograft has functioned well. The early results in this patient are comparable to those of our historical transplant control group. We suggest that the impact of donor organ shortages may be lessened by use of innovative procedures and extended donor selection criteria.

An ex vivo model for the reperfusion of explanted human hearts.

A model of an ex vivo-reperfused human heart was developed by using a modified Langendorff coronary perfusion circuit. The technical and physiologic aspects of reestablishing myocardial contractility are described. Preliminary studies were conducted in animals. In the present study, we obtained 12 human hearts that had been arrested with cardioplegic solution and excised from cardiac transplant recipients. The perfusate contained type-specific human donor red blood cells in a lactated Ringer's solution containing 5% dextrose. Myocardial contractility was successfully reestablished in 11 hearts and sustained for an average of 98 minutes (range, 79 to 180 minutes) at a coronary perfusion pressure of 80 mmHg. Left ventricular contraction pressures reached 40 mmHg (against intraventricular balloons at an internal pressure of 50 to 75 mmHg). Partial oxygen pressure (PO2) dropped significantly across the empty beating myocardium (from 498 +/- 40 mmHg to 219 +/- 53 mmHg [mean +/- SD]), but no significant change in hemoglobin saturation was observed. Myocardial failure generally stemmed from edematous changes leading to progressive impairment of myocardial relaxation. The intracoronary insertion of over-the-wire catheters did not adversely affect myocardial function. In conclusion, an ex vivo-supported human heart model has been developed that may have a number of applications, including the preclinical evaluation of new interventional diagnostic and therapeutic techniques aimed at the coronary circulation, and the investigation of myocardial mechanics, preservation, and metabolism.

[The importance of annulo-ventricular integrity in replacement of the mitral valve. Experience with the double-disc low profile Carbo Medics mechanical valve]. / Význam annuloventrikulárnej integrity pri náhradách mitrálnej chlopne. Skúsenosti s dvojdiskovou nízkoprofilovou mechanickou chlopnou Carbo Medics.

In the submitted paper the authors compare the results of the conventional replacement of the mitral valve with total excision of the subvalvular apparatus and the results of mitral replacement with a completely or partly preserved or reconstructed integrity of the annulopapillary structures. During the last five years the authors operated by the former method 115 patients (group A) and the second surgical method was used in 93 patients (group B). In both groups the authors compared 33 demographic, clinical, peroperative, postoperative and echocardiographic indicators. Group B comprised substantial more patients with severe myocardial disorders. In the latter group significantly more frequently a mechanical double-disc valve Carbo Medics was implanted than other types of synthetic valves which were used mostly in patients of group A. In patients of group B the operation took longer and after operation they needed more frequently intense inotropic support. Despite that their mortality on hospitalization was lower -3.2% than in group A where it was 6.9%. The late echocardiographic results were also in favour of group B where, contrary to group A, after operation the left ventricular function improved. The authors' experience support the view that preserving the integrity of the annulopapillary apparatus is nowadays one of the demands in surgical correlation of a mitral defect and is of decisive importance for the subsequent fate of the thus treated patients.

[Treatment of defects of soft tissue and sternum, as postoperative complications of A-C bypass, case report]. / Terapija defekata mekih tkiva i sternuma kao postoperativnih komplikacija operacija na srcu.

Medial sternotomy is optimal approach for great number of heart surgery. Deep infection of sternum and mediastinis are very rear, but very dangerous complications followed by high rate of morbidity and mortality. Factors which can be responsible for these complications are numerous: post operation bleedings, surgery reinterventions, extended mechanical ventilation, liver chronic diseases, older age, diabetes, previous irradiation therapy, respiratory obstructions and use of steroids. Clinical signs for these complications are: red skin around the surgical wound, leaking, dehiscence, increased body temperature and instability of sternum. Early diagnosis, adequate antimicrobial therapy, and aggressive surgical and multidisciplinary approach in initial phase, are base for successful treatment. Surgical treatment most often assumes use of flaps. Our main objective in this work was to present treatment of defect of sternum and soft tissues, after triple aorto-coronary bypass. After the surgery patients got slack of sternum's ficsation and reficsation. With satisfactory respiratory function, corrections of defect was achieved by omentum and bipedicular myocutan flaps. (m. pectoralis major flap). There was no complications.

Treating cardiac allograft rejection: present approach--analysis of 100 consecutive patients.

In addition to rejection, complications of rejection prophylaxis and treatment are major causes of mortality and morbidity during the first year after heart transplantation. To decrease complications related to antirejection treatment, our present approach is to assess each rejection episode individually and to adjust treatment accordingly. This article presents the analysis of rejection in the last 100 patients who underwent heart transplantation at our institution.

Improved survival after Hemopump insertion in patients experiencing postcardiotomy cardiogenic shock during cardiopulmonary bypass.

Immediate placement of a Hemopump (HP) ventricular assist device was undertaken in nine patients (seven men, two women) after other attempts at weaning from cardiopulmonary bypass (CPB) after coronary bypass surgery had failed. All nine patients (100%) were successfully weaned from CPB, and six (63.3%) gradually improved enough to permit removal of HP support. Five (83.3%) of the six who were weaned from CPB survived beyond hospital discharge. HP support was evaluated in terms of vital organ function, incidence of complications, and clinical outcome. In both survivors (S) and nonsurvivors (NS), serial hemodynamic measurements were taken. Although there were few differences in hemodynamic parameters between groups at 4 hr, by 24 hr the S group had markedly improved cardiac index, Glasgow Coma Scale, urinary output, and pulse pressure and required far less inotropic support than did the NS group. All four patients who required high dose inotropic agents to maintain acceptable end-organ perfusion on HP support died; three were unable to tolerate weaning from the HP, and all died within 72 hr of surgery because of ineffective myocardial recovery. None of the survivors required additional early inotropic augmentation. Renal perfusion appeared to be well maintained, even with mean arterial pressures below 60 mmHg during HP support. There were no episodes of hemolysis, infection, or limb ischemia in either group. Thus, the Hemopump provided excellent circulatory support for those patients who could not be weaned from CPB by traditional methods.

[Perioperative myocardial failure and mechanical cardiac support --a five year experience]. / Perioperaciona slabost srca i mehanicka potpora radu srca--petogodnisnje iskustvo.

Inability to wean a patient from the cardiopulmonary bypass after open heart procedure is reality of the clinical practice. The only realistic chance for these patients is some form of mechanical circulatory support. Over the period from November 1988 to November 1993, in 17 patients the roller-pump mechanical assist device was inserted, i.e. 0.47% of 3589 patients were operated on during this period. Thirteen patients required mechanical circulatory support immediately after surgical procedure due to inability to wean them from cardiopulmonary bypass. In three patients the roller-pump was inserted preoperatively (percutaneous insertion), and in one patient mechanical circulatory support was started six hours after the procedure for sudden cardiac deterioration. Partial and temporary "bypass" of the damaged left ventricular function is achieved by insertion of inflow cannula into the left atrium, and outflow cannula into the ascending aorta. Depending on the inflow cannula size and volume load, we were able to achieve blood flow of 3.5 to 5 liters/minute. Using this system we were able to improve the left ventricular function in eight patients (47%), and five patients were discharged from hospital (29.4%). The roller-pump mechanical circulatory support proved to be efficient, reliable, easy to monitor and operate. Overall results are comparable to the published data as well as to other types of more versatile and costly devices for mechanical circulatory support.

Nutritional assessment of patients with extended left ventricular assist device support.

The nutritional status of nine patients with end-stage heart disease who were supported by a left ventricular assist device (LVAD) for more than 30 days while awaiting cardiac transplantation was evaluated. Nutritional status was indicated by the following scale: 0-2, adequate nourishment; 3-5, moderate malnourishment; greater than 5, severe malnourishment. This scale was based on serial assessments of albumin, transferrin, total lymphocyte count, percentage of ideal body weight, midarm circumference, triceps skinfold, and arm muscle circumference. Each variable was compared with established standards before implantation and before transplantation times and assessed 1 point if less than the normal value and 0 points if within the normal range. At the time of LVAD implantation, 5 patients had a score of 0-2, 3 patients had a score of 3-5, and 1 patient had a score greater than 5. At the time of cardiac transplantation, 7 patients had a score of 0-2, 2 patients had a score of 3-5, and no patients had a score greater than 5. The patients who were able to meet at least 50% of their daily caloric and protein requirements by oral intake alone were noted. At LVAD implantation, only 2 patients (22%) met this requirement; however, 6 patients (67%) met this requirement at the time of cardiac transplantation. All 9 patients underwent cardiac transplantation, and 8 survived. Thus, it appears that extended LVAD support and maintenance of hemodynamic stability allow patients to regain the desire and ability to achieve adequate nutritional status, which may considerably reduce their perioperative transplant risks.