Cardiac pacemakers in the transplanted heart: short term with the biatrial anastomosis and unnecessary with the bicaval anastomosis.

Sinus node dysfunction occurs commonly after orthotopic heart transplantation and may be caused by surgical trauma, ischemia to the sinus node, rejection, drug therapy and increasing donor age. In the past, using the standard biatrial technique described originally by Lower and Shumway, many series have reported permanent pacing in more than 10% of patients. Unlike sinus node dysfunction in nontransplanted patients, which typically worsens with time, sinus node dysfunction in the transplanted heart usually improves over a period of weeks to months. Delaying the implantation of a permanent pacemaker may render it unnecessary. The development of the bicaval technique for implantation of the donor heart appears to have decreased even further or even eliminated the need for early permanent pacing. Because sinus node dysfunction in the transplanted heart does not predict subsequent development of atrioventricular (AV) node dysfunction, rate-responsive atrial pacing should be used in the majority of cases. Even after appropriate pacing for sinus node dysfunction, the sinus node may recover and permanent pacing may be discontinued. AV conduction abnormalities are far less common and generally occur late after transplantation. Dual-chamber pacing is required and permanent pacing should be continued indefinitely.

Accelerated coronary atherosclerosis in cardiac transplantation.

The implications of this new aggressive form of coronary disease for the transplant population are obvious. It appears that for the majority of transplant patients we have simply bought some time. We have given them a temporary respite from congestive failure and cardiomyopathy while they surmount the daily challenges imposed by immunosuppression. Clearly, this issue now looms as a major stumbling block toward improving long-term survival. It is no longer enough to simply perform the procedure and submit the patient to the rigors of transplantation, only to obtain 50 percent 5-year survival. We must pay particular attention to the patient postoperatively and make those modifications necessary to improve the individual's risk profile. Moreover, we must continue to concentrate our research efforts on interventions in accelerated coronary disease.

Orthotopic cardiac transplantation: evaluation with CT.

As cardiac transplantation has become widely available, computed tomography (CT) of the chest has played a useful role in the examination of patients after heart transplantation. To determine anatomic features related to the procedure, the authors evaluated 59 scans in 46 patients who had undergone orthotopic cardiac transplantation. Aortic anastomosis (seen in 98% of scans) and altered spacing between the great vessels (83%) proved to be the most common and most reliable findings. Other features including atrial anastomosis, high main pulmonary artery segment, remnant superior vena cava, and cardiac reorientation were also seen. Accurate interpretation of adenopathy, mediastinal abscess, and pericardial effusion will be enhanced in these patients through a better understanding of the cardiovascular-pericardial complex, which is afforded by CT.

Homograft replacement of single aortic valve cusps: 22 years follow-up.

Single aortic valve cusp replacement with fresh aortic homografts were performed in four patients from November 1966 to April 1970. All had preoperative aortic insufficiency due to destruction of a single cusp, with the remaining two cusps structurally and functionally intact. Replacement was performed using the noncoronary cusp from fresh aortic valve homografts. Patient one had homograft cusp replacement of the left coronary cusp at age 13 due to bacterial endocarditis. She recently underwent mitral valve replacement; study and inspection of the aortic valve showed it to be structurally and functionally intact 22 years following homograft cusp replacement. Patient two sustained a gunshot wound perforating his right coronary cusp. He underwent single cusp replacement in January 1967. Currently, he is asymptomatic and has been without evidence of significant aortic valve dysfunction for the past 21 years. Patient three had destruction of the noncoronary cusp due to endocarditis and had homograft cusp replacement in October 1967. Four and a half years later he developed recurrent endocarditis, presented with severe congestive heart failure due to aortic insufficiency, and died. Patient four had bacterial endocarditis affecting the right coronary cusp and had replacement in April 1970. In February 1980, he underwent aortic valve replacement for aortic stenosis. Inspection revealed calcification of the other two cusps with the homograft cusp structurally normal. In summary, follow-up of homograft replacement of single aortic valve cusps from 4 1/2 to 22 years, shows it to be a durable and feasible alternative to prosthetic valve replacement.

Tandem 8.5-French subclavian catheters: a technique for rapid volume replacement.

A technique for the ipsilateral insertion of tandem 8.5-French catheters for subclavian catheters is presented. This technique allows rapid volume administration while minimizing the risk associated with bilateral subclavian insertions.

Are steroids essential for successful maintenance of immunosuppression in heart transplantation?

To determine the necessity for maintenance dosages of prednisone in the management of heart transplant patients, a retrospective study was made of 86 patients undergoing orthotopic heart transplantation and two patients having heart-lung transplantation from June 1985 through October 1986. Group 1 (n = 52) had maintenance immunosuppressive therapy that included cyclosporine, azathioprine, and prednisone. Group 2 (n = 36) received only cyclosporine and azathioprine with no maintenance dosage of steroids. Data were analyzed for frequency of rejections, infections, noninfectious complications, and mortality. The rate of rejection was 1.44 episodes per patient in group 1 and 1.58 episodes per patient in group 2. Twenty of 52 patients (38%) in group 1 had no rejection compared with 12 of 36 patients (33%) in group 2 (p = not significant [NS]). One or more infections occurred in 30 patients (58%) in group 1, whereas only 12 patients (33%) in group 2 had infections (p less than 0.05). Noninfectious complication rates were noted to be similar in both groups (27% versus 25%, p = not significant). There were five deaths in group 1: three from infections, one from rejection, and one from trauma. There were three deaths in group 2: two from infection and one from rejection. Although 14 patients in group 2 eventually were placed on low-dosage steroid maintenance, the remaining 22 patients (61%) never received maintenance dosages of steroids. We conclude that some patients can be successfully managed without maintenance dosages of steroids after heart transplantation. Such patients do not appear to have an increased risk of rejection and may have a reduced rate of infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of prophylactic rabbit antithymocyte globulin in cardiac allograft recipients treated with cyclosporine.

The prophylactic use of rabbit antithymocyte globulin (RATG) was evaluated in 13 cardiac allograft recipients who received a low-dose of RATG (175 +/- 32 mg) after transplantation (group 1). The patients were retrospectively compared with 13 parallel cases receiving the same treatment except for the initial RATG (group 2). There were no differences in the patient composition and the level of the basic immunosuppression therapy with cyclosporine. The patients treated with RATG (group 1) showed substantially greater suppression of T helper and total T cells up to 10 and 20 days after surgery, respectively. The incidence of rejection episodes during the initial admission seemed lower in patients receiving RATG, with a borderline significance (1.4 versus 2.4, p = 0.06). This accounts for the reduced requirement of methylprednisolone in treating rejection in patients in group 1 (1.3 gm versus 4.0 gm, p less than 0.02). Moreover, the patients without initial doses of RATG (group 2) more frequently experienced recurrent rejection (five of 12 versus nine of 10, p less than 0.05), which necessitated rescue RATG; the initial difference in the RATG usage disappeared by the time of discharge. Serious infection occurring after antirejection therapy was common in the group 2 patients without initial doses of RATG, although the overall incidence of infection was not statistically different. Prophylactic use of RATG at the dosage used appeared to reduce the incidence of rejection and the requirement for intravenous steroids and other immunosuppressants. It seems warranted to test this approach in a prospective randomized manner.

Pretransplant transfusions in cardiac allograft recipients.

The role of pretransplant transfusion in cardiac allograft recipients was determined retrospectively in 68 patients. Three groups were studied: group 1 (n = 29) received no pretransplant transfusion, group 2 (n = 15) received transfusion over one year prior to transplantation, and Group 3 (n = 24) received 5 or 10 50-100 ml units of random donor red blood cells or buffy coat 2-4 weeks prior to transplantation. Data were analyzed for survival, number of rejection episodes, and number of infections. Immunosuppression included azathioprine, prednisone, and antithymocyte globulin. Survival in transfused patients (groups 2 and 3) was 68% and 51% at 1 and 5 years, respectively, while in the nontransfused population (group 1) it was 35% and 16%. The incidence of rejection episodes per year of survival was similar in the three groups (group 1: 1.3, group 2: 1.1, group 3: 1.3; P greater than 0.05). The number of infections per year of survival were greater in the transfused patients but this did not achieve statistical significance (group 1: 1.0, group 2: 1.2, group 3: 1.7; P greater than 0.05). Thus, we conclude that cardiac transplant recipients who have received blood transfusions prior to transplantation may have enhanced survival over patients who have not received preoperative transfusions.

Cardiopulmonary arrest following penetrating trauma: guidelines for emergency hospital management of presumed exsanguination.

Exsanguination may be presumed in pale, mottled, unresponsive trauma victims with no palpable pulse nor spontaneous respirations with noncranial penetrating wounds. Under ideal circumstances, those victims initially witnessed to have some signs of life can be successfully revived in 5 to 25% of cases. The chance for a successful outcome influences the decision to initiate resuscitation and depends on the mode of injury, anatomic location of the wound, and elapsed time until presentation as well as the organization of the available facilities and personnel. The resuscitative algorithm for presumed exsanguination is markedly different from the ACLS guidelines for cardiogenic arrest and requires some degree of surgical expertise. After confirming the witnessed cardiopulmonary arrest from presumed exsanguination, the four phases of resuscitation are restoring central oxygenation, controlling internal hemorrhage, re-establishing spontaneous cardiac function, and definitively repairing the injury. Regardless of the type or location of the noncranial penetrating injury, these phases must be accomplished sequentially to minimize the risks of cerebral and cardiac anoxia.

Pneumoperitoneum resulting from tracheal rupture following blunt chest trauma.

Pneumoperitoneum usually implies perforation of the gastrointestinal tract, although the tracheobronchial tree has been recognized as a source for free intraperitoneal air. We report a case of pneumoperitoneum resulting from tracheobronchial rupture following blunt chest trauma, which was successfully treated by surgical repair.

Selective drainage for pancreatic, biliary, and duodenal obstruction secondary to chronic fibrosing pancreatitis.

Twenty-eight patients underwent surgery for intractable pain, duodenal or extrahepatic biliary obstruction secondary to chronic pancreatitis. Eleven had pancreatic duct obstruction alone, six biliary obstruction alone, seven combined pancreatic and biliary, two combined biliary and duodenal, one combined pancreatic and duodenal, and one simultaneous pancreatic, biliary, and duodenal obstruction. Pancreatitis was secondary to alcohol in all but one case. The following operations were performed: longitudinal pancreatojejunostomy (20), choledochoduodenostomy (8), choledochojejunostomy (7), cholecystojejunostomy (1), and gastrojejunostomy (4). Of the 20 patients with pancreatic duct drainage, pain relief was complete in 11 and partial in six. Initial incomplete relief of pain, or recurrence, stimulated further diagnostic procedures, leading to improvement or correction of the problem in five patients. A significant (p less than 0.01) fall in alkaline phosphatase (935 +/- 228 to 219 +/- 61 U/L) occurred following surgery. One patient was subsequently found to have pancreatic carcinoma. Two patients were lost to follow-up and four patients died (one perioperative and three late). In conclusion, the possibility of pancreatic, biliary, and duodenal obstruction must be considered in symptomatic patients with chronic pancreatitis. Surgery must be individualized. Drainage procedures, either alone or in combination, are associated with a low morbidity and improved clinical condition and may be preferable to resection in the surgical management of these patients.

Left ventricular outflow tract obstruction with mitral valve replacement in small ventricular cavities.

The inference that mitral valve replacement (MVR) may produce left ventricular outflow tract (LVOT) obstruction has been made, but no comparative hemodynamic studies with various types of prostheses have been done. The purpose of the present study was to compare the gradients created across the LVOT with MVR in young sheep with small left ventricular cavities. Mitral valve replacement was accomplished using cardiopulmonary bypass and hypothermic cardioplegic arrest. Five animals were used for each of the following valves studied: 25-mm Ionescu-Shiley bovine pericardial valve, 25-mm Hancock porcine aortic valve, 2M-6120 28-mm Starr-Edwards ball-valve prosthesis, 25-mm Björk-Shiley 60-degree flat tilting-disc prosthesis, and 25-mm St. Jude Medical hemidisc valve. Gradients across the LVOT were measured after MVR and then during infusion of isoproterenol hydrochloride (0.05 micrograms/kg/min). Following MVR, only the Starr-Edwards valve produced an LVOT gradient (32 +/- 23 mm Hg). Substantial gradients after MVR were seen, however, with isoproterenol administration with the Ionescu-Shiley (47 +/- 4 mm Hg), Hancock (13 +/- 8 mm Hg), and Starr-Edwards (65 +/- 30 mm Hg) valves but not with the low-profile valves (Björk-Shiley and St. Jude Medical). The results of the present study demonstrate that MVR can produce LVOT obstruction. The greatest degree of obstruction was with the high-profile mechanical and bioprosthetic valves.

A prospective randomized trial of pretransfusion/azathioprine/prednisone versus cyclosporine/prednisone immunosuppression in cardiac transplant recipients: preliminary results.

Cyclosporine has gained acceptance as the immunosuppressive agent of choice in cardiac transplantation, but the validity of this assumption has yet to be established. Since January 1983, 25 patients have been randomly assigned to receive either conventional immunosuppression (azathioprine/antithymocyte globulin/prednisone) and pretransplant transfusion (PAAP, n = 11) or cyclosporine immunosuppression (cyclosporine and prednisone [CyA], n = 14). There was no difference in the age distribution (41 +/- 9 vs 38 +/- 11 years), indications for transplantation, preoperative serum creatinine level (1.2 +/- 0.2 vs 1.4 +/- 0.3 mg/dl), or postoperative follow-up time (13.5 +/- 5.4 vs 13.5 +/- 5.2 months). Mortality was not different (PAAP = 2, CyA = 3) and there was no difference in rejection episodes per patient (PAAP = 1.8, CyA = 1.9). Patients in the PAAP group had more serious infections (PAAP = 8, CyA = 3; P less than .02), but those in the CyA group developed a greater incidence of systemic hypertension (PAAP = 1, CyA = 10; p less than .02), pericardial effusion (PAAP = 0, CyA = 6; p = .05), and impaired renal function (creatinine 1.5 mg/dl, PAAP = 2, CyA = 11; p less than .02). Thus it appears that in this small series, cyclosporine is not associated with a significant increase in early survival. It does appear that patients on PAAP immunosuppression develop a greater number of serious infections, but the incidence of rejection episodes appears to be the same. Renal dysfunction and hypertension in patients receiving cyclosporine continue to be long-term concerns and may add to the morbidity and mortality of patients treated with this immunosuppressive regimen.

Comparison of immunosuppression therapy following heart transplantation: pretransfusion/azathioprine/ATG/prednisone versus cyclosporine/prednisone.

Since the introduction of cyclosporine in heart transplantation, the search for the ideal combination of immunosuppressive agents continues. Between January 1983 and February 1985, 32 patients have been randomized prospectively to either one of two immunosuppressive regimens: one includes pretransplant transfusion, prednisone, azathioprine and rabbit anti-thymocyte globulin [Group I, n = 14], the other includes cyclosporine and prednisone [Group II, n = 18]. There were no differences between Group I and II in relation to age distribution, indications for transplantation, preoperative serum creatinine, length of follow-up, mortality or number of rejection episodes per patient. However, there was a statistically significant increase in the incidence of serious infections in Group I compared to Group II patients, and also in Group II of the incidence of systemic hypertension (p less than 0.001), of symptomatic pericardial effusion (p less than 0.05) and impaired renal function (p less than 0.02). Adding cyclosporine to azathioprine immunosuppression is effective in treating ongoing rejection in patients not previously treated with cyclosporine. In conclusion, patients treated with azathioprine and prednisone (Group I) develop a greater number of serious infections, but both groups had a similar incidence of rejection. The development of renal dysfunction and hypertension in patients treated with cyclosporine continues to be of concern and may preclude its use as an effective long-term immunosuppressive agent in heart transplant recipients.