Pneumonectomy for lung cancer in heart transplant recipient.

Prolonged nonspecific immunosuppression after solid-organ transplantation is associated with an increased risk of certain cancers. Review of the medical literature reveals that the combination of profound immunossuppression (triple-drug immunosuppression), a heavy smoking history, advanced age and a working exposition puts cardiac transplant recipients at increased risk for the development of aggressive lung cancer. These tumors in cardiac transplant recipients carry a poor prognosis. We present one case of bronchogenic carcinoma in a cardiac transplant patient. The patient was operated to resect the tumor and a long-term cure and a good quality of life should, however, be offered.

Haemodynamic changes during minimally invasive coronary artery bypass surgery using high-dose esmolol.

UNLABELLED: We aimed to investigate the effects of high-dose esmolol on haemodynamics and oxygen extraction in minimally invasive direct coronary artery bypass (MIDCAB) surgery patients. METHODS: In 18 patients, heart rate (HR), mean arterial (MAP), central venous (CVP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and mixed venous oxygen saturation (Sv0(2)) were prospectively measured after induction of anaesthesia (T1), start of surgery (T2), during bypass grafting with beta-blockade (T3), and at the end of surgery (T4). RESULTS: Mean esmolol dose at T3 was 0.44+/-0.2mgkg(-1)min(-1). HR was unchanged, whereas significant decreases in mean CO (3.1+/-0. 8 vs 4.8+/-1.0lmin(-1)m(-2), pre-esmolol), MAP (53+/-10 vs 89+/-14mmHg), and SvO(2) (65+/-10 vs 81+/-4%) were observed during esmolol administration. All haemodynamic parameters normalized immediately after termination of esmolol (T4). CONCLUSIONS: Despite unchanged HR esmolol reduced CO and MAP suggesting a favorable reduction of myocardial oxygen consumption. Mean Sv0(2) during esmolol administration reflects an acceptable ratio of whole-body oxygen delivery and consumption. Haemodynamic changes with high-dose esmolol during MIDCAB surgery remain within safety margins.

Comparison of cardiac output assessed by pulse-contour analysis and thermodilution in patients undergoing minimally invasive direct coronary artery bypass grafting.

OBJECTIVE: To investigate the precision and accuracy of continuous pulse contour cardiac output (PCCO) compared with intermittent transcardiopulmonary (TCPCO) and pulmonary artery thermodilution (TDCO) measurements in patients undergoing minimally invasive coronary bypass surgery (MIDCAB). DESIGN: Prospective, controlled, clinical study. SETTING: University hospital. PARTICIPANTS: Twelve patients undergoing MIDCAB. INTERVENTIONS: Thirty-six measurements of PCCO and thermodilution cardiac output (CO) were simultaneously performed after the start of surgery, during bypass grafting, and at the end of surgery. TCPCO and TDCO were simultaneously assessed by three injections of ice-cold saline randomly spread over the respiratory cycle. The pulse contour device was initially calibrated with an additional set of aortic thermodilution measurements. MEASUREMENTS AND MAIN RESULTS: Absolute values of CO ranged between 1.6 and 9.2 L/min. A close agreement among the three techniques was observed at all measurements. Mean bias between PCCO and TDCO and TCPCO was 0.003 L/min (2 SD of differences between methods = 1.26 L/min) and 0.27 L/min (2 SD of differences between methods = 1.16 L/min), respectively. The correlation coefficients were r2 = 0.90 for TCPCO versus PCCO and r2 = 0.88 for TDCO versus PCCO. CONCLUSION: The results of the present study show that compared with thermodilution CO, pulse contour analysis enables accurate measurement of continuous CO in patients undergoing MIDCAB.

Experiences with the Toronto SPV bioprosthesis after three years follow-up.

BACKGROUND: Stentless aortic valve prostheses are considered to be hemodynamically superior to mounted bioprostheses. The Toronto SPV bioprosthesis is a Dacron covered stentless porcine aortic prosthesis. METHODS: From March 1993 to October 1997, 175 patients underwent aortic valve replacement with the Toronto SPV bioprosthesis, 126 patients with leading aortic stenosis, 14 with valve insufficiency, and combined lesion in 35 patients. Preoperatively all patients were in NYHA class III-IV. All patients underwent transesophageal echocardiography (TEE) intraoperatively after institution of cardiopulmonary bypass (CPB). The patients underwent clinical and echocardiographic examinations at 1 week, 6 months, 12 months, 24 months, and 36 months postoperatively. RESULTS: Mean age was 71.3 years (range 29-84). Additional coronary artery bypass grafting (CABG) was performed in 74 patients. Mean ischemic time was 58 minutes (range 49-129) for singular aortic valve replacement (AVR) and 86 minutes (range 66-136) with additional CABG. The 30-day mortality was low at 4% (7/175). 139 patients were seen at 2 years and 77 at 3 years follow-up. At 3 years 67% (51/77) of our patients were in NYHA functional class I and 33% (26/77) were in class II. Minimal aortic valve incompetence was seen in 17% (13/77) at 3 years. CONCLUSIONS: The Toronto SPV bioprosthesis shows good results both hemodynamically and clinically. Most patients are in NYHA functional class I or II after 3 years. Perioperative mortality was low and no valve-related complications occurred.

Heart transplantation after successful donor postpartum pulmonary embolectomy.

A fulminant pulmonary embolism can be treated surgically if thrombolytic therapy is contraindicated. A 31-year-old woman developed a fulminant pulmonary embolism after right-sided deep venous thrombosis 1 day after undergoing a cesarean section. A pulmonary embolectomy with cardiopulmonary bypass was performed, but the patient was brain-dead. After 2 days of echocardiographic observation, her heart was explanted for a 61-year-old man with ischemic cardiomyopathy. His right heart data were unremarkable, and he remains well 16 months after transplantation. Despite the sudden strain on the right ventricle that occurs with a pulmonary embolism, such a heart may be transplanted successfully after a pulmonary embolectomy.

Resection for CMV ileitis in a patient supported by a left-ventricular assist device.

We describe a patient requiring a HeartMate 1000 IP left-ventricular assist device (LVAD) due to cardiogenic shock. After prolonged gastrointestinal bleeding without identifying the source of bleeding technetium scintigraphy pointed to the right lower abdomen. The patient underwent a laparotomy and inflamed ileum was resected. Pathologic examination revealed cytomegalovirus ileitis. This was treated with ganciclovir and acyclovir. The patient is now (14 months later) awaiting heart transplantation since she could not be weaned from LVAD. The diagnostic and management problems are discussed as well as the relevance for future transplantation.