Updated feasibility trial experience with the Viaderm percutaneous access device.

The percutaneous access device (PAD) is used to connect an external drive unit to the Kantrowitz CardioVad (KCV), a cardiac assist device for the treatment of chronic heart failure. The PAD conveys pneumatic power from a drive unit to the implanted blood pump and an electrocardiogram signal from the myocardium to the drive unit. The device-tissue interface of the PAD is precoated with autologous fibroblasts cultured from a skin sample of the intended recipient. This preparation demonstrated long-term stability in animals and was adopted for use in patients receiving the KCV. The KCV is activated intermittently, and the drive unit may be connected and disconnected by the patient, which subjects the PAD to frequent manipulation. To date, the PAD has been implanted in nine patients ranging in age from 41 to 74 years. Implant times ranged from 2 to 458 days, for a total of 1082 days, of which 557 days were in an outpatient setting. Two patients experienced episodes of infection that did not originate from the PAD-tissue interface. This feasibility study demonstrated that (1) the PAD is stable and infection resistant in long-term ambulatory patients, (2) the PAD withstood the challenge of daily manipulation (the KCV is turned on and off electively), and (3) PADs can be replaced, if necessary.

Five new species of Coccidia (Apicomplexa: Eimeriidae) from colubrid snakes of Ecuador.

Fecal samples from 11 colubrid snakes, representing 10 species, collected in Ecuador during October 1994 were examined for coccidian parasites. Feces of 4 individuals, representing 4 host species, contained coccidian oocysts. Three species of Eimeria and 2 species of Isospora were observed and are described here as new. Oocysts of both Eimeria and Isospora were found in the feces of a slug-eating snake, Dipsas vermiculata. Sporulated oocysts of the Eimeria sp. are spheroid to subspheroid, 16.7 by 16.6 microm (14-18 by 14-18 microm) and those of the Isospora sp. are spheroid and 15.0 microm (13-18 microm) in diameter. Imantodes cenchoa, the common bluntheaded treesnake, was infected with a species of Eimeria. These sporulated oocysts are ellipsoid, 23.3 by 16.2 microm (25-21 by 15-17 microm). Sporulated eimerian oocysts from Leptodeira annulata, the southern cat-eyed snake, are subspheroid, 22.5 by 18.8 microm (19-26 by 17-21 microm). Feces of a juvenile Imantodes lentiferus, the bluntheaded vine snake, contained ovoid to ellipsoid isosporan oocysts, which measured 21.6 by 15.0 microm (20-23 by 14-16 microm) when sporulated.

The leukocytes of the roughtail gecko Cyrtopodion scabrum: a bright-field and phase-contrast study.

The morphology of the peripheral blood leukocytes of the roughtail gecko, Cyrtopodion scrabum, is carefully described in Wright-Giemsa and toluidine-blue-stained blood films, and in the living condition by phase-contrast microscopy, using supravitally stained preparations. Mature eosinophils, basophils and small lymphocytes commonly occur in the blood, while monocytes are rarely seen. In addition, macrophages are occasionally encountered, but neutrophils cannot be observed. Developmental stages in eosinophil and basophil differentiation can be seen. This study serves as a basis for the cytochemical localization of substances within these blood cells.

A mechanical auxiliary ventricle. Histologic responses to long-term, intermittent pumping in calves.

The mechanical auxiliary ventricle (MAV) is an avalvular, inseries left ventricular assist device (LVAD) comprised of a 60 cc Biomer blood pump implanted in the descending thoracic aorta, a percutaneous access device (PAD), and an external pneumatic drive. In four calves the MAV was implanted and activated intermittently for 192, 249, 423, and 785 days, respectively; no anticoagulants were administered. When the animals were killed, the implants were retrieved, and autopsies, including gross, light microscopic, scanning electron microscopy (SEM), and transmission electron microscopy (TEM) examinations, were performed. The MAV was securely attached to the aorta in every animal. A thin, even smooth, pseudoneointimal layer (PNI) contiguous with the aorta at the level of the suture line covered the MAV's blood-contacting surface. Areas of calcification beneath the PNI, expected in growing animals with implanted pumping devices, were noted. At autopsy there was no evidence of thrombosis or infection in the regions of the blood pump or the PAD. These findings confirm the calves' benign histologic response to the MAV, and together with the results of hematologic and biochemiccal studies, and bench tests of system components being reported elsewhere, indicate the system's readiness for limited clinical investigation in selected patients with chronic congestive failure.

Percutaneous intra-aortic balloon counterpulsation.

Intra-aortic balloon pumping is the mainstay in the management of acute left ventricular dysfunction in the critical care setting. Percutaneous insertion affords rapid initiation of the procedure. Complications are in greatest part vascular and infectious. The advent of new-generation, totally automatic, closed-loop IABP systems offers the prospect of increasing the effectiveness of IABP support under most conditions, and especially during arrhythmias. This and other developments suggest that despite its standing as the most widely used temporary cardiac assist device, IABP has still to realize its full therapeutic potential.

Initial clinical trial of a closed loop, fully automatic intra-aortic balloon pump.

A new generation, closed loop, fully automatic intraaortic balloon pump (CL-IABP) system continuously optimizes diastolic augmentation by adjusting balloon pump parameters beat by beat without operator intervention. In dogs in sinus rhythm and with experimentally induced arrhythmias, the new CL-IABP system provided safe, effective augmentation. To investigate the system's suitability for clinical use, 10 patients meeting standard indications for IABP were studied. The patients were pumped by the fully automatic IABP system for an average of 20 hr (range, 1-48 hr). At start-up, the system optimized pumping parameters within 7-20 sec. Evaluation of 186 recordings made at hourly intervals showed that inflation began within 20 msec of the dicrotic notch 99% of the time. In 100% of the recordings, deflation straddled the first half of ventricular ejection. Peak pressure across the balloon membrane averaged 55 mmHg and, in no case, exceeded 100 mmHg. Examination of the data showed that as soon as the system was actuated it provided consistently beneficial diastolic augmentation without any further operator intervention. Eight patients improved and two died (one of irreversible cardiogenic shock and one of ischemic cardiomyopathy). No complications were attributable to the investigational aspects of the system. A fully automated IABP is feasible in the clinical setting, and it may have advantages relative to current generation IABP systems.

Testicular myxosporidiasis in the flat-backed toad, Bufo maculatus (Amphibia: Bufonidae), from Cameroon, Africa.

Macroscopic cysts measuring less than or equal to 860 x 500 microns were found in the testes of a flat-backed toad, Bufo maculatus, collected in Cameroon, West Africa. On histologic examination, the cysts contained numerous spores of a Myxobolus sp. (Myxozoa: Myxobolidae). Spores in fixed tissues measured 9.2 microns long, 8.9 microns wide, and 4.0 microns thick; the range of values for length, width, and thickness were 8.8 to 9.6 microns, 8.6 to 9.4 microns, 3.6 to 4.4 microns, respectively (n = 20). The shape index (length/width) was 1.03, and ranged from 1.00 to 1.09. Pathology was limited to a slight constriction of adjacent seminiferous tubules by the cysts. No host inflammatory response was noted. This myxozoan is distinct from all other members of the genus infecting anurans and is assigned the name Myxobolus bufonis sp. n.

A new host and locality record for Mesocestoides sp. tetrathyridia (Cestoidea: Cyclophyllidea), with a summary of the genus from snakes of the world.

A new host and distribution record is reported for tetrathyridia of Mesocestoides sp. One of 5 (20%) Namib tiger snakes, Telescopus beetzi, from South Africa was infected. Numerous tetrathyridia were found encapsulated in mesentery attached to the small intestine. Morphological examination of tetrathyridia revealed absence of buds, multiple scoleces, or any other evidence of asexual proliferation. A summary of the snakes of the world reported as hosts of tetrathyridia of Mesocestoides sp. is presented.

Identification of a 15-kilodalton surface glycoprotein on sporozoites of Cryptosporidium parvum.

An immunoglobulin A monoclonal antibody (MAb5C3) was developed against a 15-kDa surface glycoprotein (GP15) of Cryptosporidium parvum sporozoites. Indirect immunofluorescence and colloidal gold immunoelectron microscopy revealed that the antibody reacted with both the sporozoite and merozoite surface plasma membranes. On Western immunoblots, MAb5C3 binding was found to be strongly inhibited when 200 mM N-acetylglucosamine was used as a competing sugar. N-Acetylgalactosamine inhibited binding of the antibody only slightly, whereas glucose, mannose, and galactose failed to inhibit binding. MAb5C3 was found to recognize a similar 15-kDa epitope associated with a Cryptosporidium sp. isolated from guinea pigs. However, MAb5C3 failed to react with any proteins or glycoproteins associated with C. baileyi from chickens, Cryptosporidium sp. (= bovine C. muris) from cattle, C. serpentis from a rat snake, bradyzoites of Besnoitia darlingi from an opossum, sporozoite/oocyst extracts of Caryospora bigenetica from an eastern diamondback rattlesnake, sporozoites of Eimeria nieschulzi and E. papillata from rats and mice, or tachyzoites of Toxoplasma gondii (RH strain). When hybridoma supernatants containing MAb5C3 were administered orally to suckling mice experimentally infected with C. parvum, a 75% reduction in developmental stages was seen histologically at 72 h postinfection and a 67.5% reduction in mean oocyst output was found at 6 days postinfection.

Cryptosporidium spp. in wild and captive reptiles.

Between 1986 and 1988, 528 reptiles originating from three continents were examined for Cryptosporidium spp. Fifteen specimens representing eight genera and 11 species were infected. Statistical evaluation of oocyst structure suggests that multiple species of Cryptosporidium may exist among the reptiles examined.

Intraaortic balloon pumping for prolonged circulatory support.

Prolonged circulatory support with an intraaortic balloon pump (IABP) is controversial, in part because it has not been performed frequently enough to base treatment policy on adequate data. To help clarify this problem, 733 cases of consecutive patients who were supported by IABP between 1967 and 1982 were analyzed. Twenty-seven patients were supported for 20 days or more (range 20 to 71). Twelve (44%) had prior histories of chronic congestive heart failure. Complications were more frequent in prolonged-support patients than in those assisted for less than 20 days (vascular, 37% vs 15%, p = 0.001; infectious, 67% vs 25%, p = 0.0001; and bleeding, 26% vs 15%, p = 0.04, respectively). The survival rate of prolonged-support patients, however, was 63% (17 of 27), essentially the same as that of the controls (57%, p = 0.5). Of 17 prolonged-pumping patients discharged alive from the hospital, 9 died within 6 months but 8 survived greater than 2 years. Among congestive heart failure patients, none was a long-term survivor. Prolonged IABP support in congestive heart failure patients lacking surgically correctable lesions can extend life while arrangements for definitive therapy are made (transplant, permanent mechanical assistance). Where definitive therapy is unavailable, IABP may provide additional months of life.

Risks associated with intraaortic balloon pumping in patients with and without diabetes mellitus.

Between 1967 and 1982, intraaortic balloon pumping (IABP) was attempted in 733 patients. Of these, 132 were diabetic: 51 patients were managed with diet alone, 46 patients took oral hypoglycemic agents and 35 patients required insulin. Vascular complications associated with IABP occurred in 34% of the insulin-dependent diabetics, in 18% of other diabetics and in 14% of nondiabetic patients. Infectious complications were 37, 22 and 25%, respectively. Seventy-five diabetic patients (57%) were discharged alive from the hospital after balloon pumping, essentially the same proportion as among nondiabetic patients (58%). It is concluded that although diabetics incur a higher complication rate, IABP is not contraindicated.

Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques.

To compare the percutaneous and surgical techniques of intraaortic balloon pump insertion, 101 patients referred for this procedure were randomly assigned to either percutaneous or surgical insertion. Insertion using the designated technique was successful in 45 (88%) of 51 patients with percutaneous insertion and 48 (96%) of 50 patients with surgical insertion (difference not statistically significant). The time from the beginning of the insertion procedure to the initiation of counterpulsation was 13 +/- 8 minutes for the percutaneous technique versus 31 +/- 16 minutes for the surgical technique (p less than 0.001). In the percutaneous group, 10 patients required Fogarty thrombectomy after balloon pump removal, and 1 patient developed severe leg ischemia requiring immediate termination of balloon pump support. In the surgical group, one patient developed leg ischemia requiring surgical intervention, three patients developed sepsis with bacteremia (including one patient who required vein patch repair of the femoral artery), one patient developed a wound infection requiring debridement and one patient had a cerebral embolus. Aortic dissection, aortoiliac perforation or amputation did not occur in either group. Major vascular complications occurred in 11 patients (22%) with percutaneous insertion versus 2 patients (4%) with surgical insertion (p less than 0.05). It is concluded that although the percutaneous technique for intraaortic balloon pump insertion is faster than the surgical technique and is technically easy, it is associated with a higher incidence of vascular complications.

Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients.

Between June 1967 and December 1982, 872 attempts at intraaortic balloon pumping (IABP) were made in 733 patients. Nearly 75% of the patients were men; the proportion of women has increased in recent years. The principal indication for IABP support initially was cardiogenic shock, but over the years, preoperative support, weaning from cardiopulmonary bypass and unstable angina have become the primary indications. Complications of IABP were classified and distributed by severity (minor: I [15%] and II [26%]; major: III [3%] and IV [1%]) and type ([vascular [22%], infectious [22%], and bleeding [7%]). Vascular complication rates were higher in women (32 vs 18%; p = 0.0001), in diabetic patients (32 vs 20%, p = 0.003), and in hypertensive patients (27 vs 20%, p = 0.02). These did not vary with the duration of IABP support (range of duration 0 to 76 days). The rate of infectious complications was related to location where IABP was performed (coronary care unit 26%, operating room 12%). The rate of fever and bacteremia increased significantly with duration of IABP support, but the rate of local wound infection did not. In conclusion, most IABP complications are minor, resolve after balloon removal, are related to vascular status of the patient and, with the exception of bacteremia, are independent of IABP duration.

Prolonged left ventricular dysfunction induced by sequential multifocal ischemic infarcts in dogs.

A method of creating multifocal ischemia in animals leading to left ventricular (LV) functional impairment is described. In a series of 10 mongrel dogs, electrodes were implanted in multiple branches of the coronary arteries. Subsequently, in seven animals, an 800-microA anodal current was applied for 3 h repeatedly over a span of 4-9 weeks. After current application, serum creatine kinase cardiac isoenzyme increased by 12.2 +/- 4.6 U/L (p less than 0.01) and ischemic electrocardiographic changes were consistently present. After an average of 10.7 current applications, all animals were tachypneic on mild exertion. Repeated measurement of LV function demonstrated a substantial reduction in cardiac reserve. No significant changes in three control animals were observed. The animals were sacrificed 80 days (range 49-108 days) after the initial current application. Presacrifice cineangiography and postmortem examination disclosed coronary artery occlusions, stenoses, recanalizations, and collateralization in the distributions expected on the basis of the time elapsed since electrode activation. In all cases, the myocardium exhibited diffuse fibrosis. This method reliably brings about multifocal myocardial ischemic changes in dogs and may provide a chronic LV failure model particularly suitable for the evaluation of LV assist systems.