Cardiac transplantation in adults with congenital heart disease.

BACKGROUND: Due to increasing success with repair or palliation in childhood, there is a rapidly growing population of adult patients with complex congenital heart disease who may require transplantation. There remains little data on outcomes of cardiac transplantation in this group. METHODS: 38 orthotopic cardiac transplants were performed in 37 patients (18 men) > or =18 years of age with congenital heart disease (CHD) from 1988 to 2009 in our institution. Outcomes were reviewed using medical records and transplant databases. RESULTS: 15 patients (41%) had univentricular and 22 (59%) biventricular physiology. The biggest group was transposition of the great arteries following atrial switch in eight patients (22%). Six (16%) had no previous surgical intervention. Mean age at transplant was 33.5 years (range 19.1-59.9 years). 11 patients (30%) required additional surgical procedures at transplant. 16 (43%) died, 12 early and 4 late deaths (1.8, 2.4, 2.7 and 7 years). Survival was 70% at 30 days, 68% at 1 year, 58% at 5 years and 53% at 10 and 15 years. Outcome improved in later eras with reduction in 30-day mortality from 50% to 18% and increase in 5-year survival from 50% to 69%. Two patients developed post-transplant lymphoproliferative disease. None required long-term renal replacement therapy. One patient was re-transplanted for cardiac allograft vasculopathy. CONCLUSIONS: While operative mortality following cardiac transplantation for adult congenital heart disease is higher than for other diagnostic groups, long-term survival is good and comparable to patients without CHD. Disappointing early results are improved with increasing experience.

Outcomes following infant listing for cardiac transplantation: the impact of strategies introduced to counteract limited donor availability.

BACKGROUND: Survival following cardiac transplantation in infancy has improved substantially. There is a growing shortage of donors, the impact of which may be offset by increase in ABO-incompatible transplants, size-mismatching and mechanical support. The authors reviewed their results and outcomes following infant listing for cardiac transplantation over 22 years. METHODS: Children <12 months at time of listing for cardiac transplant in 1987-2008 were identified using the departmental cardiopulmonary transplant database. Details were obtained from databases and hospital medical records and subdivided into two eras, 1987-1997 and 1998-2008. RESULTS: In 1987-2008, 49 infants were listed, and 28 (57%) underwent cardiac transplantation (12 in 1987-1997 and 16 in 1998-2008). 15 patients (31%) died on the waiting list, 6 patients were delisted (5 of these because of recovery of cardiac function). There was a decrease in suitable donor offers from a mean of 36 per year in 1996-2000 to 11 per year in 2001-2006 (p=0.008). In 1998-2008, nine listed infants were on mechanical support; there were seven ABO-incompatible transplants, and all transplants were size-mismatched with donors on average 2.7 times heavier than recipients. Waiting times decreased from median 83 to 47 days. Six (21%) of the transplanted patients died, the majority in 1987-1997 and perioperatively. CONCLUSIONS: There has been a fall in suitable donors for infant cardiac transplants over time despite increased demand. However, the introduction of size-mismatching, ABO-incompatible transplants and mechanical support has enabled an increase in the number of transplants to be carried out despite this fall in donor numbers. Outcomes following transplantation have improved over time.

Pulmonary homograft endocarditis 19 years after a Ross procedure.

We report the case of a patient with acute pulmonary homograft endocarditis secondary to Streptococcus agalactiae from a cat-bite. He had undergone a Ross procedure nineteen years earlier. In view of unremitting infection with large pulmonary trunk and right pulmonary artery vegetations, the patient underwent successful pulmonary vegetectomy and homograft replacement.

Staged surgical management of hypoplastic left heart syndrome: a single institution 12 year experience.

OBJECTIVE: To describe a 12 year experience with staged surgical management of the hypoplastic left heart syndrome (HLHS) and to identify the factors that influenced outcome. METHODS: Between December 1992 and June 2004, 333 patients with HLHS underwent a Norwood procedure (median age 4 days, range 0-217 days). Subsequently 203 patients underwent a bidirectional Glenn procedure (stage II) and 81 patients underwent a modified Fontan procedure (stage III). Follow up was complete (median interval 3.7 years, range 32 days to 11.3 years). RESULTS: Early mortality after the Norwood procedure was 29% (n = 95); this decreased from 46% (first year) to 16% (last year; p < 0.05). Between stages, 49 patients died, 27 before stage II and 22 between stages II and III. There were one early and three late deaths after stage III. Actuarial survival (SEM) was 58% (3%) at one year and 50% (3%) at five and 10 years. On multivariable analysis, five factors influenced early mortality after the Norwood procedure (p < 0.05). Pulmonary blood flow supplied by a right ventricle to pulmonary artery (RV-PA) conduit, arch reconstruction with pulmonary homograft patch, and increased operative weight improved early mortality. Increased periods of cardiopulmonary bypass and deep hypothermic circulatory arrest increased early mortality. Similar factors also influenced actuarial survival after the Norwood procedure. CONCLUSION: This study identified an improvement in outcome after staged surgical management of HLHS, which was primarily attributable to changes in surgical technique. The RV-PA conduit, in particular, was associated with a notable and independent improvement in early and actuarial survival.

Progression to 100% off-pump coronary artery bypass with the Octopus 1 dual holder.

BACKGROUND: Can off-pump coronary artery bypass grafting become the routine standard in all elective primary coronary artery bypass grafting (CABG) operations? This paper shows how this aim has been achieved during one year in 130 off-pump cases performed through a sternotomy. This strategy allows for full revascularization (up to six grafts) without the disadvantage of cardiopulmonary bypass. The study introduces a variant of the Octopus stabilizer, a single Octopus 1 arm (Medtronic, Inc., Minneapolis, MN) with a dual holder. MATERIALS AND METHODS: From November 1998 through February 2000, 130 patients underwent coronary artery bypass grafting through a sternotomy off-pump utilizing a stabilizer and CO2 blower. The stabilizer most frequently used to achieve this was a single Octopus 1 arm equipped with a dual holder to accommodate two straight suction pods. The holder allowed increased flexibility and manipulation of the suction pods with an equivalent of seven degrees' freedom of motion at the dual holder junction. Techniques for carrying out total revascularization are discussed. The progress of proportion of elective primary CABG revascularization performed off-pump is shown and results are compared with published reviews of the literature for off-pump coronary revascularization. RESULTS: Patient demographics included: age range 32 to 87, mean 61.3; female sex: 17%; ejection fraction < 50%: 54%; presence of left main stem disease: 17%. Overall Parsonnet risk score ranged 0-31, with a mean of 8.8. Graft numbers carried out were: 34 x 2, 34 x 3, 32 x 4, 25 x 5 and 5 x 6 anastomoses respectively. The mean number of distal anastomoses was 3.6 +/- 1.0. There was extensive coverage of the lateral aspect of the heart (153 circumflex territory grafts, 33%). Radial artery, left internal mammary artery or saphenous vein sequential (jump) grafts were used in 26 cases (20%). Apart from general experience, the use of the dual holder and wide opening of the right pleura were the two important factors allowing freedom for multi-vessel lateral and posterior wall grafting. Thirteen Genzyme (Genzyme Surgical Products, Inc., Cambridge, MA) and ten Octopus 2 (or 2+) stabilizers were used, mostly for two or three grafts. The remainder were carried out using the Octopus 1 (dual holder: 83). In the first three-month period, 31% of cases were off-pump compared to the last three-month period, when 96% were off-pump. In the last two months we performed 100% of all 27 cases referred off-pump. There were no deaths, strokes or myocardial infarctions. Ventricular arrhythmia occurred in two cases. Conversions to bypass were undertaken twice. Two unexpected renal failures occurred, neither of which were from the 13 patients with preoperative incipient renal failure, of whom none suffered a rise in postoperative creatinine of greater than 30%. The results compare favorably with published results despite having a large mean number of grafts of 3.6. CONCLUSION: Off-pump surgery with full revascularization has now become feasible for all primary elective coronary artery graft operations.

C-reactive protein and complement are important mediators of tissue damage in acute myocardial infarction.

Myocardial infarction in humans provokes an acute phase response, and C-reactive protein (CRP), the classical acute phase plasma protein, is deposited together with complement within the infarct. The peak plasma CRP value is strongly associated with postinfarct morbidity and mortality. Human CRP binds to damaged cells and activates complement, but rat CRP does not activate complement. Here we show that injection of human CRP into rats after ligation of the coronary artery reproducibly enhanced infarct size by approximately 40%. In vivo complement depletion, produced by cobra venom factor, completely abrogated this effect. Complement depletion also markedly reduced infarct size, even when initiated up to 2 h after coronary ligation. These observations demonstrate that human CRP and complement activation are major mediators of ischemic myocardial injury and identify them as therapeutic targets in coronary heart disease.

Mutagenicity of pesticides evaluated by means of gene-conversion in Saccharomyces cerevisiae and in Aspergillus nidulans.

Nine pesticides, Afugan, Atrazine, Benomyl, Captan, Daconil, Melthaumittel, Plantvax, Saprol, and Wepsin were tested for the induction of mitotic gene-conversion in two different eucaryotic microorganisms, Saccharomyces cerevisae and Aspergillus nidulans. In S cerevisiae the pesticides were also tested after mouse liver microsomal activation; in A nidulans all tests were performed using both resting and germinating conidia. Among the tested pesticides, only Captan revealed a consistent genetic activity, three times greater than that observed with the standard mutagen methylmethansulphonate. This genetic activity of Captan is suppressed after mammalian metabolic conversion. The use of germinating conidia in A nidulans for scoring the induction of mitotic gene-conversion did not give any further information on the activity of the tested pesticides.