Midazolam and dexmedetomidine sedation impair systolic heart function.

BACKGROUND: Sedation is an essential part of clinical practice. Despite this fact, we still lack data describing the exact impact of sedation on heart function. PURPOSE: To compare the changes in heart function, induced after sedation with either midazolam or dexmedetomidine, using cardiac magnetic resonance imaging (MRI). METHODS: A total number of 30 volunteers were randomized into two groups: 15 participants in the midazolam group (MID) and 15 participants in the dexmedetomidine group (DEX). Every participant underwent a one-session cardiac MRI before and after sedation onset. The following parameters were recorded: left and right ventricle stroke volume (Ao-vol and Pul-vol resp.) and maximum flow velocity through the mitral valve during early (E-diast) and late diastole (L-diast). A monitor recorded values of mean blood pressure (MAP), pulse (P) and blood oxygen saturation (SpO2) in 5-minute intervals. RESULTS: Dexmedetomidine led to a statistically significant decrease in Ao-vol (p = 0.006) and Pul-vol (p = 0.003), while midazolam decreased E-diast (p = 0.019) Ao-vol (p = 0.001) and Pul-vol (p = 0.01). The late diastolic filling was not influenced by the sedation technique. CONCLUSION: Both sedation regimens worsened the systolic function of both ventricles. Midazolam moreover attenuated early diastolic filling of the left ventricle (Tab. 3, Fig. 4, Ref. 19).

New haemostat in thoracic surgery.

INTRODUCTION: The authors present the results of a promising method to reduce peroperative bleeding in thoracic surgery within large thoracic surgical interventions. Usage of a resorbable haemostat on the basis of oxidized cellulose in the form of cotton wool may minimize the cause of bleeding, mainly in patients with post-inflammatory thoracic complications. The strong point of this material is its easy application and malleability. Another advantage is the long-term antibacterial effect caused by lowering pH during its biodegradation. AIM: Retrospective evaluation of post-operative blood losses, time of thoracic drainage, length of hospitalisation, and development of inflammatory indicators between groups using and not using haemostats. METHODOLOGY: A group consisted of 48 patients (group A), who underwent operation for post-inflammatory thoracic complications and where haemostat was used. Using the pair selection method, 48 patients were selected to the control group B, where no haemostats were applied during operation. The selection depended on a similar demographic profile, identical diagnosis, and a type of operations. Post-operational blood loss, dynamics of haematological profile, time of thoracic drainage, blood parameters value, inflammatory response of the organism, and length of hospitalisation. RESULTS: A key differentiation of dynamics in development was found between the groups in the concentration of haemoglobin and haematocrit in the post-operative period, in the time of thoracic drainage, and in total length of hospitalisation. A sudden rise of CRP serum values in the group A after 12 hours after application of haemostat was recorded, most probably as manifestation of the aseptic pleuritic (Tab. 4, Fig. 1, Ref. 16).

Perspective in predicting the effect of pleurodesis in the treatment of malignant pleural effusions.

BACKGROUND: Pleurodesis with talc has been used for many years. No objective criteria of inflammatory symptoms are known in order to use them to predict the effect of therapy and selection of patients. PURPOSE OF THE STUDY: To objectify the course of local inflammatory changes in the pleural cavity, quantify their dynamics in a clinically used procedure, and to determine specific predictors of inflammation as perspective markers of selection of patients suitable for talcage. MATERIAL AND METHOD: A total of 114 patients were retrospectively divided into Group A (n1 = 98) of patients without relapse and Group B (n2 = 16) of patients with relapse of exudate. The need for repeated thoracic punctures or drainages over the course of a 12-month monitoring period was the criterion of treatment failure. RESULTS: The groups were not different as for the baseline values of sTLR-2 (p0 = 0.638). Group A showed a marked growth during the monitoring period in 2 hours following talcage (p2= 0.002) and in 24 hours (p24 = 0.016). Group B showed higher sCD-163 levels (p0 < 0.001). The initial sTREM-1 values and those after two hours were similar in both groups (p0 = 0.146; p2 < 0.0641). In 24 hours, Group A had markedly higher values (p24 < 0.001). CONCLUSION: The sTLR-2, sCD-163 and sTREM-1 values can be prospectively determined. High sCD-163 values predict unsuitable selection of a candidate for talcage. The degree of inflammatory response can be evaluated using sTLR-2 or sTREM-1. Talcage using an inserted thoracic drain can be repeated at low levels. The cost of ELISA examination is approximately 18 euros (Tab. 1, Fig. 4, Ref. 20).

Inhibitory CD200R and proapoptotic CD95/CD95L molecules on innate immunity cells are modulated by cardiac surgery.

INTRODUCTION: Cardiac surgery directly initiates a systemic inflammatory response with the activation of both cellular and humoral parts of the immune system. Exaggerated immune system activation is associated with a risk of life-threatening multi-organ dysfunction (MOD) and increased morbidity and mortality in the postoperative period. The immune system response is regulated and terminated by inhibitory mechanisms, including the regulatory membrane molecules, such as CD200R, CD95, CD95L and soluble sCD200R. METHODS: We measured the expression of CD95, CD95L, CD200R and sCD200R molecules in granulocyte and monocyte populations in blood samples of 30 patients who underwent coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB). Samples collected before surgery, after surgery and in the postoperative period were analyzed by flow cytometry and ELISA. RESULTS: We found a significant increase in the percentage of granulocytes featuring the anti-inflammatory molecule CD200R (from 5% to 17.8%) after surgery. We presume that these cells were less susceptible to apoptosis because they rarely expressed CD95 as the CD200R(+)CD95(-) granulocyte sub-population prevailed. Only a small percentage of CD200R(+) granulocytes expressed simultaneously CD95 (from 0.5 to 2.06 %). This small population of CD200R(+)CD95(+) cells decreased expression of CD200R after surgery and, thus, was likely to be a source of increased sCD200R in serum (from 96 to 294 ng/mL). Also, the expression of CD95L on CD200R(+) granulocytes and CD95 on CD200R(+) monocytes was affected by surgery. The percentage of CD200R(+) monocytes was elevated on the 1(st) postoperative day (from 30.6 to 49.4 %) and dropped below the preoperative value on the 7(th) day after surgery (from 30.6 to 19.8 %). This population comprised mainly CD200R(+)CD95(+) monocytes in which the enhanced expression of CD95 was found. CONCLUSION: Our data show that the expression of CD200R, CD95 and CD95L was influenced by cardiac surgery and imply the role of these membrane molecules in cell regulation-inhibition and apoptosis following cardiac surgery.

Actual position of interleukin(IL)-33 in atherosclerosis and heart failure: Great Expectations or En attendant Godot?

Atherosclerosis has been recognized as an inflammatory/autoimmune disease. The long-standing low-grade inflammation which fuels its development is primarily focused on the components of the vessel wall. Originally, inflammation in atherogenesis was supposed to be driven by the pro-inflammatory Th1 cellular and cytokine immune response. On the basis of accumulating evidence, this view has been re-evaluated to include the Th17/Th1 axis which is shared by most diseases of sterile inflammation. The anti-inflammatory Th2 cellular and cytokine immune response is initiated concomitantly with the former two, the latter dampening their harmful reactions which culminate in full-blown atherosclerosis. Interleukin-33, a novel member of the IL-1 cytokine superfamily, was suggested to take part in the anti-atherogenic response by mediating the Th1-to-Th2 switch of the immune reactions. However, IL-33 is a multifaceted mediator with both pro- and anti-inflammatory activities, also called a "dual factor" or a "Janus face" interleukin. IL-33 occurs both in an extracellular (cytokine-like) and in a nuclear-bound (transcription factor-like) form, each of them performing distinct activities of their own. This review article presents the latest data relevant to IL-33's role in atherosclerosis and cardiac diseases as perceived by a cardiologist and a cardiac surgeon.

Combined surgical treatment of lung cancer and heart diseases.

OBJECTIVE: The co-incidence of lung cancer and heart disease is increasing. This can be caused by population ageing, which has more co-morbidities and most likely due to the common etiological causes of both entities, i.e. smoking, hypertension and obesity. The aim of this study was to analyze the outcomes of simultaneously performed heart surgery and pulmonary resection in a selected group of patients. METHODS: From January 2002 to December 2011 we performed in our department 1115 pulmonary resections for lung tumor. Significant heart disease requiring surgical treatment was diagnosed in 21 patients from the whole group. In 12 patients, group A; simultaneous heart surgery and lung resection procedure were performed. RESULTS: Group A consisted of 8 men and 4 women with the median age of 67.8 ± 5.9 years. In this group, 10 lobectomy procedures and 2 wedge resections for pulmonary metastasis were done. Nine patients underwent coronary artery revascularization, 2 patients underwent mitral valve replacement and one patient underwent tumor removal from the left atrium. In 5 patients, extracorporeal circulation (ECC) was needed, the remaining 7 patients underwent myocardial revascularization using an off-pump technique. Group B consisted of 7 men and 5 women with the age of 68.5 ± 7.4 years. Ten lobectomy procedures and 2 wedge resections were performed. CONCLUSION: The risk of simultaneously performed lung resection and cardiac surgery is not high. Despite the certain differences in clinical indicators between group A and B, the safety of simultaneous procedure, in group A, was evident. Furthermore, earlier lung resection was enabled and the eventual complications from further surgical procedure were avoided (Tab. 5, Ref. 33).

The long pentraxin PTX3: a candidate anti-inflammatory mediator in cardiac surgery.

Coronary artery bypass grafting (CABG) is performed with the use of cardiopulmonary bypass (CPB) and cardioplegic arrest (CA) of the heart. The advantage of this technique, alternatively referred to as "on-pump" surgery, resides, for the surgeon, in relatively easy access to and manipulation with the non-beating, bloodless heart. However, the advantage that is, thereby, gained by the patient is paid off by an increased susceptibility to postoperative systemic inflammatory response syndrome (SIRS). Under unfavorable conditions, the inflammatory syndrome may develop into life-threatening forms of MODS (multiple organ dysfunction syndrome) or even MOFS (multiple organ failure syndrome). Deliberate avoidance of CPB, also known as "off-pump" surgery, attenuates early postoperative inflammation throughout its trajectory of SIRS→MODS→MOFS, but, in the long run, there appears to be no substantial difference in the overall mortality rates. In the last years, our knowledge of the pathophysiology of surgical inflammation has increased considerably. Recent findings, highlighting the as yet rather obscure role of pentraxin 3 (PTX3) in these processes, are discussed in this review article.

Impact of methylprednisolone in priming solution of cardiopulmonary bypass on anti-inflammatory CD163 receptor during cardiac surgery.

We evaluated the influence of methylprednisolone in cardiopulmonary bypass fluid on scavenger receptor for hemoglobin CD163 molecule expression on monocytes of patients who underwent elective coronary artery bypass grafting with cardiopulmonary bypass with either exposure to methylprednisolone present in the cardiopulmonary bypass fluid (20 patients), or without methylprednisolone in the cardiopulmonary bypass fluid (22 patients) and operated on without cardiopulmonary bypass (42 patients). The dynamics of CD163 expression was also followed in patients operated on without cardiopulmonary bypass. This study was a retrospective analysis of a comparison of two studies. The expression of CD163 was determined quantitatively by standardized flow cytometry technique. The similarities in the dynamics of CD163 monocyte expression, comparing the patients operated on with or without cardiopulmonary bypass, were found. Compared to the preoperative level, CD163 monocyte expression was significantly elevated on the 1(st) postoperative day. Monocyte CD163 expression on the 1(st) postoperative day was evidently similar in both groups of patients operated without cardiopulmonary bypass (median value of mean fluorescence intensity (MFI) 18,896; interquartile range from 27,538 to 57,711; median value of MFI 18,863; interquartile range from 16,514 to 26,559; n.s.), suggesting high reproducibility of our flow cytometric method; the monocyte CD163 expression was significantly higher (median value of MFI 37,902; interquartile range from 27,538 to 57,711) on the 1(st) postoperative day in patients exposed to methylprednisolone compared to patients without this exposure (median value of MFI 20,995; interquartile range from 16,321 to 29,623) (p<0.001). We concluded that the expression of hemoglobin scavenger receptor CD163 on monocytes of cardiac surgical patients is induced by methylprednisolone present in cardiopulmonary bypass fluid.

Interferon gamma receptor expression on granulocytes of cardiac surgical patients is modulated differently by the type of cardiopulmonary bypass used.

AIMS: To follow the IFNγ receptor expression on monocytes and granulocytes of cardiac surgical patients with respect to the type of cardiopulmonary bypass (CPB). METHODS: Expression of IFNγ receptor on monocytes and granulocytes of 26 cardiac surgical patients operated with the use of either "standard" or "miniaturised" CPB was determined by flow cytometry. RESULTS: The significant increase in IFNγ receptor expression on monocytes on the 1(st) and on the 3(rd) postoperative days was revealed in both groups of patients (p<0.001) irrespective of the type of CPB used, being non-significantly different between groups. In contrast, the expression of IFNγ on granulocytes displayed significant differences in terms of the CPB used. Whereas, in "standard" CPB patients, granulocyte INFγ receptor expression reached its maximum immediately after surgery (p<0.01), in "miniivasive" CPB patients, the peak in INFγ receptor expression was postponed to the 1(st) postoperative day (p<0.05). Statistically significantly higher IFNγ receptor expression on granulocytes was found in "standard" CPB patients (p<0.05). CONCLUSION: Compared to "miniaturised" CPB patients, the significantly higher IFNγ receptor expression on granulocytes was found in "standard" CPB patients (p<0.05) on the 1(st) postoperative day.

Direct oxymetric peripheral tissue perfusion monitoring during open heart surgery with the use of cardiopulmonary bypass: preliminary experience.

BACKGROUND: Regional hypoperfusion has been associated with the development of postoperative organ dysfunction in cardiac surgery involving cardiopulmonary bypass (CPB). Direct tissue oxymetry is a potentially new method for monitoring the quality of the peripheral tissue perfusion during CPB. The aim of this study was to assess the effects of CPB in skeletal muscle oxygenation when measured in the deltoid muscle by direct oxymetry during perioperative period. METHOD: Seven patients underwent on-pump coronary artery bypass grafting. Direct oxymetry was performed by an optical cathether introduced into the deltoid muscle. Continuous measurement was made during the surgical procedure and the postoperative period. Mean arterial blood pressure, blood flow during CPB, laboratory markers of tissue hypoperfusion, blood gases and body temperature were also recorded. RESULTS: Interstitial muscle tissue oxygen tension (pO(2)) decreased after the introduction to anaesthesia and, more significantly, during CPB. After the disconnection from CPB at the end of the operation, the pO(2) returned to pre-anaesthetic values. During the first hours after admission of the patients to the intensive care unit, the pO(2) progressively decreased, reached a minimum value after four hours, and increased slowly thereafter. There was a significant correlation of pO(2) with mean arterial blood pressure and blood flow during that time. CONCLUSION: The result of this first measurement seems to demonstrate that the standard technique of conducting cardiopulmonary bypass produces low muscle oxygen tension and, thus, little perfusion of skeletal muscle. The data also indicate that both high mean arterial blood pressure and high flow are necessary during CPB to ensure skeletal muscle perfusion. The investigation is continuing.

Neutrophil apoptosis by Fas/FasL: harmful or advantageous in cardiac surgery?

Polymorphonuclear leukocytes or neutrophils are the main executors of cellular death, both in septic inflammation during bacterial infection and in sterile inflammation during trauma or surgery. Whereas in septic inflammation neutrophils perform a useful function to fortify the host's defense against infection, in sterile inflammation, by contrast, they contribute to unwelcome tissue damage. Regardless of the situation, activated neutrophils exhibit a prolonged lifespan and delayed apoptotic death which, under normal conditions, is a prerequisite for their natural renewal. Traditionally, delayed neutrophil apoptosis was considered to promote trauma or surgical injury. According to the results of recent studies, however surprising they may appear, the reverse might be in keeping with what happens IN VIVO. Apoptotic signaling in neutrophils could, by contrast, contribute to intrinsic protection of the host's tissues. This review article, aimed preferentially but not exclusively at the cardiac surgeon, presents some new information in support of this viewpoint, which fits in with our own observations.

Impact of cardiopulmonary bypass on peripheral tissue metabolism and microvascular blood flow.

The aim of this study was to monitor and compare the changes in metabolism and blood flow in the skeletal muscles during cardiac operations performed with cardiopulmonary bypass (CPB) and operations without CPB (off-pump) by means of interstitial microdialysis (Figure 1). Surgical revascularization, coronary artery bypass grafting (CABG), was performed in 40 patients randomized to two groups. Twenty patients (On-Pump Group) were operated on using CPB, 20 patients (Off-Pump Group) were operated on without CPB. Interstitial microdialysis was performed by 2 probes of a CMA 60 (CMA Microdialysis AB, Solna, Sweden) inserted into the patient's deltoid muscle. Microdialysis measurements were performed at 30-minute intervals. Glucose, lactate, pyruvate and glycerol as markers of basic metabolism and tissue perfusion were measured in samples from the first probe, using a CMA 600 Analyzer (CMA Microdialysis AB). Blood flow through the interstitium was monitored by means of dynamic microdialysis of ethanol as a flow-marker in the dialysates taken from the second probe (ethanol dilution technique). Results in both the groups were statistically processed and compared. Both the groups were similar in respect of preoperative characteristics. Dynamic changes of interstitial concentrations of the measured analytes were found in both the patient groups (on-pump vs. off-pump) during the operation. There was no significant difference in dialysate concentrations of glucose and lactate between the groups. Significant differences were detected in pyruvate and glycerol interstitial concentrations, lactate/pyruvate ratio and lactate/glucose ratio between the on-pump vs. off-pump patients. In the Off-Pump Group, pyruvate concentrations were higher and the values of concentrations of glycerol lower. The lactate/pyruvate ratio and the lactate/glucose ratio, indicating the aerobic and anaerobic tissue metabolism status, were lower in the Off-Pump Group. There was no significant difference in dialysate concentrations of ethanol as a flow-marker during the surgery in either of the groups. There was no statistically significant difference between the groups (On-Pump Group vs. Off-Pump Group) comparing the postoperative clinical outcome (ICU stay, ventilation duration, length of hospital stay). The dynamic changes in the interstitial concentrations of the glucose, glycerol, pyruvate and lactate were found in both the groups of patients (On-Pump Group and Off-Pump Group), but there was no difference in local blood flow when the ethanol dilution technique was used. These results showed significantly higher aerobic metabolic activity of the peripheral tissue of patients in the Off-Pump Group vs. the On-Pump Group during the course of cardiac revascularization surgery. Results suggest that extracorporeal circulation, cardiopulmonary bypass, compromises peripheral tissue (skeletal muscles) energy metabolism. These changes have no impact on the postoperative clinical outcome; no significant difference between the groups was found.

How long can the previously assembled cardiopulmonary bypass circuit stay sterile?

The sterility of previously assembled cardiopulmonary bypass circuits was investigated for 100 extracorporeal circuits. The closed circuits were assembled using aseptic technique and remained in the pump room until time of use. The mean time from point of setup to point of priming for the 100 consecutive circuits was 32 hours, with a range of 19 to 89 hours. Circuits were primed with the calculated volume of priming solution, circulated for 5 minutes and tested for microbial contamination by withdrawing 20 ml of the priming solution and 10 days incubated in Thioglycolate and Sabouraud culture mediums. All were found to be free of microbial contamination. The results of this investigation demonstrate that the sterility of the extracorporeal circuit, pre-assembled in advance of actual priming, can be maintained over an extended interval when standard aseptic technique is used. This allows the utilization of a pre-assembled circuit for emergency cardiopulmonary support.

Modifiable risk factors for vascular access site complications in the IMPACT II Trial of angioplasty with versus without eptifibatide. Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis.

OBJECTIVES: This study was designed to identify potential predictors of vascular access site (VAS) complications in the large-scale Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis (IMPACT) II trial, which studied angioplasty with versus without a new glycoprotein (GP) IIb/IIIa receptor inhibitor (eptifibatide). BACKGROUND: GP IIb/IIIa receptor inhibition during coronary interventions has been associated with excess VAS complications. If other predictors of VAS complications could be identified, they might be manipulated to reduce complications. METHODS: A total of 4,010 patients undergoing percutaneous transluminal coronary revascularization (PTCR) were randomized into one of three bolus/20- to 24-h infusion arms: placebo bolus/placebo infusion; 135-microg/kg body weight eptifibatide bolus/0.5-microg/kg per min eptifibatide infusion; or 135-microg/kg eptifibatide bolus/0.75-microg/kg per min eptifibatide infusion. Heparin during the procedure was weight adjusted and stopped 4 h before sheaths were removed. Logistic regression modeling was used to identify independent predictors of VAS complications. RESULTS: VAS complications were more common in patients treated with eptifibatide (9.9% vs. 5.9% placebo-treated patients, p < 0.001). Multivariate analysis identified eptifibatide therapy (p < 0.0001), advanced age (p = 0.0001), longer time to sheath removal (p = 0.0002), stent placement (with intense post-stent anticoagulation) (p = 0.0004), female gender (p = 0.0006), PTCR within 24 h of thrombolytic therapy (p = 0.002), larger heparin doses during PTCR (p = 0.009), major coronary dissection (p = 0.03) and placement of a venous sheath (p = 0.04) as independent predictors of VAS complications. CONCLUSIONS: VAS complications may be reduced by early sheath removal, by avoiding placement of venous sheaths and by limiting heparin dosing to avoid excessive activated clotting times. Early sheath removal during inhibition of platelet aggregation by eptifibatide is feasible.

Pulmonary manifestations of chronic heart failure.

These findings underscore the importance of understanding the complex interactions of multiple-organ systems in a chronic systemic disease state like congestive heart failure. The exaggerated ventilatory response in patients with heart failure is clearly multifactorial and it remains difficult to decipher whether this response results from or contributes to the sensation of dyspnea. Pulmonary dysfunction including ventilation-perfusion mismatching, decreased lung compliance, restriction, airway obstruction, decreased diffusion capacity, and decreases in respiratory muscle strength and endurance contribute to an inefficient breathing pattern and increased work of breathing. This is further compounded by the limited ability of the failing heart to meet the metabolic demands of the respiratory muscles, leading to under-perfusion and ischemia. This imbalance contributes to perceived dyspnea and exercise limitations. Understanding these physiologic cardiopulmonary interactions may lead to therapeutic modalities, such as respiratory muscle training, aimed at disrupting this intertwined cycle of events and improving functional capacity in patients with heart failure.

Angle closure glaucoma complicating systemic atropine use in the cardiac catheterization laboratory.

Atropine may precipitate angle closure glaucoma in those predisposed to the disorder. Previously reported cases demonstrate the frequent misdiagnosis of acute glaucoma as conjunctivitis. Resultant delays in treatment can lead to vision loss. The present case describes a 66-yr-old man who developed acute angle closure glaucoma after receiving atropine during a coronary angioplasty produce. Clinicians who utilize atropine should be aware of the possibility of precipitating angle closure glaucoma and the predisposing factors, signs, and symptoms to facilitate prompt diagnosis and treatment of this disorder.

[Effect of local administration of aprotinin on surgical blood loss after myocardial revascularization]. / Ovlivnení krevních ztrát po revaskularizaci myokardu lokální aplikací aprotininu.

The authors compare three groups of patients operated at the cardiosurgical clinic of the Faculty Hospital in Hradec Králové on account of ischaemic heart disease. Group A comprised 50 patients where for revascularization of the myocardium venous grafts were used, group B comprised 50 patients where also the mammary artery was used/IMA/. The postoperative blood losses are compared and the number of administered blood transfusions in the two groups. Group C is formed by 50 patients where after preparation of the IMA aprotinin/100 000 u./was administered locally. The authors provide evidence that the use of IMA increases significantly the postoperative blood losses/in group A 675 ml +/- 352.9, in group B 1232 ml +/- 336.5/and increases the number of required transfusions/group A 2.44 +/- 1, group B 3.45 +/- 1/. By local aprotinin application to the wound surface during preparation of IMA the authors reduced in group C the blood losses to 896 +/- 231.9 ml and the number of administered transfusions to 2.74 +/- 0.8.

Acalculous candidal cholecystitis: a previously unrecognized complication after cardiac transplantation.

Acalculous cholecystitis is a life-threatening complication in critically ill surgical patients. Whereas Candida albicans and Torulopsis glabrata have been reported as the primary pathogens in 14 previous cases of acalculous cholecystitis, we report the first case of Candida parapsilosis as a biliary pathogen in a patient after cardiac transplantation. Although cardiac transplant recipients often have many of the risk factors for acalculous candidal cholecystitis, including major surgery, immunosuppression, antibiotic therapy, parenteral nutrition, and prolonged intensive care unit stay, this entity has not been previously reported in the cardiac transplant population. Although rare, acalculous candidal cholecystitis is associated with very high morbidity and a mortality rate of 40%. Early diagnosis necessitates an aggressive approach to the critically ill patient with abdominal complaints. Prompt drainage or cholecystectomy, if possible, represent the mainstays of therapy and offer the greatest chance for survival.

Serial assessment of exercise capacity after heart transplantation.

BACKGROUND: Exercise capacity after heart transplantation is abnormal. This reduced exercise performance may in part be due to treatment with high-dose immunosuppressive therapy, deconditioning, graft rejection, or cardiac denervation. METHODS: To investigate whether exercise capacity significantly improves over time as immunosupression is lessened or whether reinnervation occurs, we measured peak exercise oxygen consumption in 60 patients 0.5 to 60 months after transplantation (age: 52 +/- 11 years; left ventricular ejection fraction: 56% +/- 10%) and in 14 healthy subjects (age: 44 +/- 8 years; p = Not significant). Resting hemodynamic measurements, left ventricular ejection fraction, and immunosuppressive therapy were recorded at the time of each of the patients' 116 exercise tests. Exercise test results were stratified into groups according to time after transplantation. RESULTS: Exercise capacity significantly improved after transplantation (pretransplantation peak exercise oxygen consumption: 9.9 +/- 4.3; posttransplantation: 16.6 +/- 4.0 ml/kg/min; p < 0.001). Patient groups after transplantation were without significance differences with regard to age, gender, left ventricular ejection fraction, resting hemodynamic measurements, antihypertensive regimen, and number of rejection episodes. For those patients exercising at 2 months compared with the patients exercising at 12 months, a significant increase was observed in peak exercise oxygen consumption (14.0 +/- 3.8 ml/kg/min at 2 +/- 2 months to 16.2 +/- 3.8 ml/kg/min at 12 +/- 2 months) and maximum heart rate (124 +/- 24 to 137 +/- 24 beats/min). No significant changes were found in peak exercise oxygen consumption or maximum heart rate after the first year after transplantation. Patients' exercise capacities as measured by peak exercise oxygen consumption remained abnormal (N1 peak exercise oxygen consumption: 35 +/- 11 ml/kg/min) despite significant reductions in steroid, azathioprine, and cyclosporine therapy. Peak exercise oxygen consumption was significantly correlated with maximal heart rate (r = 0.42) (p < 0.0001) but not with maximal blood pressure response, change in heart rate, left ventricular ejection fraction, or resting cardiac index (all p = Not significant). CONCLUSIONS: Exercise capacity is markedly improved after heart transplantation although it remains impaired compared with healthy individuals. Patients achieve their maximal exercise capacity by 1 year after transplantation. Subsequently, exercise capacity does not improve despite significant reductions in immunosuppressive agents. The lack of alteration in the heart rate response to exercise over time suggests that no significant functional reinnervation occurs.