Clarithromycin for safe and cost-effective reduction of cyclosporine doses in lung allograft recipients.

BACKGROUND: This study was done to analyze the economic effect of clarithromycin on the daily dosing of cyclosporine in lung transplantation. METHODS: Nine consecutive patients (mean age +/- SEM, 34.6 +/- 5.2 years) had transplantation from June 1995 to June 1996. Median follow-up time was 649 days (range, 431 to 799 days). Preoperative diagnoses were cystic fibrosis (n = 4), idiopathic pulmonary fibrosis (n = 2), emphysema, bronchiectasis, and obliterative bronchiolitis. Median time from transplantation to addition of clarithromycin to a standard immunosuppressive regimen was 86 days (range, 14 to 181 days). RESULTS: Baseline cyclosporine dose (9.9 +/- 2.2 mg/kg/day) was reduced to 5.8 +/- 1.0 mg/kg/day and 4.1 +/- 0.8 mg/kg/day at 1 month and 1 year, respectively, after initiation of clarithromycin therapy. Estimated annual savings were $3,400 per patient. There was no increase in infection or rejection episodes. CONCLUSIONS: Clarithromycin safely reduced the dose and cost of cyclosporine in this series.

Long-term outcome of cardiac allograft vasculopathy treated by transmyocardial laser revascularization: early rewards, late losses.

Transmyocardial laser revascularization (TLR) was initially touted as a promising therapeutic alternative for tackling the growing problem of cardiac allograft vasculopathy in late heart transplant survivors. We first described 4- and 8-week observations of application of this surgical technique, in which we professed enthusiasm for TLR in providing symptomatic relief and in reducing ischemic burden. In this report, we present the long-term (24-month) impact of TLR on clinical outcome, channel patency, and recrudescence of ischemic burden. In the long term, surgical TLR provides neither consistent symptomatic improvement nor an ameliorative effect on the natural history of cardiac allograft vasculopathy.

Minimally invasive thoracic surgery.

To reduce the risk, trauma, and expense of intrathoracic surgical treatments, minimally invasive procedures performed with the assistance of fiberoptic video technology have been developed for thoracic and bronchial surgeries. The surgical treatment of nearly every intrathoracic condition can benefit from a video-assisted approach performed through a few small incisions. Video-assisted thoracoscopic and rigid-bronchoscopic surgery have improved the results of thoracic procedures by decreasing postoperative pain and speeding the return to normal activity. From January 1992 to February 2000, 185 patients underwent 189 video-assisted thoracoscopic procedures in Ochsner Foundation Hospital for various conditions with good results; only 18 procedures (9.5%) required conversion to open thoracotomy. Video-assisted rigid bronchoscopic surgery has been helpful in managing tracheobronchial conditions and complications following lung transplantation. Ninety-nine patients with bronchial complications following lung transplantation and 20 patients with tracheobronchial conditions not related to transplantation have undergone therapeutic techniques involving video-assisted rigid bronchoscopy.

Cardiac allograft valvulopathy: a case of donor-anorexigen-induced valvular disease.

We report on the transplantation of a cardiac allograft from a donor with prolonged exposure to anorexigens. This event allowed us to not only examine the early pathological alterations that characterize anorexigen-induced valvular damage, but to also study the posttransplantation outcome after the donor heart had been removed from the offending milieu. A donor history of anorexigen use should be sought, and if detected, careful evaluation for underlying valvular disease should be entertained. Early valvulopathy may appear clinically mild yet pathologically significant. Our single-case experience also suggests that anorexigen-induced valvulopathy may be a progressive disorder despite removal of the heart from the causative environment.

Recurrent juvenile-onset laryngotracheal papillomatosis with transformation to squamous cell carcinoma of the lung.

A 47-year-old female patient with recurrent juvenile-onset laryngotracheal papillomatosis for 27 years had multiple bilateral pulmonary lesions, the largest of which was a well-differentiated squamous cell carcinoma. This case is unique because the malignant transformation occurred in a nonirradiated, nonsmoking patient.

Advances in lung transplantation.

Success in lung transplantation (LT) has been attributed to proper patient and donor selection, better preservation and surgical techniques, and experience in postoperative management. In 1995, we refined our perioperative management by implementing newer perioperative strategies with critical pathways and have reduced use of cardio-pulmonary bypass (CPB), thereby improving survival after LT. We compared survival, use of CPB, intubation, intensive care unit (ICU) stay, and hospital times between PRE (prior to 1995) and POST cohorts to analyze our changes in LT. The 1-and 3-year survival rates were 57% and 29% for PRE, and 86% and 62% for POST, p < 0.01. The intubation time and ICU and hospital length of stay were significantly reduced in the POST cohort. Also, the need for CPB was reduced by about 40% in the POST group.

Recurrent catamenial hemopneumothorax.

A case of recurrent hemorrhagic catamenial hemopneumothorax resulting from diffuse pleural endometriosis is presented. The pathogenesis of this rare entity is discussed, and the immediate and long-term surgical and medical options for therapy are reviewed.

Lung transplantation.

Although we have not yet obtained the survival results that have been observed in heart and renal transplantation, the survival rate in lung transplantation is improving. Because the lung is the only organ that is continuously exposed to the environment after transplantation, infection continues to be the major cause of early and late morbidity and mortality. Bronchiolitis obliterans, the second most common cause of late morbidity and mortality, is a progressive and currently untreatable condition resulting in lung dysfunction. The cause of this condition after transplantation is likely multifactorial and related to processes that result in allograft lung injury, such as rejection, bacterial infection, and cytomegalovirus infection. Future improvement in intermediate and long-term survival after lung transplantation will largely depend on prevention and long-term control of infection and subclinical rejection.

Thoracoscopic surgery.

Video-assisted thorascopic surgery has evolved rapidly and has demonstrated utility in the diagnosis and management of a variety of chest disorders. An historical perspective, considerations on patient selection, anesthetic and operative management, and a summary of the Ochsner Clinic institutional experience with this procedure are presented. Special emphasis is given to the treatment of disorders of the autonomic nervous system, esophageal achalasia, and a rare symptomatic congenital pericardial defect. Video-assisted thorascopy provides a promising alternative to many of the more invasive open thoracic surgical procedures.

Atrial replacement and tricuspid valve reconstruction after angiosarcoma resection.

A cardiac angiosarcoma was resected and successfully managed by replacement of the right atrium and bileaflet reconstruction of the tricuspid valve by conserving non-involved valvular tissue. Competency of the new valve was confirmed intraoperatively by transesophageal echocardiography and reconfirmed at discharge. Evaluation 3 months postoperatively revealed no evidence of valvular insufficiency or right heart failure. In selected patients, resection of extensive primary cardiac neoplasms may be possible without necessitating prosthetic valve replacement.

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Repletion of high energy phosphates in the postischemic neonatal heart.

Milrinone improves function in failing adult hearts, but it has not been examined in the immature myocardium. The purpose of this study was to characterize the effects of milrinone, a phosphodiesterase inhibitor, on immature hearts, and compare these to dobutamine, a commonly used catecholamine inotrope. One hundred isolated working neonatal rabbit hearts were used. Hearts were made ischemic (37 degrees C) for 1 hour and reperfused for 0, 10, 40, or 70 minutes. In separate groups, infusion of milrinone (1.0 microg/mL) or dobutamine (0.1 microg/mL) was begun after reperfusion for 10 or 40 minutes. High energy phosphates, total nondiffusable nucleotides, cyclic adenosine monophosphate (cAMP), and the percent recovery of cardiac output were determined. Cardiac output returned to normal, and adenosine triphosphate (ATP) and total nondiffusable nucleotide levels did not decline when dobutamine or milrinone were begun after 10 minutes of reperfusion. In hearts receiving inotropes after 40 minutes of reperfusion, when high energy phosphates were low, ATP increased, and total nondiffusable nucleotide repletion was observed. Cardiac output did not improve when inotropes were begun after 40 minutes. cAMP was higher in milrinone hearts compared to dobutamine, but there was no simple relation between cAMP and ventricular function. Inotropes may increase purine salvage pathway activity. Deriving maximum benefit from inotropes may depend on beginning infusions early, before the appearance of irreversible changes.

Pericardiectomy for pericardial constriction.

Constrictive pericarditis is a pathologic condition that may lead to significant morbidity. Definitive management of constrictive pericarditis requires pericardiectomy. A retrospective review of pericardiectomy for constrictive pericarditis at the Ochsner Clinic was undertaken. Twenty-one patients (17 male, four female) underwent pericardiectomy for constrictive pericarditis between January 1969 and June 1994. Ages ranged from 15 to 66 years (mean 41.5 years). Pedal edema, dyspnea, fatigue, and chest pain were the most common symptoms. Fifteen patients had important comorbidities. Preoperative New York Heart Association (NYHA) class was I (2), II (8), III (6), IV (5). Mean preoperative catheterization data, available in 17 patients (81%), demonstrated elevated intracardiac pressures (right atrial 17.4 mm Hg, right ventricular end-diastolic 22.4 mm Hg, pulmonary artery 26.2 mm Hg, pulmonary capillary wedge 20.2 mm Hg, left ventricular end-diastolic 20.1 mm Hg). A total pericardiectomy was performed in nine patients (sternotomy 8, thoracotomy 1). Pericardiectomy limited anteriorly to the phrenic nerves was performed in 11 patients (sternotomy 9, thoracotomy 2). One partial pericardiectomy was performed through a sternotomy. Cardiopulmonary bypass was used in six patients (29%). Mean hospital stay was 12 days (preoperative 4.2, postoperative 7.67). All patients achieved NYHA Class I postoperatively. Sixteen patients were discharged in sinus rhythm. No early mortality (<30 days), or major postoperative complications were observed. Pericardiectomy for pericardial constriction can be performed safely low morbidity and mortality and can favorably impact the natural history of this debilitating condition.

Pharmacologic support with high-energy phosphate preservation in the postischemic neonatal heart.

Milrinone improves function in failing adult hearts. This study examined its effect on immature myocardium. Using an isolated working neonatal rabbit heart preparation, we measured myocardial function, high-energy compounds, and cyclic adenosine monophosphate. Hearts were subjected to 1 hour of normothermic ischemia, 10 minutes of reperfusion with Ringer's solution, and 30 minutes of reperfusion with either unaltered Ringer's, Ringer's with dobutamine (0.1 microgram/mL), or Ringer's with milrinone (1 microgram/mL). These hearts were compared with each other, with a control group continuously perfused for 70 minutes, and with a group of hearts that were made ischemic and reperfused for only 10 minutes. There was a progressive decline in adenosine triphosphate levels measured in hearts from the groups receiving 10 and 40 minutes of reperfusion with unaltered perfusate, and cardiac output fell to 82% +/- 4% of preischemic control in the latter group. When either dobutamine or milrinone was added to the reperfusion solution, postischemic myocardial function was restored completely, and the loss of adenosine triphosphate with reperfusion was halted. Cyclic adenosine monophosphate level was highest in ischemic/40-minute reperfused hearts, and there was no measurable increase in cyclic adenosine monophosphate level in the group of hearts receiving milrinone. The mechanism of preservation of high-energy stores with inotropic agents is not known but may involve potentiation of mitochondrial oxidative phosphorylation.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous torsion of the right lung: a case report.

Pulmonary torsion is an uncommon event and may occur spontaneously or after trauma or surgery. It may involve the entire lung or individual lobes. Early recognition with prompt intervention is required to prevent hemorrhagic infarction or gangrene and salvage parenchyma. Surgical options of detorsion or resection are dependent upon tissue viability. A case of spontaneous torsion of the entire right lung is presented that reflects the first successful nonresectional management of this entity to be reported. Guidelines for appropriate management are discussed based on an understanding of the etiology, pathophysiology, and natural history.

Lung transplantation in Louisiana: report of the first twenty lung transplants performed in the state.

Lung transplantation is a successful alternative treatment for a variety of end-stage lung diseases. The first 20 lung transplants performed in Louisiana between November 1990 and July 1994 are reported from Ochsner Foundation Hospital. Transplant procedures included 1 heart-lung, 11 bilateral sequential lung, and 8 single-lung transplants in 8 males and 11 females (1 retransplantation). The average age was 38 years (range 7-60), and the median waiting time was 34.5 days (range 1-329). Indications for transplant included emphysema, pulmonary fibrosis, pulmonary hypertension, cystic fibrosis, bronchiectasis, and bronchiolitis obliterans. Overall 1-year and 3-year survival were 65.0% and 58.5%, respectively. Infection was the major cause of morbidity and mortality. Rejection episodes were observed but treated successfully in all 20 patients. Lung transplantation has proved to be a successful treatment for a variety of severely limiting and terminal pulmonary conditions for patients in our state.