Cardiac lipomas. Description of 3 cases.

Cardiac lipomas, extremely rare benign tumours, can develop in the pericardial surface or inside the cardiac chambers. We report three cases, 2 intracardiac (one in the left and right atrium at the level of the interatrial septum and the other in the right ventricle) and one epicardial at the level of the left atrial roof. All patients underwent surgery and are now asymptomatic.

Echo-controlled endomyocardial biopsy in orthotopic heart transplantation with bicaval anastomosis.

Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.

Afterload mismatch-related problems after "domino" heart transplantation.

UNLABELLED: The heart transplants with domino technique, which uses donor hearts from heart-lung recipients, increases the pool of donors, provides the advantage of shortening the ischemic time and makes suitable hearts for patients with pulmonary hypertension. The present study aimed to characterise the pre- and post-transplant clinical and hemodynamic profiles of patients that underwent domino transplant in Pavia. METHODS: Between 1991 and 1992, 9 heart transplants were performed with the domino procedure at I.R.C.C.S. Policlinico S. Matteo of Pavia. Domino donors (6 with primary pulmonary hypertension, 2 with Eisenmenger's syndrome due to atrial septal defect, 1 with cystic fibrosis) underwent electrocardiographic, echocardiographic, chest roentgenogram studies, and right heart catheterization and coronary angiography (for donor older than 40). Domino recipients, 6 males and 3 females with a mean age of 44 years, had dilated cardiomyopathy (4 cases), coronary artery disease (4 cases) and valvular heart disease (1 case) (group 1). Seven of the 9 cases entered the study; 2 were excluded: one because had undergone heterotopic transplantation, the other had received the heart from another country and therefore the graft had suffered from a very long ischemic time. Controls group consisted of 12 patients who had consecutively undergone cardiac transplantation with non-domino donors during the same period (group 2). Immunosuppression was similar in both groups, and consisted of a combination of cyclosporin A, azathioprine and corticosteroids, plus a 7-day-course of antithymocyte globulin. Hemodynamic and echocardiographic controls were performed at 2, 3 and 4 weeks (short-term control) and at 2 and 6 months (mid-term control) after surgery. RESULTS: Domino donors (39 +/- 12.5 years) had significantly higher mean right ventricular end-diastolic diameter and lower left ventricular diameter than normal mean values. Domino recipients had significantly higher mean pulmonary arteriolar resistances than controls; mean ischemic time was also significantly lower in group 1 than in group 2. Short- and mid-term controls after surgery in group 1 showed persistently higher systemic vascular resistances and pulmonary vascular resistances and lower cardiac output than in group 1. Two patients developed an early and unexpected increase in pulmonary wedge pressure accompanied by severe paroxysmal nocturnal dyspnea and mitral regurgitation. In all cases, the left ventricles were relatively inadequate; the combination of low cardiac output and of high systemic vascular resistances favoured the occurrence of an afterload mismatch condition that was worsened by chronic hypoxia. This condition must be known and expected in these patients after transplantation in order to provide timely and effective treatment to potentially life-threatening left ventricular failure episodes. IN CONCLUSION, the subset of transplanted patients that receives domino donors may develop left-side afterload mismatch which, combined with low cardiac output, with high systemic vascular resistances and with the effects of chronic hypoxia originally suffered by the heart, may cause sudden and unexpected left-side heart failure which has to be timely recognised and managed. Although hemodynamic adaptation of this patients is highly problematic, it does not limit the value of the domino procedure.

[Lung transplantation in Pavia. Clinical experience]. / Il trapianto di polmone a Pavia. Esperienza clinica.

Single and bilateral lung transplantation represents the most recent success in the field of organ replacement. The procedure underwent a very long period of laboratory and clinical experimentation and it is still a high-risk procedure to be performed by a few highly specialized centers. At our Department of Cardiac Surgery, the preliminary experience in lung replacement was obtained by clinically applying heart-lung transplantation in patients with both vascular and parenchymal lung disease during 1991. In the following years, the indications for isolated lung transplantation were enlarged by some centers with good results; this consideration, together with the scarce availability of integral heart-lung blocks, led us to use single and bilateral lung transplantation initially for parenchymal disease and subsequently also for vascular disease. Since February 1992, 12 single lung transplantations and 12 bilateral lung transplantations have been performed at our Center. In this report the selection criteria, the preoperative characteristics and the perioperative variables of donors and recipients are discussed. Particular emphasis is given to immunosuppression treatment, diagnosis of rejection and airways suture complications. The conclusions summarize the present indications for the different types of lung transplantations according to the different preoperative diagnosis.

Successful treatment of aortic dissection after heterotopic heart transplantation.

Heterotopic heart transplantation is a valid option when there is a large donor-recipient size mismatch. However, the presence of the diseased native heart can jeopardize the medium-term and long-term outcome. The problems stemming from this most commonly described in the literature are thromboembolism, angina, and arrhythmias. In this report, we describe the case of a type A aortic dissection in the native aorta that occurred 30 months after heterotopic heart transplantation and the surgical technique successfully applied for its repair. We also discuss some of the alternative techniques.

Different results of cardiac transplantation in patients with ischemic and dilated cardiomyopathy.

We retrospectively analyzed 275 consecutive transplanted patients, dividing them into group A (128 patients) affected by ischemic cardiomyopathy and group B (147 patients) affected by dilated cardiomyopathy. The difference in demographic, clinical and hemodynamic preoperative and postoperative data between the groups was studied; group A patients presented at transplantation with a less compromised hemodynamic picture, requiring inotrope infusion and mechanical assistance less frequently. The influence of etiology on early postoperative complications was also analyzed: group A patients needed postoperative mechanical assistance, inotrope, infusion and prolonged mechanical ventilation more often, therefore requiring a longer stay in the intensive care unit (ICU). Hospital mortality was twice as high in group A. The older age of group A patients per se did not influence these results significantly. The long-term follow-up was then studied with particular attention to parenchymal functions, hemodynamics, coronary artery disease, metabolic and surgical complications, and survival. The complication rate was higher in group A, with more severe hypertension and higher cholesterol levels at 1 year, a higher prevalence of accelerated coronary artery disease (CAD) and a more frequent onset of insulin-dependent diabetes. Surgical and vascular complications were also more frequent. The final result was a better 5-year actuarial survival rate for group B patients. Donor and recipient ages at the time of transplant did not influence this result. We conclude that ischemic patients, even if they are transplanted in better condition and operated more electively, have a more critical early and long-term postoperative course and a worse survival rate. These findings are not explained by advanced age, but could be due to the impact of atherosclerosis and metabolic impairments associated with ischemic disease.

Predictors of prognosis in patients awaiting heart transplantation.

Patients enrolled in a clinical heart transplantation program were evaluated to identify the predictors of prognosis in patients with advanced heart disease and to optimize timing of heart transplantation. Three hundred eighty-eight subjects were consecutively evaluated from 1985 through 1989. One hundred eighty-four patients (47.5%) had dilated cardiomyopathy; 164 patients (42.2%) had ischemic heart disease; 34 patients (8.8%) had valvular heart disease, and six patients (1.5%) had miscellaneous disorders. In each patient, 45 different parameters were considered. During follow-up (mean, 8.4 months) 166 patients underwent heart transplantation; 99 patients died (heart failure, 66 patients; sudden death, 26 patients; thromboembolism, two patients; noncardiac causes, five patients). The actuarial survival was 83% at 3 months, 77% at 6 months, 73% at 9 months, 70% at 1 year, and 59% at 2 years. The median survival time was 28 months. Analysis by Cox proportional hazard regression model revealed seven independent and significant prognostic factors: etiology (p < 0.05), NYHA class (p < 0.05), third heart sound (p < 0.05), diastolic pulmonary artery pressure (p < 0.05), pulmonary wedge pressure (p < 0.01), mean systemic blood pressure (p < 0.05), and cardiac output (p < 0.05). Cox's analysis allows the computation of patient-specific curves for predictions of residual survival time at any moment during follow-up. Moreover it can be used to calculate a simple prognostic index, which enables stratification of the patient population into three risk classes: patients at high (n = 105), intermediate (n = 160) and low (n = 123) risk of early death. Pairwise comparisons of survival between the classes were significant at 1% level.

Emergency and elective cardiac retransplantation.

Among 265 patients transplanted at our Institution, 7 underwent cardiac retransplantation. There were five emergency retransplantations, the indication being graft failure in one case and acute rejection in four cases. Two patients, retransplanted because of acute rejection, had a positive panel reactivity antibody and a negative donor crossmatch. In the rejection cases immunosuppression was enhanced by perioperative plasmapheresis and a postoperative 1-month course of cyclophosphamide. In two cases emergency retransplantations were successfully performed despite a highly positive prospective crossmatch. Two patients underwent elective retransplantations for chronic rejection 12 and 41 months, respectively, after the primary transplants. The overall early and late survival rates are 71% and 57%, respectively, with a mean follow-up of 48.5 months. The early and late mortality for elective retransplantation is zero. Our experience confirms both the high operative risk for emergency retransplantation and the excellent results for elective retransplantation. The use of plasmapheresis and cyclophosphamide allowed us to undertake retransplantation successfully in 2 cases with positive donor crossmatch. Both hyperimmunized patients in our series were retransplanted because of irreversible acute rejection despite a negative crossmatch with the primary donor. The meaning of negative crossmatch in patients with preformed cytotoxic antibodies is therefore questionable.

Right ventricular failure after heart transplantation: relationship with preoperative haemodynamic parameters.

The prevalence of right ventricular failure after orthotopic heart transplantation, evaluated in 196 patients, was 11.7%, as assessed by the presence during the first postoperative month of right atrial pressure > 10 mm Hg. Two deaths, related to refractory right ventricular failure, were observed within the first month, both in subjects with preoperative pulmonary arteriolar resistances > 5 Wood Units. The haemodynamic profile after heart transplantation showed a significant decrease (P < 0.01) and an early normalization of pulmonary arterial pressure, pulmonary wedge pressure and pulmonary arteriolar resistances, while right atrial pressure slowly decreased until the third month. In a long-term analysis of survival (death within 1 year) the probability of death was significantly related to the values of right atrial pressure and cardiac index during the first month after heart transplantation. Otherwise, the presence of elevated values of right atrial pressure did not show a significant correlation with the echocardiographic right ventricular end-diastolic diameter nor with the presence of right bundle branch block. The careful selection of patients referred for the cardiac transplantation (mean value of pulmonary arteriolar resistances in the evaluated subjects was 2.5 +/- 1.5 Wood Units) improves the probability of avoiding the appearance of severe right ventricular failure in the postoperative period in most cases. The best predictor of right ventricular failure remains to be clearly identified.