Association of race and socioeconomic position with outcomes in pediatric heart transplant recipients.

We assessed the association of socioeconomic (SE) position with graft loss in a multicenter cohort of pediatric heart transplant (HT) recipients. We extracted six SE variables from the US Census 2000 database for the neighborhood of residence of 490 children who underwent their primary HT at participating transplant centers. A composite SE score was derived for each child and four groups (quartiles) compared for graft loss (death or retransplant). Graft loss occurred in 152 children (122 deaths, 30 retransplant). In adjusted analysis, graft loss during the first posttransplant year had a borderline association with the highest SE quartile (HR 1.94, p = 0.05) but not with race. Among 1-year survivors, both black race (HR 1.81, p = 0.02) and the lowest SE quartile (HR 1.77, p = 0.01) predicted subsequent graft loss in adjusted analysis. Among subgroups, the lowest SE quartile was associated with graft loss in white but not in black children. Thus, we found a complex relationship between SE position and graft loss in pediatric HT recipients. The finding of increased risk in the highest SE quartile children during the first year requires further confirmation. Black children and low SE position white children are at increased risk of graft loss after the first year.

Retrospective study of dystocia in mares at a referral hospital.

REASONS FOR PERFORMING STUDY: The period between the onset of dystocia and its resolution has an important bearing on fetal outcome. There are few published data on which to base decisions regarding optimum management of cases in practice. OBJECTIVES: To evaluate and compare the effects of a coordinated dystocia management protocol (CDMP) with that of a previous protocol of random management on time to resolution and outcome in both an emergency dystocia referral population of mares (referred emergency cases: EM) and in a population of mares residing in hospital due to high risk pregnancy (HRP) concerns that then experience dystocia at parturition. METHODS: Retrospective study performed at a university hospital referral centre of cases presenting from 1991-2004 divided into Group 1 (pre-CDMP) and Group 2 (CDMP). RESULTS: Medical records of 71 cases with dystocia were retrieved and data recorded. For referred emergency cases (EM), time from hospital presentation to resolution decreased significantly by 32 min (P = 0.03) after institution of CDMP. Survival rate of mares at discharge was 86%. Survival of EM foals was low, with 10% in Group 1 and 13% in Group 2, surviving to discharge. For EM foals delivered alive, survival to discharge was 30% and 43% in Groups 1 and 2, respectively. Median Stage II was significantly (P < 0.001) different at 71 and 282 min for EM foals delivered alive vs. those not alive at delivery, respectively. Median duration of Stage II was also significantly (P < 0.001) different between EM foals surviving and not surviving to discharge, at 44 and 249 min, respectively. Survival of HRP dystocia foals to discharge was 79%. CONCLUSIONS: Although CDMP reduced the time from presentation at the hospital to resolution significantly for EM, total duration of Stage II for EM was unchanged, as was foal outcome. POTENTIAL RELEVANCE: Very early referral of mares with dystocia to referral centres with dystocia management protocols may improve fetal outcome as increased duration of Stage II in the horse affects fetal outcome negatively.

Association of viral genome with graft loss in children after cardiac transplantation.

BACKGROUND: The survival of recipients of cardiac allografts is limited by rejection, lymphoproliferative disease, and coronary vasculopathy. The purpose of this study in children who had received heart transplants was to evaluate the cardiac allografts for myocardial viral infections and to determine whether the presence of viral genome in the myocardium correlates with rejection, coronary vasculopathy, or graft loss. METHODS: We enrolled heart-transplant recipients 1 day to 18 years old who were undergoing evaluation for possible rejection and coronary vasculopathy. Endomyocardial-biopsy specimens were evaluated for evidence of rejection with the use of standard criteria and were analyzed for the presence of virus by the polymerase chain reaction (PCR). RESULTS: PCR analyses were performed on 553 consecutive biopsy samples from 149 transplant recipients. Viral genome was amplified from 48 samples (8.7 percent) from 34 patients (23 percent); adenovirus was found in 30 samples, enterovirus in 9 samples, parvovirus in 5 samples, cytomegalovirus in 2 samples, herpes simplex virus in 1 sample, and Epstein-Barr virus in 1 sample. In 29 of the 34 patients with positive results on PCR (85 percent), an adverse cardiac event occurred within three months after the positive biopsy, and 9 of the 34 patients had graft loss due to coronary vasculopathy, chronic graft failure, or acute rejection. In 39 of the 115 patients with negative results on PCR (34 percent), an adverse cardiac event occurred within three months of the negative PCR finding; graft loss did not occur in any of the patients in this group. The odds of graft loss were 6.5 times as great among those with positive results on PCR (P=0.006). The detection of adenovirus was associated with considerably reduced graft survival (P=0.002). CONCLUSIONS: Identification of viral genome, particularly adenovirus, in the myocardium of pediatric transplant recipients is predictive of adverse clinical events, including coronary vasculopathy and graft loss.

Pediatric cardiac retransplantation: intermediate-term results.

BACKGROUND: Cardiac retransplantation (re-CTx) in children is a controversial therapy, yet it remains the best treatment option to recipients with failing grafts. Our objective was to determine the incidence of re-CTx in a large pediatric population of recipients and evaluate the outcome of such therapy. METHODS: Between November 1985 and November 1999, 347 children underwent cardiac transplantation at the Loma Linda University Medical Center. Of these, 32 children were listed for re-CTx. Ten patients died while waiting, and 22 recipients underwent re-CTx. Median age at re-CTx was 7.1 years (range, 52 days to 20.1 years). RESULTS: Indications for re-CTx were allograft vasculopathy (n = 16), primary graft failure (n = 5), and acute rejection (n = 1). Two patients with primary graft failure underwent retransplantation within 24 hours of the first transplantation procedure while on extracorporeal membrane oxygenation support. Median time interval to re-CTx for the others was 7.2 years (range, 32 days to 9.4 years). Operative mortality for all cardiac re-CTx procedures was 13.6%. Causes of hospital mortality were pulmonary hypertension with graft failure (n = 2) and multiorgan failure (n = 1). Median hospital stay after re-CTx was 14.1 days (range, 6 to 45 days). There was one late death from severe rejection. Actuarial survival at 3 years for re-CTx was 81.9% +/- 8.9% compared with 77.3% +/- 2.6% for primary cardiac transplantation recipients (p = 0.70). CONCLUSIONS: Elective re-CTx can be performed with acceptable mortality. Although the number of patients undergoing retransplantation in this report is small and their long-term outcome is unknown, the intermediate-term survival after re-CTx is similar to that of children undergoing primary cardiac transplantation.

Late rejection is a predictor of transplant coronary artery disease in children.

OBJECTIVE: The study objectives were to determine posttransplant coronary artery disease (TxCAD) incidence, predisposing factors and optimal timing for retransplantation (re-Tx) in pediatric heart transplantation (Tx) recipients. BACKGROUND: The TxCAD limits long-term survival following heart Tx, with re-Tx being the primary therapy. Information on risk factors and timing of listing for re-Tx is limited in children. METHODS: The records of children who survived >1 year post-Tx at Loma Linda University were reviewed. Nonimmune and immune risk factors were analyzed. RESULTS: TxCAD was documented in 24 of 210 children. Freedom from TxCAD was 92 +/- 2% and 75 +/- 5% at 5 and 10 years' post-Tx, respectively. The TxCAD diagnosis was established at autopsy in 10 asymptomatic patients who died suddenly within nine months following the most recent negative angiograms. The remaining 14 children had angiographic diagnoses of TxCAD and had symptoms and/or graft dysfunction (n = 10) or positive stress studies (n = 4). Three of 14 died within three months after the diagnosis was made. Eleven patients underwent re-Tx within seven months of diagnosis; nine survived. Univariate and multivariate analyses showed that only late rejection (>1 year posttransplant) frequency (p = 0.025) and severity (hemodynamically compromising) (p < 0.01) were independent predictors of TxCAD development. Freedom from TxCAD after severe late rejection was 78 +/- 8% one year postevent and 55 +/- 10% by two years. CONCLUSIONS: Late rejection is an independent predictor of TxCAD. Patients suffering severe late rejection develop angiographically apparent TxCAD rapidly and must be monitored aggressively. Both TxCAD mortality and morbidity occur early; therefore, we recommend immediate listing for re-Tx upon diagnosis.

Outcome of infants with hypoplastic left heart syndrome who undergo atrial septostomy before heart transplantation.

This study evaluated the procedural and long-term outcome of infants who underwent atrial septostomy while awaiting transplant. The results suggest that septostomy improved outcome in these patients although infants needing a transseptal perforation were at higher risk.

Caesarean section and other methods for assisted delivery: comparison of effects on mare mortality and complications.

Data from 116 mares that had caesarean section or vaginal delivery at 2 university hospitals were analysed in 5 groups, as follows: dystocia corrected by caesarean section, Group DCS (n = 48); elective caesarean section, Group ECS (n = 10); caesarean section concurrently with colic surgery, Group CCS (n = 8); assisted vaginal delivery, Group AVD (n = 22); and controlled vaginal delivery under general anaesthesia, Group CVD (n = 28). Survival rate in all mares that had caesarean section, excluding Group CCS, was 88% (51/58). All mares in Group ECS survived and Group CCS had the lowest survival rate (38%). In 98 mares with dystocia, Groups DCS (15%) and AVD (14%) had significantly lower (P<0.05) mortality rates than Group CVD (29%). There were no differences between groups for duration of dystocia. The placenta was retained in 75 (65%) of 116 mares, and for a longer period following elective caesarean section than following assisted vaginal delivery. Multiple complications (> or = 3) were recorded in 6 mares in Group CVD but not in the other groups. Of the 102 foals delivered from 98 mares with dystocia, 11 (11%) were alive at delivery and 5 (5%) survived to discharge. Survival rate for foals was 38% in Group CCS, and 90% in Group ECS. Under conditions similar to those in this study, it is calculated that caesarean section is preferable to CVD if dystocia is protracted and great difficulty and trauma is involved, even if CVD allows delivery of the foal.

An evaluation of the haemostatic suture in hysterotomy closure in the mare.

This study was designed to evaluate the haemostatic suture as a means of preventing haemorrhage from the hysterotomy in mares after caesarean section. At 2 university hospitals 1982-1994, 48 mares had caesarean section for dystocia, 10 as an elective, and 8 mares concurrently with colic surgery. The haemostatic suture was used in 31 of 66 mares (47%) and surgery period was significantly (P<0.05) shorter when it was not applied. Anaemia (PCV<30%) was recorded in 13 (22%) of 58 mares, excluding the colic group, and the haemostatic suture did not after this proportion of mares that had anaemia. Anaemia was 5 times more probable following caesarean section than vaginal delivery, evidence that bleeding from the hysterotomy is a serious and common complication of caesarean section in mares. Severe uterine haemorrhage was recorded in 3 mares that had an haemostatic suture (10%) and in 2 mares that did not (6%). The latter two mares died of haemorrhage. The suture, therefore did not eliminate post operative anaemia and severe uterine haemorrhage. If omitted, the hysterotomy should be closed with a full thickness pattern that is sufficiently tight to compress vessels in the uterine wall.

Cecocolic and cecocecal intussusception in horses: 30 cases (1976-1996).

OBJECTIVE: To determine the prognosis in horses with cecocolic or cecocecal intussusception. DESIGN: Retrospective study. ANIMALS: 30 horses with cecocolic intussusception or cecocecal intussusception. PROCEDURE: Information on history, physical examination findings, and laboratory values was summarized from the medical records. Laboratory data included results of hematologic examination, serum biochemical analysis, and peritoneal fluid color, total nucleated cell count, and total protein concentration. A one-year follow-up via the telephone was used to determine long-term survival. RESULTS: Horses ranged from 7 months to 30 years old, but 63% were < or = 3 years. Standardbred horses were significantly overrepresented. Twenty-six horses had acute-to-subacute disease, and 4 had a chronic wasting disease. Cecal intussusceptions were suspected on the basis of finding a mass on abdominal palpation per rectum (14 of 24 horses) and positive ultrasonographic findings (2 of 3 horses). Thirteen horses with colic for > 1 day had scant, soft feces. Six horses died or were euthanatized without undergoing surgery, and 24 were treated surgically. Six of the latter horses were euthanatized during surgery because of peritonitis, rupture of the cecum, and irreducible intussusception. All 4 horses with a chronic disease were euthanatized because of irreversible changes in the cecum. Of the 18 horses allowed to recover from surgery, 15 survived long-term. Surgical treatments were reduction, with or without partial typhlectomy (6 horses), partial typhlectomy through a colotomy and reduction (6), reduction through a colotomy and partial typhlectomy (3), partial typhlectomy for a cecocecal intussusception (1) and an ileocolostomy (2). CLINICAL IMPLICATIONS: Cecal intussusception has a good prognosis with surgical correction without delay. Reduction through colotomy has a high success rate. Bypass by ileocolostomy should be used as a last resort.

Ethical challenges in infant heart transplantation: a clinical case presentation.

Although heart transplantation has become recognized as a viable option for the treatment of incorrectable heart disease in infants and children, its application becomes less clear in infants with potentially serious neurologic impairment. The following case study illustrates one transplant team's approach to decision making in the case of an infant born with a chromosomal deletion syndrome.

Combined anti-vascular cell adhesion molecule-1 and anti-leukocyte function-associated molecule-1 monoclonal antibody therapy does not prolong allograft survival in an ovine model of renal transplantation.

This study investigates the therapeutic efficacy of an anti-vascular cell adhesion molecule (VCAM)-1 monoclonal antibody (mAb), alone or in combination with an anti-leukocyte function-associated-1 mAb, in prolonging allograft survival in an ovine model of renal transplantation. The kinetics of VCAM-1 induction and expression during renal allograft rejection have also been studied. Sheep receiving anti-ovine VCAM-1 antibody demonstrated graft failure at a mean of 8.4 (+/- SD; 0.7) days after transplantation compared with 9.3 (+/- 0.5) days after transplantation for the group given control antibody and 7.7 (+/- 0.3) days after transplantation in the animals given the combined anti-VCAM-1 and anti-leukocyte function-associated-1 mAb therapy. VCAM-1 expression was detected in the allografts at day 1 after transplantation, with peak expression detected by day 5. Tubular expression of VCAM-1 was minimal, with sparse focal staining at the basolateral surfaces. The degree of mononuclear cell infiltrate in the allografts paralleled the progressive increase in VCAM-1 expression after transplantation, and there was no difference in the level of mononuclear cell infiltrate compared with controls.

Posttransplant recoarctation of the aorta: a twelve year experience.

OBJECTIVES: This study was undertaken to investigate the incidence of posttransplant recoarctation of the aorta, delineate the mode of presentation, identify risk factors that predict recoarctation and examine the results of intervention for posttransplant recoarctation. BACKGROUND: Patients with aortic arch hypoplasia require extended arch reconstruction at transplant, with an inherent possibility of subsequent recoarctation of the aorta. METHODS: This was a retrospective review of all children (age <18 years) who underwent cardiac transplantation over a 10-year period. Collected data included pretransplant diagnosis, details of the transplant procedure and posttransplant data including development of recoarctation of the aorta, interventions for recoarctation and the most recent follow-up assessment of the aortic arch. RESULTS: Two hundred eighty-eight transplants were performed on 279 children (follow-up = 1,075 patient-years; range 0 to 133 months, median 43.7). Thirty-two of 152 patients (21%) who underwent extended aortic arch reconstruction subsequently developed recoarctation. All but one patient developed recoarctation within 2 years after transplant; 87% were hypertensive at presentation. Of 30 patients who underwent intervention for recoarctation (balloon angioplasty [n = 26] and surgical repair of recoarctation [n = 4]), 26 (87%) have remained recurrence-free (follow-up = 133 patient-years; range 8 to 106 months, median 47). CONCLUSIONS: The high frequency of recoarctation after cardiac transplantation with extended aortic arch reconstruction mandates serial echocardiographic evaluation of the aortic arch. Patients typically present with systemic hypertension within the first two years after transplantation. Balloon angioplasty is a safe, effective and durable method of treatment.

Diseases and surgery of the large colon.

Displacements and intraluminal obstructions of the large colon carry a good to excellent prognosis for long-term recovery, and surgery for these diseases is rarely followed by short-term or long-term complications. Entrapment of the large colon over the renosplenic ligament is amenable to medical therapies so that surgery can be avoided in many cases. However, preoperative diagnosis of all nonstrangulating diseases of the large colon can be difficult. Vascular diseases of the large colon, such as thromboembolic diseases and large colon volvulus, are more difficult to treat and carry a poorer prognosis for survival.

Limitations to survival for infants with hypoplastic left heart syndrome before and after transplant: the Loma Linda experience.

Untreated, hypoplastic left heart syndrome is a lethal cardiac defect. Heart transplant has become an accepted therapeutic option for this condition. However, significant limitations to survival remain for infants with this condition who are referred for heart transplantation. Attention to the prevention, early detection, and management of common problems occurring at each stage of the transplantation process is important for improving survival rates. This study retrospectively reviewed the cases of 195 infants with hypoplastic left heart syndrome registered for heart transplantation at Loma Linda University Medical Center between November 1985 and July 1996 to determine causes of death. During the waiting period, progressive cardiac failure and complications from interventional procedures were the leading causes. In the early postoperative period, technical issues and acute graft failure were most important, whereas late deaths (more than 30 days after transplant) were most often related to rejection and posttransplant coronary artery disease.

Transplantation as a primary treatment for hypoplastic left heart syndrome: intermediate-term results.

BACKGROUND: Hypoplastic left heart syndrome is a lethal malformation. For the last 10 years, orthotopic cardiac transplantation has been our preferred treatment for infants with hypoplastic left heart syndrome. METHODS: One hundred seventy-six infants with hypoplastic left heart syndrome were entered into a cardiac transplant protocol between November 1985 and November 1995. Interventional procedures to stent the ductus arteriosus or enlarge the interatrial communication were performed in 8 and 35 patients, respectively. Thirty-four patients (19%) died during the waiting period, and 142 infants underwent cardiac transplantation. Age at cardiac transplantation ranged from 1.5 hours to 6 months (median, 29 days). The majority of grafts were oversized, and the median graft ischemic time was 273 minutes (range, 60 to 576 minutes). The implantation procedure used a period of hypothermic circulatory arrest ranging from 23 to 110 minutes (median, 53 minutes). Repair of other significant defects included interrupted aortic arch and total or partial anomalous pulmonary venous connection. RESULTS: There were 13 early and 22 late deaths. Patient actuarial survival at 1 month and at 1, 5 and 7 years was 91%, 84%, 76%, and 70% respectively. Half of the late deaths were due to rejection. Severe graft vasculopathy was confirmed in 8 patients. Retransplantation was performed in 5 patients for graft vasculopathy 4 and rejection 1. Lymphoblastic leukemia developed in 1 patient 3 years after cardiac transplantation. CONCLUSIONS: Cardiac transplantation can be performed in infants with hypoplastic left heart syndrome with good operative and intermediate-term results. Improved survival can be achieved with increased donor availability, better management of rejection, and control of graft vasculopathy.

Cardiac pacemakers in pediatric heart transplant recipients: incidence, indications, and associated factors. Pediatric Heart Transplant Group-Loma Linda.

This study was undertaken to assess the incidence, indications, and predisposing factors for pacemaker placement in a pediatric heart transplant population. From November 1985 to May 1994, 246 pediatric patients have undergone cardiac transplantation at Loma Linda University Medical Center. Seven (2.8%) have received pacemaker placement with an 8-50 month follow-up period. Median age at transplant was 462 days (0 days to 2.5 years). The median time to pacemaker placement was 190 days (18-1,672 days) after transplantation. Indications were sick sinus syndrome (SSS) in 5 and heart block in 2 patients (1 during acute rejection). Three patients with SSS underwent electrophysiology studies (EPS); 1 was normal and 2 showed sinus node dysfunction. The mode of pacing was VVIR in 6 patients and VVI in 1 patient. All 6 survivors are doing well and 5 patients' pacemakers still provide support. These 7 patients were compared with 185 pediatric patients (0 days to 12-years-old) transplanted during 1985 through 1993 who survived at least 6 months after transplantation. There was no correlation between the receipt of a pacemaker and graft cold ischemic time, rejection history, donor age, or recipient age at transplantation. The 5 patients with SSS had significantly lower average heart rates in the first month after transplantation (108 +/- 16 vs 130 +/- 12; P = 0.0002). The need for permanent pacemakers in this population is uncommon. Pacemakers, however, can be safely performed when necessary with excellent clinical results.