Diagnosis and treatment of Aspergillus flavus sternal wound infections after cardiac surgery.

We report the clinical data for 9 patients affected during an outbreak of Aspergillus flavus sternal wound infections after cardiac surgery. In 7 patients, the infection had a locally invasive character, with 3 of these patients having multiple relapses; 2 patients had fulminant mediastinitis and died. Most patients received combined surgical and medical treatment.

Pulsatile compared with nonpulsatile perfusion using a centrifugal pump for cardiopulmonary bypass during coronary artery bypass grafting. Effects on systemic haemodynamics, oxygenation, and inflammatory response parameters.

The present study investigated the influence of pulsatile or nonpulsatile flow delivery with a centrifugal pump for cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) in two randomized groups of 19 patients each. All patients received a standard anaesthetic and surgical protocol. Pulsatile perfusion during CPB was created by accelerating the baseline pump speed of the Sarns centrifugal pump at a rate of 50 cycles per minute. Measurements included perioperative systemic haemodynamics and oxygen exchange, total haemolytic complement (CH50), polymorphonuclear (neutrophil) granulocyte (PMN) count and plasma granulocyte elastase bound to alpha 1-proteinase inhibitor (E-alpha 1-PI). Laboratory measurements were corrected for haemodilution. During and after CPB there were only a few significant differences between the groups in systemic haemodynamics and oxygenation, i.e. a lower mean arterial blood pressure after the end of CPB in the nonpulsatile group (65 mmHg, SD = 11 vs 76 mmHg, SD = 11) and a lower SvO2 during rewarming on CPB in the nonpulsatile group (62%, SD = 8 vs 67%, SD = 8). The decrease in percentage of PMNs in the total white blood cell count during CPB was greater in the nonpulsatile group than in the pulsatile group (from 61 to 46% vs 63 to 53% of prebypass value). The steep increase of PMN count at the end of CPB and postoperatively was comparable in both groups. The maximal decrease of CH50 levels, occurring after surgery, was significantly higher in the nonpulsatile group (70% SD = 15 vs 79%, SD = 16, of baseline value), suggesting a greater complement activation. E-alpha 1-PI levels increased significantly in both groups during and after CPB with higher peak levels, obtained at one hour after admission to an intensive care unit, in the nonpulsatile group (316 micrograms/l, SD = 102) than in the pulsatile group (247 micrograms/l, SD = 106). There was a partly inverse correlation between the peak postoperative elastase levels and the PaO2/FiO2 ratios at the first postoperative morning. This ratio was significantly lower in the nonpulsatile group (211, SD = 56) than in the pulsatile group (247, SD = 62). Postoperative respiratory tract infection was more frequent in the nonpulsatile group (n = 9) than in the pulsatile group (n = 2). Adding a pulsatile component to centrifugal blood pumping during CPB may have benefits with regard to the possibly detrimental whole body inflammatory response to CPB. Further studies are warranted to investigate whether these differences will affect clinical outcome.

Heart transplantation in Berlin.

Since July 1983, our group experience with heart transplantation as a routine procedure now includes 346 patients. Predominant diagnosis was dilated cardiomyopathy (64%). The age range was 3 months to 68 years (mean 44.3 years). Immunosuppression has followed several evolving protocols and now emphasizes preoperative administration of cyclosporine A and quadruple immunosuppression with additional azathioprine, cortisone medication, and early postoperative cytolytic prophylaxis with rabbit ATG. We have accepted donor organs up to 55 years without coronary angiography and with very satisfying functional and late results. The diagnosis of rejection by endomyocardial biopsy has been supplemented by routine use of telemetric intramyocardial electrogram monitoring and M-mode echocardiography. Routine use of these methods has distinctly increased diagnostic safety. Eleven children between the ages of 3 months and 18 years have been transplanted with a 72% overall survival rate. Four children younger than age 8 have been followed with noninvasive methods for rejection diagnosis exclusively. A bridge to transplantation program was initiated in July 1987; 31 patients were bridged, 18 of whom could be transplanted. Thirteen patients were discharged after a mean posttransplant period of 31 days. Future development issues will include extension of donor heart criteria, noninvasive diagnosis of rejection, and increasing experience with mechanical bridging.

Cardiac arrest due to aberrant left coronary artery originating from the right sinus of Valsalva in a young girl.

We report a 14-year-old girl who sustained a syncope followed by cardiac arrest. She was kept alive for three days by full cardiocirculatory support using left and right ventricular assist devices, but subsequently died in multiple organ failure. Autopsy revealed an anomalous origin of the left coronary artery (LCA) from the right sinus of Valsalva (RSV) and a major left anterior wall infarction. A cyclo-ergometric stress test performed two years before having been negative, we discuss its value in preventing sudden death due to coronary anomalies.