Percutaneous transvenous endomyocardial biopsy in human heart recipients. Experience with a new technique

Sixty-seven cardiac biopsy procedures have been performed in 17 cardiac transplant recipients at Stanford University Medical Center. Six other patients were biopsied as part of their assessment prior to transplantation. Biopsies were performed percutaneously through a sheath inserted into the right internal jugular vein. Two instruments were used, a Konno-Sakakibara bioptome and a new catheter biopsy forceps of our own design. Biopsies of the endomyocardium sufficient for examination by light and electron microscopy were obtained on all but one occasion. There were no deaths and no serious complications.Serial biopsies performed in the first two months after transplantation were used to diagnose and aid the management of acute rejection episodes. Biopsies on long-term survivors permitted the recognition of late acute rejection episodes and provided a new assessment of the myocardium following cardiac transplantation.Percutaneous transvenous endomyocardial biopsy is simple and safe to perform and is an important new aid in the management of patients following cardiac transplantation.     

Traumatic incarceration of the jejunum between two lumbar vertebrae.

An unusual case of traumatic herniation of the upper jejunum into the lumbar spine is presented. A suggested mechanism of injury is discussed.     

Late right heart reconstruction following repair of tetralogy of Fallot.

Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.     

Compartment syndromes of the forearm: early recognition using tissue pressure measurements.

A compartment syndrome of the forearm can be a devastating injury if not relieved promptly by early fasciotomy. Of five patients who developed compartment syndromes, compartment pressures were measured in four and found to average 69 mm Hg. Tissue pressure measurements provided early objective evidence of the presence of the compartment syndrome and contributed significantly to the ultimate functional recovery. We would advise repeating the measurement for pressures in excess of 30 mm Hg in the upper extremity, and fasciotomy for pressures in excess of 40 mm Hg when accompanied by any neurovascular compromise.     

The nature of the glomerular injury in minimal change and focal sclerosing glomerulopathies

Glomerular barrier function was evaluated in 12 healthy human volunteers and in 16 proteinuric patients in whom the nephrotic syndrome was associated with alteration of glomerular epithelial cells alone (minimal change nephropathy [MCN]) or in combination with focal glomerular sclerosis (FGS). We determined the glomerular sieving coefficient for each of nine narrow dextran fractions (Einstein Stoke radius [ESR] = 30 to 46 A), and directly measured, or indirectly estimated, values for the determinants of glomerular ultrafiltration. These quantities were then subjected to analysis based on an hydrodynamic theory of solute transport through an isoporous membrane. The results indicate that relative to normal subjects, effective pore radius is reduced from 59 to 55 and 53 A in McN and FGS, respectively; while the ratio, pore area to pore length (a measure of pore density) is correspondingly reduced from 21.7 X 10(6) to 10.1 X 10(6) and 4.7 X 10(6) cm. respectively, We suggest that collapse of the anionic glomerular membrane matrix in these proteinuric disorders may lead to pore shrinkage and reduced pore density, but that reduced electrostatic repulsion of anionic albumin (ESR = 36 A) facilitates its permeation into Bowman's space. The qualitatively similar disorder of glomerular barrier function in MCN and FGS is consistent with a unitary pathogenesis, but may represent a nonspecific response to depletion of glomerular polyanion.     

Simultaneous Correction of Aortic Coarctation and Partial Anomalous Pulmonary Venous Return

A 23-year-old asymptomatic woman with aortic coarctation and anomalous drainage of the right inferior and left pulmonary veins underwent correction. Coarctation repair was followed by anastomosis of the anomalous vertical vein to the left atrium under femoral-femoral bypass. A left thoracotomy offered excellent exposure for simultaneous repair of this unusual combination of vascular anomalies.     

Patient-related risk factors as predictors of results following isolated mitral valve replacement

Results following isolated mitral valve replacement in 897 consecutive patients over a twelve-year period were analyzed with regard to the influence of various preoperative patient-related risk factors. Actuarial data analysis allowed definition of major preoperative, etiological, clinical, and hemodynamic correlates to both perioperative and long-term postoperative patient survival. Patient age below 60 years, preoperative New York Heart Association Functional Class of III or less, cardiac index greater than 2.0, and left ventricular end-diastolic pressure of less than 12 mm Hg were all highly significant correlates of improved perioperative as well as long-term patient survival. Patients whose predominant functional lesion was mitral insufficiency had only a 53% five-year survival (187 of 352 patients) following mitral valve replacement as opposed to 70% (521 of 745 patients) for those who had mixed or stenotic mitral lesions. Primary ischemic mitral dysfunction was associated with only 31% five-year survival (17 of 54 patients) after mitral valve replacement in contrast to 69% (480 of 695 patients) for patients with rheumatic mitral lesions. The presence of occlusive coronary artery disease coexisting with, but not the primary cause of, mitral dysfunction was associated with decreased perioperative and late postoperative survival. Results support both earlier operative intervention and wider use of associated procedures, ie, coronary bypass grafting, with mitral valve replacement. Recognition of major preoperative patient-related risk factors should enhance survival following this procedure.     

Clinical experience with a porcine aortic valve xenograft for mitral valve replacement

Between March, 1971, and July, 1973, 103 patients underwent mitral valve replacement with a glutaraldehyde-preserved porcine aortic valve mounted on a flexible polypropylene, Dacron-covered stent. Overall operative survival was 95.1%. Actuarial analysis of late postoperative results indicates 92% survival through 2 years, with functional improvement in nearly all patients. The rate of systemic thromboembolism has been approximately 1.7% per patient-year without anticoagulants. No valve failure has occurred. We conclude that this xenograft prosthesis provides a technically and functionally satisfactory valve substitute, the durability of which appears to significantly exceed that of previously available tissue valves for mitral replacement.     

Simplified operative method for heart and lung transplantation

An operative method was developed to facilitate heart and lung transplantation. Four consecutive operations in small cynomolgus monkeys (average 4.7 kg) are described in which central cannulation and cardiopulmonary bypass were employed. The major modification from previous reports is the use of a retained portion of the right atrium for a single inflow anastomosis. Preservation of the donor sinoatrial node assures normal sinus rhythm postoperatively. The method obviates potential caval stenosis, and would facilitate the operation in man where the intrathoracic component of the inferior vena cava is short.     

Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease

Phrenic nerve injury (PNI) with resulting hemidiaphragmatic paralysis occurred in 19 (2.1 +/- 0.5%) of 891 closed cardiac surgical procedures during a twenty-three-year period. Diagnosis was confirmed by standard radiographic criteria. Phrenic nerve injury was most commonly noted following systemic-pulmonary artery anastomosis, ligation of persistent ductus arteriosus plus pulmonary artery banding, and atrial septectomy. Most patients were managed conservatively (nasotracheal or orotracheal intubation and positive end-expiratory pressure). Although no deaths were a direct result of PNI, major complications occurred in 15 of the 19 instances of PNI (79% +/- 10%). The serious morbidity and the hospital costs associated with this complication, however, underscore the cardinal importance of prevention. If injury does occur, early surgical intervention (diaphragmatic plication) in very young infants may reduce the attendant morbidity, but the complete role of diaphragmatic plication remains to be defined.     

Heart-Lung Transplantation for Irreversible Pulmonary Hypertension

Combined heart and lung transplantation was carried out in 17 patients at Stanford University between March, 1981, and December, 1983. The recipients were between 22 and 45 years old. All patients had end-stage pulmonary hypertension; 10 had Eisenmenger's syndrome and the remaining 7, primary pulmonary hypertension. Five patients died within the first few postoperative weeks. The remainder are well between four weeks and 33 months from operation.The immunosuppressive protocol has consisted of cyclosporine with an initial course of rabbit antithymocyte globulin. Azathioprine also was given for the first two weeks and then was replaced with prednisone. Rejection, as diagnosed by cardiac biopsy, was treated with high doses of methylprednisolone. Modifications of technique that have developed include the removal of the recipient heart and lungs separately, and preservation of the lungs with a modified Collins' solution instead of a cardioplegic solution.Rejection occurred in 6 of the 12 survivors. Infections developed in 9 patients, but only one resulted in a fatal outcome (Legionella). Thus, the results of clinical heart-lung transplantation have been considerably superior to clinical efforts in lung transplantation. It is suggested that the combined operation is preferable for the following reasons: (1) all diseased tissue is removed, thus eliminating recurrent infection and ventilation/perfusion disparity; (2) transplantation of the entire heart-lung block preserves coronary–bronchial vascular anastomoses and makes airway dehiscence less likely; and (3) to date, diagnosis of rejection by cardiac biopsy has appeared to be a satisfactory method of diagnosing and treating pulmonary rejection. Cardiopulmonary transplantation represents a viable therapeutic approach for patients with end-stage pulmonary hypertension with or without associated congenital heart disease.     

Double-Patch Technique for Correction of Complete Atrioventricular Canal

This technique involves the use of a crescent-shaped Teflon patch to close the ventricular septal defect and resuspend the septal components of the atrioventricular valves. A pericardial patch is used to close the atrial septal defect. Exposure is excellent and allows accurate leaflet rearrangement.