Changes in right ventricular dimensions and performance after passive cardiac containment

Background

Previous studies have shown that the cardiac support device (CSD) improves left ventricular structure and function in patients with heart failure by preventing further cardiac enlargement. The aim of this study was to identify effects on the right ventricle (RV).

Methods

Ten male patients with idiopathic dilated cardiomyopathy underwent electron-beam computed tomographic (CT) examination within 1 month before, and 6 to 9 months after CSD implantation. The RV end-diastolic and end-systolic volumes (EDV, ESV) and diameters (EDD, ESD), stroke volume (SV), ejection fraction (EF), total and forward RV output (RVO, fRVO), and tricuspid regurgitation fraction (TRF) were calculated.

Results

The EDV measurements decreased from 182.1 ± 49.6 to 137.5 ± 37.0 mL, ESV from 114.8 ± 47.0 to 68.3 ± 23.8 mL, EDD from 48.2 ± 6.6 to 41.6 ± 7.1 mm, and ESD from 39.6 ± 6.9 to 32.7 ± 6.5 mm (p < 0.05 for each). Ejection fraction increased from 38.5 ± 8.9 to 52.0% ± 7.7% and fRVO from 4.0 ± 0.8 to 4.6 ± 1.1 L/min (each with p < 0.05). TRF decreased from 18.2 ± 14.1 to 10.4% ± 13.5%, whereas SV and RVO remained nearly unchanged. Postoperatively, RV volumes, EF, and fRVO were not different from 15 age- and gender-matched normal control patients.

Conclusions

Implantation of a CSD leads to a decrease in RV size and improved RV performance. These data together with the results of previous studies demonstrating improved left ventricular structure and function confirm the biventricular nature of recovery with the CSD.     

Extracorporeal membrane oxygenation and Thoratec pneumatic ventricular assist devices as double bridge to heart transplantation

Introduction

Ventricular assist devices have benefited patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experiment of HTx using extracorporeal membrane oxygenation (ECMO) with Thoratec pneumatic ventricular assist device (TpVAD).

Methods

From May 1996 to June 2011, among 410 patients who underwent HTx 23 required mechanical circulatory support (MCS) with implantation of the TpVAD and 15 (65%) of them received grafts.

Results

The 23 patients included 4 female and 19 male patients of age range 10 to 80 years. Eighteen (78%) of them needed ECMO before TpVAD implantation. Twelve (67%) were implanted with a TpVAD double bridge to HTx. The demand for MCS among patients with acute hemodynamic collapse has led to major improvements in the existing systems such as ECMO with double bridge to TpVAD.

Conclusion

We used ECMO as a rescue procedure for acute hemodynamic deterioration. However, during ECMO support, left ventricular afterload increased. If prolonged support is required, TpVAD might be required: 15 (65%) of patients supported by ECMO with TpVAD needed to a wait a suitable donor. We recommend the application of ECMO for short-term support (within 1 week), and TpVAD as a bridge for medium- or long-term support.     

The effect of pericardial incision on right ventricular systolic function: a prospective observational study

Background

Echocardiographic longitudinal markers of right ventricular (RV) systolic function are commonly depressed after coronary artery bypass graft surgery (CABG) despite an uncomplicated course and good clinical recovery. The exact timing and cause of these changes is unknown. The aim of this observational study was to monitor echocardiographic markers of RV systolic function intraoperatively during CABG. We used angle-independent speckle tracking to measure the primary endpoints of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (S′) before and after pericardiotomy.

Methods

Twenty-four patients undergoing elective on-pump CABG were enrolled in the study. Speckle tracking-derived TAPSE, S’, free wall systolic strain, RV outflow tract strain, colour tissue Doppler-derived isovolumic acceleration (IVA) and two-dimensional RV dimensions and fractional area change (FAC) were measured at three intraoperative time points: 1) after sternotomy immediately prior to pericardiotomy; 2) after pericardiotomy and placement of pericardial retraction sutures; and 3) following cardiopulmonary bypass after chest closure.

Results

Adequate image quality to perform speckle tracking measurements was obtained in twenty-one patients. We found that there were no significant changes to echocardiographic parameters of RV systolic function between pre- and post-pericardiotomy. The mean (SD) of the primary endpoints were: TAPSE [28.1 (5.1) mm vs 27.7 (7.4) mm, respectively; mean difference, ?0.4 mm; 97.5% confidence interval (CI), ?4.0 to 3.1; P = 0.76] and S′ [10.4 (2.1) cm·sec^?1 vs 10.8 (1.9) cm·sec^?1, respectively; mean difference, 0.4 cm·sec^?1; 97.5% CI, ?0.9 to 1.7; P = 0.48]. Significant reductions in the parameters of RV systolic function were found only after cardiopulmonary bypass and chest closure.

Conclusion

Pericardial opening and suspension had no significant effect on the indices of RV systolic function derived from speckle tracking or colour tissue Doppler.

     

Perinatal profile of ventricular overload markers in congenital diaphragmatic hernia

Background

In congenital diaphragmatic hernia (CDH), pulmonary hypertension increases right ventricle (RV) afterload, which could impair heart function and contribute to poor outcome for most affected infants. Nevertheless, the real significance of vascular pulmonary alterations in perinatal hemodynamics is largely unknown. It is defined that ventricular pressure overload induces increased myocardium gene expression of B-type natriuretic peptide (BNP) and components of the renin-angiotensinogen and endothelin (ET)-1 systems. Our aim was to evaluate perinatal myocardium expression of these genes associated with ventricular pressure overload in a nitrofen-induced CDH rat model.

Methods

In the nitrofen-induced CDH rat model, fetuses from dated pregnant Sprague-Dawley rats at 15.5, 17.5, 19.5 and 21.5 days postcoitum as well as newborn pups were assigned to 3 experimental groups: control, nitrofen (exposed to nitrofen, without CDH), and CDH (exposed to nitrofen, with CDH). Myocardial samples collected from the RV and left ventricle (LV) were processed for quantification of messenger RNA (mRNA) of BNP, angiotensinogen, and ET-1.

Results

The perinatal expression of BNP, angiotensinogen, and ET-1 mRNA in the RV and LV of the control group revealed daily changes. During gestation, the expression of BNP and angiotensinogen mRNA underwent significant oscillation compared with control in both nitrofen-exposed fetuses, although we cannot identify significant differences between the nitrofen and CDH groups. After birth, we found a significant increasing expression of all studied genes only in the RV of CDH pups.

Conclusions

Perinatal myocardial quantification of BNP, angiotensinogen, and ET-1 mRNA levels suggests that both nitrofen-exposed and control pups revealed prenatal variations of expression of the studied genes. Moreover, CDH is associated with significant molecular alterations only in the RV after birth.     

Validation of a Cutoff Value on Echo Doppler Analysis to Replace Right Heart Catheterization During Pulmonary Hypertension Evaluation in Heart Transplant Candidates

Background

Heart transplantation (OHT) has traditionally been contraindicated in the presence of severe pulmonary hypertension (PH), as detected by right heart catheterization. Noninvasive methods are still not reliably accurate to make this evaluation.

Objectives

Determine the efficacy of echo Doppler analysis for the diagnosis of severe PH.

Methods

One hundred thirty patients (mean age = 42 ± 15 years, 82 men) showed severe left ventricular dysfunction (mean ejection fraction = 29 ± 12%; functional class III-IV). We excluded patients with atrial fibrillation, heart failure secondary to congenital disease, and valvulopathy. The pulmonary parameters defined as severe PH were: systolic pulmonary artery pressure (sPAP) ≥ 60 mm Hg; a mean transpulmonary gradient ≥ 15; or pulmonary vascular resistance ≥ 5 Wood units. Patients underwent a right heart catheterization using a Swan-Ganz catheter to measure hemodynamic parameters and to noninvasively estimate right-sided pressures from spectral Doppler recordings of tricuspid regurgitation velocity (right ventricular systolic pressure [RVsP]). A Pearson correlation of sPAP was obtained with RVsP by; the sensitivity of RVsP for the diagnosis of PH was determined by a receiver operating characteristic (ROC) curve.

Results

A good correlation between sPAP and RVsP was obtained by Pearson correlation analysis (r = 0.64; 95% confidence interval [CI] 0.50-0.75; P < .001). The ROC curve analysis showed a sensitivity of 100%, a specificity of 37.2%, (95% CI 0.69-0.83, P < .0001) of a RVsP < 45 mm Hg (cutoff) on the exclusion of severe PH.

Conclusions

The cutoff of RVsP < 45 mm Hg, on noninvasive echo Doppler evaluation of PH is an efficient method to replace invasive heart catheterization in OHT candidates.     

Severity of intraoperative tricuspid regurgitation predicts poor late survival following cardiac transplantation

Background

This study evaluates the significance of tricuspid regurgitation (TR) on long-term survival as detected by intraoperative transesophageal echocardiography at the time of orthotopic heart transplantation. Although significant (2+ to 4+) TR after orthotopic heart transplantation is rare, its influence on long-term survival is unknown, warranting further investigation.

Methods

Between January 1992 and July 2001, 181 consecutive patients underwent orthotopic heart transplantation. Tricuspid regurgitation was graded by intraoperative transesophageal echocardiography after final separation from cardiopulmonary bypass in 130 of 181 patients (72%).

Results

Although 80% (104/130) of patients had either no (0, n = 77) or trace (1+, n = 27) TR, 9% (12/130 patients) had mild (2+), 10% (13/130 patients) had moderate (3+), and 0.8% (1/130 patients) had severe (4+) TR. The severity correlated strongly with the presence of right ventricular dysfunction (p < 0.001). In a multivariate regression model, gender mismatch (p = 0.002) and right ventricular dysfunction (p < 0.001) were independent predictors for equal to or greater than mild (2+ to 4+) TR (p = 0.015). Although the degree of recipient pulmonary vascular resistance did not influence the grade (p = 0.600), higher pulmonary vascular resistance tended to increase the severity of TR in the setting of prolonged donor ischemic times (p = 0.054). Proportional hazards regression analysis demonstrated significantly decreased survival for patients with mild or greater (2+ to 4+) TR detected by transesophageal echocardiography at the time of transplantation (p < 0.001) and RV dysfunction (p = 0.023).

Conclusions

Even mild (≥ 2+) TR identified by transesophageal echocardiography at the time of orthotopic heart transplant predicts poor late survival, suggesting a possible role for concomitant tricuspid valve repair at the time of transplant. Whether or not tricuspid valve repair will improve long-term survival is unknown.     

Poor Correlation of Estimated Pulmonary Artery Systolic Pressure Between Echocardiography and Right Heart Catheterization in Patients Awaiting Cardiac Transplantation: Results From the Clinical Arena

Background

Pulmonary arterial pressure measurement is an integral part of the pre-heart transplant evaluation. In the clinical arena, the correlation and agreement between pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography versus catheterization in pre-heart transplant patients has not been studied.

Methods

Data on all patients evaluated for heart transplantation at our program between 2003 and 2005 (n = 176) were retrospectively reviewed. Patients with both transthoracic echocardiography (with interpretable images) and right heart catheterization performed were included (n = 108; mean time difference, 2.2 days; median, 2 days). The tricuspid valve regurgitant jet was identified by color flow Doppler and jet maximum velocity was measured by continuous wave Doppler. The PASP was estimated by using the modified Bernoulli equation and adding right atrial pressure. We correlated echocardiographically estimated PASP with that measured by right heart catheterization.

Results

Mean estimated PASP by echocardiography was 46.6 ± 13.7 mmHg versus 44.8 ± 17.9 mmHg by right heart catheterization (P = NS). However, the correlation between echocardiographic and measured PASP was poor (r = 0.49, P < .001). The correlation was poor in both ischemic and nonischemic cardiomyopathy.

Conclusion

Among patients referred for heart transplant evaluation, there is poor agreement and correlation between echocardiographically estimated PASP and values obtained by right heart catheterization. Furthermore, echocardiographically obtained estimates of PASP should not be exclusively relied upon to exclude heart transplant recipient candidates.     

Prediction of Short-Term Outcomes in Patients With Idiopathic Dilated Cardiomyopathy Referred for Transplantation Using Standard Echocardiography and Strain Imaging

Objective

We sought to evaluate the short-term prognostic value of echocardiography including two-dimensional (2D) strain imaging in patients with end-stage idiopathic dilated cardiomyopathy (IDCM).

Methods

To evaluate the short-term (6-month) prognostic value of different parameters used for the assessment of IDCM patients referred for heart transplantation, we performed at the baseline transthoracic echocardiography including 2D strain imaging, N-terminal pro-BNP measurements, and exercise testing for all patients included in the study. After 6 months, all parameters, including endsystolic strain (ESS), peak systolic strain rate (SSR_max), early and late diastolic strain rates, their ratio (diastolic strain rate E [DSR_E], dialostolic strain rate A [DSR_A], diastolic strain rate E and A wave ratio [DSR_E/A]), and systolic intraventricular dyssynchrony indexes (IVDSI) were tested for their prognostic value to predict a patient's outcome.

Results

At the baseline stable patients had significantly lower transmitral E and A wave ratio (E/A), DSR_E/A, higher DSR_A values, longer transmitral E wave deceleration time (DcT), higher longitudinal ESS and SSR_max values, lower systolic circumferential and longitudinal IVDSI.

Conclusion

The highest sensitivity for rapid heart failure progression was shown by DcT <100 ms, E/A > 1.5, DSR_A < 0.3/s, circumferential IVDSI > 0.16, and longitudinal IVDSI > 0.22 (91%, 78%, 94%, 83%, and 75%, respectively).     

Evaluation of TAPSE as a measure of right ventricular output

Purpose

This study was designed to show the relationship between tricuspid annular plane systolic excursion (TAPSE) and stroke volume (SV) by thermodilution using three different methods and also to assess whether TAPSE can track hemodynamic changes associated with volume loading and ephedrine administration.

Methods

This was an observational study in 61 elective patients with a pulmonary artery catheter who were undergoing coronary artery bypass graft surgery in a cardiac surgical centre. We measured TAPSE by three methods using transesophageal echocardiography: M mode, speckle tracking at the lateral wall, and tissue tracking at the inferior wall. There were two interventions: leg raising (volume recruitment) or administration of ephedrine 5?mg iv. Echo and hemodynamic measurements were performed before and after each intervention.

Results

Eleven patients were excluded due to poor imaging. There were 26 patients in the leg raising group and 24 patients in the ephedrine group. The correlation coefficient between stroke volume (SV) and TAPSE by M mode, speckle tracking, and tissue tracking was 0.48, 0.44, and 0.09, respectively. There was a significant increase in SV following each intervention; however, the changes in TAPSE by any method and velocity were not large enough to reach statistical significance.

Conclusion

Tricuspid annular plane systolic excursion by M mode and by speckle tracking correlates modestly with SV. There was no correlation between TAPSE and SV by tissue tracking at the inferior wall of the right ventricle. Tricuspid annular plane systolic excursion by M mode and by speckle tracking does not track changes in SV following either volume loading or ephedrine administration.     

Late right ventricular performance after mitral valve repair assessed by exercise echocardiography

Objectives

The aim of the study was to evaluate the right ventricular (RV) performance during exercise in patients who underwent mitral valve repair for chronic mitral valve insufficiency relative to healthy individuals and to assess exercise capacity using a semisupine ergometer.

Methods

We studied 56 patients who underwent mitral valve repair for degenerative posterior mitral leaflet prolapse between 2005 and 2014 and a control group of 13 healthy individuals. Clinical data were collected prospectively, and echocardiographic measurements of RV function were obtained at rest and at peak exercise.

Results

One-third of the study patients had RV systolic dysfunction as indicated by tricuspid annular plane excursion (TAPSE) at rest. Resting TAPSE was lower in the study group (16.7?±?3.3 mm) than in the control group (24.4?±?4.3 mm), p?<?0.001. TAPSE increased in both groups during exercise and exercise was shown to have a significant main effect on TAPSE F(1, 52)?=?80, p?<?0.001. TAPSE increased more in the control group and an interaction was detected between the participant groups (study group vs. control group) and exercise, F(1, 52)?=?24, p?<?0.001. In the study group, Poor postoperative RV function was associated with preoperative left ventricular dilatation but was not correlated with impaired maximum exercise capacity.

Conclusions

Despite the excellent clinical outcome during rest and exercise after mitral valve repair, our results suggest patients that have undergone mitral valve repair due to posterior leaflet prolapse have significantly reduced RV function at rest and during exercise compared to healthy controls at long-term follow-up, as measured by TAPSE.

     

Heart Transplantation in Arrhythmogenic Right Ventricular Dysplasia: Case Reports

Objective

Arrhythmogenic right ventricular dysplasia (ARVD) is a myocardial disease of familiar, origin where the myocardium is replaced by fibrofatty tissue predominantly in the right ventricle. Herein we have presented the clinical courses of 4 patients with ARVD who underwent orthotopic heart transplantation.

Patients and Methods

Among 358 adult patients undergoing heart transplantation, 4 (1.1%) displayed ARVD. The main indication for transplantation was the progression to heart failure associated with arrhythmias. All 4 patients displayed rapid, severe courses leading to heart failure with left ventricular involvement and uncontrolled arrhythmias.

Results

In all cases the transplantation was performed using a bicaval technique with prophylactic tricuspid valve annuloplasty. One patient developed hyperacute rejection and infection, leading to death on the 7th day after surgery. The other 3 cases showed a good evolution with clinical remission of the symptoms. Pathological study of the explanted hearts confirmed the presence of the disease.

Conclusions

ARVD is a serious cardiomyopathy that can develop malignant arrhythmias, severe ventricular dysfunction with right ventricular predominance, and sudden cardiac death. Orthotopic heart transplantation must always be considered in advanced cases of ARVD with malignant arrhythmias or refractory congestive heart failure with or without uncontrolled arrhythmias, because it is the only way to remit the symptoms and the disease.     

N-Terminal Brain Natriuretic Peptide as a Diagnostic Test in Cirrhotic Patients With Pulmonary Arterial Hypertension

Background

The aim of this study was to assessed the correlation of N-terminal natriuretic peptide type B (NT-proBNP) with echocardiographic and hemodynamic indexes of right ventricular (RV) function and to evaluate the sensitivity and specificity of Doppler echocardiography in the diagnosis of portopulmonary hypertension.

Methods

All patients underwent liver transplantation for cirrhosis. We obtained clinical data, NT-proBNP levels, echocardiography, and right heart hemodynamic measurements before transplantation.

Results

Patients with pulmonary hypertension displayed significantly higher levels of NT-proBNP. They also showed higher model for End-stage Liver Disease scores and higher indices of RV overload on cardiac hemodynamics. The negative predictive value of echocardiography to identify pulmonary hypertension was 83%. A correlation was not observed between systolic pulmonary artery pressures measured by the two methods; however, NTproBNP showed a trend toward a significant correlation with mean pulmonary pressure as determined by hemodynamics (r = .3; P < .01).

Conclusion

We concluded that NT-proBNP values showed significant correlations with pulmonary hypertension that could assist in a noninvasive diagnoseis for this group of patients.     

Preoperative evaluation improves the outcome in heart transplant recipients with pulmonary hypertension--retrospective analysis of 106 cases

Objectives

The objectives of this study were to retrospectively analyze the value of preoperative evaluation and to analyze the risk factors of long-term mechanical ventilation in heart transplant recipients.

Methods

We analyzed the data of 106 patients prepared to receive heart transplants. Before the operation, according to the pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG), the patients were divided into 2 groups: a pulmonary hypertension (PH) group and a pulmonary artery pressure normal (N) group. The vasodilator conditioning test as a predictive factor was performed in the PH group. Univariate analysis and logistic regression were used to examine the relationship between risk factors and long-term mechanical ventilation. The 30-day and long-term survival rates were followed.

Results

PVR and TPG significantly decreased among the PH group after intravenous infusion epoprostenol and inhalation (nitric oxide). After preoperative evaluation, 96 patients underwent heart transplantation. There were no short-term deaths related to PH. There was no significant difference in mortality between the PH group and the N group. PH, hypotension after cardiopulmonary bypass, renal dysfunction, donor heart ischemia time, and ejection fraction <25% were risk factors for long-term mechanical ventilation. PH was not related to long-term deaths.

Conclusion

A vasodilator conditioning test was reliable for PH patients undergoing heart transplantation for preoperative evaluation and preparation.     

A one-year comparison of prophylactic donor tricuspid annuloplasty in heart transplantation

Background

The bicaval technique for orthotopic heart transplantation decreases the incidence of tricuspid valve regurgitation when compared with the standard biatrial technique. This study was designed to study the effects of prophylactic tricuspid valve annuloplasty during bicaval orthotopic heart transplantation on survival, renal function, and amount of tricuspid valve regurgitation.

Methods

Between April 1997 and March 1998, 60 patients (age 18 to 70 years, 22 women) randomly received either bicaval orthotopic heart transplantation (n = 30) or bicaval orthotopic heart transplantation with DeVega tricuspid valve annuloplasty (n = 30). Tricuspid valve annuloplasty was performed on the donor heart before implantation using pledgeted 2-0 polypropylene suture and sized to an annulus of 29 mm. Echocardiographic variables, laboratory values, and hemodynamics were obtained prospectively and reviewed by an independent data analyst.

Results

Intraoperatively, the group undergoing tricuspid valve annuloplasty had a shorter reperfusion time (46 ± 29 minutes versus 65 ± 48 minutes; p < 0.05) and higher mean pulmonary artery to central venous pressure difference (11.8 ± 3.7 mm Hg versus 15.3 ± 4.1 mm Hg; p = 0.001). Additional differences between the two groups included early mortality from donor dysfunction (4 of 30 patients versus 0 of 30 patients; p < 0.05), amount of tricuspid valve regurgitation at 1 year (1.3 ± 1.0 versus 0.2 ± 0.3; p < 0.05), and percentage of patients with 2+ or greater tricuspid valve regurgitation (34% versus 0%; p < 0.05).

Conclusions

Tricuspid valve annuloplasty of the donor heart before bicaval orthotopic heart transplantation improves immediate donor heart function as demonstrated by better right ventricular performance, lower perioperative mortality, and shorter reperfusion times. At 1 year, there is less tricuspid valve regurgitation but no difference in renal function. Considering the ease and safety of tricuspid valve annuloplasty and its advantages, it should be performed as a routine adjunct with bicaval orthotopic heart transplantation.     

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation

Study Objective

To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia.

Design

Prospective, randomized, double-blinded, placebo-controlled study.

Setting

Large university-affiliated community hospital.

Patients

81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section.

Interventions

Parturients received 1.0 to 1.5 L of intravenous Ringer's lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg).

Measurements

Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline.

Main Results

None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia (P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate.

Conclusion

Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.     

Bacillus Calmette-Guérin without maintenance therapy for high-risk non-muscle-invasive bladder cancer

Background

Bacillus Calmette-Guérin (BCG) is the standard intravesical treatment of high-risk noninvasive (Ta, T1, Tis) bladder cancer. Maintenance BCG is recommended for maximum efficacy.

Objective

We compared our results in a large cohort of high-risk bladder cancer patients who received BCG without maintenance with published results from randomized maintenance BCG trials.

Design, setting, and participants

A cohort of 1021 patients underwent restaging transurethral resection for high-risk (Ta, T1, Tis) bladder cancer.

Intervention

Patients received a 6-wk induction course of BCG therapy. Responding patients did not receive maintenance BCG. Relapsing patients were eligible for retreatment with BCG. All patients were followed for a minimum of 5 yr.

Measurements

End points were 5-yr tumor- and progression-free survival rates.

Results and limitations

Of 816 complete responders to induction BCG, 2- and 5-yr recurrence-free survival rates were 73% and 46%, respectively. The progression-free survival rate was 89%. Progression-free survival time was 56 mo (95% confidence interval, 55-58 mo). Thirty-two percent of the patients required another course of BCG therapy. We cannot exclude that maintenance BCG may benefit patients beyond 5 yr over induction BCG alone and selective BCG retreatments.

Conclusions

Our results with BCG treatment without maintenance of patients with high-risk non-muscle-invasive bladder cancer compare favorably with trials in which comparable patients received maintenance BCG.     

Atrial Flutter after Heart Transplantation: Mechanism and Catheter Ablation

Background

Atrial flutter is a frequent arrhythmia after heart transplantation, but little is known about its mechanism and treatment. We report the results of an electrophysiologic study in patients with atrial flutter after orthotopic heart transplantation, describing its mechanism and demonstrating the acute and long-term efficacy of catheter ablation for treating this arrhythmia.

Methods

We included 14 patients with symptomatic atrial flutter after orthotopic heart transplantation. All of them underwent an electrophysiologic study to determine the mechanism of the arrhythmia and catheter ablation when possible.

Results

Counterclockwise right atrial circuit around the tricuspid annulus involving the cavotricuspid isthmus was demonstrated in 13 patients (86%). Catheter ablation of the isthmus was performed with good acute results in all but 1. During a mean follow-up of 24 ± 17 months, recurrent atrial flutter was documented in 3 patients and atrial fibrillation in 2. In another patient, we demonstrated a left atrial origin.

Conclusions

The most common mechanism of atrial flutter in heart transplant recipients is a counterclockwise circuit around the tricuspid annulus involving the cavotricuspid isthmus. Catheter ablation of the isthmus between tricuspid annulus and posterior atrial suture line represents an effective treatment in these patients. This condition may be avoided by changing the surgical technique to a bicaval anastomosis.     

Surgical therapy of end-stage heart failure in pediatric patients

Objective

We herein review our experience with ventricular assist device (VAD) implantation and heart transplantation in children with end-stage heart failure.

Methods

We performed a retrospective nonrandomized review of all patients who underwent insertion of a Berlin Heart Excor VAD or heart transplantation in our clinic. The study spans from July 2005 to July 2010. We transplanted 11 patients of mean age 11.8 ± 4.49 years, 3 of whom with critical hemodynamic situations were bridged to heart transplantation by VAD implantation. Despite the poor right ventricular systolic functions, they did not require right rVAD. In addition, 2 patients who underwent VAD implantation are still awaiting a donor heart. The mean follow-up was 825.27 ± 630.23 days (range, 21-1,888 days).

Results

There was no serious complication during VAD support. The overall heart transplantation mortality rate was 9.1% (1/11). In all patients, impaired end-organ functions were improved by VAD implantation before the heart transplantation. Cardiac biopsies revealed 4 grade 2R rejection episodes, which were successfully controlled in 3 patients.

Conclusion

Heart transplantation is highly effective therapy for pediatric patients with end-stage heart failure. Pediatric VAD implantation provided satisfactory safe circulatory support for small children in poor condition on the waiting list. This option should be considered for all pediatric candidates who show a poor hemodynamic status.     

Excellence of Suito Index for Assessing Clinical Outcome of Islet Transplantation

Background

Monitoring functional islet mass after transplantation is critical to follow patients. Previously we demonstrated that the average secretory unit of islet transplant objects (SUITO) index within 1 month was an excellent predictor of insulin-free status or reduction in insulin dose. In this study, we analyzed the usefulness of daily SUITO index to assess clinical outcomes.

Methods

Five patients underwent islet transplantation, including 3 who received 2 transplantations and 2 who received a single graft. All 5 patients achieved insulin-free status with 3 remaining insulin free at the time of evaluation. We analyzed the daily relative insulin dose and SUITO index. The daily relative insulin dose was calculated as the total daily insulin dose/average pretransplant insulin dose. The SUITO index was calculated as [fasting C-peptide (ng/mL)]/[fasting blood glucose (mg/mL) − 63] × 1,500. The data analyzed based on time after islet transplantation were categorized as within or after 1 month.

Results

Within 1 month after islet transplantation, there was no correlation between the daily relative insulin dose and the daily SUITO index (P = .068; R = −0.33). After 1 month, the daily relative insulin dose and the daily SUITO index were strongly correlated (P < .0001; R = −0.70). When the cutoff value of the SUITO index was decided at 26 for insulin-free status, the positive predictive value was 84.1% and negative predictive value 89.4%.

Conclusion

SUITO index was an excellent index to assess clinical outcomes beyond 1 month after islet transplantation.