Clinical features of non-tuberculous constrictive pericarditis

Ikram, H., Banim, S. O., and Makey, A. R. (1974).Thorax, 29, 204-208. Clinical features of non-tuberculous constrictive pericarditis. This paper describes the clinical features of five cases of constrictive pericarditis of non-tuberculous aetiology. The findings in this syndrome are compared with those in tuberculous constrictive pericarditis. The non-tuberculous variety had a short history, and absence of ascites and third heart sounds. Pericardial calcification, paradoxical arterial pulse, and the marked `y' descent in the venous pulse were absent in contrast to tuberculous constriction. An atrial sound was usual and the chief venous wave was the `a' wave.     

原位心脏移植术后并发急性肾损伤临床分析

目的分析原位心脏移植受者术后急性肾损伤(acute kidney injury,AKI)发生情况并总结相关防治经验。 方法回顾性分析南京市第一医院2014年1月至2018年12月行原位心脏移植术的38例受者临床资料,根据2012年改善全球肾脏疾病预后组织发布的AKI诊断标准分为AKI组(21例)及对照组(17例),并对发生AKI的受者进行肾功能损伤分期。比较两组受者术后一般资料及预后转归。采用两独立样本t检验比较两组受者年龄,体表面积,体质指数,术前血清肌酐、肾小球滤过率、血红蛋白、血糖、肺动脉收缩压、左室射血分数、心输出量,术中心肺转流时间、主动脉阻断时间、尿量、输注晶体量/胶体量、手术时间,术后中心静脉压(CVP)、右心室直径、左室射血分数、24 h尿量以及机械通气时间、ICU停留时间和总住院时间。采用Fisher确切概率法比较两组受者性别、术前合并症以及术后28、90和180 d死亡比例。P<0.05为差异有统计学意义。 结果38例受者中有21例(55.3%)术后7 d内发生AKI,其中AKI 1期15例,AKI 2期4例,AKI 3期2例。AKI组受者术前肺动脉收缩压为(60±18)mmHg(1 mmHg＝0.133 kPa),高于对照组[(45±15)mmHg],差异有统计学意义(t＝2.790,P<0.05)。截至2019年6月,所有受者随访时间为6～56个月。AKI组和对照组受者术后CVP、术后右心室直径和ICU停留时间分别为(12.1±4.1)和(9.3±2.8)mmHg、(26.1±2.7)和(23.7±2.4)mm、(10.0±9.4)和(5.2±1.6)d,差异均有统计学意义(t＝2.365、2.829和2.038,P均<0.05)。经过治疗,15例AKI 1期受者中12例肾功能恢复正常,2例遗留慢性肾功能不全,1例因纵隔严重感染致多器官功能衰竭死亡。4例AKI 2期受者中3例肾功能恢复正常,1例遗留慢性肾功能不全。2例AKI 3期受者均对利尿剂反应不佳,最终1例心功能恢复,但遗留慢性肾功能不全,另1例因多器官功能衰竭死亡。 结论AKI是心脏移植术后较为常见的并发症之一,但只要积极预防、及时诊断、有效处理,大部分受者肾功能可恢复。     

Clinical significance of tricuspid valve dysfunction after orthotopic heart transplantation.

OBJECTIVES: Tricuspid regurgitation (TR) is common after heart transplantation (OHT), but its clinical relevance is undetermined. This study documents the clinical progress of patients with TR after OHT in relation to the severity of TR. METHODS: We studied 238 transplant recipients who had survived for at least 12 months after OHT. Tricuspid regurgitation was graded clinically and by assessing regurgitant jet area. Recipients were divided into those with no TR Group 1 (n = 64), those with sub-clinical TR (TR absent clinically and regurgitant jet area <25%, Group 2 (n = 89), and those with clinical TR (with clinical TR or regurgitant jet area > or =25%, Group 3 (n = 85). RESULTS: We found no significant difference among the groups in terms of age, or pre-operative events. At 12 months after OHT, mean right atrial and pulmonary artery pressures were higher in Group 3 than in Group 1 or Group 2 (p = 0.005 and 0.03, respectively). Right ventricular end-diastolic and end-systolic volumes were smaller for recipients in Groups 1 and 2 compared with those in Group 3 (p = 0.01 and 0.02). The annual development of renal impairment was 0.019 (95% confidence interval [CI], 0.014-0.029), 0.026 (95% CI, 0.022-0.62), and 0.613 (95% CI, 0.346-0.756) in Groups 1, 2, and 3, respectively (p = 0.02). At the most recent follow-up, mean New York Heart Association class for Group 1 was 1.4, for Group 2 was 1.7, and for Group 3 was 2.7 (p = 0.04). CONCLUSIONS: The integrity of the tricuspid valve has a significant impact on long-term clinical progress of OHT recipients. Recipients with significant TR are more symptomatic and have poorer right-sided heart function compared with those with mild or no TR.     

心脏移植术后心内膜—心肌活检的临床应用

结合３例同种原位心脏移植患者术后３３例次心内膜－心肌活检，探讨活检钳进入静脉的径路，ＥＭＢ取材部位，ＥＭＢ的并发症以及ＥＭＢ在诊断急性心脏排斥反应中的作用等。ＥＭＢ取对静脉插管使用最多的是锁骨下静脉及股静脉，颈内静脉２次，多在右心室间隔部取材，每次取材２－３块。３例患者行ＥＭＢ均未发生严重并发症。     

Microcirculatory alterations after orthotopic pig-to-baboon heart transplantation

Bauer A, Renz V, Baschnegger H, Abicht J‐M, Beiras‐Fernandez A, Brenner P, Thein E, Schmoeckel M, Reichart B, Christ F. Microcirculatory alterations after orthotopic pig‐to‐baboon heart transplantation. Xenotransplantation 2011; 18: 232–238. © 2011 John Wiley & Sons A/S. Abstract: Background: Whilst macrohemodynamic function of porcine xenografts transplanted into baboons has been assessed perioperatively, the ability of the xenograft to maintain systemic microcirculatory perfusion has not been investigated after pig‐to‐baboon xenotransplantation so far. Methods: We investigated the sublingual microcirculation of six baboons undergoing orthotopic transplantation of hCD46‐transgenic pig hearts using orthogonal polarization spectral imaging. Microvascular measurements were performed after induction of anesthesia, in the early phase of cardiopulmonary bypass (CPB), during reperfusion of the porcine heart and 1 h after the xenograft had resumed its life‐supporting function. Microvascular blood flow was analyzed semiquantitatively and the number of visualized cell‐to‐cell interactions was counted. Results: The proportion of continuously perfused microvessels was 97 (96 to 97) % at baseline and 95 (94 to 97) % in the early phase of CPB. It decreased significantly (P < 0.05) during CPB to 89 (84 to 91), and alterations were still present (P < 0.05) when CPB was terminated and the xenograft had taken over systemic perfusion 83 (81 to 85) %. The microcirculatory changes correlated with the lactate levels (y = 18.1–0.18 x; r² = 0.55; P < 0.001), but no correlation with macrohemodynamic parameters was found. Conclusion: Microvascular blood flow is altered after orthotopic pig‐to‐baboon heart transplantation, despite systemic hemodynamic parameters being well maintained by the porcine xenograft. These changes are moderate but persist after termination of CPB. Further studies need to elucidate whether these changes are transient or add to the mortality associated with cardiac xenotransplantation.     

Mitral regurgitation after pericardiectomy for constrictive pericarditis

We report a case of constrictive pericarditis in which trace mitral valve regurgitation was detected preoperatively and temporarily worsened after a pericardiectomy was performed. The early postoperative data suggested that the increased mobility of the lateral wall, in conjunction with an increase in the left ventricular volume, might be one of the causes of the perioperative mitral valve dysfunction. The mitral valve function returned to the preoperative baseline thirteen months after the pericardiectomy.     

Transient constrictive pericarditis after coronary bypass surgery

Constrictive pericarditis is a rare complication after coronary artery bypass grafting In most cases pericardiectomy is required as a definitive treatment. However, there are several types of constrictive pericarditis such as transient cardiac constriction. Some types of constrictive pericarditis can only be managed with medical therapy. We report a 72-year-old female patient who developed subacute transient constrictive pericarditis with persistent left pleural effusion as a result of postcardiac injury syndrome. The patient went through coronary bypass surgery that was successfully treated with postoperative steroid therapy.     

Predictors of pericardial effusion after orthotopic heart transplantation

OBJECTIVES: Pericardial effusion occurs frequently after orthotopic heart transplantation, but the causes of this complication have not been well described. This study was designed to identify factors predisposing toward the development of significant postoperative pericardial effusions in a large, single-institution population of orthotopic heart transplant recipients. METHODS: A retrospective review of more than 90 preoperative, intraoperative, and postoperative variables was conducted for 241 patients undergoing orthotopic heart transplantation from September 1988 to December 1999. Patients who had significant postoperative pericardial effusions develop were identified from postoperative echocardiograms by standard criteria. Factors associated with the development of significant pericardial effusions were determined by multivariate logistic regression analysis. RESULTS: Echocardiographic data were available for 203 of 241 transplant recipients. Forty-two patients (21%) had significant effusions develop. According to multivariate analysis, pericardial effusions were less likely to occur in recipients with a history of previous cardiac surgery (odds ratio 0.13, 95% confidence interval 0.05-0.36, P <.0001) and with greater weight (odds ratio 0.96, 95% confidence interval 0.94-0.99, P <.0048). Pericardial effusions were more likely to occur in patients who had received aminocaproic acid during the operation (odds ratio 5.92, 95% confidence interval 2.23-15.72, P <.0008). Patient survival and hospital length of stay did not differ between patients with and without postoperative pericardial effusions. CONCLUSIONS: Postoperative pericardial effusions develop in approximately 20% of patients undergoing orthotopic cardiac transplantation. On the basis of the risk factors identified in this study, prevention may prove difficult, although avoidance of the intraoperative use of aminocaproic acid may be helpful.     

Hepatic function after surgical repair of constrictive pericarditis

We report the results of long-term follow up in 9 patients who underwent pericardiectomy for constrictive pericarditis. In order to test whether if congestive liver dysfunction due to the disease could be reversible or not after the surgical repair, the patients were evaluated by indocyanine green (ICG) clearance test. All the patients improved in NYHA classification after long-term periods following surgical repairs. The percentage of ICG retention at 15 minutes (ICG-R15) improved in most of the patients. However, two patients who had a long history from the onset before surgery became worse in ICG-R15. From the above reports, reversibility of hepatic function might be dependent on the duration of liver congestion before surgical repairs.     

原位心脏移植术后早期超声心动图改变

目的  探讨应用超声心动图在原位心脏移植术后的早期应用价值。方法  应用超声心动图对29例原位心脏移植术后患者进行早期监测, 于术后1、7、14、30 d记录左心室舒张末径(LVDd)、右心室舒张末径(RVDd)、室间隔厚度(IVST)、左心室后壁厚度(LVPWT)和三尖瓣反流面积, 并计算左心室射血分数(LVEF)、左心室Tei指数(LV-Tei)。同时记录患者血压、中心静脉压(CVP)。结果  与术后1 d比较, 术后7、14、30 d的LVDd均较大, RVDd均较小(均为P < 0.05)。与术后7 d比较, 术后1、14、30 d的IVST、LVPWT数值均较低(均为P < 0.05)。与术后7 d比较, 术后1、14、30 d的血压、CVP、LV-Tei数值均较低, 差异有统计学意义(均为P < 0.05);各时间点LVEF比较差异无统计学意义(均为P>0.05)。超声心动图检查于术后3~4 d发现三尖瓣反流, 三尖瓣反流面积于术后5~8 d达最大面积(9.2±2.5) cm², 此后反流面积逐渐减少, 术后1个月时减少至(4.7±2.4)cm²。结论  在原位心脏移植术后早期, 应用超声心动图可有效监测移植心脏的结构及功能情况, 及时为临床医师提供多种参数作为诊疗的依据。     

Quality of life after orthotopic heart transplantation.

During the last decade heart transplantation has become the chosen method to treat terminally ill patients suffering from severe cardiac illness. It was the aim of our study to retrospectively survey life quality of donor organ recipients who underwent heart transplantation during the first years of transplantation at our center (1984 through 1987). Thirty-five patients were asked to evaluate their postoperative improvement or deterioration and their satisfaction with the level reached on visual scales. Life quality was defined in nine areas: physical, emotional, mental, vocational, and sexual status, financial situation, leisure activities, partnership, and overall life quality. The following results were obtained: (1) our former patients informed us about a distinct improvement in almost all dimensions (except financial situation). We found an absolute increase in life quality after heart transplantation. (2) Although improvement was ranked best for physical status, there was also a high amelioration in psychosocial fields. (3) A significant difference was seen between changes in condition and satisfaction in the financial situation (z = 2.3) and in partnership (z = 2.9), in which the latter was ranked higher. (4) The date of transplantation (less/more than 2 years ago) had no influence on the evaluation of postoperative life quality.     

Noninfectious constrictive pericarditis in a heart transplant recipient.

Acute rejection, infection, and allograft coronary artery disease have been recognized as the major causes of postoperative morbidity and mortality in cardiac transplant patients. More recently, pericardial and mediastinal complications have been recognized as a more common complication than previously believed. We describe a case of a heart transplant recipient admitted for apparent congestive heart failure exacerbation who was unresponsive to standard medical management of congestive heart failure and rejection. After further invasive evaluation, it was discovered the patient's condition was attributable to posttransplantation constrictive pericarditis. It is appropriate to consider this diagnosis in any postcardiac surgery (especially heart transplant recipients) in patients presenting with congestive heart failure exacerbations refractory to usual medical management.     

Thoracic and cardiovascular interventions after orthotopic heart transplantation.

BACKGROUND: The long-term outcome of orthotopic heart transplantation is limited by the development of cardiac allograft vasculopathy, rejection, infection, and malignancy. METHODS: After heart transplantation, we treated patients with thoracic and cardiovascular diseases: preexisting coronary artery sclerosis in 2 patients, cardiac allograft vasculopathy in 19, valvular disease in 3, mycotic ascending aortic aneurysm in 2, superior vena cava stenosis in 2, and lung neoplasm in 10 patients. RESULTS: We successfully performed coronary artery bypass grafting for preexisting coronary artery sclerosis, valve replacement for valvular disease, and patch enlargement for superior vena cava stenosis. Percutaneous transluminal coronary angioplasty for cardiac allograft vasculopathy achieved excellent initial results, but the incidence of restenosis was high (67%). One patient who underwent coronary artery bypass grafting for cardiac allograft vasculopathy died immediately after operation. Graft replacement was performed for mycotic aortic aneurysm, but 1 patient required reoperation because of recurrent aneurysm. The long-term survival rate in patients undergoing surgical resection for lung neoplasm was poor (50%). CONCLUSIONS: The need for thoracic and cardiovascular interventions in patients after heart transplantation was low (4.7%). Use of the appropriate procedures can improve the long-term survival after heart transplantation.     

Tumor marker determination after orthotopic heart transplantation.

BACKGROUND: Because the risk of developing malignant tumors after heart transplantation is approximately 100-fold higher, methods for rapid diagnosis must be developed to allow early and aggressive treatment in these patients. Although tumor markers have been used frequently for surveying already detected cancer, we studied their value in screening for tumors in heart transplant patients. METHODS: The levels of the tumor markers CEA, CA19-9, CA125, CA72-4, TPA, TPS, and CYFRA 21-1 were determined prospectively in 3-month intervals in 91 heart transplant patients between 1993 and 1998. RESULTS: In eight patients a definite diagnosis of cancer was made during the marker survey (mean observation time 2.85 +/- 1.3 years), including bronchogenic carcinoma in six, renal carcinoma in one, and colon cancer in one. All patients with bronchogenic carcinoma were smokers. The markers had a sensitivity below 60% to detect cancer. Given a 2-fold cutoff level (10 ng/mL), the CEA was the only marker with sufficient specificity (93.8%, only one false-positive result). Two patients were symptom-free even though they had elevated CEA levels. In one of those patients, disseminated intractable cancer was diagnosed at first evaluation, whereas no tumor was found in the other case at first evaluation. Subsequently, by means of fluorodeoxyglucose positron emission tomography, a hypermetabolic region was found in the right upper mediastinum. Control computed tomographic scan 4 weeks after the first investigation showed disseminated intractable disease also in this patient. Another heart transplant patient with colon cancer showed a normalization of the CEA after hemicolectomy and an increase in the CEA when liver dissemination developed. There was a relationship between cardiac death and CA125 and TPS in some heart transplant patients. CONCLUSIONS: We conclude that the CEA is the only tumor marker with adequate sensitivity and specificity to detect subclinical malignancies in the follow-up of heart transplant patients. However, because of several limitations (limited diagnostic and therapeutic possibilities and enormous costs), we cannot recommend screening by tumor markers on a regular basis. Because of the elevated risk of cancer in patients who had organ transplantation, further prophylactic measures, especially smoking cessation programs, must be developed. Once a malignancy is diagnosed, tumor markers can help target clinical decisions. Additionally, nonspecific increases in CA125 and TPS levels might be related to nonmalignant circulatory disturbances and cardiac death.