Embolisation of pulmonary arteriovenous malformations: results and follow up in 32 patients.

BACKGROUND--Pulmonary arteriovenous malformations may cause a number of complications when left untreated. Embolisation of the feeding vessels is a relatively new approach and information concerning its efficacy and long term results is scarce. METHODS--Pulmonary arteriovenous malformations with feeding arteries of > 3 mm were treated by embolisation. Right to left shunt fraction and arterial oxygen pressure breathing air (PaO2) were measured before and after treatment. Six monthly measurement of shunt fraction was used for follow up. RESULTS--In 32 patients 92 pulmonary arteriovenous malformations were treated by coil embolisation. Mean shunt fraction decreased from 16.6% to 7.4% and PaO2 increased from 9.6 kPa to 11.5 kPa. Treatment was incomplete in two patients, one of whom was subsequently treated surgically. Serious complications occurred in one patient. Recanalisation of embolised vessels occurred in two cases after 22 and 28 months, respectively. Mean period of follow up was 25 months. CONCLUSIONS--Embolisation is a safe and efficacious treatment for most pulmonary arteriovenous malformations. Long term studies are necessary to determine the risk of recanalisation.     

Aortic arch aneurysms: Surgical results and follow up in 56 patients

From January 1989 to December 1994, 56 patients, 43 male and 13 female, mean age 61.21 ± 10.05 years, underwent surgical procedures on the aortic arch at our institution. Forty-six patients underwent emergency or urgent operations, fourty-four of them presented acute aortic dissections involving the aortic arch. All operations were performed in cardiopulmonary by-pass, 39 operations in deep hypothermic circulatory arrest, 10 in deep hypothermic circulatory arrest and hypothermic retrograde cerebral perfusion. The overall hospital mortality was 17.9% (10 patients). The main causes of hospital mortality were: multiorgan failure (3 patients) and major neurological damage (2 patients). In the group of patients that underwent hypothermic retrograde cerebral perfusion there was no major neurological damage. In the follow up there were no deaths and 4 reoperations related to the aortic pathology. The cerebral protection represents the main problem in the aortic arch surgery. The deep hypothermic circulatory arrest is an effective method to reduce the cerebral and visceral ischemia, in particular in acute dissection; nevertheless this method leads to more bleeding complications and lengthening of the cardiopulmonary bypass in time. In our experience, the hypothermic retrograde cerebral perfusion associated with deep hypothermic circulatory arrest appears to be a useful method to prevent cerebral damage. However this procedure needs further investigation.     

Mid-term results of ATS open pivot bileaflet mechanical prosthetic heart valve.

We investigated mid-term results of the patients with an ATS bileaflet valve in our institution. In the past 6 years, 69 patients received valve replacement with an ATS valve. We assessed the changes of serum lactate dehydrogenase (LDH) level in the hospital, and the valve's closing sound. The serum LDH level had almost normalized one week postoperatively and they have maintained normal levels since then. According to the questionnaire about the valvular sound at a random period after surgery, it was unnoticeable in 61 (88.4%) of the patients with ATS valve. In the 8 patients (12.6%) who recognized the valve sound, 7 of them were reoperation cases. As to the frequency analysis for the valve's closing sound, the sound peak was indicated at around 1.2 kHz in the patients with ATS valves. In patients with St. Jude Medical (SJM) valves, it appeared not only around 1.2 kHz but also around 2 to 7 kHz. Postoperative cerebral infarction was complicated in one patient. Mortality occurred in 4 (5.7%) of the patients with ATS valves. The follow up periods were from one to 66 months. Thromboembolic event free and actuarial survival rate in the patients with ATS valves were 98.6% and 94.2%, respectively. These results indicated that the ATS valve is considered to be a safe valve and mid-term follow-up shows excellent results in terms of the patients quality of life.     

Echocardiographic evaluation of mitral annuloplasty. Immediate and longterm follow up results

Mitral annuloplasty is preferable to mitral replacement for patients with pure mitral insufficiency. This conservative procedure can be applied to those patients with torn or significantly stretched chordae tendineae unrelated to the site of lesions of the chordae tendineae. The 6 recent recent patients were examined by echocardiography pre- and postoperatively.The study of 35 long term follow up patients revealed longevity and safety of this procedure. Echocardiograms document normalization of abnormal mitral motion, reduction of excursion, and diastolic velocity of the leaflets, and decrease in left atrial size. These findings, showing apparent diminution of mitral flow, suggest significant improvement in valve function.     

Atrial function in heart transplant recipients operated with the bicaval technique

Objectives: In heart transplantation (HTx) with the bicaval technique the whole right atrium (RA) is donor tissue while the left atrium (LA) consists of both donor and recipient tissue. The aims of the study were to describe atrial function in comparison with healthy controls and to identify determinants of dysfunction. Design: Forty-three patients and 30 controls were retrospectively included. Echocardiography was performed within 24 h of right heart catheterization (RHC) (HTx recipients). Results: The peak longitudinal atrial systolic strain (?) described the atrial reservoir function. The LA and RA reservoir function were reduced versus controls (LA-? 18?±?8 versus 44?±?10%; RA-? 22?±?10 versus 69?±?17%, p?<?0.001). There were moderate relationships between atrial-? and ventricular filling pressure (r?=??0.64 for LA-?; r?=??0.57 for RA-?). In a multiple regression analysis the LA-? was determined by pulmonary capillary wedge pressure (PCWP) and LA minimum volume index (r?=??0.71) while RA-? was dependent on the right ventricular ? (r?=??0.77). Conclusions: Atrial reservoir function is markedly reduced in HTx recipients related to elevated PCWP and LA-enlargement in the LA and in the RA impaired longitudinal right ventricular function.     

Long time follow up of CD28- CD4+ T cells in living kidney transplant patients

We previously reported that the CD28(-) CD4(+) T cell subpopulation was expanded in the kidney allograft patients with long graft survival, although these T cells were rarely found in patients with graft survival <5 yr. To understand the CD28(-) CD4(+) T cells in the long-term acceptance of kidney allografts, we examined functions of this population and performed a 4 yr follow up study. Peripheral blood mononuclear cells (PBMC) were obtained from 47 long-term living related kidney allograft recipients. CD28(+) CD4(+) and CD28(-) CD4(+) T cells purified by cell sorting were analyzed for expression of V(beta) repertoire. Donor-specific response was examined in mixed lymphocyte reaction (MLR). A follow up study with long-term kidney allograft patients was performed for 4 yr about the rate of CD28(-) CD4(+) T cells. Eleven patients were examined by MLRs against donors and third party. Four patients with a marked increase of CD28(-) CD4(+) T cells showed the donor-specific responses appeared to be lower when compared with third party-specific responses. Freshly sorted CD28(-) CD4(+) T cells showed a restricted V(beta) repertoire, whereas the V(beta) usage of CD28(+) CD4(+) T cells from the same patients was much diversified. Such difference in V(beta) repertoire was not evident between the two populations from healthy control. A follow up study showed the ratio of CD28(-) CD4(+) T cells appeared to be lower in patients who were suspected of chronic rejection. These unusual CD4(+) T cells might be related to the long-term acceptance of human transplant allografts.     

Cholelithiasis in heart transplant patients

The incidence of cholelithiasis is increased in heart transplant recipients. STUDY AIM: The aim of this retrospective study was to report a series of 27 heart transplant recipients operated for cholelithiasis and to assess the indications and safety of cholecystectomy in this population. PATIENTS AND METHODS: Over a 9-year period, from January 1991 to December 1999, 27 heart transplant recipients (21 men and 6 women; mean age: 54.6 years, mainly transplanted for ischemic or dilated cardiomyopathy) underwent cholecystectomy. All patients received immunosuppressive therapy with a combination of corticosteroids and cyclosporin and 10 also received azathioprine. Five patients admitted urgently with calculous acute cholecystitis and one patient with previous gastrectomy underwent laparotomy, while the other 21 patients were operated by laparoscopy. RESULTS: There were no postoperative deaths. In patients operated by laparoscopy, there was no conversion to laparotomy and oral immunosuppressive drugs were continued without interruption. There was one postoperative hemoperitoneum related to liver biopsy performed concomitantly. In patients operated by laparotomy, intravenous cyclosporin was necessary until return to bowel function and the only complication was a wound abscess. Mean length of hospital stay was 3.1 days after laparoscopy and 8.8 days after laparotomy. CONCLUSION: Systematic ultrasound screening of cholelithiasis after heart transplantation is necessary because cholelithiasis carries a risk of septic complications in these patients. Laparoscopic cholecystectomy, associated with a low morbidity, is justified even in asymptomatic cases. In patients with acute cholecystitis, "open" cholecystectomy must be preferred in order to minimize the risk of biliary complications which would be very serious in these immunosuppressed patients.     

Mid-term results of patients undergoing endovascular aortic aneurysm repair

BACKGROUND: The utilization of endovascular aneurysm repair (EAR) is increasing significantly; however, few papers have outlined mid-term outcomes. METHODS: Patients undergoing EAR with an AneuRx endograft between September 1997 and May 2001 were evaluated. Mean follow-up was 20.7 +/- 11.9 (SD) months. RESULTS: In all, 101 EAR devices were successfully deployed in 105 attempts. Four open conversions (2 acute, 2 delayed) were performed for complications of EAR. Technical, clinical, and 1 to 3 year continuing success rates were 75%, 73%, and 78% to 83%. When divided by the median date, significantly fewer patients in the later group required secondary procedures compared with the early group. Vascular insufficiency occurred in 12 patients; 11 were treated with a secondary procedure. For 9 type I and 9 type II persistent endoleaks, secondary procedures were attempted and successful in 10 patients. Of successful EAR deployments, including secondary interventions, 85% demonstrated no persistent leak, rupture, increase in aneurysm size, or migration at most recent follow-up. CONCLUSIONS: EAR is successful in selected individuals; however, continuing follow-up is of paramount importance.     

Laparotomy in HIV-infected patients. Indications, results apropos of 104 operated patients]

From May 1st 1983 to March 1st 1991, 126 laparotomies were performed on 104 patients infected by human immunodeficiency virus (HIV). We report the operative indications, macroscopic findings, anatomopathologic and microbiological results, and hospital mortality in this population. In 12.5% of cases, infection by HIV was established after operation. Sixty-eight percent of patients presented criteria for AIDS. The population was divided into 4 groups of indications: Group I: 30 patients had an emergency exploratory laparotomy. Laparotomy provided a diagnosis in 80% of cases, with a hospital mortality in 66%. Group II: 45 patients had an emergency laparotomy with a preoperative diagnosis. Hospital mortality was 24.4%. Group III: 29 patients had a non-urgent laparotomy with no mortality. Group IV: 14 patients were reoperated (22 laparotomies). For the entire population, hospital mortality was 9.3% for seropositive patients and 38.8% for AIDS patients.     

Long term results of arthrodesis of the wrist: a 6-15 year follow up of 35 patients.

A total of 40 wrists in 35 patients were investigated 10.5 (range 6-15) years after arthrodesis. The most common diagnosis was rheumatoid disease. There were 21 Mannerfelt, and 21 plate, arthrodeses. The patients were assessed clinically and up-to-date radiographs obtained. Two Mannerfelt arthrodeses had failed to fuse. Pain during the last week before review and total satisfaction with the operation were excellent in 28 and 30 wrists, respectively. The mean score on the "Disability of arm, shoulder and hand" (DASH) questionnaire was 38 (range 2-75). Plate arthrodeses gave better results than Mannerfelt arthrodeses for all variables studied. Wrists plated in dorsal extension gave the best scores for function and strength. We conclude that either method gives good long term results. Although few of the individual differences were statistically significant, we think that fusion with plates, and in particular plates with dorsal extension, is preferable.     

Management of biliary tract stones in heart transplant patients.

OBJECTIVE: The authors report their experience with biliary tract stones in adult and pediatric heart transplant patients, and review the current literature relative to this problem. SUMMARY BACKGROUND DATA: Prior studies in adults have noted that heart transplant patients frequently have cholelithiasis, but offer no consensus about treatment strategy. Few studies exist for pediatric heart transplant patients. A higher rate of hemolysis and cyclosporine-induced changes in bile metabolism may contribute to lithogenesis in this population. METHODS: A chart review was conducted for 211 patients who had heart transplants between January 1988 and September 1994 to determine prevalence of biliary tract stones, management strategies used, and outcome. RESULTS: Of 175 long-term heart transplant survivors, 52 (29.7%) had stones detected: 32.8% of adults (47/143) and 15.6% of children (5/32). The majority of patients (31) were diagnosed 4 months (mean) after transplantation; cholelithiasis developed in 10 of these patients (32%) within 11 months (median) after a negative ultrasound. Symptoms developed in 45% of patients. All patients underwent either elective (36) or urgent (6) cholecystectomy via an open (32) or laparoscopic (10) approach, or endoscopy for common bile duct stones (2). There were no deaths or complications during a follow-up period of up to 7 years. CONCLUSION: Heart transplant patients have a high prevalence of symptomatic biliary tract stone disease. They can be treated safely via an open or laparoscopic approach after transplantation. The authors recommend routine gallbladder ultrasound screening and elective cholecystectomy in the post-transplant period if stones are detected.     

Prevalence and management of cholelithiasis in heart transplant patients.

There is no accepted approach in the field of heart transplantation for the management of asymptomatic cholelithiasis. To help formulate a strategy, we retrospectively reviewed the records of the 159 patients who underwent heart transplantation at our institution from March 1984 to January 1990. Information on the biliary tract was available in 141 (88.7%) of these patients. Before transplantation, 18 (11.3%) had undergone cholecystectomy. Of the 141, 99 (70.2%) had undergone ultrasonographic examination of the biliary tree: 74 (74.8%) had no gallstones seen on ultrasonograms; 8 (8.1%) had sludge; 16 (16.2%) had gallstones; and 1 had a probable polyp. Further information on the biliary tree by ultrasonography became available after transplantation in 24 of 42 patients who did not undergo ultrasonographic examination before transplant. After transplant, gallstones were found by means of ultrasonography or at autopsy in 13 more patients. Seven (4.4%) patients underwent cholecystectomy after transplant because of symptomatic cholelithiasis. Only one of these patients belonged to the group known to have gallstones before transplant. For the entire group, the prevalence of cholelithiasis was 29.6%. Multivariate analysis demonstrated that gallstones were significantly more common in older patients. We conclude that the prevalence of cholelithiasis in the heart transplant population is high but that only a minority of patients with asymptomatic gallstones will become symptomatic after heart transplantation. When they do, cholecystectomy may be safely performed. Prophylactic cholecystectomy and screening ultrasonography are not indicated in patients with asymptomatic cholelithiasis.     

Neostigmine decreases heart rate in heart transplant patients

Purpose

This study evaluated the effect of neostigmine on heart rate in cardiac transplant patients.

Methods

Neostigmine (2.5–50 μg · kg^?1) was administered to ASA 1 or 2 patients with normally innervated hearts (controls), and to patients who had undergone recent (<six months before study) or remote (> six months before study) cardiac transplantation.

Results

Baseline heart rate was 66 ± 3 beats · min^?1 in controls (n = 10, mean ± SEM), which was slower than that observed in recently (95 ± 4 beats · min^?1, n = 15, P < 0.001) and in remotely (88 ± 3 beats · min^?1, n = 16, P < 0.001) transplanted patients. Neostigmine produced a dose-dependent decrease in heart rate in all patients. Controls were the most sensitive to neostigmine, with a 10% decrease in heart rate produced by an estimated dose of 5.0 ± 1.0 μg · kg^?1. The recently transplanted group was the least sensitive, with the maximum dose producing only an 8.3 ± 0.9% reduction. The response to neostigmine of the remotely transplanted patients was variable. The estimated dose to produce a 10% decrease in heart rate in this group was 24 ± 6 μg · kg^?1 which was greater than that for controls (P = 0.008). Administration of atropine (1.2 mg) reversed the neostigmine-induced bradycardia in all three groups. Reversal of the bradycardia consisted of a transient peak increase in heart rate in controls to 145 ± 6% of baseline, a value which was greater than that observed in recent (103 ± 1%, P < 0.001) and in remote (109 ± 3%, P < 0.001) transplants.

Conclusions

Neostigmine produces a dose-dependent brady-cardia in heart transplant patients. Some remotely transplanted patients may be particularly sensitive to the bradycardic effects of neostigmine.     

Long-term results of CMV hyperimmune globulin prophylaxis in 377 heart transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) has emerged as the most important pathogen to affect the post-operative course after heart transplantation. We performed a retrospective analysis to evaluate the efficiency of CMV hyperimmune globulin (CMVIG) prophylaxis in preventing CMV disease in aggressively immunosuppressed patients after heart transplantation. METHODS: We studied 377 heart transplant recipients who received quadruple-immunosuppressive therapy and CMVIG as sole CMV prophylaxis. The study population was categorized into 4 groups according to donor and recipient CMV serology at the time of transplantation (D+/R+, D+/R-, D-/R+, D-/R-) and was monitored for CMV immediate early antigen in peripheral blood cells, in urine sediments, and in throat washings; for the presence of serum CMV immunoglobulin M and CMV immunoglobulin G; and for clinical evidence of CMV-related symptoms. In addition, we compared the incidence of cardiac allograft vasculopathy and infection among the groups. RESULTS: During the first 5 years after transplantation, CMV disease developed in 79 patients (20.96%). Comparison among the groups showed significantly increased risk for CMV disease in allograft recipients of organs from seropositive donors (D+, 27.31%; D-, 11.33%; p = 0.0003). We observed 6 CMV-associated deaths, all in CMV-antibody-negative recipients. Additionally CMV-positive recipients had a greater incidence of cardiac allograft vasculopathy (p = 0.048), and a greater overall infection rate (p = 0.0034). CONCLUSIONS: Cytomegalovirus hyperimmune globulin administration prevents CMV disease and infection in aggressively immunosuppressed heart transplant recipients. Because fatal CMV disease in CMV-negative recipients of organs from seropositive donors could not be prevented with CMVIG alone, we recommend the additional use of prophylactic ganciclovir in this CMV-mismatched population.