Prognostic value of FDG uptake in early stage non-small cell lung cancer

Background: Non-small cell lung cancer (NSCLC) has a poor prognosis even for early stages of the disease (stage I and II). We studied the prognostic value of PET FDG in patients with completely resected stage I and II NSCLC. Methods: Retrospective study of 96 patients with NSCLC whose staging included ¹⁸F-FDG PET (fluoro deoxy glucose positron emission tomography). Histopathological stage was either stage I (75) or stage II (n = 21). FDG uptake was measured as maximal standardized uptake value for body weight (SUVmax). Mean follow-up was 45 ± 30 months (1–142 months). Overall and cancer-free survival rates were recorded. Results: SUVmax were higher for stage II than for stage I (10.5 ± 4.5 vs 8.5 ± 5, p = 0.04). Mean tumor volumes were equivalent for both stages (33 cm³, p = 0.18), excluding a partial volume effect. The median SUVmax in the whole study population was 7.8. The median survival was significantly longer in patients with a lower (SUVmax ≤ 7.8) FDG uptake (127 months vs 69 months, p = 0.001). For stage I tumors (n = 75), high FDG uptake was significantly associated with reduced median survival: 127 months if SUVmax ≤ 7.8 and 69 months if SUVmax > 7.8 (p = 0.001). For stage II tumors (n = 21), no statistical difference was observed: 72 months vs 40 months for SUVmax ≤ 7.8 and for SUVmax > 7.8, respectively (p = 0.11), although there was a clear trend towards reduced survival for highly metabolic tumors. Disease-free survival was also significantly better for lower metabolic tumors: 96.1 months vs 87.7 months (p = 0.01). Conclusion: High FDG uptake is associated with reduced overall survival and disease-free survival of patients with completely resected stage I–II NSCLC. Whether patients with highly metabolic tumors should undergo a closer postoperative surveillance or adjuvant chemotherapy has to be addressed in a properly designed prospective trial.     

The effects of therapeutic sulfide on myocardial apoptosis in response to ischemia–reperfusion injury

Objective: Ischemia–reperfusion (I/R) injury, often encountered clinically, results in myocardial apoptosis and necrosis. Hydrogen sulfide (H₂S) is produced endogenously in response to ischemia and thought to be cardioprotective, although its mechanism of action is not fully known. This study investigates cardioprotection provided by exogenous H₂S, generated as sodium sulfide on apoptosis following myocardial I/R injury. Methods: The mid-LAD coronary artery in Yorkshire swine (n = 12) was occluded for 60 min, followed by reperfusion for 120 min. Controls (n = 6) received placebo, and treatment animals (n = 6) received sulfide 10 min prior to and throughout reperfusion. Hemodynamic, global, and regional functional measurements were obtained. Evans blue/TTC staining identified the area-at-risk (AAR) and infarction. Serum CK-MB, troponin I, and FABP were assayed. Tissue expression of bcl-2, bad, apoptosis-inducing-factor (AIF), total and cleaved caspase-3, and total and cleaved PARP were assessed. PAR and TUNEL staining were performed to assess apoptotic cell counts and poly-ADP ribosylation, respectively. Results: Pre-I/R hemodynamics were similar between groups. Post-I/R, mean arterial pressure (mmHg) was reduced by 30.2 ± 4.3 in controls vs 8.2 ± 6.9 in treatment animals (p = 0.01). +LV dP/dt (mmHg/s) was reduced by 1308 ± 435 in controls vs 403 ± 283 in treatment animals (p = 0.001). Infarct size (% of AAR) in controls was 47.4 ± 6.2% vs 20.1 ± 3.3% in the treated group (p = 0.003). In treated animals, CK-MB and FABP were lower by 47.0% (p = 0.10) and 45.1% (p = 0.01), respectively. AIF, caspase-3, and PARP expression was similar between groups, whereas cleaved caspase-3 and cleaved PARP was lower in treated animals (p = 0.04). PAR staining was significantly reduced in sulfide treated groups (p = 0.04). TUNEL staining demonstrated significantly fewer apoptotic cells in sulfide treated animals (p = 0.02). Conclusions: Sodium sulfide is efficacious in reducing apoptosis in response to I/R injury. Along with its known effects on reducing necrosis, sulfide's effects on apoptosis may partially contribute to providing myocardial protection. Exogenous sulfide may have therapeutic utility in clinical settings in which I/R injury is encountered.     

Mitral valve repair by Alfieri''s technique does not limit exercise tolerance more than Carpentier''s correction

Objective: The main goal of this study was to evaluate if the edge-to-edge mitral repair could be a limiting factor for exercise tolerance and to compare these results to those of classical techniques. Methods: Between 2000 and 2002, 54 consecutive patients were operated on for mitral valve regurgitation (MR). Twenty-five patients were operated with Alfieri's technique (group A) and 29 patients with Carpentier's technique (group C). The mean age was 63.9 years in group A and 63.8 years in group C (p = 0.98). After a mean follow-up of 16.2 ± 12 months, survivor patients were seen at the outpatient clinic, by the same physician for a clinical evaluation, an echocardiogram at rest and at peak exercise, and received a cardiorespiratory exercise testing with maximal oxygen uptake (VO₂ max) recording. Results: Clinical status improved with 0% of the patients in class NYHA III or IV in either group postoperatively versus 77% preoperatively. There was no significant MR in 80% of cases in group A versus 89.6% in group C (p = 0.54). The mean mitral valve area was 2.5 and 2.9 cm² in groups A and C, respectively (p = 0.018). The mitral gradient at rest was 3.8 and 3.3 mmHg (p = 0.31) and the mitral gradient at peak exercise was 8.5 and 9.7 mmHg (p = 0.22) in groups A and C, respectively. Cardiorespiratory exercise testing showed a mean VO₂ max of 73.7 ± 15% of normal value in group A versus 79.6 ± 13.1% in group C (p = 0.18). Conclusion: Alfieri's technique has the same efficiency on improvement of MR and clinical status than classical repair. Despite a higher restriction of mitral valve area at rest in group A, gradient and mean VO₂ max at peak exercise were similar in both groups.     

Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective

Objective: In an effort to minimize the effect of extracorporeal circulation (ECC), mini-bypass is gaining clinical acceptance in routine coronary artery bypass grafting (CABG). These small circuits target combine the clinical advantages of reduced prime, 100% bio-coating and suction blood separation. We demonstrate that the use of mini-bypass in routine CABG reduces homologous blood product use and postoperative bleeding. Our goal was to also demonstrate that these small systems are effective in gaseous microemboli (GME) management as compared to a conventional extracorporeal system. Methods: Prospective, randomized study comparing 30 mini-bypass (Dideco ECC.O™) to 30 conventional systems (n = 30, Dideco 903 Avant™). Study included CABG cases only, independent of preoperative coagulative status; clinic ethical committee approval and informed patient consent was obtained before initiating study. Results: There were no statistical differences in terms of patient demographics. Statistically significant differences were seen in transfusion frequency (27% of the study group vs 43% in the control group, p = 0.05), transfused volume (133.3 ± 244.5 ml vs 325 ± 483.1 ml, p < 0.05), fresh frozen plasma (0 unit vs 3 units, p < 0.001), postoperative bleeding (301.8 ± 531.9 ml vs 785.5 ± 1000.4 ml, p < 0.05) and GME activity post-arterial filter (0.14 μl vs 5.32 μl, p < 0.05). Conclusions: The adoption of mini-bypass significantly potentially reduces hemodilution, donor blood usage, postoperative bleeding and exposure to GME in routine CABG patients as compared to the use of conventional extracorporeal circulation circuits.     

Inhaled iloprost to control residual pulmonary hypertension following pulmonary endarterectomy

Objective: Pulmonary endarterectomy (PEA) is the standard therapy for patients with chronic thromboembolic pulmonary hypertension (CTEPH). In the immediate postoperative period, persistent pulmonary hypertension increases the risk of acute respiratory or right heart failure. In pulmonary arterial hypertension, prostanoid inhalation has been found to improve pulmonary hemodynamics, right ventricular function, gas exchange, and clinical outcome. We report the results of a double-blinded randomized trial with the aerosolized prostacyclin analogue iloprost in patients with residual pulmonary hypertension after PEA. Methods: Twenty-two patients (age, 55 ± 13 years; 8 females; propofol- and sufentanil-based anesthesia; pressure-controlled mechanical ventilation) were randomized to receive either a single dose of 25 μg aerosolized iloprost (iloprost group; n = 11) or normal saline (placebo group; n = 11) immediately after postoperative ICU admission. Primary endpoints were changes in gas exchange, pulmonary and systemic hemodynamics, and clinical outcome. Results: Iloprost significantly enhanced cardiac index (CI) and reduced mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance [PVR (dyn s cm⁻⁵)] in contrast to placebo. Placebo: pre-inhalation 413 ± 195 versus post-inhalation 404 ± 196 at 30 min (p = 0.051), 415 ± 189 at 90 min (p = 0.929). Iloprost: pre-inhalation 503 ± 238 versus post-inhalation 328 ± 215 at 30 min (p = 0.001), 353 ± 156 at 90 min (p = 0.003). Blood oxygenation remained unchanged. Conclusion: In addition to the effect of PEA, iloprost reduces residual postoperative pulmonary hypertension, decreases right ventricular afterload and may facilitate the early postoperative management after PEA.     

Systematic mediastinal lymphadenectomy does not increase postoperative immune response after major lung resections

Objective: To assess the influence of mediastinal lymphadenectomy on postoperative concentration of interleukin 6 (IL-6) and interleukin 1 receptor antagonist (IL-1ra) in serum, sputum, and pleural fluid, in patients operated upon due to lung cancer and benign pulmonary diseases. Methods: Thirty-three patients undergoing uncomplicated resections, including 23 with lung cancer and 10 with benign diseases, were analyzed. In patients with right lung cancer we performed a systematic lymphadenectomy, while in patients with left lung cancer systematic sampling was performed. Serum IL-6 and IL-1ra concentration was measured before and after surgery, and on postoperative days 1, 3, and 7, as well as in sputum at the end of surgery and in pleural fluid on postoperative day 1, by ELISA test. Results: In 23 patients with cancer, 19.0 ± 11.43 mediastinal lymph nodes were removed (in 11 patients with right lung cancer 27.6 ± 7.6 and in 12 patients with left lung cancer 11.1 ± 8.1). No differences were found in serum and sputum concentration of IL-6 and IL-1ra between patients after right and left thoracotomy due to cancer and between patients with cancer and patients with benign diseases. Patients with cancer had a lower concentration of IL-1ra in pleural fluid (median 16950, range 16050–45470.05 pg/ml) than patients with benign diseases (76665.6 pg/ml (range 53618–89617.9); p = 0.0008). In 23 cancer patients a negative correlation between concentration of cytokines in pleural fluid and a number of mediastinal lymph nodes resected was observed (Spearman correlation coefficient for IL-6: r = −0.44, p = 0.04; for IL-1ra: r = −0.57, p = 0.01). Such correlation was not observed for a number of positive N2 lymph nodes. Conclusions: Systematic lymphadenectomy added to major lung resection does not increase postoperative humoral immune response in uncomplicated cases, as measured by levels of IL-6 and IL-1ra in serum, pleural fluid, and sputum.     

Comparison of on pump and off pump coronary surgery: risk factors for neurological outcome

Objective: Cerebrovascular accidents (CVA) are devastating complications after coronary artery bypass grafting (CABG). The reported incidence of neurological complications after conventional CABG (CCABG) is 3–6%. Off-pump coronary bypass grafting (OPCAB) has been associated in recent studies to a decreased morbidity and risk of perioperative stroke. Nevertheless, uncertainty still surrounds the relative benefits of OPCAB. We investigated whether, in our experience, OPCAB was associated with lower neurological morbidity than conventional CABG approach. Methods: Eight thousand and two patients underwent isolated CABG at our institution between January 1998 and January 2005. OPCAB operation was performed on 1415 patients. Data were prospectively collected. A multiple logistic regression analysis was used to evaluate the influence of the two different surgical techniques on the neurological outcomes. Results: Patients in the OPCAB group were significantly older (66.2 vs 63.5%, p < 0.0001), had a higher incidence of renal injury (5.4 vs 2.4%, p < 0.0001), and were more redo interventions (6.95 vs 1.53%, p < 0.0001). The CCABG patients were more urgent at operation (5.46 vs 3.26, p = 0.0007), were less hypertensive (57.6 vs 63% of the patients, p = 0.0003) more diabetics (22 vs 20.6%, NS), and had an ejection fraction less than 0.40 (10.4 vs 9.6%, NS). CVA incidence was similar in both groups (Type I outcome: OPCAB = 0.70% vs CCABG = 0.68%, p = 0.91; Type II outcome OPCAB = 0.70% vs CCABG = 0.83%, p = 0.63). Conclusions: In our experience patients undergoing CCABG were not exposed to a grater risk of neurological adverse events when compared to OPCAB patients.     

Assessment of pulmonary function after lobectomy for lung cancer — upper lobectomy might have the same effect as lung volume reduction surgery

Objective: Lung volume reduction surgery (LVRS) in well-selected patients with severe emphysema results in postoperative improvement in symptoms and pulmonary function. Experience with LVRS suggests that predicted postoperative FEV_1.0 may be underestimated after lobectomy in patients with lung cancer and emphysema. As most of the patients with lung cancer have more or less emphysematous changes in the lungs, we assumed that lobectomy would achieve the same effect as LVRS even in patients without chronic obstructive pulmonary disease on the pulmonary function test. We assessed changes in pulmonary function in terms of ‘volume reduction effect’ after lobectomy for lung cancer. Methods: Forty-three patients underwent right upper lobectomy (RUL), 38 patients left upper lobectomy (LUL), 39 patients right lower lobectomy (RLL), and 38 patients left lower lobectomy (LLL). Pulmonary function tests were performed preoperatively and 6 months to 1 year after surgery. Results: Percent change in FEV_1.0 after lobectomy was −6.9 ± 16.1% in RUL group, −11.2 ± 16.9% in LUL group, −14.7 ± 9.8% in RLL group, and −12.8 ± 9.5% in LLL group. We evaluated the correlation between a preoperative FEV_1.0% of predicted and percentage change in FEV_1.0 after lobectomy. There were no significant relationships between these variables in RLL or LLL group. In contrast, there were significant negative relationships between these variables in RUL and LUL groups. Correlation coefficients were r = −0.667, p < 0.0001 for RUL and r = −0.712, p < 0.0001 for LUL. In RUL and LUL groups, patients with a higher preoperative FEV_1.0% of predicted had a more adverse percentage change in FEV_1.0 after surgery. In addition, all 13 patients with a preoperative FEV_1.0% of predicted <60% in RUL and LUL groups had an increase in FEV_1.0 postoperatively. Patients with a lower preoperative FEV_1.0% of predicted had a greater ‘volume reduction effect’ with an increase in FEV_1.0 after upper lobectomy. Conclusion: Upper lobectomy might have a volume reduction effect.     

Impact of HIV Infection on Total Body Composition in Treatment—Naive Men Evaluated by Dual-Energy X-ray Absorptiometry Comparison of 90 Untreated HIV-Infected Men to 241 Controls

The aim of this study was to establish the contribution of human immunodeficiency virus (HIV) itself on body composition changes evaluated by dual-energy X-ray absorptiometry (DXA). Body composition evaluated by DXA in 90 HIV never treated men, without comorbidity, or current or past opportunistic infections were compared with 241 healthy volunteers. The mean duration of seropositivity from HIV diagnosis was 41 ± 62 mo, mean CD4 and viral load at the time of DXA were 402/mm³ ± 263 (control values 500–1200/mm³) and 4.2 log copies/mL ± 1.3. Mean age (41 vs 39 yr, respectively, for HIV never treated patients and controls) and mean height (174.5 vs 176 cm) were not different, but mean weight was lower among HIV never treated patients (69.8 vs 78.7 kg). Mean total body bone mineral density (BMD) of naive HIV-infected patients was lower than that of controls (1.20 vs 1.23 g/cm², p = 0.01) but not after adjustment on age, height, lean mass (LM), and fat mass ratio (FMR = % trunk fat mass/% lower limb fat mass). Fat mass (13.2 vs 16.5 kg, p < 0.0001) and LM (53.5 vs 59 kg, p < 0.0001) of naive HIV-infected patients were lower whatever the adjustment variables. The FMR was lower in naive HIV-infected men (1.0 vs 1.3, p < 0.0001) because of a decreased trunk fat mass. After adjustment on age, height, LM, and fat mass, the lower limbs fat mass percentage was higher in HIV-infected men. The profile of naïve HIV-infected patients displayed low lean and fat masses, and a fat mass repartition characterized by a predominant loss in the trunk. Those alterations may result from the catabolic effect of the chronic HIV infection.     

Effects of atorvastatin on arterial endothelial function in coronary bypass surgery

Objective: Endothelial dysfunction represents a critical early component of organ injury following cardiopulmonary bypass. Recent studies demonstrate that the treatment with atorvastatin is associated with a significant improvement of endothelial function independently of its efficacy on cholesterol levels. Therefore, we investigated the effects of preoperative atorvastatin treatment on endothelium function after coronary surgery. Methods: Forty patients undergoing coronary surgery were randomized to treatment with atorvastatin (20 mg/die; N = 20) or placebo (N = 20) 3 weeks before surgery. Twenty normal patients served as control group. The flow-mediated dilations (FMD) of the brachial artery after both reactive hyperemia (endothelium dependent) and nitroglycerin administration (endothelium independent) were evaluated at baseline, at 48 h, and 5 days postoperatively. Results: At baseline, the endothelium-dependent FMD was significantly attenuated in coronary versus normal patients (normal 10.3 ± 1.8% vs coronary 4.1 ± 1.6%, p < 0.01). At 48 h postoperatively all patients exhibited a reduced FMD compared with baseline values: the endothelium-dependent dilatation showed a drop of 60.1 + 15% in the patients of the placebo group compared with 45.8 + 16.6% (p < 0.05) those in the atorvastatin group. At the univariate analysis, no significant correlation was found between serum levels of either total cholesterol or HDL cholesterol and FMD. The nitroglycerin-induced dilation was not significantly influenced by extracorporeal circulation as well as by atorvastatin treatment. Conclusions: The endothelial dysfunction following cardiopulmonary bypass is improved by the treatment with atorvastatin, by a mechanism unrelated to the drug efficacy of controlling serum cholesterol levels.     

Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Prediabetes and older age increase the risk of post-transplantation diabetes mellitus: Qatar experience

Post-transplantation diabetes mellitus (PTDM) is a major complication in kidney transplant recipients leading to reduced allograft and patient survival. Given the high prevalence of diabetes in Qatar, which is twice the global average, we were interested in determining the incidence of PTDM, identifying risk factors, and comparing clinical outcomes in kidney transplant recipients with and without diabetes. We retrospectively followed up 191 adult kidney allograft recipients transplanted between January 1, 2012, and December 31, 2016, for a median of 41 months. A total of 76 patients (40%) had pre-existing diabetes. A total of 39 patients developed PTDM during follow-up; they represent 34% of patients who did not have diabetes prior to transplantation. Two thirds of PTDM occurred within 3-6 months post-transplantation. Prediabetes before transplant [OR = 6.07 (1.24-29.74), P = .026] older recipient's age at the time of transplantation [OR = 1.10 (1.00-1.20), P = .039] and average fasting blood sugar during 3-6 months post-transplant [OR = 1.06 (1.01-1.11), P = .010] were independently associated with PTDM. Patient and kidney allograft survival rates exceeded 97% in all groups. The incidence of PTDM in kidney transplant recipients living in Qatar is high. Older age and prediabetes are independent risk factors for developing PTDM.     

Midterm follow-up of the status of Gore-Tex graft after extracardiac conduit Fontan procedure

Objective: Extracardiac conduit Fontan procedure has some theoretical advantages over other types of Fontan procedures, such as optimized flow dynamics, a lower frequency of arrhythmias, and technical ease of procedure. However, lack of growth potential and thrombogenicity of the artificial conduit is the main concern and can possibly lead to reoperation for the conduit stenosis. In this study, we investigated the change and the status of the Gore-Tex graft used in extracardiac conduit Fontan procedure. Methods: Between 1996 and 2005, 154 patients underwent extracardiac conduit Fontan procedure using Gore-Tex graft. Among these, 46 patients underwent cardiac catheterization during follow-up period. We measured the internal diameter of the conduit and inferior vena cava angiographically. Results: Mean follow-up duration was 36.1 ± 19.7 months. The conduit diameter used was 16 mm in 10 patients, 18 mm in 16, 20 mm in 14, 22 mm in 4, and 24 mm in 2 patients. The mean conduit-to-inferior vena cava cross-sectional area ratio was 1.25 ± 0.33. According to the conduit size used, this ratio was 1.03 ± 0.17 for 16 mm conduits, 1.33 ± 0.37 for 18 mm, 1.33 ± 0.36 for 20 mm, 1.28 ± 0.26 for 22 mm, and 1.05 ± 0.06 for 24 mm conduits (p < 0.05, 16 mm vs 18 mm and 20 mm). The mean percent decrease of the conduit cross-sectional area was 14.3 ± 8.5%, and this did not differ significantly according to the conduit size (p = 0.82). Follow-up duration and the percent decrease of the conduit cross-sectional area did not show significant correlation (r = 0.22, p = 0.14). There was no reoperation due to conduit stenosis. Conclusions: During midterm follow-up of about 3 years, the conduit cross-sectional area decreased by 14%, and this did not differ according to the conduit size used. The extent of decrease of the conduit cross-sectional area remained stable irrespective of the follow-up duration. Sixteen millimeters conduit showed no evidence of clinically significant stenosis, but careful follow-up is warranted because of the possible conduit stenosis relative to the patients’ somatic growth.     

Post-Transplant Diabetes Mellitus: Is It Associated With Poor Allograft Outcomes in Renal Transplants?

Background

Post-transplant diabetes mellitus (PTDM) is a common metabolic complication whose incidence ranges from 2 to 50%, reflecting wide variations in population type, criteria for diagnosis, and immunosuppressive regimen. PTDM is associated with poor graft outcomes and increased infections and cardiovascular disease following renal transplants. Therefore, we assessed the incidence of PTDM and examined the association between PTDM and graft function after transplantation.

Materials and methods

We investigated 565 renal transplants in our center. The patients were divided into 2 groups, depending on the time of surgery: group 1 (n = 228, from January 1990 to December 1995) and group 2 (n = 377, from January 1996 to December 2011). In each group, patients were divided into no diabetes mellitus (non-DM), preexisting diabetes mellitus (pre-DM), and PTDM subgroups. PTDM was defined as fasting plasma glucose ≥126 mg/dL. We started treatment by modification of lifestyle and/or antidiabetic medication. All patients in group 1 received cyclosporine (CsA) and patients in group 2 received CsA or tacrolimus. We analyzed the clinical characteristics of recipients, serum creatinine levels, and long-term graft survival.

Results

The overall incidence of PTDM was 11.7% (n = 66); 9.2% (n = 21) in group 1, and 13.4% in group 2. There was a higher incidence of PTDM in the recipients who received tacrolimus than in those who received CsA (25.0% vs 9.5%, P < .001) and the delay before the appearance of PTDM was shorter (38.58 ± 6.94 vs 75.85 ± 7.67, P = .017). Also the tacrolimus dose (20.4l ± 4.28 ng/mL) at the time of PTDM diagnosis was above the therapeutic range (5–20 ng/mL). There were no significant differences in infection and cardiovascular complication rates between the non-DM, pre-DM, and PTDM patients in group 1. In group 2, the use of tacrolimus significantly increased the incidence of PTDM compared with CsA (P < .001). However, there were no significant differences between subgroups in other variables. Serum creatinine levels 10 years after renal transplantation (P = .756 in group 1 and P = .559 in group 2) and long-term graft survival in those groups were not significantly different (P = .067 in group 1 and P = .125 in group 2).

Conclusion

Renal function and allograft outcomes are more impaired in patients with PTDM than in either non-DM or pre-DM patients. However, if regular screening of plasma glucose levels, early diagnosis, and appropriate treatment of PTDM are carried out, the risk of complications can be minimized and the long-term allograft outcomes improved.     

Preliminary experience with inhaled milrinone in cardiac surgery

Background: Inhaled administration of milrinone reduces pulmonary artery pressure. Pulmonary hypertension (PH) and right heart failure are associated with difficult separation from cardiopulmonary bypass (CPB). Therefore, inhaled milrinone could facilitate separation from CPB. Objective: To determine the impact and timing of administration of inhaled milrinone. Methods: A retrospective analysis of our experience on high-risk patients receiving inhaled milrinone was conducted to evaluate the postoperative course after administration of the drug. Results: Seventy-three patients received inhaled milrinone from June 2002 to February 2005. Mean age was 64 ± 13 years, with a mean preoperative Parsonnet score of 27 ± 14. Inhaled milrinone (5 mg) was administered before (n = 30) or after (n = 40) CPB, three patients had off-pump procedures and were excluded. CPB time was 145 ± 78 min with cross-clamping times of 91 ± 56 min without any significant difference between groups. Fifty-four patients (74%) had difficult separation from CPB, 14 patients (19%) required an intra-aortic balloon pump and 10 patients (14%) needed emergency reinitiation of CPB for hemodynamic instability. Ten patients died in the perioperative period (13.7%). Patients receiving inhaled milrinone prior to CPB initiation had a lowering pulmonary artery pressure after CPB (p < .01) and had less emergency reinitiation of CPB after weaning (3% vs 23%, p = .02) as compared to those with administration after CPB. No detectable side effects were directly linked to the administration of the drug. Conclusion: In this high-risk cohort, use of inhaled milrinone was well tolerated. Administration before initiation of CPB could help weaning from CPB.     

Improving the surgery for sigmoid achalasia: long-term results of a technical detail

Objective: Heller myotomy results for the treatment of sigmoid achalasia are worse than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasia patients, in which we performed (1) the standard Heller–Dor procedure (no pull-down) and (2) the Heller–Dor plus a technique apt to obtain the verticality of the oesophageal axis (pull-down). We verified whether the latter technique improved long-term results. Materials and methods: We considered 33 patients affected by primitive oesophageal sigmoid achalasia operated upon consecutively (1979–2005). Diagnosis was based on symptoms, manometry, radiology and endoscopy. After 1987, we routinely isolated 360° of the gastro-oesophageal junction and the lower oesophagus and applied U stitches at the right side of the lower oesophagus to pull down and rotate the gastro-oesophageal junction toward the right. Fifteen patients underwent the no pull-down and 18 patients underwent the pull-down technique. Postoperative follow-up included objective clinical and instrumental evaluation (questionnaire filled by a surgeon including the assessment of symptoms and endoscopic reflux oesophagitis according to a semi-quantitative scale) and subjective evaluation (self-evaluation SF-36 questionnaire). Results: The mean follow-up period was 89 months (range 12–261 months). The postoperative dysphagia score was significantly improved in the entire group. Excellent results were present in 12 patients (36.4%), good in 11 (33.3%), fair in 3 (9.1%) and insufficient in 7 patients (21.2%). No statistically significant differences were observed between the two groups with regard to the postoperative symptoms and oesophagitis. Postoperative radiological measurements of oesophageal diameter and residual barium column were significantly improved in the whole group and within each group with respect to the radiological variables measured preoperatively (p = 0.000). In the comparison of the two groups, statistically significant differences were observed with regard to mean oesophageal diameter (p = 0.030) (pull-down, 4 ± 0.9 cm; no pull-down, 4.7 ± 0.6 cm) and residual barium column (p = 0.048) (pull-down, 6.2 ± 3.4 cm; no pull-down, 9.6 ± 5.8 cm). Conclusions: The Heller–Dor operation is effective in the presence of sigmoid achalasia. The clinical objective and subjective evaluations show a trend toward the improvement of results with the pull-down technique. Stronger statistical significance would probably be obtained from a larger case series.     

Long-term experiences on cardiac retransplantation in adults

Background: It remains disputed whether cardiac retransplantation should be performed. This study aimed to evaluate our long-term experiences on cardiac retransplantation in adults. Patients and methods: Between March 1989 and December 2004, 2% (28/1290) of cardiac retransplantations were performed. Results: The reasons for cardiac retransplantation were cardiac allograft vasculopathy (n = 13; 47%), primary graft failure (n = 11; 39%), and refractory acute rejection (n = 4; 14%). The 30-day mortality risk was 29% (acute rejection: 50%; primary graft failure: 36%; cardiac allograft vasculopathy: 15%, p = 0.324), compared to 8.5% for primary cardiac transplantation (p < 0.001). The causes of early death were acute rejection (n = 3; 37%), multiorgan failure (n = 3; 37%), primary graft failure (n = 1; 13%), and right ventricular failure (n = 1; 13%). The late mortality rate was 96/1000 patient-years. The causes of late death were acute rejection (n = 4; 50%), cardiac allograft vasculopathy (n = 2; 25%), multiorgan failure (n = 1; 13%), and infection (n = 1; 13%). The 1-, 5-, 10-, and 15-year survival was respectively 78, 68, 54, and 38% (primary cardiac transplantation), and 46, 41, 32, and 32% (cardiac retransplantation) (p = 0.003). The short-term survival for cardiac retransplantation due to cardiac allograft vasculopathy was likely better than primary graft failure and refractory acute rejection (p = 0.09). Conclusion: The overall outcomes of cardiac retransplantation are significantly inferior to primary cardiac transplantation. Cardiac retransplantation should be only performed for selected patients.     

The impact of early-diagnosed new-onset post-transplantation diabetes mellitus on survival and major cardiac events

The impact of early-diagnosed new-onset post-transplantation diabetes mellitus (PTDM) on cardiovascular (CV) disease is not well described. The objectives of the present prospective single-center observational study were to assess the long-term effects of early-diagnosed new-onset PTDM on major cardiac events (MCE; cardiac death or nonfatal acute myocardial infarction) and patient survival. Diabetic status and CV risk factors were assessed in 201 consecutive renal allograft recipients 3 months after transplantation (baseline) during a period of 16 months (1995-96). Follow-up data until January 1, 2004 were obtained from the Norwegian Renal Registry. The 8-year (range 7-9 years) cumulative incidence of MCEs was 7% (nine out of 138) in recipients without diabetes, 20% (seven out of 35) in patients with new-onset PTDM and 21% (six out of 28) in patients with diabetes mellitus before transplantation (DM). Proportional hazards regression analyses (forward stepwise regression) revealed that patients with PTDM had an approximately three-fold increased risk of MCEs as compared with nondiabetic patients (hazard ratio (HR)=3.27, 95% confidence interval (CI)=1.22-8.80, P=0.019). A total of 61 patients (30%) died. Eight-year patient survival was 80% in the nondiabetic group, 63% in the PTDM group and 29% in the DM group, respectively. Pretransplant diabetes (HR=5.09, 95% CI=2.60-9.96, P<0.001), age (HR=1.03, 95% CI=1.01-1.05, P=0.016), cytomegalovirus (CMV) infection (HR=2.66, 95% CI=1.27-5.53, P=0.009), and creatinine clearance (HR=0.98, 95% CI=0.96-1.00, P=0.046), but not PTDM (HR=1.20, 95% CI=0.58-2.49, P=0.621), were independent predictors of death in the multiple Cox regression model. Early-diagnosed PTDM is a predictor of MCEs, but not of all-cause mortality, the first 8 years after renal transplantation.     

Retrograde flush following topical cooling is superior to preserve the non-heart-beating donor lung

Objective: The use of non-heart-beating donors (NHBD) has been propagated as an alternative to overcome the scarcity of pulmonary grafts. Formation of microthrombi after circulatory arrest, however, is a major concern for the development of reperfusion injury. We looked at the effect and the best route of pulmonary flush following topical cooling in NHBD. Methods: Non-heparinized pigs were sacrificed by ventricular fibrillation and divided into three groups (n = 6 per group). After 1 h of in situ warm ischaemia and 2.5 h of topical cooling, lungs in group I were retrieved unflushed (NF). In group II, lungs were explanted following an anterograde flush (AF) through the pulmonary artery with 50 ml/kg Perfadex^® (6 °C). Finally, in group III, lungs were retrieved after an identical but retrograde flush (RF) via the left atrium. Flush effluent was sampled at intervals to measure haemoglobin concentration. Performance of the left lung was assessed during 60 min in our ex vivo reperfusion model. Wet-to-dry weight ratio (W/D) of both lungs was calculated as an index of pulmonary oedema. IL-1ß and TNF- protein levels in bronchial lavage fluid from both lungs were compared between groups. Results: Haemoglobin concentration (g/dl) was higher in the first effluent in RF versus AF (3.4 ± 1.1 vs 0.6 ± 0.1; p < 0.05). Pulmonary vascular resistance (dynes × s × cm⁻⁵) was 975 ± 85 RF versus 1567 ± 98 AF and 1576 ± 88 NF at 60 min of reperfusion (p < 0.001). Oxygenation (mmHg) and compliance (ml/cmH₂O) were higher (491 ± 44 vs 472 ± 61 and 430 ± 33 NS, 22 ± 3 vs 19 ± 3 and 14 ± 1 NS, respectively) and plateau airway pressure (cmH₂O) was lower (11 ± 1 vs 13 ± 1 and 13 ± 1 NS) after RF versus AF and NF, respectively. No differences in cytokine levels or in W/D ratios were observed between groups after reperfusion. Histology demonstrated microthrombi more often present after AF and NF compared to RF. Conclusion: Retrograde flush of the lung following topical cooling in the NHBD results in a better washout of residual blood and microthrombi and subsequent reduced pulmonary vascular resistance upon reperfusion.