Lipids,lipoprotein (a) and coronary artery disease in patients following cardiac transplantation

Cardiac allograft vascular disease (CAVD) is the most important cause of late mortality in cardiac transplant recipients. While the pathogenesis of the disease is believed to be immunological, other factors like hyperlipidaemia may contribute. Total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apolipoprotein A1 and B and Lp(a) levels were measured in 174 cardiac transplant recipients attending our clinic for routine follow-up. Univariate and multivariate logistic regression analysis was carried out to assess the relationship of the variables studied to the presence of CAVD diagnosed with coronary angiography. CAVD was present in 42 of the 174 patients. The group with CAVD had a higher total cholesterol (6.8 vs 6.3 mmol/l), lower HDL cholesterol (0.8 vs 0.9 mmol/l), higher triglyceride (2.8 vs 2.0 mmol/l) and higher Lp(a) level (317.5 vs 95 mg/l) than the group without CAVD. In multivariate analysis, after adjusting for gender, hypertension, time from transplantation, preoperative diagnosis and lipid-lowering therapy, Lp(a), total cholesterol, HDL cholesterol and triglycerides remained significantly correlated with CAVD. The results indicate a significant association between hyperlipidaemia, Lp(a) levels and allograft vascular disease. Further studies are needed to show whether treatment of hyperlidaemia in this population delays the onset or slows the progression of CAVD.     

Fatal primary multidrug-resistant tuberculosis in a heart transplant recipient

The incidence of tuberculosis (TB) worldwide is currently on the rise, not only in the general population but also quite notably among immunosuppressed patients. Its incidence among patients undergoing antirejection therapy is considerably higher than in the general population, and heart transplant recipients have been found to carry the highest risk of TB. There are no reported data, however, on primary TB caused by multidrug-resistant (MDR) Mycobacterium tuberculosis (M. tuberculosis) in heart transplant recipients. We describe the case of a patient who developed active primary MDR TB following the reactivation of a latent tuberculous infection 6 months after transplantation. The patient was most likely infected by M. tuberculosis during a period of time he spent in prison 10 years before undergoing transplantation, but he never developed active tuberculosis, nor did he ever receive antituberculous medication prior to transplantation. Because of the atypical clinical presentation, establishment of the diagnosis was postponed, and the resistance pattern of the isolate grown from bronchoalveolar lavage (BAL) specimens (resistant to isoniazid and rifampicin) led to treatment failure and a fatal outcome. The adoption of the most rapid diagnostic tools for the identification of M. tuberculosis and for a quick screening of drug-resistant isolates is urgently needed in those centers where organ transplantation is carried out. Received: 16 December 1997 Received after revision: 25 February 1998 Accepted: 16 March 1998     

冠状动脉旁路移植术同期经旁路血管移植自体干细胞治疗缺血性心衰

目的 评价冠状动脉旁路移植手术同期经旁路血管移植自体骨髓干细胞治疗缺血性心衰的可行性和安全性.方法 40例需外科手术治疗的陈旧性心梗伴左室功能不全病人,在冠状动脉旁路移植手术同期经旁路血管移植自体骨髓单个核细胞.结果 全组手术死亡1例.手术早期无心梗发生,无肝、肾功能衰竭,无新发恶性心律失常.结论 冠状动脉旁路移植术同期经旁路血管移植自体骨髓单个核细胞治疗冠心病陈旧心梗,为缺血性心衰病人提供了一个全新的综合治疗选择.     

同期或分期行颈动脉支架置入术与非体外循环冠状动脉旁路移植术治疗冠心病合并颈动脉狭窄

目的 观察同期或分期行颈动脉支架置入术与非体外循环冠状动脉旁路移植术治疗冠心病合并颈动脉狭窄的临床疗效及安全性.方法 2008年1月至2010年12月,30例合并严重颈动脉狭窄(≥70％)的冠心病患者行非体外循环冠状动脉旁路移植术,男24例,女6例;年龄51～79岁,平均(67.6±7.4)岁,同期或分期行颈动脉支架置入术各15例.结果 30例手术均获成功,无手术死亡.同期手术组术后早期出现轻度脑卒中1例,中度脑卒中1例.分期手术组术后早期二次开胸止血、新发房颤和急性肾功能衰竭各1例.同期手术组与分期手术组术后胸腔引流量(945±260) ml对(764±334)ml,P=0.109;住ICU(87.7±61.6)h对(52.3±80.8)h,P=0.189;呼吸机使用(31.7±27.8)h对(17.9±7.06)h,P=0.073.同期手术组术后住院(9.7±3.3)天,与分期手术组(17.1±6.9)天相比明显减少(P=0.001),平均住院费用降低了16.7％.术后随访6～42个月,平均(22.0±9.6)个月,随访期内.两组均无死亡、心肌梗死、脑卒中和心绞痛等并发症.结论 慎重选择患者,严格掌握手术适应证,同期或分期行颈动脉支架置入术与非体外循环冠状动脉旁路移植术治疗冠心病合并颈动脉狭窄临床效果均满意.中、远期效果还需进一步观察.     

Immunologically induced coronary artery stenosis in allografts after heart and heart-lung transplantation in rats

The role of the lung in suppressing immunologically induced coronary artery stenosis after heterotopic allograft transplantation was studied in rats. Thirty-nine recipients were divided into two groups: untreated and treated. The untreated group was divided into two subgroups — the heart allograft TH group and the heart-lung allograft THL group. The treated group was divided further into four subgroups depending on when the graft was harvested, after 30 days or 60 days (T_30-H and T_30-HL group, and T_60-H, T_60-HL, respectively). Rejection was assessed by Lurie's classification. The percent of intraluminal stenosis (PIS) was determined by planimetry. All treated animals received cyclospolin A 10 mg/kg/day intramuscularly for 20 days. In the untreated group, heart-lung allograft survival was longer than heart allograft survival. In the treated group, all grafts were still beating when the animals were killed. The rejection grade score in the T_30-H and T_30-HL groups were lower than those in the T_60-H or T_60-HL groups. The PIS in the THL group was slightly lower than that in the TH group. However the PIS increased over time in both the TH and THL groups. This study demonstrates that the lung suppresses but does not abolish immunologically induced coronary atherosclerosis-like occlusive lesions after cardiac transplantation.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

非体外循环下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变

目的探讨非体外循环心脏跳动下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变的早期临床结果和经验。方法2003年5月—2005年5月,对53例弥漫性冠状动脉病变患者行非体外循环下冠状动脉内膜剥脱后搭桥手术治疗。53例中,男性41例、女性12例,年龄55～79(64±7)岁。加拿大心脏病协会心绞痛分级：Ⅰ～Ⅱ级15例,Ⅲ级6例,Ⅳ级32例。有心肌梗死史26例(49%)。冠状动脉造影：双支病变3例,3支病变50例,其中合并左主于病变9例。左心室射血分数0．26～0．65(0．52±0．17)。53例共行70支冠状动脉内膜剥脱：左前降支系统38支,其中5例内膜剥脱后先用大隐静脉片行前降支成形,再在补片上用乳内动脉搭桥;回旋支的钝缘支8支;右冠状动脉系统24支。应用左乳内动脉53支,桡动脉2支,余均为大隐静脉桥,人均搭桥(3．8±1．1)支,再血管化指数1．03±0．07。结果术中桥血流测定显示63支桥血流满意,7支欠满意。术后2例发生围手术期心肌梗死,但对血流动力学无明显影响。53例皆痊愈出院。44例随访6～29个月,无心绞痛发作;9例失访。6例在手术后3～27个月复查冠状动脉造影,显示桥血管均通畅。结论非体外循环下冠状动脉内膜剥脱后搭桥,安全可行,再血管化程度高,是治疗弥漫性冠状动脉病变的有效方法。     

Acute diverticulitis in heart transplant recipients

Immunosuppressed patients are susceptible to complicated diverticulitis, but reports of this complication are scarce in heart graft recipients. To estimate the prevalence of acute diverticulitis in heart graft recipients, we retrospectively reviewed the cases of diverticulitis in a series of 143 patients who underwent orthotopic heart transplantation in a period of 10 years. Six (4%) of these developed acute diverticulitis and required colectomy. All of them were male patients and were older than 50 years. Four patients underwent urgent laparotomy and colon resection with end colostomy (Hartmann procedure). The two other patients suffered from diverticulitis without generalized peritonitis and underwent laparoscopic sigmoidectomy with direct transanal end-to-end anastomosis. The postoperative outcomes of these six patients were satisfactory. As are other immunosuppressed patients, heart graft recipients are susceptible to diverticulitis. Early surgical management may be safe in well-compensated patients.     

Hyperhomocysteinemia and transplant coronary artery disease in cardiac transplant recipients

BACKGROUND: In cardiac transplant recipients, long-term survival may be limited by transplant coronary artery disease (TxCAD). Hyperhomocysteinemia (Hhcy) has been associated with vascular disease and is common in transplant recipients. The objective of this study was to determine the relationship between fasting homocysteine (Hcy) concentrations and TxCAD in a cohort of cardiac transplant recipients. METHODS: Forty-eight patients more than 5 yr after transplant were recruited from a cohort of 72 consecutive patients with in-depth analysis of homocysteine levels from the Cardiac Transplant Clinic. Early morning fasting blood was obtained, and the plasma separated and frozen within 30 min. Hcy concentrations were determined by high-performance liquid chromatography (HPLC) with pulsed integrated amperometry. Coronary angiograms were reviewed in a blinded fashion. TxCAD was diagnosed, using the most recent angiogram, when a >25% lesion was present anywhere in the coronary tree. RESULTS: Forty-eight patients transplanted between 1985 and 1994 were studied. The mean Hcy concentration for the cohort was 23.5+/-5.0 micromol/L, all patients had homocysteine levels above the upper range of normal (5-15 micromol/L). Hcy concentrations were significantly higher in patients with angiographic evidence of TxCAD: 25.0+/-5.9 vs. 21.9+/-3.4 micromol/L, p=0.03. This effect persisted when covariates were taken into account using logistic regression analysis. CONCLUSIONS: Hhcy is associated with TxCAD. Prospective studies are required to confirm this association and to assess the efficacy of Hcy-lowering therapy in this patient population.     

Coronary artery bypass grafting for coronary artery anomalies in infants and young children

Open in a separate window OBJECTIVESCoronary artery bypass grafting (CABG) has been reported for coronary artery diseases in patients with Kawasaki disease and coronary artery complications after arterial switch operations for transposition of the great arteries. However, only a few studies have explored this modality for congenital coronary artery anomalies. As congenital coronary artery anomalies, particularly left coronary artery atresia and stenosis, are one of the reasons for sudden death, coronary revascularization is often required in infants and young children. Therefore, we aimed to investigate the outcome of CABG for such anomalies in infants and young children.METHODSFrom 2014 to 2018, 3 infants and 2 children (median age: 10 months; range: 6–40 months) with coronary artery anomalies underwent CABG at our hospital. The indications for the procedure included left main coronary artery atresia and stenosis in 2 and 3 patients, respectively. Graft patency was evaluated postoperatively by contrast-enhanced computed tomography or coronary angiography, and postoperative outcomes (including death and cardiac events) were assessed during the follow-up period.RESULTSNo 30-day or in-hospital mortalities were noted. Postoperative examinations revealed patent grafts in all patients. They were discharged without any cardiac complications. Regarding the outcomes at the follow-up period, the graft patency rate was 80.0% (4/5 grafts), with no deaths or cardiac events.CONCLUSIONSCABG is a useful strategy for coronary revascularization in infants and young children with coronary artery anomalies. Although the mid-term outcomes and patency are satisfactory, careful follow-up is necessary because the long-term outcomes remain unknown.     

左回旋支先天缺如患者经皮冠状动脉介入治疗冠状动脉狭窄1例

<正>患者女,61岁,因"反复活动后胸骨后闷痛伴胸闷6个月,加重3天"入院。无放射痛,休息或含服硝酸甘油后10min可缓解,入院前3天起症状发作较前频繁。既往有高血压病史。查体:血压160 mmHg/90 mmHg,心、肺、腹部查体未见异常。     

非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病

目的探讨非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病(冠心病)的可行性. 方法回顾分析2002年1月～12月37例重症冠心病的临床资料.均采用全麻,胸骨正中切口,游离左乳内动脉及大隐静脉.心脏稳定器局部固定心肌,显露目标冠状动脉,切开后置入冠状动脉内血液分流器.一般先做左乳内动脉与左冠状动脉前降支的吻合,其余血管桥先做桥血管与主动脉的近心端吻合,然后再做桥血管与冠状动脉的吻合. 结果全组病例均在非体外循环下完成手术,搭桥1～6支,(3.2±0.5)支.术后10 d死亡1例,其余36例未发生围术期心肌梗死,无呼吸功能不全、肾功能不全、脑血管意外等严重并发症. 结论在成熟的手术技术和严格的围手术期管理的条件下,非体外循环冠状动脉旁路移植术治疗重症冠心病可行.     

非体外循环冠状动脉搭桥术术后早期心脏功能评价

目的 评价非体外循环冠状动脉搭桥术（OPCAB）术后早期心脏功能。方法 OPCAB组42例，体外循环冠脉搭桥术组63例（对照组），对比两组血浆心肌酶水平和心电图变化，利用Wwan-Ganz导管分析术中和术后血液动力学变化趋势，并评价早期临床效果。结果 两组临床资料无差别。OPCAB组中CK、CK－MB、AST、LDH的平均血浓度在术后当天、术后1d、3d和术后1周均正常，而对照组则有升高。OPCAB组心电图阳性变化数目较对照组少见。血液动力学指标显示，OPCAB组的心排指数、每搏输出量指数和左室作功能指数匀较对照组恢复迅速，而肺动脉楔压和中心静脉压水平偏低。OPCAB组近期临床效果也较对照组优越。结论 OPCAB组术后早期心脏功能优于体外循环下的冠状动脉搭桥术，提示OPCAB手术心肌保护效果好，血管吻合的精确性也令人满意。     

心脏不停跳下行瓣膜置换及冠状动脉旁路移植术

目的 总结心脏不停跳下瓣膜置换及冠状动脉旁路移植术的体会,并评估其疗效.方法 对2005年1月至2007年8月12例同时合并冠状动脉粥样硬化性心脏病和心脏瓣膜病的病人进行手术.病人术前均存在心绞痛症状,心功能为Ⅱ～Ⅳ级,术前射血分数平均0.53±0.23.不停跳下进行冠状动脉旁路移植及瓣膜置换术,比较术前及术后相关心功能指标.结果 病人均痊愈出院.平均移植血管(3.4±1.5)支.复查时所有病人均无症状.心功能及射血分数均显著提高(P<0.001).结论 在心脏不停跳下行瓣膜置换及冠状动脉旁路移植术可行,并发症少.术后早期心功能、自主症状及生活质量均显著改善.远期疗效尚需观察.     

Successful stenting for renal artery stenosis in a patient with Alagille syndrome

A 12-year-old girl with Alagille syndrome manifested severe hypertension caused by renal artery stenosis in a solitary functioning kidney. Percutaneous transluminal angioplasty (PTA) and stenting was performed, but the hypertension persisted. On the next day, acute renal failure occurred with the administration of angiotensin-converting enzyme inhibitor, and migration of the stent was confirmed by angiography. Thus, a second stent was placed with success. Since then, the hypertension has been controlled with anti-hypertensive medication, and the renal function has recovered to normal range.     

Off-pump coronary artery bypass grafting in two renal transplant patients

Coronary artery disease is a critical problem for a renal transplant patient. This paper reports offpump coronary artery bypass grafting (OPCABG) in two cases after renal transplantation. The first, a 65-year-old woman, experienced chest pain 5 years after a renal transplantation. Coronary angiography (CAG) revealed stenosis of the left anterior descending artery (LAD) and the first diagonal artery (DB1). OPCABG [left internal thoracic artery (LITA) to DB1 and LAD] was performed. The second, a 67-year-old man, underwent percutaneous coronary intervention in the LAD 10 years ago. He experienced chest pain 2 years after a renal transplantation. CAG revealed restenosis of LAD. OPCABG (LITA to LAD) was performed. The patients’ postoperative course was uneventful. OPCABG for a renal transplant patient was safe and useful since it is a less invasive procedure and easily managed perioperatively.     

Coronary artery stenting and non-cardiac surgery--a prospective outcome study

Background. A 45% complication rate and a mortality of 20% werereported previously in patients undergoing non-cardiac surgeryafter coronary artery stenting. Discontinuation of antiplateletdrugs appeared to be of major influence on outcome. Thereforewe undertook a prospective, observational multicentre studywith predefined heparin therapy and antiplatelet medicationin patients undergoing non-cardiac procedures after coronaryartery stenting. Methods. One hundred and three patients from three medical institutionswere enrolled prospectively. Patients received coronary arterystents within 1 yr before non-cardiac surgery (urgent, semi-urgentor elective). Antiplatelet drug therapy was not, or only briefly,interrupted. Heparin was administered to all patients. All patientswere on an intensive/intermediate care unit after surgery. Mainoutcome was the combined (cardiac, bleeding, surgical, sepsis)complication rate. Results. Of 103 patients, 44.7% (95% CI 34.9–54.8) sufferedcomplications after surgery; 4.9% (95% CI 1.6–11.0) ofthe patients died. All but two (bleeding only) adverse eventswere of cardiac nature. The majority of complications occurredearly after surgery. The risk of suffering an event was 2.11-foldgreater in patients with recent stents (<35 days before surgery)as compared with percutaneous cardiac intervention more than90 days before surgery. Conclusions. Despite heparin and despite having all patientson intensive/intermediate care units, cardiac events are themajor cause for new perioperative morbidity/mortality in patientsundergoing non-cardiac surgery after coronary artery stenting.The complication rate exceeds the re-occlusion rate of stentsin patients without surgery (usually <1% annually). Patientswith coronary artery stenting less than 35 days before surgeryare at the greatest risk.      

The predictive value of coronary artery calcium detected by computed tomography in a prospective study on cardiac allograft vasculopathy in heart transplant patients

The predictive value of coronary artery calcium (CAC) in heart transplant (HTX) patients is not established. We explored if the absence of CAC on computed tomography (CT) could exclude moderate and severe cardiac allograft vasculopathy [CAV_2–3; the International Society for Heart and Lung Transplantation (ISHLT) recommended nomenclature] and significant coronary artery stenosis (diameter reduction ≥50%) and predict long‐term clinical outcomes. HTX recipients (n = 133) were prospectively included and underwent CT for CAC scoring and invasive coronary angiography (ICA) 7.8 ± 5.0 years after HTX. CAC was detected in 73 (55%) patients. The absence of CAC on CT had a negative predictive value of 97% for ISHLT CAV_2–3 and 88% for significant stenosis on ICA. During 7.5 ± 2.6 years of follow‐up after CAC CT (n = 127), there were 57 (45%) nonfatal major adverse cardiac events and 23 (18%) deaths or graft losses registered as first events. Patients with CAC had significantly more events (P = 0.011). In an adjusted Cox regression analysis, the presence of CAC was significantly associated with a negative outcome (HR 1.8, 95% CI 1.1–3.0; P = 0.023). The absence of CAC predicted low prevalences of ISHLT CAV_2–3 and significant coronary artery stenosis in HTX patients. The presence of CACS was significantly associated with a worse long‐term outcome.     

冠心病合并颈动脉狭窄的治疗

目的 探讨冠状动脉旁路移植术(CABG)和颈动脉内膜剥脱术(CEA)治疗冠心病合并颈动脉狭窄的治疗方法的选择.方法 2009年1月至2011年12月期间,首都医科大学附属北京安贞医院大血管中心23例冠心病合并颈动脉狭窄患者同期或分期行CABG和CEA治疗,男16例,女7例.年龄53 ～ 82岁,平均(65.9±4.0)岁.冠状动脉造影发现左主干病变3例,2支病变3例,3支病变17例.1例合并二尖瓣关闭不全.单侧颈动脉狭窄17例,双侧狭窄6例,直径狭窄≥70％.依据患者两处病变病情严重程度而采取冠状动脉旁路移植术(CABG)和颈动脉内膜剥脱术(CEA)同期或分期治疗,术后观察围手术期发生卒中、心肌梗死的及死亡情况,并随访.结果 7例患者同期行CEA和CABG,其中1例同时行二尖瓣置换;13例患者先期行CABG后行CEA;3例患者先行CEA后行CABG.围术期死亡1例(4.3％),无心绞痛、心肌梗死和卒中.随访6个月,随访期内患者未发生死亡、卒中、心绞痛及心肌梗死.结论 同期还是分期行CABG和CEA治疗冠心病合并颈动脉狭窄应根据患者具体情况而定,个性化治疗是降低手术风险的关键.     

Coronary endarterectomy for diffuse extensive coronary artery disease

Introduction Atherosclerotic coronary artery disease is in an increasing trend in India. With the advancement of non-surgical methods of revascularisation, the patients coming for surgery are of less attractive anatomy. The role of coronary endarterectomy along with coronary artery bypass grafting for a selected group of these patients is quite promising. Materials and Methods From March 2000 to March 2005, out of 362 CABGs performed, 42 patients had undergone coronary endarterectomy. The age range being from 35 to 76 years, M: F is 38∶4 Hypertension was present in 26 (61%), diabetes mellitus in 20 (47.6%), smoking in 26 (61%) and dyslipidemia in 12 (28.5%) cases. Old myocardial infarction was present in 52.3% cases, unstable angina in 16.6%, stable angina in 23.8% and cardiogenic shock in 7.1% cases. All cases had undergone coronary artery bypass grafting with endarterectomy. Out of 18 LAD endarterectomies 17 cases LIMA was used as onlay patch. Result The average number of grafts anastomosed was 3.7. Single-vessel endarterectomy was done in 37, double vessel in 4 and four vessel in one case. LAD endarterectomy was done in 18, RCA in 12, diagonal in 10, intermediate in 1 and marginals in 8 cases. Postoperatively 3 patients had arrhythmia, two perioperative MI, one recurrent angina and one congestive cardiac failure (CCF). There was 2 (4.76%) mortality. Conclusion Hypertension and smoking are major risk factors. LAD is the most common artery requiring endarterectomy. Usage of LIMA following endarterectomy of LAD is quite satisfactory and short term results are encouraging.