Pathogenesis of acute graft-versus-host disease after open heart surgery

Acute Graft-versus-Host disease (GVHD) generally occurs after allogenic bone marrow transplantation and in immunocompromised patients who have received blood products containing viable lymphocytes. A recently recognized association is that of acute GVHD in the transfused post-open heart surgery patient. The factors that converge after open heart surgery that allow the engraftment and proliferation of donor lymphocytes are discussed and a hypothesis is developed to link the acute GVHD and open heart surgery.     

Primary cytomegalovirus infection following open heart surgery

Among 674 patients undergoing open heart surgery in 1981-82, 86 (13%) were cytomegalovirus (CMV) antibody-negative when tested by an enzyme-linked immunosorbent assay prior to operation. At follow-up, 54 (67%) of 80 patients restudied had seroconverted after the operation, and 35 of the 54 seroconvertants had been ill with fever and elevated liver enzymes. Among the latter 35 patients, 26 demonstrated a significant rise in CMV antibody titre, most often detected in the third week following the onset of illness. The older patients were more susceptible to illness and seroconversion, and there was a positive correlation between age and the number of blood units given. Thus, at least one third of the seronegative patients developed symptomatic CMV illness after open heart surgery. This is a much higher incidence than earlier reported.     

Transfusion-associated graft-versus-host disease in an immunocompetent individual following cardiac surgery

A 65-year-old man underwent coronary artery bypass graft surgery at our tertiary care hospital. Perioperatively, he was transfused with four units of nonirradiated whole blood from first-degree relatives and discharged from the hospital at postoperative day seven. He presented six days later with fever, skin rash, elevated liver enzymes, and progressive pancytopenia. Elevated bilirubin levels and diarrhea were added to the clinical picture over the following days. Clinical findings and results of a skin biopsy specimen were consistent with transfusion-associated graft-versus-host disease. The patient died 20 days after transfusion.     

The assessment of neural injury following open heart surgery by physiological tremor analysis

Introduction

The appearance of post-operative cognitive dysfunction as a result of open heart surgery has been proven by several studies. Focal and/or sporadic neuron damage emerging in the central nervous system may not only appear as cognitive dysfunction, but might strongly influence features of physiological tremor.

Material and methods

We investigated 110 patients (age: 34-73 years; 76 male, 34 female; 51 coronary artery bypass grafting (CABG), 25 valve replacement, 25 combined open heart surgery, 9 off-pump CABG) before surgery and after open-heart surgery on the 3^rd to 5^th post-operative day. The assessment of the physiological tremor analysis was performed with our newly developed equipment based on the Analog Devices ADXL 320 JPC integrated accelerometer chip. Recordings were stored on a PC and spectral analysis was performed by fast Fourier transformation (FFT). We compared power integrals in the 1-4 Hz, 4-8 Hz and 8-12 Hz frequency ranges and these were statistically assessed by the Wilcoxon rank correlation test.

Results

We found significant changes in the power spectrum of physiological tremor. The spectrum in the 8-12 Hz range (neuronal oscillation) decreased and a shift was recognised to the lower spectrum (p < 0.01). The magnitude of the shift was not significantly higher for females than for males (p < 0.157). We found no significant difference between the shift and the cross-clamp or perfusion time (p < 0.6450).

Conclusions

The assessment of physiological tremor by means of our novel, feasible method may provide a deeper insight into the mechanism of central nervous system damage associated with open heart surgery.     

Nature of reconstitution with histoincompatible maternal marrow in a case of severe combined immunodeficiency with graft-versus-host disease following maternofetal transfusion

A girl with severe combined immunodeficiency was isolated directly after birth. During the second month spontaneous graft-versus-host reaction developed in the skin caused by maternal lymphocytes. This was not followed by immunological reconstitution and the situation was complicated by agranulocytosis. A transplantation of marrow from the HLA-A, -B, and -D mismatched mother, using cyclophosphamide for conditioning, was performed. This led to a rapid engraftment of the maternal hematopoietic elements followed by immunological reconstitution. Acute graft-versus-host reaction followed. The child died from sudden infant death one month after the release from isolation. At autopsy liver damage was found with developing cirrhosis in spite of the absence of laboratory indications for chronic graft-versus-host reaction. The case shows that transplantation of an HLA-D mismatched marrow might be possible in man under gnotobiotic conditions.     

Intraspinal narcotic anesthesia in open heart surgery

Intraspinal narcotic anesthesia was performed in 180 open heart surgery patients. 0.1 mg/Kg of morphine or 1.5 mg/Kg of meperidine was administered as the primary anesthetic in the subarachnoid space using the barbotage technique. Of the 180 patients scheduled for open heart surgery, morphine was administered to 95 patients, meperidine to 55 and a mixture of morphine and meperidine to 30 patients. From a clinical point of view, there were no significant cardiovascular problems, however, respiratory depression seemed to be most serious after morphine administration. Mild complications such as pruritus (11.1%), voiding difficulty (10.6%), intraoperative awareness (4.4%) and spinal headache were observed, however these were mild, not major clinical problems and were acceptable. Postoperative analgesic effect and respiratory controllability were excellent.     

Single-dose antimicrobial prophylaxis in open heart surgery

A single one-gram pre-operative dose of ceftriaxone was compared with seven one-gram doses of cefazolin administered peri-operatively with the aim of preventing infections associated with coronary artery bypass graft surgery. Ninety-four évaluable cases were analyzed; 49 patients received ceftriaxone and 45 received cefazolin. There was no significant difference in the number of infectious complications between the two groups. Ceftriaxone had a terminal half-life of approximately 15.7 hours. There was no toxicity associated with either antibiotic. Because of the reduced number of doses, single-dose prophylaxis may result in considerable savings. Single-dose prophylaxis with ceftriaxone was found to be an effective modality for prevention of infection in open heart surgery.     

心内直视手术期间及术后血液流变性变化的临床研究

目的：观察心内直视手术期间及术后血液流变学的变化。方法：分别在麻醉前、转流前、转流后１０ｍｉｎ、心脏复跳后１０ｍｉｎ、停转后１０ｍｉｎ及术毕３ｈ测定Ｈｃｔ、血沉、血浆粘度、全血高、中、低切粘度、全血还原高、低切粘度。结果：全血高、中、低切粘度、血浆粘度及Ｈｃｔ在转流期间及复跳后１０ｍｉｎ显著下降（Ｐ＜０．００１）。其他指标无明显变化。结论：心内直视手术期间体外循环对全血粘度、血浆粘度及Ｈｃｔ有显著影响,对血沉及全血还原粘度影响不大。     

Patient monitoring during and after open heart surgery by an improved deep body thermometer

The deep body thermometer developed by Fox was improved by Togawa by thermal insulation of the probe. The present status of medical progress in clinical thermometry through the improved deep body thermometer was reviewed from the view point of cardiac surgery. The forehead and sole temperatures obtained by this improved thermometer were monitored and recorded by a multipotentiometric recorder continuously up to 12 days in the patients admitted to the ICU who underwent open heart surgery. The forehead tissue temperature measured by this thermometer is slightly lower than and parallel to the rectal temperature, being close to the pulmonary arterial blood temperature. On the other hand, the sole tissue temperature fluctuates from room temperature to the forehead tissue temperature, sometimes showing rhythmic changes. The former seems to be the core temperature and the latter, the shell temperature. The dissociation when the two temperatures are more than 7 degrees C apart from each other suggests that the hemodynamical condition is worse than in the convergence when they remain within 2 degrees C. A state of shock can be diagnosed when the arterial systolic pressure is less than 90 mmHg and the urine output less than 1 ml/min/mg in addition to the dissociation. The effect of treatment and the prognosis for the patient are predictable according to the trends of the two temperatures as divergent or convergent. The dynamic thermometry by this thermometer is very informative and the procedure is noninvasive without discomfort to the patient.     

体外循环心脏直视手术对小儿T淋巴细胞亚群的影响

目的 探讨体外循环心脏直视手术对小儿T淋巴细胞亚群的影响。方法 选择先天性心脏病需行体外循环心脏直视手术患儿60例，采用中度低温体外循环，分别于术前、术毕、术后6小时、1、4、7天采集静脉血标本。应用流式细胞技术检测CD3、CD34、CD8阳性T淋巴细胞。结果 CD3、CD4T淋巴细胞于术后下降，CD8T淋巴细胞有上升。结论 体外循环心脏直视手术对小儿T淋巴细胞功能有明显的抑制作用。     

Alloantibodies and Australia antigen after open heart surgery

The development of irregular serum antibodies (alloantibodies) following massive transfusion was studied in 144 patients who had undergone cardiac valve replacement. An overall incidence of alloimmunization of 8.3% was found. Of the 15 antibodies detected nine were Rhesus anti-E and four anti-Kell. The incidence of anti-E formation in Rhesus E-negative patients was 11.4%; the corresponding figure for anti-Kell was 3.2%. The results suggest that the risk of allo-immunization is directly related to the volume of blood transfused, and Rhesus E-negative persons appear to be at particular risk.Australia (Au) antigen investigations were also carried out in 102 of these cases. Three patients were Au antigen positive, one of them developing acute hepatitis. In each case no Au antigen could be detected in the donor blood that was used.It is suggested that tests for alloantibodies and for the Australia antigen should become part of the routine follow-up of any patient receiving massive transfusion.     

心脏跳动下心内直视手术的体外循环管理

目的探讨心脏跳动下心内直视手术中体外循环的管理方法。方法总结分析2 290例心脏跳动下行心内直视手术的体外循环管理方法。术中均常规建立左心引流,术毕采用综合序贯排气技术。转流中鼻咽温维持在30～32℃,红细胞压积维持在20%～30%,流量控制在2.4～3.2 L.m-1.min-2,采用α稳态血气管理方法,术中酌情行常规超滤或改良超滤。结果全组体外循环均顺利停机,转流时间22～179 min。术中室颤256例,其中181例自动复跳。全组死亡22例,其中复杂先天性心脏病15例,重症瓣膜病7例。全组无体外循环气栓并发症。结论浅低温体外循环方法在心脏跳动下心内直视手术中安全可行且易于管理,能有效避免心肌缺血-再灌注损伤。     

心脏不停跳直视手术的临床研究

目的通过心肌肌钙蛋白(cTnI)浓度检测及心肌超微结构的观察,评价心脏不停跳心内直视术与心脏停跳下心内直视术的心肌保护效果。方法通过对比分析心脏停跳与不停跳心内直视手术各20例的手术方法特点及效果,采用生物化学及组织形态学的研究方法,分别测定术中不同时点血浆cTn-I值,观察心肌超微结构,进行对比研究,比较两种术式对心肌损伤的影响,探讨两种术式在心肌保护方面的优缺点。结果(1)阻断前两组肌钙蛋白值均正常,且无统计学差异。(2)阻断30min和开放后20min两组肌钙蛋白值均升高(P<0.05),且不停跳组各时相点血清肌钙蛋白值明显低于停跳组(P<0.05),差异有显著性。(3)心肌超微结构显示不停跳组心肌损伤较停跳组轻。结论心脏不停跳心内直视术安全可行,具有良好的心肌保护作用。     

间充质干细胞输注对移植物抗宿主病中不同受损器官的治疗效果

背景：间充质干细胞的免疫学特性为其作为临床治疗移植物抗宿主病提供了可能。目的：分析骨髓间充质干细胞输注的安全性以及对移植物抗宿主病中不同受损器官的治疗效果。方法：8例恶性血液病患者在异基因造血干细胞移植后出现激素耐药重度急性移植物抗宿主病,在原有免疫抑制治疗的基础上给予输注间充质干细胞 1×10⁶/kg,分别输注1-4次。结果与结论：8例患者中6例经间充质干细胞治疗有效(2例完全缓解,4例部分缓解),2例无效。5例皮肤病变中4例得到改善,1例无效;3例口腔病变中2例得到完全缓解,1例部分缓解。2例肝脏病变以及2例胃肠道病变均获得完全缓解。3例眼睛病变、1例闭塞性支气管炎以及1例泌尿系统移植物抗宿主病无效。在随访中位时间28(7-62)个月期间,8例患者中3例在输注间充质干细胞后3个月内出现移植后淋巴增殖性疾病。结果表明间充质干细胞输注对皮肤、肝脏、胃肠道、口腔移植物抗宿主病有一定的疗效,对眼睛、肺部以及泌尿系统的移植物抗宿主病无效果。间充质干细胞输注过程安全,间充质干细胞的使用是否与移植后淋巴增殖性疾病的发生有关需要更多病例资料的证实。中国组织工程研究杂志出版内容重点：干细胞;骨髓干细胞;造血干细胞;脂肪干细胞;肿瘤干细胞;胚胎干细胞;脐带脐血干细胞;干细胞诱导;干细胞分化;组织工程全文链接：