Suspect the donor with potential infection in the adult deceased donor liver transplantation

Introduction

Liver transplantation is the treatment of choice for end-stage liver disease. However, the shortage of donors is still the major problem in most Asian countries. Using extended donor criteria may maximize the deceased donor pool, but some high-risk donors may show adverse recipient outcomes due to preexisting infection.

Materials and Methods

This study included deceased donor liver transplant patients from June 2002 through June 2007. We retrospectively reviewed the clinical manifestations of donors and recipients. The donors showed no definite infection at the time the organs were matched to the recipients. Routine sputum, urine, blood, and bile cultures were obtained from the donor during the perioperative period. According to the final reports of the cultures, the recipients divided into two groups: donor infection (DI) and no donor infection (NDI).

Results

This study included 59 donor and 72 recipients, including 34 who received a graft from a donor with a positive culture (47.2%) finally, defined as the DI groups, and 38 recipients (52.8%) as the NDI group. Most of them had positive sputum cultures, followed by urine cultures. Staphylococcus aureus was the most common pathogen. Using a stepwise logistical regression model to analyze the significant donor characteristics, donor admission to the intensive care unit (ICU) for 7 days or longer (P ≤ .0001), previous cardiopulmonary cerebral resuscitation (CPCR) (P = .036), and inotropic agents (P = .022) were the only three independent factors to predict donor infection. To compare the outcomes between DI and NDI groups, the days of recipient ICU or hospital admission, the 1-week or 1-month mortality rate, and the overall survival showed no significant difference between both groups. However, the hospital mortality rate was mildly higher in the DI group (P = .050).

Conclusion

Donors with prolonged ICU admissions, rescue by CPCR, and use of inotropic agents carried an high risk of potential infections. Our data did not show a significant increase in adverse outcomes if the recipient received a graft from a potentially infected donor. However, there may be an increased risk of hospital mortality. We should be careful in using these potentially infected donors in selective recipients.     

Klappenchirurgie

Indications for surgery form part of the guidelines for the treatment of valvular heart disease. The goal is to avoid risk associated with surgery as long as possible without reaching the point of irreversible damage to the heart and other organs. Since improvements of surgical techniques have reduced the operative risk these guidelines need revision periodically. Treatment of symptomatic patients is mainly consented. Despite this consensus surgery is denied to a significant number of patients with symptomatic aortic stenosis. Treatment of patients with severe but asymtomatic valvular heart disease is under debate. Excercise testing to detect surgical candidates is recommended but rarely performed. Evidence is evolving that subgroups of patients with asymptomatic aortic stenosis benefit from early surgery, but identification of these patients remains difficult. Advances in surgical reconstruction of leaking mitral or aortic valves have led to recommendations for earlier surgery of mitral insufficiencies; data generation for reconstructive surgery of the aortic valve is underway. Surgical experience with these techniques is of major importance in the process of deciding when to operate.     

Geschlechtsspezifische negative inotrope Wirkung von Übergewicht?

Objectives

The hypothesis was tested, whether there is a gender-specific association between contractile performance and obesity based on the analysis of isolated human myocardium.

Methods

Right atrial muscle preparations (0.5 x 6 mm) of 77 female and 106 male patients undergoing coronary artery bypass surgery were electrically stimulated at optimal length. Isometric force amplitude (stimulation) and resting force (relaxation) were measured (measurement conditions: 37 °C, Krebs-Henseleit solution, optimal length, supramaximal electrical stimulation). The relationship between body mass index (BMI) and measured parameters was analyzed statistically by using a linear regression model and the student’s T test.

Results

There was a gender-specific decline in isometric force amplitude (mN/mm²) and resting force (mN/mm²) with increasing BMI (p < 0.0001). The effects were more pronounced in women (p < 0.0001).

Conclusions

The data seem to indicate that in isolated human myocardium there is a considerable negative inotropic effect of BMI and this effect is more pronounced in women. Adipose tissue thus may be interpreted as an endocrine organ with the potential to exert important cardio-depressant effects that may contribute to the development of heart failure in overweight patients.     

Komplexe distale Bypasschirurgie mit der Brückenplastik nach Deutsch und der denaturierten humanen Umbilikalvene (HUV)

Introduction

Tibial and pedal reconstructions in the absence of suitable autologous vein still present a major challenge in surgical therapy of critical lower limb ischemia. Besides the widely used synthetic vascular prostheses, small caliber vascular conduits of biological origin, which may be combined with residual autologous vein, are available. Bypass run-off can be optimized by means of distal sequential anastomoses. The results of a consecutive series of sequential bypasses applying the bridge technique developed by Deutsch in combination with denaturated human umbilical vein (HUV) are reported.

Methods

In 36 limbs with critical ischemia and inadequate length of autologous vein, a bridge graft between the distal recipient vessels using residual vein was combined with a central HUV prosthetic donor graft. Patients were followed-up in terms of bypass function, limb salvage, changes in distal run-off and possible biodegeneration of the HUV.

Results

Primary and secondary bypass graft patencies were 54% and 79%, respectively, with a limb salvage rate of 92% after 36 months. Despite consecutive partial occlusion of the bypass, foot perfusion remained unimpaired in seven cases. Additional intervention was necessary in seven bypasses in order to maintain graft patency. Degenerative changes in the biological graft could not be detected during follow-up.

Conclusion

The bridge graft technique developed by Deutsch using a distal sequential autologous vein bridge provides excellent long-term results in terms of bypass patency and limb salvage when HUV is used as a central part of the construction.     

Preserving pulpal health of a geminated maxillary lateral incisor through multidisciplinary care

AIM: To report the multidisciplinary care of an unaesthetic geminated maxillary lateral incisor tooth, which allowed its preservation in the mouth. SUMMARY: Preoperative examination of an unsightly geminated maxillary lateral incisor (tooth 22) demonstrated two pulp chambers and open apices, with normal pulp sensitivity responses. At surgery, a periodontal mucoperiosteal flap was reflected and the distal part of the geminated tooth was removed. The exposed root canal of the preserved tooth was sealed with mineral trioxide aggregate (MTA). The extraction socket and osseous defect was grafted with decalcified freeze-dried bone allograft (DFDBA) before flap closure. During follow-up, distal caries in tooth 22 and a diastema between tooth 22 and 23 were managed with composite resin restorations. Forty-two months postoperatively, normal thermal and electrical pulp sensitivity tests confirmed pulp health. Convincing apexogenesis and dentinogenesis of the developing root was confirmed by radiographic examination. Acceptable periodontal health including 3-4 mm clinical probing depths was achieved. Optimizing aesthetics and occlusion was accomplished without orthodontic treatment.     

Intraoperative Evaluation von komplexen Mitralklappenrekonstruktionen durch physiologische Provokationstests

Objective

Based on experimental data it was tested, whether intraoperatively performed physiological provocation tests – in addition to morphological information – can improve the quality of complex mitral valve repair (CMVR).

Methods

The quality of CMVR (n=95) was routinely evaluated by transesophageal echocardiography. Shortly before weaning from ECC (flow: 1,5 l/min) the force frequency relation (tested by epimyocardial pacing, frequency range: 80-150 beats per minute), the Frank Starling mechanism (right atrial loading between 2-18 mmHg) and afterload dependency (systolic pressure: 70-140 mmHg) were analysed. Whenever significant mitral valve incompetence (MVI)>1.5 was detected, a surgical re-evaluation was carried out.

Results

Using these procedures, MVI>1.5, which was not observed using steady-state conditions, was detected in 19 patients. In 14 patients, the subsequently performed second repair was successful. In 5 patients the second reconstruction failed again and mitral valve replacement was performed, although neither intraoperative evaluation with saline solution nor standard echocardiography revealed MVI>1.5. In all patients the force frequency was most sensitive to detect functional problems of CMVR (n=18). Afterload alteration (n=12) and preload alteration (n=5) were less sensitive. Postoperatively MI was 0-5 in 70 pts, 0.5-1 in 20, and 1-1.5 in 5 pts.

Conclusion

The data suggest that intraoperatively performed physiological tests, especially the force frequency relation, are important tools to evaluate the myocardial component of mitral valve performance. A pathologically altered dependency on preload, afterload and frequency of mitral valve function can be easily detected by this method.