Is bridging to transplantation with a left ventricular assist device a risk factor for transplant coronary artery disease?

BACKGROUND: Left ventricular assist device (LVAD) support is associated with coagulopathy, bleeding, increased blood transfusion, and increased anti-HLA antibody production. Increased anti-HLA antibody production is associated with early transplant rejection, transplant coronary artery disease (CAD), and decreased post-transplant survival rates. We asked whether bridging to transplantation with an LVAD increases the risk of transplant CAD. METHODS: We reviewed data for all adults (>18 years old) who underwent heart transplantation at our institution between 1988 and 2000. After exclusion of transplant recipients who survived <3 years, we divided the remaining cohort into 2 groups: those bridged to transplantation with LVADs (mean duration of support, 149 +/- 107 days, n = 29) and those in United Network for Organ Sharing Status 1 bridged to transplantation without LVADs (controls, n = 86). We compared groups in terms of disease cause, age, sex, donor age, panel-reactive antibody testing, crossmatching, pre- and post-transplant cholesterol concentrations, diagnosis of diabetes mellitus or treated hypertension, infections, calcium channel blocker use, transplant rejection, ischemic time, cytomegalovirus infection, pre-transplant transfusion, and incidence of transplant CAD (defined as any coronary lesion identified by coronary angiography). We considered p < 0.05 to be significant. RESULTS: The bridged and control groups were similar in all respects except mean ischemic time (217 +/- 58 minutes vs 179 +/- 67 minutes, p = 0.007), post-transplant cholesterol concentration (212 +/- 55 mg/dl vs 171 +/- 66 mg/dl, p = 0.007), and pre-transplant transfusion incidence (100% vs 22%, p < 0.001). The incidence of transplant CAD was similar in both groups during a 3-year follow-up period (28% vs 17%, p = 0.238) and during total follow-up (34% vs 35%, p = 0.969). Multivariate logistic regression analysis identified cholesterol concentration at 1 year after transplantation as a significant predictor of CAD at 3 years after heart transplantation (p = 0.0029, odds ratio = 0.984). CONCLUSIONS: Bridging to transplantation with an LVAD does not increase the risk of transplant CAD. Nevertheless, aggressive prophylactic therapy to minimize potential risk factors for transplant CAD, such as increased cholesterol concentration, is warranted in all transplant recipients.     

Measurements of acetabular cup position and pelvic spatial orientation after total hip arthroplasty using computed tomography/radiography matching.

This study presents a clinical validation of postoperative measurements of acetabular cup alignment following total hip arthroplasty (THA). The methodology was based on concurrent anatomic three-dimensional (3D) measurements of both the acetabular cup alignment and pelvic orientation, using an original CT/X-ray matching algorithm named Xalign. The subjects were 19 patients who had undergone bilateral THA using CT-based surgical navigation. All patients had postoperative pelvic CT scans and multiple antero-posterior (AP) pelvic X-rays. Using a proprietary software algorithm, the X-rays included in the study were matched with the corresponding postoperative CT scans. The goal of this method was to allow 3D anatomic pelvic and acetabular measurements on two-dimensional AP X-rays. The postoperative cup abduction, version and pelvic flexion angles were determined in three different ways: using CT images directly, applying the Xalign method, and finally by performing conventional (abduction only) measurements on AP pelvic X-rays. The cup orientation measured on CT images was taken as the ground truth. The Xalign measurement errors were defined as the difference between the CT cup values and those obtained by applying the matching method. The mean cup abduction error was 0.85 degrees +/- 1.3 degrees (+/- standard deviation) and the mean version error was 0.01 degrees +/- 1.99 degrees . Conventionally measured cup abduction ranged from 44 degrees to 62 degrees and correlated significantly (p = 0.001, r = -0.5) with pelvic flexion angle, proving the linear negative correlation between pelvic flexion and the error in conventional radiographic cup measurements. The Xalign method offered reasonable accuracy for cup orientation, and allowed cup and pelvic 3D anatomic measurements at different times.     

Ultrasound registration of the bone surface for surgical navigation.

OBJECTIVE: To allow non-invasive registration of the bone surface for computer-assisted surgery (CAS), this investigation reports the development and evaluation of intraoperative registration using 2D ultrasound (US) images. This approach employs automatic segmentation of the bone surface reflection from US images tagged with the 3D position to enable the application of CAS to minimally invasive procedures. METHODS: The US-based registration method was evaluated in comparison to point-based registration, which is the predominant method in current clinical use. The absolute accuracy of the US-based registration was determined using a phantom pelvis, with fiducial registration providing the ground truth. The relative accuracy was determined by an intraoperative study comparing the US registration to the point-based registration obtained as part of the HipNav experimental protocol. RESULTS: The phantom pelvis study demonstrated equivalent accuracy between point- and US-based registration under in vitro conditions. In the intraoperative study, the US-based registration was sufficiently consistent with the point-based registration to warrant larger-scale clinical trials of this non-invasive registration method. CONCLUSION: Ultrasound-based registration eliminates the need for physical contact with the bone surface as in point-based registration. As a result, non-invasive registration could fully unlock the potential of computer-assisted surgery, enabling development of the next generation of minimally invasive surgical procedures.     

Evaluation of myocardial function in patients with end-stage heart failure during support with the Jarvik 2000 left ventricular assist device.

In 2 patients with the Jarvik 2000 left ventricular assist device (LVAD), we assessed left ventricular systolic function through pressure-volume loops and E(max) at the beginning and end of the support period to potentially predict the possibility of pump removal without transplantation. Immediately before LVAD implantation and explantation, pressure and volume measurements were made with catheters and echocardiography, respectively, the E(max) being calculated from the slope of the pressure-volume loops, and the left ventricular ejection fraction (LVEF) being estimated by echocardiography. Transplantation was performed after 14 and 62 days, respectively, during which the LVEF increased by 75% (from 12% to 21%) in Patient 1 and remained unchanged (from 16% to 18%) in Patient 2, whereas the E(max) increased from 0.63 and 0.42 mm Hg/ml, respectively, to 1.31 and 1.07 mm Hg/ml, reflecting a 107% and 155% improvement. In these 2 cases, the E(max) was a more reliable indicator of intrinsic myocardial contractility than was the LVEF.     

Differentiation of interstistial cells and stromal proteins in the secondary septum of early postnatal rat: Effect of maternal chronic exposure to whole cigarette smoke

The intention of this investigation was to ascertain the effect of maternal exposure to cigarette smoke on the early postnatal morphogenesis of pulmonary interstitum in offspring. Female rats were chronically exposed to whole cigraette smoke. Offspring of these and control animals were sacrificed at postnatal day 15, and their tissues were prepared for quantitative and qualitative analyses. Results indicate a diminished quantitative representaion of parenchymal tissue (P <0.01) and a slower pace of secondary septal growth (P <0.07) in the experimental lung. Furthermore, a greater cellular volume density (P <0.0002) was ascertained for the experimental septal inerstitium. There was proportionately less of elastin substances (P < 0.009), collagen together with basal laminae (P < 0.0008), and nonfibrillar, amorphous matrix (P < 0.02) in the experimental extracellular stroma. Fribrillar collagen and nonfibrillar matrix were represented quantitatively 6.3 times more in the experimental extracellular interstitum than elastin, whereas that ratio for the control tissue was only 4.2. Most experimental interstitial cells (80%) contained numerous lipid globules, which, in contrast, were only occasionally present in control cells (7.3%). Experimental cells, consequently, possessed a larger cross-sectional diameter and a smaller nucleus-to-cytoplasm volume ratio than control cells. These divergent developmental patterns are possibly suggestive of a delayed differentiation of interstitial cells and a modified production to degradation balance of stromal proteins in offspring of animals chronically exposed to whole cigarette smoke.     

Linear parameters of normal and abnormal cava septi pellucidi: a post-mortem study

Anatomical variations in the dimensions of different brain structures have been correlated with clinical syndromes. This study on the parameters of normal and abnormal cavum septi pellucidi (CSP) can be of clinical significance. We obtained 479 brains from autopsied persons (310 males and 169 females, 377 normal or asymptomatic and 102 abnormal or symptomatic persons, aged 22-89 years) and observed that 110 brains (75 males and 35 females) had CSP. These cava were classified into two groups depending on the past medical histories of the autopsied person: 40 asymptomatic and 70 symptomatic cava. We have defined symptomatic cava as those in autopsied persons who had known past medical history of psychiatric or neurological disease. Asymptomatic cava were in autopsied persons who had no known past medical history of psychiatric or neurological disease. The CSP parameters (length, width, depth) of the symptomatic and asymptomatic groups were measured and were statistically analyzed. Analysis showed that the cava in the symptomatic group were significantly longer and wider. Discriminant function analysis was used to derive a mathematical formula to classify CSP into an asymptomatic or symptomatic group based on length and width measurements of the cavum.     

Flexible tantalum stents: Effects in the stenotic canine urethra

Purpose Evaluate the effects of flexible tantalum stents (Strecker) implanted into stenotic canine urethras.Methods Eight conditioned, adult, German shepherd dogs, weighing 30–40 kg, were used. Strictures were created surgically in the bulbar urethra just proximal to the os penis. Two months postsurgery, strictures were documented radiographically and then balloon dilated. Following dilatation, a single Strecker stent was placed across the stricture. Stents were 7 mm in expanded diameter and either 2 or 4 cm in length. Retrograde urethrography was performed immediately after stent placement and then biweekly for up to 12 months. Two dogs were sacrificed at 2, 4, 6, and 12 months post-stenting, and necropsy was performed. The urethra was excised, fixed, and examined by scanning electron and light microscopy.Results Clinical success was achieved without complications in all animals. Hyperplasia of the urothelium was noted 4–6 weeks after stent placement and was most pronounced at 4–6 months. Mucosal folds were found between the stent struts. Restenosis occurred at the distal end of the stent in one dog. Histological alterations were noted in the deeper layers of the urethral wall.Conclusion Strecker stents were well tolerated in all animals and seem useful for the treatment of urethral strictures.Presented at CIRSE Annual Meeting and Postgraduate Course, Budapest, June 20–24, 1993     

Radioquimioterapia de la enfermedad limitada del carcinoma pulmonar de célula pequeña. ¿Tratamiento concomitante en protocolos asistenciales?

Purpose We retrospectively reviewed our institution’s database to investigate the outcome and impact of combined radiochemotherapy (RT/CT; concomitant or in sequence) in localised small-cell lung cancer (L-SCLC). Material and methods Between January 1995 to November 1999, 79 patients with L-SCLC received combined RT/CT at our Institution. RT was delivered concurrently or sequentially following the CT. Patients with treatment response received additional prophylactic cranial irradiation (PCI). Results Of the patients treated, 54% had received concurrent CT/RT compared to 46% receiving RT following the CT. PCI was administered to 80% of the patients. Complete response was observed in 66% of patients. With a median follow up of 30 months, median overall survival was 15.9 months; 14.3 months for patients who received RT following CT and 21.6 months for those receiving concurrent CT/RT. The type of schedule of combined radiochemotherapy was an independent prognostic factor for survival free of local recurrence, as was additional PCI for distant metastasis-free survival. Conclusions Our results are similar to those reported previously in the literature. The main point of interest is that our patients were non-selected. We strongly support the use of concurrent CT/RT so as to achieve results comparable to the best in the literature.