Mechanical circulatory support as a bridge to transplantation: current status of total artificial heart in 1989 and determinants of survival

Since April 1986, 40 total artificial hearts (TAH) were implanted as a bridge to transplantation in our institution. In an attempt to identify factors affecting survival of TAH recipients we reviewed our experience over 1000 days of mechanical support. There was no postoperative bleeding requiring surgery nor were there any clinical episodes of thromboembolic complications. Over a total functioning period greater than 3 years there were no mechanical failures in the driving system but one artificial ventricle had to be replaced because of mechanical dysfunction. Infections and multiple organ failure were the primary causes of morbidity and mortality during mechanical support. When the patients who underwent staged transplantation (no. 17) were compared with those who died during mechanical support (no. 23) there were no differences in TAH driving mode or hemodynamic variables between the groups. Although preoperative pulmonary, hepatic and renal functions were found to be similar between the groups, there were significant differences in the early evolution (3 days) of hepatic and renal functions following TAH implant (p less than 0.01). Urinary output was found to be the earliest variable discriminating recovery and survival (p less than 0.01). Finally, univariate analysis indicated age (less than 40 vs greater than 40 years) and modality of cardiac decompensation (acute vs chronic) as the most important factors affecting survival after TAH implantation. Since young patients (less than 40 years of age) with acute decompensation were successfully transplanted in 82% of cases while 100% of older patients with chronic decompensation died before or after transplantation, TAH should be advised in young patients with acute or chronic heart failure and in selected older candidates with recent, acute cardiac failure.     

Aktuelle Erkenntnisse zur Wiedereingliederung chronisch psychisch Kranker

Zusammenfassung Die aktuellen Erkenntnisse zur Rehabilitation gründen auf einem neuen Krankheitsmodell der Schizophrenie und auf klinischer Erfahrung, welche wir in zwei katamnestischen Studien überprüft haben. Das Krankheitsmodell besagt, dass der Schizophrenie nicht ein spezifischer Krankheitsprozess zugrunde liegt, sondern dass eine Vielzahl von organischen und psychosozialen Faktoren, die untereinander in einem komplexen Wechselspiel stehen, zu einer besondern Verletzlichkeit beitragen, welche in Belastungssituationen zur psychotischen Dekompensation führt. Daraus folgt, dass die optimale Behandlung eines verletzlichen Menschen einerseits die Rückfallverhütung und andererseits die behutsame und schrittweise Förderung beinhalten muss; die optimale Behandlung besteht demnach in einer Rehabilitation.Aus der klinischen Erfahrung und den katamnestischen Studien ergibt sich, dass psychisch Kranke auch nach langer Krankheitsdauer und mehrjähriger Hospitalisation stabil im Wohn- und Arbeitsbereich wiedereingegliedert werden können. Andererseits finden wir, dass unsere Patienten v.a. im sozialen Bereich weiterhin stark behindert sind, was dafür spricht, dass Rehabilitation auch nach einer erfolgreichen Wiedereingliederung weitergeführt werden muss, um Rückfälle zu verhüten und die behinderten Patienten weiter zu fördern.

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Updated considerations about rehabilitation of the chronically mental patient

Summary Our considerations are based upon a new concept of schizophrenia and upon our clinical experience which has been controlled in two catamnestic studies.The new concept contains the notion of vulnerability, saying that there is no specific process underlying mental illness but there is a variety of interacting organic and psychosocial factors causing a special vulnerability leading towards psychotic break down in situations of stress. An optimal treatment should therefore consist of preventing relapse and at the same time of a soft promoting of social learning; thus an optimal treatment is a rehabilitation.Clinical experience and catamnestic studies show that mentally ill patients can be reintegrated into occupation and independent living even after a long history of illness and hospitalization. But we also find a severe ongoing handicap concerning social relations and quality of life, a strong indicator for the fact that rehabilitation has to continue even after a successful reintegration.

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Réflexions actuelles sur la réadaptation du patient psychiatrique chronique

Résumé Nos réflexions sont basées sur une nouvelle conception de la schizophrénie et sur notre expérience clinique qui a été controlée par deux catamnèses. Nous concevons la schizophrénie comme une vulnérabilité due à de multiples facteurs organiques et psychosociaux qui mène à des poussées psychotiques dans des situations de surcharge. Selon ce modèle le traitement optimal comprend une prévention des rechutes et un entraînement des compétences sociales. En d'autres termes le traitement doit être réadaptatif. L'expérience clinique et les études catamnestiques montrent que les patients psychiatriques peuvent être réintégrés dans la société même après une longue histoire de maladie. Mais nous constatons aussi un grave handicap persistant qui se manifeste surtout dans les relations sociales et dans une dépendence financière. Cela nous indique que la réadaptation doit être conçue comme un procédé continuel pour prévenir des rechutes et pour faire progresser doucement les patients.

     

Prognostic indices of survival in patients supported with temporary devices (TAH, VAD)

In an attempt to identify current indications and patient selection criteria for the use of mechanical circulatory support, we reviewed our experience in 83 patients who received a total artificial heart (TAH; n = 43), ventricular assist device (VAD) (n = 13), centrifugal pump (n = 17) or extracorporeal membrane oxigenation (ECMO) (n = 8) as a bridge to transplantation (Group I, n = 50) or for recovery from heart failure (Group II, n = 33). Comparing patients successfully transplanted (n = 20) or weaned (n = 9) who survived initial hospitalization, and those who died on mechanical support, there were no differences in preoperative renal, hepatic or pulmonary functions. Postoperative urinary output and bilirubin levels were the earliest variables affecting survival, and urinary output 24 hours after implant was discriminative in patients who survived (p less than 0.01). Age (above or below 40 years) and modality of terminal heart failure (acute versus chronic) were the most important factors affecting survival in the bridge to transplant group: 82% of young patients with acute decompensation were transplanted and 63% are long-term survivors while all patients over 40 years with chronic heart failure died on mechanical support (MS). In postcardiotomy patients, duration of cardiopulmonary by-pass (CPB) was significantly different comparing survivors with those who died in either bridge or recovery groups and all patients who had a CPB greater than 4 hours died on MS or after transplantation or weaning. In conclusion, preoperative indices indicating reversibility of multiple organ dysfunction remain to be identified.(ABSTRACT TRUNCATED AT 250 WORDS)     

Five-Year Experience with the Medtronic Hall Prosthesis in Isolated Aortic Valve Replacement

We reviewed clinical data in 216 patients who underwent isolated aortic valve replacement with the Medtronic Hall prosthesis. Between January 1983 and December 1990, a total of 216 prosthetic valves were implanted in 180 males and 36 females. Preoperatively, 45.5% of patients were in New York Heart Association (NYHA) Class III to IV. Cumulative follow-up was 682 years, and 3.2% of patients were lost to follow-up. The actuarial 5-year survival rate was 90% for the whole group. All the patients were anticoagulated with aceno-coumarol (Sintrom^R). There were no cases of structural dysfunction and one patient presented with valve thrombosis. The Medtronic Hall valve has a low rate of thromboembolic events without structural failure. It is an excellent device for aortic valve replacement.     

Comparison of half-molar sodium lactate and mannitol to treat brain edema in severe traumatic brain injury: A systematic review

PurposeHypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP).MethodsThis study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were “half-molar sodium lactate”, “mannitol”, “cerebral edema or brain swelling”, and “severe traumatic brain injury”. The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3.ResultsFrom 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09).ConclusionHalf-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.