Plasma exchange before surgery for left ventricular assist device implantation

Abstract:  Left ventricular assist device (LVAD) implantation in end-stage heart failure patients is frequently associated with hemorrhagic complications requiring reoperation. The preoperative coagulopathic profile includes prolonged prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time; platelet dysfunction; decreased coagulation factor activity; and increased inflammatory markers. We compare outcomes in LVAD patients treated with preoperative plasma exchange with concurrent, nonrandomized control patients. We reviewed data from 68 consecutive elective patients who received LVADs at our institution. Thirty-five received LVADs after preoperative plasma exchange (replacement of one plasma volume of fresh frozen plasma), and 33 received LVADs without plasma exchange. Groups were comparable in age, sex, body weight, New York Heart Association class, intra-aortic balloon pump insertion, cardiac index, pulmonary capillary wedge pressure, creatinine, total bilirubin, hemoglobin levels, PT, international normalized ratio, PTT, and platelet count. Early mortality was lower in the plasma exchange group (0% [0/35] vs. 18% [6/33], P  = 0.026), and postoperative chest tube drainage decreased by 33% ( P  = not significant). Blood transfusion requirements were similar.Perioperative mortality decreased in patients treated with plasma exchange before LVAD implantation.     

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.     

Evaluation of a 3-week hospital rehabilitation of patients with rheumatoid arthritis

Essential for evaluation of disease activity and functional disability in rheumatoid arthritis is to monitor the disease course by the outcome measures, which show quality of care i.e. efficacy of drugs, physical therapy and rehabilitation. To assess disease activity in 21 days hospital rehabilitation we chose Disease Activity Score (DAS). Functional disability was measured by Health Assessment Questionnary (HAQ). The measures were noted at arrival and admission and we found statistically significant decrease in values of DAS (t = 5,836; p < 0.01) and HAQ (h = 16.26; p < 0.05), but without clinically valid criteria for improvement. The conclusions are: these measures are not appropriate for assessment of efficacy for a short therm hospital rehabilitation, because DAS is measure which primary shows activity of inflammatory process, and HAQ as a long term measure is not sensitive enough for the assessment of short term rehabilitation.     

Lung cancer after heart transplantation: a 17-year experience

Background

The effects of heart transplantation on lung cancer incidence in heart transplant recipients are unclear.

Methods

In an observational study, we retrospectively reviewed the charts of all patients undergoing heart transplantation at our institution from July 1982 to July 1999. Data on lung cancer incidence, risk factors, treatment, and outcome were collected.

Results

Five hundred seventy-two patients (mean age, 50 ± 11 years; range, 18 to 73) were considered at risk for lung cancer. Of these, 324 (57%) had a more than 20 pack-year history of smoking before transplantation. Lung cancer developed in 2 patients 1 year or less after transplantation and in 8 patients more than 1 year after transplantation (incidence, 2.2 per 1,000 patients per year of follow-up). Non-small cell lung cancer was diagnosed in all cases. Median survival was 10.8 months (range, 2 to 37.5). Routine annual chest radiographs after transplantation enabled early diagnosis in 5 cases (stages Ia and IIa), which correlated with better mean survival (28.1 months [range, 19 to 37.5] versus 5.1 months [range, 2 to 10.8]; p = 0.0002).

Conclusions

The incidence of lung cancer in our population of heart transplant recipients appears to be no higher than in nontransplant populations with similar risk factors (ie, smoking and age). Routine radiographic imaging of transplant recipients may allow earlier detection of lung cancer and thus offer a survival benefit.     

Phlegmonous gastritis in a patient with rheumatoid arthritis

Phlegmonous gastritis is an acute infection of the stomach wall by pyogenic bacteria. It represents an extremely rare disease with a fulminating course and a high mortality rate. A precise lifetime diagnosis is generally unsuccessful. The inflammation, most often caused by alpha-hemolytic streptococci, is most frequently expressed in patients who are more susceptible to infection. Among these are elderly patients, women, patients with chronic gastritis, chronic peptic ulcer, hepatic cirrhosis and decreased immune tolerance, T-cell leukemia, patients with a low socio-economic status and alcoholics. In our paper we are describing the case of a 66-year old female patient, who had received many years of treatment for rheumatoid arthritis. She died due to phlegmonous gastritis, which was only established post-mortem. The authors share the opinion that the occurrence of the phlegmonous form of gastritis was influenced significantly by the treatment with nonsteroidal antirheumatics and corticosteroids, which she had received for many years and also immediately prior to the complication.     

Properties and distribution of angiotensin I converting enzyme

This review summarizes some basic properties and distribution of angiotensin I converting enzyme (ACE). ACE is one of several biologically important ectoproteins that exists in both membrane-bound and soluble forms. Localized on the surface of various cells, ACE is inserted at the cell membrane via its carboxyl terminus. Human plasma ACE originates from endothelial cells while other body fluids may contain ACE that originates from epithelial, endothelial or germinal cells. The two isoforms of ACE, the two-domain somatic form and the single domain germinal form, convert angiotensin I to angiotensin II, and metabolize kinins and many other biologically active peptides, including substance P, chemotactic peptide and opioid peptides. The broad spectrum of substrates for ACE and its wide distribution throughout the body indicates that this enzyme, in addition to an important role in cardiovascular homeostasis, may be involved in additional physiologic processes such as neovascularization, fertilization, atherosclerosis, kidney and lung fibrosis, myocardial hypertrophy, inflammation and wound healing. Future research should explore the possible functions of tissue ACE and its systemic role as a pressor agent. ACE inhibitors have achieved widespread use in the treatment of hypertension and the protection of end-organ damage in cardiovascular and renal diseases. Potential problems related to side effects and compliance of such therapy need to be addressed. A safer way of producing therapeutic effects is promised by the delivery of the ACE antisense sequences by a vector producing a permanent inhibition of ACE and long-term control of blood pressure in hypertensive patients.     

Laryngotracheal stenosis and restenosis. What has the influence on the final outcome?

The aim of this study is to analyze the impact of various parameters on the course and treatment outcome in patients with laryngotracheal stenosis and recurrent stenosis. Two groups of patients were compared: Group I included 29 patients with primary stenosis, and Group II included 22 patients with recurrent stenosis. The most frequent etiological factor for the development of stenosis was prolonged endotracheal intubation (79.3:77.3%), with subglottic-tracheal (44.8:45.5%) and tracheal (48.3:36.4%) localization being the most affected. Subglottic-tracheal stenosis was more common in men. There were no significant differences between the groups in regard to the grade of lumen obstruction and the length of the resected segment. In male patients, the length of the resected stenotic segment was significantly longer. Subglottic-tracheal stenoses were longer than tracheal ones. Various surgical procedures were performed, with additional management of recurrent laryngeal nerve paralysis, if necessary. Laryngotracheal reconstruction (LTR) with costal cartilage grafting (CCG) was statistically significantly more often performed in Group II, while cricotracheal resection (CTR) was more common in Group I. The incidence of complications in Group I was 24.1%, and in Group II it was 31.8%. Satisfactory airway lumen with undisturbed breathing was achieved in 93.1% of patients in Group I, and in 95.3% in Group II. Since the success rate was similar in both groups of the patients, it could be concluded that treatment outcome depends less on the factors associated with the stenosis, and more on adequate choice of surgical procedure and surgical team know-how.     

Quality and efficacy of a telecolposcopy programme

We tested the performance of telecolposcopy in the diagnosis of various squamous intraepithelial lesions. There were three groups of physicians: Group 1 consisted of 15 gynaecologists who were not trained in colposcopy; Group 2 consisted of six experienced colposcopists (specialists); Group 3 was a supervising team consisting of three experts (colposcopists with more than 15 years of colposcopy experience). The first group took colpophotographs during gynaecological examinations and used a Web browser to compare them with examples from a database of colposcopy findings. Group 2 made their own diagnoses independently. Then the supervising team examined the findings from all 250 patients and made diagnoses that could be considered the 'gold standard'. The findings were identical for Groups 1 and 2 in 219 cases, i.e. an inter-observer agreement of 88%; Cohen's kappa was 0.81. The findings were identical for Groups 1 and 3 in 208 cases, i.e. an inter-observer agreement of 83%; Cohen's kappa was 0.74. The findings were identical for Groups 2 and 3 in 239 cases, i.e. an inter-observer agreement of 96%; Cohen's kappa was 0.93. There was high inter-observer agreement between all participants. However, there were also significant differences in some cases. In the cases of suspected invasive carcinoma, the results showed a significant difference (chi2=4.8, P< 0.005) because gynaecologists from Group 1 were not sure of their diagnosis and they wanted to obtain a second opinion by referring the decision to a higher level.