Transplantation of hearts after arrest and resuscitation. Early and long-term results

Transplant surgeons are reluctant to use hearts that have undergone cardiopulmonary resuscitation for cardiac arrest because of the fear of poor early and late cardiac function. A policy of minimizing contraindications to use of donor hearts has led to the unique opportunity of assessing the effects of donor arrest and successful cardiopulmonary resuscitation on early and late cardiac function in pediatric heart transplantation. A number of 140 infants and children undergoing transplantation from birth to 17 years of age were studied retrospectively and divided into two groups on the basis of cardiopulmonary resuscitation status. Group 1 (72 patients) received donor hearts that were not subjected to cardiopulmonary resuscitation; group 2 (68 patients) received donor hearts that had cardiopulmonary resuscitation for a mean of 18.8 +/- 14.6 minutes, the longest period of time being 60 minutes. Mean ischemic times were almost identical in the two groups: 4.43 +/- 2.0 hours (cardiopulmonary resuscitation) versus 4.5 +/- 2.1 hours (no cardiopulmonary resuscitation). Early cardiac function was assessed on the basis of the number of days the recipient was supported by the ventilator, days receiving dopamine, days receiving isoproterenol, and the amount of inotropic agents required after the operation. The groups did not differ. Parameters of systolic function included fractional shortening, posterior wall thickening, and maximum velocity of change in left ventricular posterior wall dimension during systole. Diastolic function was measured on the basis of left ventricular end-diastolic volume, left ventricular mass, and maximum velocity of change in left ventricular posterior wall dimension during diastole. Both systolic and diastolic function were measured and analyzed from M-mode echocardiography at 1 week, 1 month, 6 months, 1 year, and 2 years after the operation. There were no statistically significant differences in graft function between the two groups in any of the echocardiographic parameters studied, even at 2 years. No group differed from ranges of normal. Our results suggest that hearts undergoing cardiopulmonary resuscitation for periods of up to 60 minutes can be used safely without evidence of deterioration of early or late cardiac function.

Thyroid nodules in female uremic patients on maintenance hemodialysis

We investigated the incidence of thyroid nodules in female uremic patients on maintenance hemodialysis using a high-frequency sonographic scanner. In 47 (21.0%) of the 224 female normal controls and 33 (55.0%) of the 60 female patients, thyroid nodules were detected. The difference in these incidences between controls and patients was significant. There were no differences in age, duration of hemodialysis, the level of blood urea nitrogen, parathyroid hormone or thyroid stimulating hormone between the patients with thyroid nodules and those without nodules. Although there is a correlation between uremia and the development of thyroid nodules, the details of the underlying mechanism of their association remain unclear.

Prolonged survival of orthotopically transplanted heart xenograft in infant baboons

Orthotopic concordant xenotransplantation in a juvenile primate model was examined. Eighteen donor rhesus monkeys weighing 2.4 to 3.8 kg (mean 2.9 kg) were matched with juvenile baboons, aged 9 to 19 months (mean 12.7 months) and weighing 3.2 to 4.8 kg (mean 3.9 kg), using ABH blood type and mixed lymphocyte culture. Rhesus monkey hearts were orthotopically transplanted without immunosuppression into six control baboons (group I). In five baboons (group II), 4 mg/kg per day of antilymphocyte globulin was administered for 3 days before the operation and 5 days after the operation. Splenectomy was also performed, and 18 mg/kg per day of FK 506 was administered orally. Intravenous methotrexate, methylprednisolone, or both were used as rescue therapy. Seven baboons (group III) received the same immunosuppression as those in group II, but an intravenous dose of methotrexate (0.1 to 5 mg) was given twice weekly to suppress the proliferative response as monitored by in vitro immunologic assays. Baboons in group I had a mean survival of 8 days; all died as a result of classic cellular rejection. Baboons in group II had a mean survival of 48.4 days (p < 0.05 versus group I). Two died during rescue therapy for rejection, and three died of cytomegalovirus infection. Two group II baboons showed mild rejection at autopsy. Baboons in group III had a mean survival of 127 days, and one baboon was still alive after 286 days. Two died of cytomegalovirus infection, one of toxoplasmosis, one of Klebsiella pneumoniae, one of massive micropulmonary embolism, one of renal failure aggravated by ganciclovir. Only two of the baboons that died showed rejection (estimated as mild) at autopsy. The baboon still alive at 286 days had no rejection on myocardial biopsy on the two hundred forty-fourth postoperative day. FK 506 coupled with low-dose maintenance methotrexate and splenectomy has produced prolonged host survival in this xenotransplantation model. Results suggest that concordant xenotransplantation would be a suitable biologic bridge to allotransplantation.

Transplantation and reanimation of hearts removed from donors 30 minutes after warm, asystolic 'death'

OBJECTIVE

To test whether hearts from "dead," pulseless, asystolic donors could be transplanted and reanimated successfully using reperfusion manipulations.

DESIGN AND INTERVENTIONS

Ten infant lambs (mean [+/- SD] weight, 4 +/- 1 kg) were anesthetized and pretreated with 50% dextrose, methylprednisolone, prostaglandin E1, and sublingual nifedipine. Five of these lambs were paralyzed; hypoxic asystolic arrest occurred 10 +/- 2 minutes later. Thirty minutes following asystole (mean, 40 +/- 2 minutes after paralysis) sternotomy was performed and the hearts were excised. Aortic blood gases were as follows: pH, 6.6 +/- 0.1; PCO2, 180 +/- 20 mm Hg; and PO2, 8 +/- 2 mm Hg. Donor hearts were given 30 mL/kg of Cardiosol (Water's Instrument Co, Danburg, Conn), a new cardioplegic agent, at 4 degrees C, and explanted into iced saline. The remaining five lambs then underwent cardiopulmonary bypass, were cooled to 20 degrees C, and hypothermic arrest was instituted. After excision of the recipient's heart, the donor heart was implanted in an orthotopic position. Total cold ischemic time was 1 hour 40 minutes +/- 10 minutes. The donor heart was retroperfused for 10 minutes with low-hematocrit, low-calcium blood via a coronary sinus catheter, then normal aortic inflow reperfusion was continued for 50 minutes.

MAIN OUTCOME MEASURES

Removal of the cardiopulmonary bypass and measurement of hemodynamic parameters.

RESULTS

One half hour after the bypass, mean systolic aortic pressure was 71 +/- 6 mm Hg; mean right atrial pressure was 6 +/- 2 mm Hg; mean left atrial pressure was 7 +/- 2 mm Hg; and mean pulmonary arterial pressure was 20 +/- 8 mm Hg. No inotropic drugs were given for postbypass blood pressure support.

CONCLUSION

It is possible to transplant and reanimate hearts that have been dead for 30 minutes. When further developed, the use of donors who were not brain dead but allowed to die naturally could greatly increase the donor pool.

Myosin light chain efflux after heart transplantation in infants and children and its correlation with ischemic preservation time

Serum levels of cardiac myosin light chain 1 after heart transplantation were studied in 24 infants and children who underwent heart transplantation between June 1990 and April 1991. The ages of the patients ranged from 4 days to 6 years 7 months (mean, 9.9 months), and their body weights ranged from 2.2 to 20 kg (mean, 5.6 kg). The ages of the donors ranged from 2 days to 8 years, 7 months (mean, 26.6 months), and their body weights ranged from 2.5 to 26 kg (mean, 11.4 kg). The donor heart ischemic time ranged from 90 minutes to 482 minutes (mean, 279 minutes). Peak myosin levels after heart transplantation showed significant correlation with the duration of graft ischemia (p < 0.01) and with diastolic cardiac function in the first posttransplant week (p < 0.05). Peak myosin levels did not correlate with systolic cardiac function, age of the donor, or age of the recipient. Myosin levels of the 15 patients with graft ischemic times exceeding 4 hours averaged 6.30 +/- 3.50 ng/ml. These levels were significantly higher than those of patients with graft ischemia lasting less than 4 hours (2.60 +/- 1.20 ng/ml; p < 0.01). Both of the values are higher than previously reported values of normal controls but lower than previously reported values of patients with myocardial infarction. Preservation techniques used for this series of transplant operations provided good clinical protection of the donor heart for up to 8 hours, although release of the cardiac myosin light chain fragment correlated with duration of graft ischemia. Cardiac myosin levels appeared to be a good indicator of heart graft damage during ischemic preservation. It remains to be determined at what level of myosin release (and, hence, at what duration of graft ischemia) irreversible myocardial damage, which might result in permanent functional compromise, occurs.

Retrograde gastric varices in a patient with total cavopulmonary shunt

Gastric varices formed in a patient who had undergone a total cavopulmonary shunt operation 7 years previously. The varices were found to be due to development of collaterals from high-pressure systemic vein to low-pressure portal vein. Bleeding gastric varix can be a late complication of total cavopulmonary shunt.

Methotrexate as rescue/adjunctive immunotherapy in infant and adult heart transplantation

Methotrexate may be a useful adjunct to more conventional immunosuppression in heart transplantation, but experience is limited. We report our findings in 18 patients aged 19 days to 64 years, who were treated with methotrexate. Five patients were less than 1 year of age; 11 patients were over 16 years of age. Indications could be divided in two groups. Seven patients were treated with methotrexate as rescue therapy for unresolving acute grade 3 rejection or for early recurrence after one rejection episode that had been treated with steroids and antilymphocyte serum. All infants were treated with methotrexate for life-threatening rejection. Methotrexate was given as an adjunct to conventional treatment in six patients for mild rejection, which occurred while steroids were being decreased or in patients with relative contraindications to high-dose steroids. One grade 3b rejection could not be reversed with methotrexate and led to the patient's death 3 months later. One grade 1b rejection only temporarily improved and was actually reversed with high-dose steroids after 4 months. All other rejections were rapidly reversed with the use of methotrexate. Tolerance of methotrexate has been very good with transient leukopenia in four patients, with ulcerative stomatitis in one patient, and with transient elevation of liver enzymes in two patients. We conclude that methotrexate is a valuable rescue/adjunctive immunotherapeutic agent that is capable of altering heart rejection with considerable safety and efficacy.

[Surgical treatment of patients with congestive heart failure]

Surgical intervention is a treatment of choice in chronic congestive heart failure from long standing myocardial ischemia or old myocardial infarction. Right sided heart failure is a higher risk factor for surgery than a left sided one. Hemodynamic instability following acute myocardial ischemia in spite of medical treatment is an indication for urgent surgery. Hemodynamic deterioration from acute valvular lesions, such as infectious endocarditis, malfunction of the prosthetic valve, and trauma, are also indications for urgent surgery. Although surgical results are correlated with NYHA classification, chronic right sided heart failure increases the morbidity. Dynamic cardiomyoplasty is a new treatment for otherwise uncorrectable congestive heart failure. Multicenter trial reported 40% of mortality and an average improvement of NYHA class from 3.5 to 2.1.

Male donor into female recipient increases the risk of pediatric heart allograft rejection

Sixty-one infants and children, 12 years old or younger, who received an orthotopic cardiac allograft between November 1985 and December 1989 were analyzed for the incidence of rejection. Rejection was diagnosed non-invasively within the first 3 months and during the first year. Rejection episodes were diagnosed by signs and symptoms according to previously reported criteria. Multiple regression analysis with recipient age, donor age, donor-recipient weight ratio, number of HLA mismatches, sex of the recipient, sex-encoded minor tissue antigen incompatibility (H-Y: female recipients receiving male donor organ), graft ischemic time, lowest cyclosporine level during the first 2 postoperative weeks, and prophylactic use of OKT3 showed that H-Y was the only significant contributing factor for rejection at 3 months and 1 year (r = 0.308, p < 0.02; r = 0.308, p < 0.02; respectively). Patients were divided into two groups: group 1, 45 patients who were H-Y compatible (male and female recipients receiving female donor hearts); and group 2, 16 patients who were H-Y incompatible (female recipients with male hearts). Patients in group 2 had significantly more episodes of graft rejection than did patients in group 1 by 3 months and by 12 months after heart transplantation (3 months: 2.75 +/- 1.48 versus 1.67 +/- 1.41, p < 0.05; 1 year: 4.80 +/- 1.87 versus 2.59 +/- 1.93, p < 0.01; respectively). There were six grafts lost due to rejection in group 2 (6/15, 37.5%) and 7 grafts lost (7/45, 15.5%) in Group 1 (not significant). Heart transplantation with H-Y incompatibility resulted in a significantly greater incidence of rejection episodes.

Utilization of pediatric donors salvaged by cardiopulmonary resuscitation

The efficacy of using infant donors with an extended cardiopulmonary resuscitation (CPR) history was investigated. Eight heart transplantations with donors who had no or minimal (less than 10 minutes) history of CPR (group A) and seven heart transplantations with donors with extended CPR history (35 to 125 minutes; mean, 59 minutes; group B) were compared for peak myosin levels after transplantation, and systolic and diastolic cardiac function in the first week after transplantation. All donor hearts had normal hemodynamics in the early postoperative period. No significant differences were found between the groups with regard to age of donors, age of recipients, donor heart ischemic time, and cardiac function in the first week after transplantation. In group B, peak myosin levels were 1.4, 4.6, 7.0, 11.3, 14.8, 20.2, and 21.3 ng/ml. These values were significantly (p < 0.05) higher than those in group A but represented only minimal myocardial damage when compared with the values in previous myocardial infarction studies. Although donors with a history of protracted CPR had higher efflux of myosin light chains perioperatively, hemodynamic recovery suggests that use of pediatric donor heart grafts after prolonged CPR is safe and efficacious.

Neuromas of the facial nerve: a report of 12 cases

Twelve patients with facial nerve neurinoma have been treated at The National Hospital, Queen Square, London, during the last 20 years. Nine tumours lay in the middle fossa arising from the area of the geniculate ganglion, two lay in the posterior fossa arising from the segment of the facial nerve in the internal auditory canal, and one tumour arose from the vertical segment of the facial nerve with extracranial extension through the stylomastoid foramen. Two patients had neurofibromatosis. The clinical and radiographic features of those tumours, the operative approaches employed, and the postoperative outcome are described. Complete tumour excision was achieved in all patients; all 12 remain free of recurrence 3-80 months after surgery. Facial nerve function was restored at least in part in all cases by transposition with end-to-end anastomosis, placement of a cable graft from the sural nerve or hypoglosso-facial anastomosis. The major determinant of the outcome of facial nerve function was the duration of preoperative facial paralysis, the results being invariably poor when this was of long duration.

Prolonged preservation of human pediatric hearts for transplantation: correlation of ischemic time and subsequent function

Ninety-one infants and children, aged 0 days to 12 years, who received 93 hearts from donors aged 2 days to 24 years between November 1985 and September 1990 were retrospectively studied. Forty-three children were less than 1 month of age; 31 children were between 1 month and 6 months of age, and 19 children were between 6 months and 12 years of age. The donor heart ischemic time ranged from 51 minutes to 8 hours 17 minutes (mean, 4 hours 2 minutes). Fifty-one hearts had an ischemic time of less than 4 hours (group 1), and 42 hearts, more than 4 hours (group 2). No significant difference was noted in the age of donor or recipient or in donor/recipient weight ratio. No correlation was found between ischemic time and number of primary graft failures between groups. Inotropic support was required for 3.9 +/- 3.3 and 5.2 +/- 3.7 days for group 1 versus group 2 (not significant). Ventilator status was the same between the groups. A significant decrease of posterior wall movement in diastole (p < 0.01) occurred among patients of group 2 at 1 week after transplantation, but no difference was found between groups at 2 weeks, 1 month, and 3 months after operation. Posterior wall movement of group 2 heart grafts recovered completely by week 2. No difference was noted in the fractional shortening between the groups; but in both groups, fractional shortening significantly increased from week 1 to week 2. We conclude that ischemic times up to nearly 8 1/2 hours are well tolerated by donor hearts used in pediatric transplantation.

Subfrontal schwannoma--case report

A rare case of subfrontal schwannoma occurred in a 33-year-old male with the chief complaint of headache. Computed tomography demonstrated a low-density mass in the subfrontal region. Magnetic resonance imaging indicated the mass extension into the ethmoidal sinus. The tumor was totally removed via a subfrontal approach. The histological diagnosis was schwannoma. The most likely origin of the tumor is the meningeal branches or anterior ethmoidal nerve.

The Mustard procedure for correction of simple transposition of the great arteries before 1 month of age

Since April 1976, 34 infants (25 male and 9 female) less than 1 month of age underwent a Mustard intraatrial baffle procedure for repair of simple transposition of the great arteries. Thirty patients were less than 2 weeks old and 19 patients less than 1 week (mean 7.8 +/- 6 days). The weights ranged from 2.6 to 4.4 kg (mean 3.4 +/- 0.4 kg). Rashkind balloon atrial septostomy was performed in the first hours or days of life in 29 patients. The average interval from balloon atrial septostomy to baffle repair was 3.9 days (range 2 hours to 14 days). Mechanical ventilation was required in eight patients preoperatively and prostaglandin E1 was infused in 17 patients to maintain ductal patency. In all patients, the Mustard procedure was performed with the use of deep hypothermic circulatory arrest, averaging 53 minutes (range 37 to 82 minutes). The duration of postoperative intubation and ventilatory support averaged 1.7 +/- 1.0 days (range 1 to 5 days). Inotropic drugs were used in 24 patients during a period of 1.4 +/- 1.3 days (range 1 to 6 days) postoperatively. There were no hospital deaths. Follow-up evaluation has extended from 1 month to 14 years (mean 3 +/- 3 years). One infant died 2 months postoperatively as a result of milk aspiration; no cardiac defects were found at the autopsy. A second infant died at 1 year with right ventricular and tricuspid valve dysfunction. Baffle complications occurred in 6 of the 32 survivors, including superior vena caval stenosis in 4, inferior vena caval stenosis in 1, and pulmonary venous obstruction in 3. Reoperations for baffle obstructions were performed in three patients (8.8%) and balloon angioplasties in two. One patient required permanent pacemaker implantation. Results with the Mustard procedure before 1 month of age show that it can be performed with negligible mortality and a low incidence of late complications at an age comparable to when arterial switching would be performed. Until long-term studies demonstrate superiority of arterial operations, the low operative mortality favors continued evaluation of the neonatal Mustard repair as a valid alternative to the arterial switch.

The effects of donor-recipient size disparity in infant and pediatric heart transplantation

To determine the effect of heart donor and recipient size mismatches in infant and pediatric heart transplantation, we studied all 69 patients (age 1 day to 11 years) having 71 orthotopic heart transplants from 1985 to 1989. Patients were divided into three groups based on donor to recipient weight ratios. Group I comprised 13 heart transplants with a donor to recipient weight ratio less than 0.95 (mean 0.81, range 0.48 to 0.94); group II comprised 29 heart transplants with a weight ratio between 0.95 and 1.60 (mean 1.28); and group III had 27 heart transplants with weight ratios greater than 1.60 (mean 2.2, range 1.61 to 3.09). All chests were closed primarily. The cardiothoracic ratio by chest radiography was significantly larger in group III (p = 0.0002); 75% of group III patients had periods of lobar or complete lung collapse by chest radiography compared with 28% of group II and 19% of group I patients (p < 0.05). Despite this, there was no difference in the number of days of ventilator support for any group (p = 0.92). There was no difference in graft ischemic time or inotropic drug use among groups, nor were differences found in the cardiac systolic function parameters of left ventricular preejection time (p = 0.975), left ventricular ejection time (p = 0.975), left ventricular fiber shortening (p = 0.97), and left ventricular fractional shortening (p = 0.596). Thus despite a high incidence of transient lobar or complete lung collapse in high donor to recipient weight ratio transplants, large donor heart size produces very little clinical impairment in recipient lung function. Size mismatches do not influence cardiac systolic function. Overall, large size mismatches appear to be very well tolerated in infant and pediatric heart transplantation.

Electrical stimulation of motor cortex in experimental cortical ischaemia: pyramidal responses at C5 and the surface EMG

In 7 baboons maintained under propofol anaesthesia, pyramidal tract responses were related to the corresponding peripheral EMG evoked by electrical stimulation of the motor cortex under conditions of focal cortical ischaemia. Pyramidal responses were recorded epidurally at the C5 level and the EMG was recorded from the contralateral hand or foot muscle using subdermal needle electrodes. Cortical ischaemia was produced by transorbital occlusion of the common anterior cerebral artery, and regional cortical blood flow was measured by the hydrogen clearance method. In the normally perfused brain, the later I waves of the C5 response required a lower stimulus strength to elicit them than the earlier I1 wave. It was more difficult to record the EMG from the hand than from the foot following stimulation of the corresponding cortex even though the C5 responses were always obtained in both cases. With moderate ischaemia, the later I waves were selectively abolished, leaving the D and I1 waves. EMG amplitude was significantly correlated with cortical blood flow (r = 0.88, P less than 0.005), and the threshold of cortical flow for the EMG was 10-13 ml/100 g/min. Our results indicate that changes in amplitude of the late I waves and particularly of the EMG are sensitive indicators of cortical ischaemia.

Successful transplantation of hearts harvested 30 minutes after death from exsanguination

The donor pool for heart transplants is severely limited. Unfortunately, many trauma patients who might be donors die of exsanguination before their organs can be used. We tested whether hearts "dead" for one half hour after exsanguination could be used as heart transplants in 8 lambs (mean weight, 8 kg). Four lambs were exsanguinated by severing the subclavian artery while simultaneously infusing intravenous saline solution to mimic resuscitation attempts. All animals died. Thirty minutes after hypotensive arrest and death, simulating the time needed to secure donation permission, the heart was harvested, perfused with 250 mL of cold cardioplegia containing 200,000 units of streptokinase to dissolve intravascular clots, and stored in iced saline solution for a mean of 1.5 hours while 4 recipient lambs were prepared for operation. After bypass and recipient heart excision, the "dead" donor heart was transplanted orthotopically. The heart was reperfused with low flow (25 mL/min), low pressure (30 mm Hg), low hematocrit (hematocrit, 0.08 to 0.12) blood supplemented with prostaglandin E1 and nifedipine for 15 minutes, followed by full flow rewarming for 45 minutes. All hearts resumed normal contractions. All animals were weaned from bypass without inotropes. Pressures a half hour after bypass were (in mm Hg): aorta, 80 +/- 10; pulmonary artery, 20 +/- 5; right atrium, 9 +/- 5; and left atrium, 9 +/- 2. We conclude that hearts "dead" for one half hour after exsanguination are capable of being reanimated and used successfully as donor organs. With further development, this method could potentially greatly expand the donor heart pool.

The Dynamic Dento-palatography System: a new approach for evaluating speech

The assessment of speech in patients with craniofacial anomalies is important to develop appropriate treatment strategies to optimize this aspect of oropharyngeal function. The Dynamic Dento-palatography System which uses multi-electrode array sensors to detect tongue position during articulation is described. Three levels of the speech chain, articulatory, auditory and acoustic, may be analysed in an integrated fashion using this instrument; preliminary results are described. These studies suggest that the quality of speech sounds such as 's' and 't' improve post-operatively.

Real-time monitoring of the endomyocardial biopsy site with pediatric transesophageal echocardiography

We studied the feasibility of transesophageal echocardiography to guide endomyocardial biopsies in five heart transplant patients and two baboons with heart transplantations. The patients were 1 month to 1.5 years old with weight range of 2.9 to 9.5 kg. The two juvenile baboons weighed 6.6 and 7 kg. Transesophageal echocardiography was performed uneventfully in all cases with the use of sedation and anesthesia, which were necessary for catheterization. The combination of four-chamber and short-axis views easily identified the exact location of the bioptome within the heart, views that fluoroscopic imaging could not provide. Transesophageal echocardiography proved to be a safe and useful tool for guiding the endomyocardial biopsy procedure. With further refinement endomyocardial biopsy with only transesophageal echocardiography guidance could become the routine method for endomyocardial biopsies in infants, particularly when there are abnormalities of heart situs or position.

Aggressive peritoneal dialysis for treatment of acute kidney failure after neonatal heart transplantation

Many infants with hypoplastic left heart syndrome are now treated with heart transplantation. Preoperative or postoperative systemic/renal hypoperfusion occurs frequently, however, resulting in perioperative kidney failure. Of 45 neonates undergoing heart transplantation at our institution, we report on 10 (22%) who required postoperative peritoneal dialysis. Patients' age at transplantation ranged between 1 and 31 (mean, 16.7) days, average weight was 2912 (range, 2140 to 3664) gms. Peritoneal dialysis was started at a mean of 51 hours after transplantation for treatment of anuria (5 patients, 50%), oliguria (3 patients, 30%), fluid overload or hyperkalemia (1 patient each, 10%) and continued for a mean of 101 +/- 90.5 (range, 33 to 270) hours. The value for blood urea nitrogen fell from 46.7 +/- 15.6 mg/dl to 14.3 +/- 10.5 mg/dl, and serum creatinine levels decreased from 2.4 +/- 1.0 mg/dl to 0.6 +/- 0.3 mg/dl throughout peritoneal dialysis. All patients continued to receive cyclosporine during dialysis. Hyperglycemia developed in four patients. Five of 10 patients had ongoing sepsis during dialysis, but only one died while on dialysis (10%). Two patients died late, after peritoneal dialysis was discontinued. Follow-up ranges from 2 months to 5 years. At most recent follow-up, mean creatinine level was 0.5 +/- 0.1 mg/dl. We conclude that aggressive peritoneal dialysis may result in high salvage rates with low morbidity, without the need to discontinue cyclosporine in the setting of neonatal heart transplantation and acute kidney failure.

Changes in left ventricular mass with rejection after heart transplantation in infants

Thirty-three infants who underwent successful heart transplantation before 6 months of age were studied to evaluate subacute changes in left ventricular mass (LVM) and its correlation to a history of rejection episodes. LVM and left ventricular wall mass (LVWM) and their percentage of predicted normal values were analyzed by means of M-mode echocardiography. LVM (as a percentage of predicted normal for body surface area) at 1 week, 1 month, and 3 months after transplantation was 103.2% +/- 24.5%, 137.3% +/- 36.0%, and 138.6% +/- 32.0%, respectively. Values for the wall mass were 82.1% +/- 23.0%, 111.3% +/- 35.7%, and 104.6% +/- 30.4%. After 1 and 3 months, both LVM and LVWM were significantly (p less than 0.01) increased from the values in the first week. The patients were subdivided on the basis of a history of rejection. There were six patients without a rejection episode within 1 month (group 1), 17 patients with one rejection episode (group 2), and 10 patients with two or more episodes (group 3). LVM at 1 month was 104.5% +/- 27.7% for group 1, 142.5% +/- 27.7% for group 2 (p less than 0.05), and 148.9% +/- 31.3% for group 3 (p less than 0.05). LVWM at 1 month was 83.4% +/- 24.6%, 114.8% +/- 35.3%, and 122.2% +/- 36.2% (groups 1 through 3, respectively). Thus an increase in posttransplant LVM may signify a rejection episode. Heart transplantation in infancy increases LVM and LVWM (septum and posterior wall); the degree of thickening of septum correlates well with rejection episodes.

A model of acute focal ischemia in the territory of the anterior cerebral artery in baboons

BACKGROUND AND PURPOSE

We developed a model of acute focal ischemia in the territory of the anterior cerebral artery in baboons to study the ischemic pattern following occlusion and changes in regional cerebral blood flow.

METHODS

In nine anesthetized animals, a Scoville clip was placed on the proximal segment of the common anterior cerebral artery via a unilateral transorbital approach. Regional cerebral blood flow was measured by hydrogen clearance in the cortex and corpus callosum. Postexperimentally, arteries were selectively injected.

RESULTS

The resulting ischemia involved both hemispheres symmetrically and the corpus callosum. Cortical flows were significantly reduced within a region 15 mm from the midline on each side (p less than 0.01). A gradient of cortical flow reduction was produced between 10 and 25 mm from the midline. This area defines the boundary region between the territories of the anterior and middle cerebral arteries, and is identified as the "penumbra" of the ischemic core, which itself lies within 10 mm of the midline. Blood flows in the corpus callosum decreased from an average of 21.0 to 6.7 ml/100 g/min in the body (p less than 0.01) and from 22.5 to 10.7 ml/100 g/min in the genu (p less than 0.05).

CONCLUSIONS

This ischemic model has close physiological and morphological relevance to stroke-related clinical circumstances, in particular the acute conditions of focal cerebral ischemia associated with vascular surgery. It also provides a new framework for experimental investigation of the ischemic penumbra.

[Selection and management of donor hearts in infant and pediatric heart transplantation: Loma Linda experience]

One hundred and six infant and pediatric patients received 108 heart transplantations between November 1985 and December 1990. The age of the recipients was from 0 day to 12 years (mean 11.1 months) and the age of the donors were from 2 days to 24 years (mean 18.3 months). The body weight ratio of donor and recipient were from 59% to 315% (mean 163%). Large donor hearts were well tolerated without serious complication even in small infants. The graft ischemic time was from 51 minutes to 505 minutes (mean 244 minutes) and fifty four grafts had ischemic time more than 4 hours. There was no difference of the frequency of primary graft failure between the grafts with longer and shorter ischemic time. Although diastolic function in the first week post-transplant was more depressed in the grafts with longer ischemic time, no difference was observed after the second post-transplant week. There was no difference in the systolic function in accordance with the ischemic time. Eight hours and more ischemic time was well tolerated in our donor grafts.

[Infant and pediatric heart transplantation: Loma Linda experience]

One hundred and six infant and pediatric recipients underwent 108 heart transplantation from November 1985 to December 1990 in Loma Linda University Medical Center. Forty-seven recipients were under one month of age at the time of transplantation, 46 from one month to 2 years and 15 over two years. Seventy recipients underwent heart transplantation under the diagnosis of hypoplastic left heart syndrome or the diseases equal to hypoplastic left heart syndrome, seventeen for complex congenital heart disease, sixteen for cardiomyopathy, and five for other reasons. Early mortality was 13% and late mortality was 11% for all cases. Early mortality for the infants under one month of age was 13% and late mortality was 8%. Heart transplantation was considered to be the treatment for choice for the patient with otherwise fatal cardiac diseases.

[A case of disproportionately large communicating fourth ventricle (DLCFV) combined with syringomyelia and Chiari malformation]

We report a rare case of disproportionately large communicating fourth ventricle (DLCFV) combined with syringomyelia and Chiari malformation. The case was a 27-year-old male who underwent ventriculoperitoneal (V-P) shunt on the right side for hydrocephalus caused by traumatic intracerebral and intraventricular hemorrhage. One month later, he became somnolent with posterior fossa symptoms (nausea, vomiting and nystagmus). CT scan demonstrated enlarged fourth ventricle, which was diagnosed as DLCFV because the ventriculogram revealed patency of the aqueduct. One and half month later a second V-P shunt was made on the left side to increase the shunt flow. He became ambulatory with a cane, although the fourth ventricle remained moderately dilated on CT scan. Two months after the additional V-P shunt, he slipped and hit the occiput and immediately became tetraparetic. The patient was treated conservatively under the diagnosis of central spinal cord injury. The MRI taken 2 months after the accident revealed Chiari malformation (type 1), syringomyelia and a dilated fourth ventricle which was compressing the brainstem. After the fourth ventriculoperitoneal (FV-P) shunt, the tetraparesis transiently improved but then again worsened. On the CT scan the syrinx did non change in size, while the size of the fourth ventricle became normal. After syringoperitoneal (S-P) shunt the patient showed a moderate improvement of tetraparesis. Unfortunately he suffered appendicitis complicated with peritonitis and all the shunts were immediately changed to external drainage. However, the patient developed meningitis and became paraplegic. The motor function of the upper extremities slightly improved by aspiration of fluid via the external drainage system from the syrinx.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance demonstration of the effect of carotid artery ligation for a giant internal carotid artery aneurysm: case report

Ligation of the carotid artery remains an accepted treatment for unclippable giant carotid artery aneurysms. Post-operative evaluation is commonly made subsequently by CT scan and angiography, the latter involving an invasive procedure. This paper describes the magnetic resonance (MR) appearance of a traumatic giant terminal carotid artery aneurysm treated by common carotid ligation. MR appears to be the imaging technique of choice for follow-up of giant aneurysms of the terminal carotid artery treated by carotid ligation, the accuracy of delineation of the aneurysm and its content surpassing that of the CT scan.

[Exercise tolerance after correction of tetralogy of Fallot]

Twenty-six postoperative patients with tetralogy of Fallot (TF) were evaluated by exercise stress test with an upright cycle ergometer. Oxygen uptake was assessed at the anaerobic threshold and the peak achieved work load. Oxygen uptake at the anaerobic threshold (VO2AT) was in the normal range regardless of the existence of residual stenosis (PS) or pulmonary regurgitation (PR). However, oxygen uptake at the peak achieved workload (VO2max) was subnormal in patients with PS or PR. Maximal heart rate in TF patients was lower than normal. Patients with PR showed significantly reduced VO2max as compared with those without PR (p less than 0.05). This is found to be resulted from limitation of the oxygen pulses increase.

Diagnosis of cardiac allograft rejection by the detection of circulating plasma cardiac myosin light chains

Twenty adult male Japanese monkeys of the species Macaca fuscata were randomly paired and subjected to heterotopic cardiac transplantation performed by the Ono-Lyndsey method. Without immunosuppression, graft survival ranged between 8 and 27 days, with a mean survival of 14 days. Plasma cardiac myosin light chains were measured by radioimmunoassay, which showed transient increases in myosin levels just following transplantation. Three hearts showed high values at this period and stopped beating when the myosin levels decreased (type 1). The other 7 hearts showed low myosin values after transient increases and 5 of them were rejected with a preceding reincrease in the myosin levels (type 2). Pathological study revealed myocardial necrosis, perivascular cuffing of mononuclear cells and/or neutrophils and/or plasma cells in the type 1 hearts. Measurement of the plasma myosin light chain level was therefore revealed to be of great value in the monitoring of cardiac allograft rejection.

[The role of stimulation of the medullary reticular formation on intracranial pressure in cold injured brain]

This study was carried out to study the effect of stimulation of the reticular formation of the medulla oblongata on intracranial pressure (ICP) and cerebral blood volume (CBV) in injured brain with increased ICP. CBV was measured by the photoelectric method from the parietal lobe. Seventeen hours prior to the experiments, cold induced edema was produced to increase basal ICP. In 15 cats, electric stimulation produced temporary increases in BP, ICP and CBV and progressive intracranial hypertension was never observed (Group A). In 9 animals, progressive increases in CBV and ICP up to 50 to 100 mmHg were evoked after cessation of stimulation (Group B). Prestimulation ICP in Group B was significantly higher than that of Group A. Rapid and simultaneous increases in ICP and CBV following stimulation strongly suggested that global increments of CBV secondary to loss of cerebral vasomotor tonus were responsible for producing progressive intracranial hypertension. In Group B, the stimulation electrodes were invariably located at the area of the nucleus reticularis parvocellularis and gigantocellularis. Our experimental results show that in increased ICP a stimulated or irritable condition of the medullary reticular formation will cause acute progressive intracranial hypertension.

Rotation-advancement flap method for correction of partial anomalous pulmonary venous drainage into the superior vena cava

Three patients with partial anomalous pulmonary venous drainage into the superior vena cava underwent repair by a rotation-advancement flap method. The technique consisted of atrial partitioning, enlargement of the superior vena cava, and protection of sinus node function. Follow-up studies of all patients were done between 12 and 15 months after the operation. The superior vena cava was not stenosed and its diameter was normal, as demonstrated by cavograms. Pulmonary venous return appeared normal on angiograms, and sinus node function was normal by electrophysiologic studies.

[Oxygen uptake during exercise before and after cardiac valve surgery: anaerobic threshold and maximal oxygen uptake]

Exercise stress tests with bicycle ergometer were performed before and after surgery in 14 patients with valvular heart diseases. Aortic valve replacements were performed in two patients, open mitral commissurotomy in two, mitral valve replacement in eight and combined valvular procedure in two. All patients except one showed improved NYHA function class after the surgery. Oxygen uptake was assessed at anaerobic threshold and peak achieved workload. One patients who failed to increase his heart rates during exercise both before and after surgery revealed unchanged NYHA function class and decreased oxygen uptake postoperatively. The other patients showed statistically significant increases of oxygen uptake not only at anaerobic threshold but also at peak achieved workload. At anaerobic threshold, oxygen uptake was 0.92 + 0.14 l/min before surgery and 1.09 + 0.22 l/min after surgery. Maximal oxygen uptake increased from 1.11 + 0.27 l/min to 1.47 + 0.36 l/min postoperatively. Heart rates at anaerobic threshold and at peak workload showed no significant differences. Postoperative increases of oxygen uptake was achieved by the increases of oxygen pulses, which was considered to be from the increases of stroke volumes.

[Malignant fibrous histiocytoma of the rib: a case report of repetitive extensive resections and reconstruction of the chest wall]

A forty-seven-year-old woman visited our hospital in March 1987 suffering from the local recurrence of the tumor. Her right 7th and 8th rib had been resected 2 years and 11 months before because of the malignant fibrous histiocytoma (MFH) originated from the right 7th rib. In May 1987, wide resection of the right lateral chest wall and partial resection of the right diaphragm were done. Dacron meshed silicon plate (Silastic) and musculocutaneous flap of the right latissimus dorsi were used to reconstruct the chest wall. Seven months after the second operation, local recurrence occurred again on the anterior chest wall, involving the right diaphragm and right lower lobe of the lung. In March 1988, extensive resection of the anterior chest wall with partial resection of the right diaphragm and the right lower lobe was followed by reconstruction of the chest wall by Silastic. The patient recovered uneventfully without any respiratory disturbances after both operations which included wide resection of the chest wall. Multiple pulmonary metastases were found 4 months after the operation, and she died of respiratory failure 7 months after the final operation. Although MFH was one of the most common sarcomas of the soft tissues, only one case of the MFH originated from the rib had been reported previously in this country. Silastic was proved to be a useful prosthesis for the reconstruction of widely resected chest wall.

[Double orifice mitral valve associated with bicuspid aortic valve]

A 63-year-old man with double orifice mitral valve (DOMV) and bicuspid aortic valve was reported. Preoperative echocardiography showed prolapse of the posterior leaflet and mitral regurgitation but was unable to show the existence of the duplication of the mitral valve. He underwent aortic and mitral valve replacement and did well after surgery. DOMV is a rare congenital malformation, and DOMV associated with bicuspid aortic valve is the first reported case in Japan.

[Anaerobic threshold and oxygen uptake in patients with mitral stenosis]

The exercise stress test with a bicycle ergometer was performed for 31 patients with mitral stenosis and for 10 normal subjects. The patients were categorized in two groups. Group 1 consisted of 16 patients having indication for surgical intervention and Group 2 consisted of 15 patients without such surgical indications. Oxygen uptakes at the anaerobic threshold and at peak exercise (MAX) were assessed by percent attainment of the predicted normal value from Posner's equation. Heart rates during exercise did not differ between the two groups. However, Group 1 had significantly smaller values of percent attainment of oxygen uptake both at the anerobic threshold and peak exercise than the controls and Group 2. Oxygen pulses in Group 1 were also significantly less than in the controls or Group 2. Seven cases were reassessed six months or more after surgery including open mitral commissurotomy in two and mitral valve replacements in five. The improvement of oxygen pulse showed a statistical significance. Percent oxygen uptake attainment was also significantly improved both at the anaerobic threshold and at peak exercise. Percent attainment of oxygen uptake in mitral stenosis differed significantly according to the NYHA class both at the anaerobic threshold and peak exercise. These values are considered useful for making decisions for surgical treatment in borderline cases.

[Rotational stenosis of the vertebral artery at the atlantoaxial joint: report of three cases]

Three cases of vertebral artery stenosis or occlusion at the level of the atlantoaxial joint during head rotation were reported. The vertebral artery was mechanically compressed on the side of the head opposite to the direction in which the heads was turned. One case was associated with atlantoaxial dislocation due to rheumatoid arthritis. Posterior fixations of C1 - C2 or C1 - C3 using iliac bone and wire were performed in two cases, and a neck collar was applied in another case. All of the three cases have been free from vertebrobasilar insufficiency since the treatment. The pathogenesis and treatment of vertebral artery occlusion at the atlantoaxial joint are discussed.

[Extracranial surgery of vertebrobasilar insufficiency. Reconstruction of the vertebral artery in the distal first portion]

Fourteen patients with symptoms of vertebrobasilar insufficiency caused by vertebral artery stenosis in the distal first portion underwent surgical reconstruction. They ranged in age between 42 and 73 years, with a median age of 57 years. Their symptoms included vertigo, dysarthria, syncope, hemiparesis, and homonymous quadrant anopsia. The etiologies of the stenoses involved kinking in 12 cases and mechanical compression due to cervical sympathetic nerve, osteophyte, or fibrous bands in two cases. Digital subtraction angiography revealed that stenosis was maximal at systole and minimal at diastole in six of eight cases. In two of the 14 cases, stenosis was not demonstrated in the neutral position, but stenosis of the left vertebral artery appeared when the head was rotated to the right. Surgical procedures involved 13 decompressions of the vertebral artery and one subclavian artery-vertebral artery bypass using the saphenous vein. Postoperatively, 12 cases of miosis and one of asymptomatic phrenic nerve palsy were observed, but there were no serious complications. All but two patients had complete resolution of their symptoms. Stenosis due to kinking and/or mechanical compression disappeared in all cases after decompression of the vertebral artery. The effects of arterial pulse and neck rotation on vertebral artery stenosis in the distal first portion are discussed.

[Roentogenologic pathologic evaluation of allograft rejection in heart-lung transplantation--an experimental study in Japanese monkey]

Experimental heart-lung transplantation was carried out in Japanese Monkey (Macaca fuscata). Twelve monkeys survived two to thirty-three days. Pathologic examination of the lung was performed at the time of open lung biopsy and autopsy. Postoperative chest roentogenogram was also studied in seven monkeys. In the early postoperative period, central cloudiness and enhancement of the interstitial change were observed, which started from the second or third postoperative day and reached their peak between the fifth and eighth postoperative day. Pathological study revealed no obvious monocyte infiltration in the lung of this stage. Two types of pulmonary rejection were observed, one is alveolar and vascular rejection. The other is vascular type of rejection, which started as early as in the twelfth postoperative day in a case. In the former, consolidation of the lung was noticed and useful in the diagnosis, but in the latter, no distinct change was observed in plain chest roentogenogram.

[Combined aortic and mitral valve replacement with or without preservation of posterior mitral apparatus]

Seventy patients who underwent aortic and mitral valve replacement were reviewed. 37 patients had the mitral valve replaced with preservation of posterior mitral apparatus (AVR and modified MVR; modified group), and the others without (AVR and conventional MVR; conventional group). Hospital deaths occurred in 4 patients (12.1%) in conventional group and in only 1 patient (2.7%) in modified group. Four out of these five hospital deaths were due to low output syndrome (LOS). The other one died of unknown cause. Severe LOS, necessitating intra-aortic balloon pumping, occurred in 4 (12.1%) in conventional group and in 2 (5.4%) in modified group. In the early postoperative period modified group showed better left ventricular function than conventional group in terms of cardiac index and left ventricular stroke work index. Cardiac performance was evaluated by means of echocardiography at the time of discharge. Modified group showed better fractional shortening and shorter PEP/ET (pre-ejection period/ejection time). These findings suggest that the lower mortality of modified group is due to better left ventricular function preventing LOS in the early postoperative period, and that preserving the posterior mitral apparatus has a more beneficial effect on postoperative left ventricular function even in combined valve disease.

Stimulation of the medullary reticular formation in cold-injured brain

The vasopressor response (Cushing) in patients with high intracranial pressure (ICP) has been thought to be a result of lower brainstem dysfunction. This study was carried out to study the effect of stimulation of the reticular formation of the medulla oblongata on ICP and cerebral blood volume (CBV) in injured brain with increased ICP. The CBV was measured by the photoelectric method from the uni- or bilateral parietal lobe. Seventeen hours prior to the experiments, cold-induced edema was produced to increase basal ICP. In 15 cats, electric stimulation produced temporary increases in blood pressure (BP), ICP, and CBV and progressive intracranial hypertension was never observed (group A). In 9 animals, progressive increases in CBV and ICP up to 50-100 mmHg occurred after cessation of stimulation (group B). Prestimulation ICP in group B was significantly higher than that of group A (p less than 0.01). Rapid and simultaneous increases in ICP and CBV following stimulation strongly suggested that global increments of CBV secondary to loss of cerebral vasomotor tonus were responsible for producing progressive intracranial hypertension. In group B, the stimulation electrodes were invariably located at the area of the nucleus reticularis parvocellularis and gigantocellularis. Our experimental results show that under conditions of increased ICP, a stimulated or irritable condition of the medullary reticular formation will cause temporary or progressive intracranial hypertension.

[Werner's syndrome associated with meningioma: case report]

We present two cases of Werner's syndrome associated with intracranial meningioma. Characteristic clinical features of Werner's syndrome include short stature with slender extremities, premature senility, juvenile cataract, skin changes, a tendency to diabetes mellitus and familial occurrence. A 44-year-old female, who had been treated for diabetes mellitus, was diagnosed as having Werner's syndrome because of various characteristic features. A falx meningioma was incidentally found on CT scan, and was surgically removed. Her diabetes mellitus improved. The second case was a 28-year-old male was diagnosed as having Werner's syndrome, diabetes mellitus, juvenile cataract, together with diabetes insipidus, and liver dysfunction. He developed severe headache, gait disturbance and then became unconscious with right hemiparesis. He was found to have a parasagittal meningioma by CT scan and angiography. After removal of the tumor, diabetes mellitus, diabetes insipidus and liver dysfunction improved. The reported incidence of neoplasms associated with Werner's syndrome is about 10%. The majority of associated tumors were mesenchymal in origin. Ten meningiomas, 1 neurinoma and 2 gliomas are reported as associated tumors in the central nervous system. Most of the associated meningiomas were asymptomatic and found incidentally at autopsies or CT scans. Diabetes mellitus associated with Werner's syndrome is generally mild with high immunoreactive insulin value and is controllable by diet therapy and oral antidiabetic drugs. Daily profile of blood sugar improved after the removal of tumor in our cases. In 50 gm glucose tolerance test, tendency of delayed appearance of peak value, which is common in Werner's syndrome, was not altered in our cases. Discussion is made as to the association of Werner's syndrome with meningioma and diabetes mellitus.