Improving clinical outcome with centrifugal mechanical assist for postcardiotomy ventricular failure

Between October 1986 and May 1994, 65 patients undergoing cardiac surgery required centrifugal mechanical assist devices to separate from cardiopulmonary bypass. This experience was arbitrarily divided into early (n = 33) and recent (n = 32) groups for the purpose of comparing trends in morbidity and mortality. The incidence of mechanical assist application decreased from 2.19% in the early group to 0.96% in the recent group (p < 0.0001). Ability to wean patients from centrifugal assist increased from 33% in the early group to 53% in the more recent group, and hospital survival increased from 15 to 28%. The median chest tube drainage during the first 24 h decreased from 3,245 ml to 1,535 ml, and the incidence of renal failure decreased from 39.4% and 18.8% in the more recent group. Clinically relevant improvement in patient outcome following application of centrifugal mechanical assist for postcardiotomy ventricular failure is being observed.

Massive phrenic perineurioma mimicking an unresectable cardiac tumor

Malignant peripheral nerve sheath tumors of the phrenic nerve are rare. A 24-year-old woman presented with a massive perineurioma of the phrenic nerve that invaded the pericardium and left heart. Diagnosis, surgical treatment, and 1-year follow-up are discussed.

Progress in renal transplantation. A single center study of 3359 patients over 25 years

OBJECTIVE

The study analyzed 3359 consecutive renal transplant operations for patient and graft survival, including living related, cadaveric, and living unrelated patients. The analysis was separated into three groups according to immunosuppression and date of transplant.

SUMMARY BACKGROUND DATA

Improvements in renal transplantation in the past 25 years have been the result of better immunosuppression, organ preservation, and patient selection.

METHODS

A single transplant center's experience over a 25-year period was analyzed regarding patient and graft survival. Potential risk factors included patient demographics, tissue typing, donor characteristics, number of transplants, acute and chronic rejection, acute tubular necrosis, primary disease, and malignancy.

RESULTS

The primary cause of graft loss was rejection. Improvement in cadaveric graft survival since 1987 with quadruple therapy was not apparent in living donor patients. Race continued to be a negative factor in graft survival. Avoiding previous mismatched antigens and the use of flow cytometry improved allograft survival. The leading cause of death in the past 7 years in cadaveric recipients was cardiac (52%).

CONCLUSIONS

Improved graft survival in the past 25 years was related to 1) advances in immunosuppression, 2) better methods of cytotoxic antibody detection, and 3) human lymphocyte antigen match.

Cyclosporine inhibits the renal response to L-arginine in human kidney transplant recipients

To evaluate the association of cyclosporine (CsA)-related nephrotoxicity with nitric oxide (NO) and endothelin, the effects of L-arginine (LA) and branched-chain amino acid (BCAA) infusions on renal hemodynamics in 5 normal volunteers and 12 renal transplant recipients were assessed. In normal humans, LA, but not BCAA, reduced mean arterial pressure and renal vascular resistance while increasing RPF and urinary nitrate (NO3-) excretion. Group 1 included six transplant recipients not on CsA; Group 2 subjects (N = 6) were receiving CsA. In both groups, mean arterial pressure declined during the infusion of LA (116 +/- 4 to 109 +/- 4 mm Hg; P < 0.001) but not BCAA (116 +/- 3 to 115 +/- 3; P = not significant). In Group 1, LA increased RPF 33 +/- 13% (329 +/- 48 to 436 +/- 77 mL/min per 1.73 m2; P = 0.01) and GFR 37 +/- 16% (95 +/- 7 to 130 +/- 18 mL/min per 1.73 m2; P = 0.01); renal vascular resistance declined 27 +/- 6%. In Group 2, LA did not affect renal hemodynamics. No changes occurred with BCAA in either group. LA increased urinary NO3-excretion by 27 +/- 17% in Group 1 (P < 0.05), but only by 16 +/- 13% in Group 2 (P = not significant). Urinary endothelin excretion was higher in Group 2 subjects (10.1 +/- 1.3 versus 5.3 +/- 0.8 pg/mL of GFR, P < 0.01). LA-induced renal vasodilation is associated with the increased urinary excretion of NO3-.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchial erosion by an indwelling central venous catheter

Despite improved technology, central venous catheters are associated with many complications that occur usually within 48 h of placement. We report a 42-year-old man with a rare erosion of a venous catheter (Silastic) into a bronchus 2 years after its insertion.

Erythropoiesis after withdrawal of enalapril in post-transplant erythrocytosis

Enalapril effectively decreases hematocrits in patients with postrenal transplant erythrocytosis (PTE). We studied the effect of enalapril withdrawal on erythropoiesis in 18 patients with PTE who had been treated for 13 +/- 8 months. Hematocrit, reticulocyte count, plasma erythropoietin, and plasma insulin-like growth factor I were measured biweekly for six weeks. Red cell mass, plasma volume, transferrin saturation, and plasma angiotensin II were measured at withdrawal and six weeks later. Hematocrit increased by at least 0.04 in 13 patients ('responders') but changed by -0.08 to 0.01 in five patients ('nonresponders'). In the responder subgroup, hematocrit increased from 0.43 +/- 0.05 to 0.51 +/- 0.05 (P < 0.001), red cell mass increased from 25.4 +/- 5.9 to 28.9 +/- 5.9 ml/kg body weight (P < 0.001), and transferrin saturation decreased from 41 +/- 16 to 27 +/- 9 percent (P < 0.01). Reticulocyte count increased two weeks after withdrawal of enalapril. Plasma volume did not change significantly. No measurement changed in the nonresponder subgroup. Plasma levels of erythropoietin, total erythroid stimulating activity, insulin-like growth factor I, and angiotensin II did not change significantly in either subgroup. Enalaprilat did not inhibit erythropoiesis in cell culture. Thus, erythropoiesis increased in 13 of 18 patients after stopping enalapril and was independent of changes in circulating concentrations of several erythropoietic factors, including erythropoietin. The pathogenesis of PTE and mechanism underlying the beneficial effect of angiotensin converting enzyme inhibition remain undetermined.

Coronary revascularization in the elderly: determinants of operative mortality

Over a 13-year period, 668 patients 70 years of age or older underwent isolated primary coronary artery bypass grafting at our institution. There were 472 men and 196 women, ranging from 70 to 90 years of age (median age, 74 years). Hospital mortality was 5.2% (35/668). In patients 70 to 79 years of age, hospital mortality was 4.2% (25/600), whereas in patients 80 years of age or older, mortality was 14.7% (10/68; p < 0.001). Twenty-seven clinical or hemodynamic variables hypothesized as predictors of operative mortality were examined. Mortality was higher in women than in men (9% versus 3.6%; p = 0.006). Those who died were a mean of 3 years older (77 versus 74 years old; p < 0.05) and were more likely to have unstable angina or Canadian class III or IV angina (p < 0.01). Patients requiring urgent operations, preoperative intraaortic balloon assist, intravenous nitroglycerin, or inotropic agents, and those with preoperative hypotension or cardiac arrest were most likely to die in the hospital (p < 0.001). Multivariate logistic regression analysis revealed advancing age, female sex, bypass time, urgency of operation, preoperative cardiac arrest, and unstable angina as primary determinants of mortality (p < 0.05). Although mortality after coronary artery bypass grafting increases with age, the greatest risk of death is in the acutely ill patient with few options for management other than surgical intervention.

Strangulated parahiatal hernia: not just another paraesophageal hernia

Exploratory thoracotomy was necessary to establish the diagnosis of a rare incarcerated parahiatal hernia. Symptomatology, signs, and radiographic findings are compared with those of paraesophageal hernias.

Posttransplant erythrocytosis: an enigma revisited

Posttransplant erythrocytosis (PTE) is an often-recognized but poorly understood complication of renal transplantation. Defined as a persistently elevated hematocrit (> 0.51), it occurs most commonly during the first 2 years posttransplant in hypertensive males with excellent allograft function. Its consequences are disputed, but may include increased risk of thromboembolic events. Traditionally, PTE has been thought to reflect excess erythropoietin production, of either native kidney or allograft origin, and to abate spontaneously with time. More recent data indicate that factors other than erythropoietin may be involved in the pathogenesis of PTE and that spontaneous resolution is relatively uncommon. Standard treatments have included serial phlebotomy and native kidney nephrectomy. It now appears that PTE also can be managed safely and effectively with converting enzyme inhibitors, a development that challenges our previous understanding of PTE and offers new avenues for investigating its pathogenesis.

Use of a rate-limited ultrafiltration circuit with centrifugal ventricular assist

Renal insufficiency and pulmonary edema are frequently observed in patients who require centrifugal ventricular assist for postcardiotomy ventricular failure. We describe a technique of using a rate-limited ultrafiltration device in parallel with the assist device circuit to remove excess intravascular volume.

Severe dysphagia from an Angelchik prosthesis: futility of routine esophageal testing

A 33-year-old woman presented with progressive dysphagia 3 years after implantation of an Angelchik prosthesis for esophageal reflux disease. Routine esophageal testing was normal. Esophagogastroduodenoscopy and computed tomography suggested migration of the prosthesis. Because of the persistent and progressive dysphagia, the device was removed. All symptoms of dysphagia or reflux have since resolved. Routine esophageal testing may not be helpful in the evaluation of dysphagia associated with the Angelchik prosthesis.

Preferential rejection of the kidney in a simultaneous kidney-pancreas transplant

A case of selective kidney allograft rejection with stable pancreas function in a patient who received simultaneous kidney-pancreas allograft from the same donor is reported. Pancreas function was shown to be normal within the first month posttransplant by both a glucose tolerance test (despite a high corticosteroid dose) and stable urinary amylase values during biopsy-proven acute renal allograft rejection. This patient subsequently rejected his kidney allograft as documented by histopathologic evidence of severe chronic vascular rejection and acute tubulointerstitial rejection, yet his pancreas function remained intact. He subsequently received a six-antigen-matched kidney, continues to have normal fasting glucose and normal glucose tolerance by oral glucose tolerance test, and is without evidence of glucosuria. He has never had a clinical rejection of his pancreas, as evidenced by either a decline in urinary amylase or hyperglycemia, and has not required insulin except in the perioperative period of his second kidney transplant, at which time he was receiving high doses of both corticosteroids and cyclosporin. It is suggested that preferential rejection and subsequent loss of the kidney, although infrequent, do occur in combined renal-pancreas allografts and that maintenance of immunosuppression is justified until retransplant of kidney is available.

Clinical documentation of end-stage renal disease due to hypertension

Hypertensive end-stage renal disease (ESRD) purportedly accounts for 25% of new ESRD patients each year in the United States, but remains poorly understood. Clinical features include normal renal function at diagnosis of hypertension, family history of hypertension, left ventricular hypertrophy, and minimal proteinuria. We evaluated clinical and historic data documenting the diagnosis of hypertensive ESRD in 43 patients with ESRD attributed to hypertension who were referred to our center for renal transplantation. Hypertensive ESRD patients were more likely to be black patients with left ventricular hypertrophy compared with our overall population. Few of the hypertensive ESRD patients had undergone kidney biopsy, none of whom had classic features of benign nephrosclerosis. Less than 5% of patients had hypertension documented at any time with normal renal function. Based on our review, it is clearly possible that the number of patients reaching dialysis and transplantation with renal failure attributed to hypertensive ESRD may be overestimated.

Unrecognized intrapleural missile--a rare cause of chronic pain following gunshot wounds: case report

A young farmer was disabled by chronic pain for more than one year from a free intrapleural missile. Radiologic evidence of missile immobility and the tendency to observe chronically embedded missiles led to a delay in diagnosis. Intrapleural foreign bodies need to be considered in the evaluation of pain following chest or upper abdominal gunshot wounds.

Lack of cardioplegia uniformity in clinical myocardial preservation

Advances in myocardial preservation have led to improved patient survival after open heart operations. However, few studies have detailed the nature of national or regional patterns of cardioplegia use. To determine the regional pattern, all open heart surgery programs in Missouri were surveyed. During 1 year, it was found that cardioplegia was administered to 8,382 patients by 61 cardiothoracic surgeons at ten academic affiliated hospitals and 16 nonteaching hospitals. All cardioplegic solutions were hospital produced. Of 13 crystalloid solutions, 11 differed from one another and eight were intracellular formulations. Of 28 multidose blood-based cardioplegic solutions, there were 23 different mixtures. Most crystalloid (69%) and blood-based (89%) solutions differed substantially from commonly reported formulations. The incidences of the various additives to crystalloid solutions were as follows: bicarbonate, 92%; glucose, 69%; lidocaine, 54%; mannitol, 46%; magnesium, 31%; calcium, 23%; methylprednisolone, 15%; heparin, 8%; and acetate, 8%. Of the common blood-based cardioplegic solution additives, the following incidences were observed: glucose, 79%; bicarbonate, 43%; trishydroxyaminomethane, 36%; acetate, 29%; magnesium, 29%; procaine (or lidocaine), 25%; citrate-phosphate-dextrose, 18%; mannitol/albumin, 14%; nitroglycerin, 11%; glutamate/aspartate, 11%; calcium, 7%; insulin, 3%; and methylprednisolone, 3%. No calcium channel blocker or high-energy phosphate additives were reported. We conclude that many different cardioplegic admixtures that have not been tested experimentally are used routinely in clinical practice, presumably with acceptable results. Because the salutary effects of induced cardiac arrest and hypothermia may mask suboptimal solutions, further study of customized cardioplegia should be considered, particularly with regard to high-risk patients.

Hypertension following kidney transplantation

Patients often have hypertension after successful kidney transplantation. In the long term, this hypertension adds to patient mortality and morbidity. The widespread use of cyclosporine appears to have changed the nature of posttransplantation hypertension. In humans, cyclosporine-associated hypertension seems to involve sodium retention and stimulation of the sympathetic nervous system.

Frequency of seal disruption with the sarns centrifugal pump in postcardiotomy circulatory assist

We have used the Sarns centrifugal pump for uni- or biventricular assist in 58 patients with postcardiotomy cardiogenic shock. This device utilizes a spinning impeller pump that is magnetically coupled to a motor imparting rotary motion to incoming perfusate. Nine patients (16%) experienced 22 device failures, which consisted of a nonvisible disruption of the seal within the pumphead. This allowed fluid to accumulate between the pumphead and the motor necessitating change of the pumphead. The time to seal disruption was 10-149 h (median 48). Of the 22 seal disruptions, 18 occurred in 73 left ventricular pumps (25%), and 4 occurred in 38 right ventricular pumps (11%) p = 0.015. Left ventricular pumps failed at 10-144 h (median 48), and right ventricular pumps failed at 48-149 h (median 83) p = 0.02. The Sarns centrifugal pump is dependable for its intended use of cardiopulmonary perfusion. However, when used for postcardiotomy assist, seal disruption should be expected. It occurs sooner and is more common during left ventricular assist. We recommend inspection of the magnet chamber for evidence of seal disruption every 12 h with left ventricular assist and every 24 h with right ventricular assist.

Renal retransplantation: the role of race, quadruple immunosuppression, and the flow cytometry cross-match

To assess the impact of quadruple immunosuppression in black and white recipients of cadaver kidney retransplants, we reviewed data from 178 second or subsequent renal allografts performed at our center between 1985 and 1991. Sixty-six black and 102 white recipients were divided into 3 groups: groups 1 and 2 consisted of patients with a negative complement-dependent cytotoxicity (CDC) T cell cross-match, receiving triple drug therapy (CsA-AZA-prednisone) and quadruple immunosuppressive therapy (quad therapy; Minnesota antilymphoblast globulin-CsA-AZA-prednisone), respectively. Group 3 patients also received quad therapy, but, in addition to a negative CDC cross-match, had a negative T cell flow cytometry cross-match (FCXM). Black and white patients in groups 1 and 2 experienced similar graft survival at 1 year, ranging from 47% to 63% (P = NS). In group 3, 1-year graft survival in whites, but not blacks, improved to 82%, with fewer grafts lost to immunologic causes in the first 90 days after transplant. A parametric analysis of potential risk factors identified a significant effect of better HLA-DR matching (P = 0.0005) on improved graft survival, with previous mismatched antigens (P = 0.04), female donor (P = 0.002), and short duration of previous graft (P = 0.05) as risk factors for graft loss. Race and immunosuppressive protocol did not affect graft survival. In group 3, blacks received fewer well-matched kidneys than whites (P = 0.05), which may have contributed to poorer outcomes for black recipients. Nine of 10 patients undergoing retransplantation with a negative CDC cross-match and a positive T cell FCXM suffered graft loss at a median of 26 days after transplant. Thus, quad therapy did not enhance graft survival for either black or white patients undergoing cadaveric retransplantation. Immunologic considerations, including HLA-DR matching and the FCXM, continue to exert a strong influence on outcomes in these high-risk recipients.

A comparison of patient charges associated with percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Appropriate interventional treatment for coronary artery disease is an important component in controlling health care expenditures. We conducted a retrospective study to compare the patient charges associated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). All patients underwent treatment for left anterior descending coronary artery stenosis over a 3 year 9 month time period from March 1987 to December 1990 and were followed for 7-58 months (median 43 months) after treatment. The two groups were constructed in such a way that they were balanced for common vessels diseased, number of vessels diseased, sex, age, and ejection fraction (EF). The study included 26 PTCA patients between the ages of 33 and 86 years, 18 males and eight females, with a mean EF of 58 per cent, and 26 CABG patients from 39 to 80 years of age, 18 males and 8 females, with a mean EF of 61 per cent. Charges were categorized as to hospital, professional, cardiac medication, follow-up, and total costs. While CABG was initially more expensive, nine of the PTCA patients (38%) required further interventional treatment (3 PTCA, 5 CABG, 1 PTCA and CABG), whereas none of the CABG patients required further intervention (P < .001). This short-term follow-up demonstrated, that although initially less expensive, repeat interventional charges are significantly higher in PTCA patients. With the escalating costs of health care, the appropriate initial interventional therapy for coronary artery disease must be carefully selected to reduce long-term health care expenses.

Diagnostic and therapeutic thoracoscopy: lessons from the learning curve

A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.

Randomized, prospective comparison of first- and second-generation cephalosporins as infection prophylaxis for cardiac surgery

Surgical wound infections after cardiovascular surgery may be life threatening and are resource intensive. Second-generation cephalosporins are purported to have a broader antimicrobial spectrum than first-generation cephalosporins and, therefore, may be more efficacious for infection prophylaxis. We have conducted a randomized prospective study of 702 patients undergoing open heart surgery to test the hypothesis that the second-generation cephalosporin, cefuroxime, will be more efficacious for infection prophylaxis than the first-generation cephalosporin, cefazolin. Patients were randomized to receive cefazolin 1 g intravenously every 8 hours for 48 hours begun 1 hour preoperatively plus 1 g after 4 hours of surgery (8 doses, n = 425) or cefuroxime 1.5 g 1 hour prior to surgery plus 1.5 g every 12 hours for 3 additional doses (4 doses, n = 277). Infection was defined as a draining wound with or without a positive culture. There was no difference in the wound infection rate between the groups (p = 0.68). Chest wound infections occurred in 2.1% of patients treated with cefazolin and 2.9% of patients treated with cefuroxime (p = 0.79). The rate of true mediastinitis requiring exploration and drainage was 0.7% in both groups (p = 0.084). Leg infections occurred in 6.6% of cefazolin-treated patients and 5.6% of cefuroxime-treated patients (p = 0.83). The second-generation cephalosporin, cefuroxime, did not reduce the incidence of wound infection when compared with the first-generation cephalosporin, cefazolin. Since institutional antibiotic acquisition and administration costs vary, careful analysis of these factors will allow determination of the most cost-effective infection prophylaxis regimen in cardiac surgery.