Intraoperative Bypass Graft Angiography: Cooperation between Cardiologist and Surgeons in the Operation Room for Optimal Postoperative Results - Is this the Way for the Future?

OBJECTIVE

To confirm the quality of total arterial CABG carried out using the left internal thoracic artery (LITA) and a radial artery (RA) T-graft and distal anastomoses immediately in the OR, we developed a new technique using intraoperative graft angiography.

METHODS

A 5-Fr sheath is inserted in the proximal radial artery stump, through which a catheter for LITA angiography is later introduced. From July 2004 to March 2005, 23 patients underwent total arterial CABG with the T-graft and intraoperative graft angiography.

RESULTS

On-pump CABG was performed in 22 patients and off-pump CABG in 1 patient. Mean procedure time for the angiography was 13.7 +/- 7.3 minutes, and mean fluoroscopy time was 6.2 +/- 4.6 minutes. In two patients, the RA-marginal artery side-to-side anastomosis was stenosed and had to be revised as demonstrated by graft angiography. In one patient, the RA was kinked and in another, there was a kinking of the LITA. In both cases, kinking was corrected. The remaining anastomoses were seen to have unobstructed flow with no evidence of stenosis.

CONCLUSIONS

Intraoperative graft angiography can be performed in patients undergoing total arterial CABG. This concept of intraoperative cooperation between an interventional cardiologist and surgeons could significantly improve the operative outcome in CABG surgery.

Recommendations for the use of everolimus (Certican) in heart transplantation: results from the second German-Austrian Certican Consensus Conference

Everolimus (Certican; Novartis Pharma AG, Basel, Switzerland) represents the latest generation of proliferation signal inhibitors (PSIs). Everolimus is indicated for use as an immunosuppressive drug in renal and heart transplantation. This report reflects the recommendations of the second German-Austrian Certican Consensus Conference, held in January 2006, for the clinical use of everolimus.

Calcineurin inhibitor-free immunosuppression using everolimus (Certican) in maintenance heart transplant recipients: 6 months' follow-up

BACKGROUND

Everolimus is a proliferation signal-inhibitor recently introduced in heart transplant recipients. To date, little is known about calcineurin inhibitor (CNI)-free immunosuppression using everolimus. This study reports the results of CNI-free immunosuppression using everolimus.

METHODS

During a continuous 9-month period, 60 heart transplant recipients were enrolled. Reasons for switching to everolimus were side effects associated with prior CNI immunosuppression. All patients underwent standardized switching protocols and completed 6 months of follow-up. Blood was obtained for lipid status, renal function, routine controls, and levels of immunosuppressive agents. Echocardiography and a physical examination were performed on Days 0, 14, 28, and then every 3 months.

RESULTS

After switching to everolimus, most patients recovered from the side effects associated with CNIs. Renal function improved significantly after 6 months (creatinine, 2.1 +/- 0.6 vs 1.5 +/- 0.9 mg/dl, p = 0.001; creatinine clearance, 42.2 +/- 21.6 vs 61.8 +/- 23.4 ml/[min x 1.73 m2], p = 0.018). Arterial hypertension improved after 3 months and remained decreased during the observation period. Tremor, peripheral edema, hirsutism, and gingival hyperplasia markedly improved. Adverse events occurred in 8 patients (13.3%), including interstitial pneumonia (n = 2), skin disorders (n = 2), reactivated hepatitis B (n = 1), and fever of unknown origin (n = 3).

CONCLUSION

Preliminary data suggest that CNI-free immunosuppression using everolimus is safe, with excellent efficacy in maintenance heart transplant recipients. Arterial hypertension and renal function improved significantly. CNI-induced side effects such as tremor, peripheral edema, hirsutism, and gingival hyperplasia markedly improved in most patients.

A Novel Mechanical Circulatory Approach for Patients with Cardiogenic Shock in the Intensive Care Unit

BACKGROUND

The capacity of the heart to maintain cardiac output can be acutely impaired as a result of myocardial infarction, graft failure after transplantation, or other cardiac events. Medical therapy or the use of an intra-aortic balloon pump may be insufficient to help the patient overcome acute cardiogenic shock. The set-up of mechanical assist devices such as extracorporeal membrane oxygenation or patient relocation into the operating room requires valuable time that is often not available. The aim of our study was to test whether a novel left ventricular assist device can be percutaneously implanted without fluoroscopy under echocardiographic navigation in a preclinical model.

METHODS

Pigs were subjected to percutaneous implantation of a novel left ventricular assist device under navigation of transesophageal echocardiography (TEE) without fluoroscopic support. Percutaneous puncture of the interatrial septum using a Brockenbrough needle and insertion of the afferent cannula into the femoral vein and its advance to the right atrium and through the interatrial septum into the left atrium was performed under echocardiographic control. The efferent cannula was inserted into the contralateral femoral artery using the Seldinger technique.

RESULTS

In all animals, the percutaneous implantation of a left ventricular assist device was successful under only TEE navigation.

CONCLUSIONS

The ability to abstain from fluoroscopy and the feasibility of inserting the afferent cannula across the interatrial septum guided by TEE allows for application of this system in intensive care units, saving precious time as well as financial and human resources.

Clinically applicable 7-Tesla magnetic resonance visualization of transplanted human adult stem cells labeled with CliniMACS nanoparticles

BACKGROUND

Intra-myocardial transplantation of bone marrow derived cells is currently under clinical evaluation as a therapy for heart failure. A major limitation of all clinical studies for myocardial restoration through cell transfer is the inability to track the fate of the transplanted cells. We present a clinically applicable technique using advanced ultra high-field 7-Tesla (7T) magnetic resonance imaging (MRI) of nanoparticle-labeled transplanted human EPCs in porcine ischemic hearts.

METHODS

CD133 positive cells were isolated from bone marrow by magnetic bead selection. Positive cells (5 - 8 x 10 (6) cells) were transplanted into porcine ischemic myocardium (n = 8). Control animals (n = 3) received a medium injection. MRI on a 7T scanner was performed to demonstrate the distribution of the EPCs.

RESULTS

CD133+ cells were identified on gradient echo images (T(1)-weighted) within the myocardium 4 weeks after transplantation.

CONCLUSIONS

Magnetically labeled EPCs transplanted for therapeutic neovascularization or reduction of infarct size in myocardial ischemia can be visualized by MRI at high-field strengths.

[In vivo detection of integration of grafted cells after myocardial transplantation]

Myocardial transplantation of myocytes and bone marrow derived cells is currently under clinical evaluation as an alternative therapy of heart failure. One of the main problems of all clinical studies performed so far is the inability to track the fate of the transplanted cells. The aim of our study was the development of a potentially clinically applicable approach, which allows for detection of the transplanted cells without need for collection of tissue samples. Fetal canine cardiomyocytes were labelled with the non-toxic fluorescent membrane dye Vybrant CM-DiI and delivered into the free wall of the left ventricle of adult mongrel dogs. For subsequent tracking of the cellular graft, the dogs underwent a second operation in which an intra-vital microscope was mounted above the exposed heart within the thorax. A special computer software eliminated artefacts caused by myocardial contraction. Two months after transplantation, the fluorescent graft was macroscopically visible by intra-vital microscopy using a 10x magnification. Histological studies served as microscopic control and confirmed the existence of DiI-labelled cells at the site of injection. Connexin 43 immunoreactivity was visible at junctional complexes between donor and recipient cells, suggesting morphologic and functional coupling as a result of gap junction formation. Our results demonstrate that in vivo detection of transplanted cells in the heart is feasible. Further technical adjustments should allow for thoracoscopic/endoscopic application of this method, making it appropriate for use in other organs and in clinical studies.

Prevalence of CCR5Delta32 polymorphism in long-term survivors of heart transplantation

BACKGROUND

CC chemokine receptor 5 (CCR5) contributes to the alloimmune response following solid organ transplantation. In individuals homozygous for the CCR5Delta32 mutation, the receptor is inactive and lymphocyte recruitment and leukocyte trafficking during rejection are inhibited. A significant improvement in graft survival following renal transplantation has been observed in homozygous CCR5Delta32 patients, although conflicting data exist. To determine whether CCR5Delta32 homozygous heart transplant recipients may also benefit compared to those with a normally functioning CCR receptor, the proportion of patients with CCR5Delta32 mutation was examined in a large cohort of patients surviving for a long period after heart transplantation.

METHODS

The prevalence of CCR5 genotype was identified in patients who had survived >or=7 years after heart transplantation. Genotyping was performed centrally by polymerase chain reaction (PCR).

RESULTS

A total of 555 patients were recruited at three heart transplant centers in Germany. Of these, 442 patients (79.6%) were homozygous for the wild-type allele, 106 (19.1%) were heterozygous for CCR5Delta32 and 7 (1.3%) were homozygous for CCR5Delta32. No statistically significantly differences were observed between the incidence of CCR5Delta32 homozygosity in the study population and the estimated incidence in the normal population.

CONCLUSIONS

In the absence of a control arm, it cannot be established if homozygous carriers of the CCR5Delta32 allele experience a long-term survival benefit following heart transplantation that may be masked by underrepresentation of the CCR5Delta32 allele in recipients of a heart transplant. To answer this question, the prevalence of CCR5Delta32 homozygosity needs to be established in patients awaiting heart transplantation.

Long-term cardiac allograft valves after heart transplant are functionally and structurally preserved, in contrast to homografts and bioprostheses

BACKGROUND AND AIM OF THE STUDY

Homograft valves undergo degenerative changes over time, which finally lead to functional deterioration. Immunological events are believed to play a pivotal role in this process. To further evaluate this hypothesis, the valvular morphology and function, as well as comorbidities predisposing to deteriorative processes, were evaluated in patients who had undergone heart transplant more than 10 years previously.

METHODS

In a consecutive cohort of 146 patients (125 males, 21 females; mean age at transplant 43.8 +/- 11.2 years), heart and valve function were assessed by color Doppler echocardiography at a mean of 5306 +/- 987 days after heart transplant. Evaluated parameters included chamber dimensions, cardiac function, valvular morphology/function, and concomitant diseases.

RESULTS

Atrial and ventricular dimensions were within normal ranges for the left atrium (LA; n=7), right atrium (RA; n=7), left ventricle (LV; n=143) and right ventricle (RV; n=119). Slight enlargements occurred in the LA (n=138), RA (n=137), LV (n=1) and RV (n=11), while significant enlargements were seen in the LA (n=1), RA (n=2), LV (n=2), and RV (n=16). With regard to cardiac function, the ejection fraction (EF) was 63.9 +/- 4.9%, left ventricular isovolumic relaxation time (IVRT) 85.04 +/- 14.64 ms, fractional shortening (FS) 34 +/- 12%, and pulmonary artery systolic pressure (PASP) 29.81 +/- 6.4 mmHg. Valvular regurgitation (grade > or =2) was present in 34 patients (31 tricuspid valves, three mitral valves). No patients presented with aortic valve regurgitation. Concomitant conditions with a potential impact on calcium balance/valvular deterioration included immunologic/chronic inflammatory diseases (n=6), malignancies (n=12), kidney (n=41), cardiovascular system (n=39) and thyroid/parathyroid (n=12).

CONCLUSION

During the long term after heart transplant, heart valves were characterized by normal morphology and function in the majority of cases. Although most patients presented with concomitant conditions strongly predisposing for valvular deterioration/calcification, sole immunosuppressive/anti-inflammatory therapy appears to prevent these processes in heart transplant patients.

Improved outcome of chronic hepatitis B after heart transplantation by long-term antiviral therapy

Chronic hepatitis B progresses to cirrhosis in the majority of immunosuppressed patients. The outcome of long-term antiviral therapy in HBV-infected organ transplant recipients is unknown. In 1996, we included 20 heart transplant (HT) recipients in a pilot trial to treat chronic hepatitis B with famciclovir. At that time, bridging fibrosis or cirrhosis was evident in 15 individuals (75%). From 1998 onwards, patients were switched to lamivudine in case of primary or secondary virological nonresponse to famciclovir. Adefovir or tenofovir became available at our centre for HT recipients in 2002. After 103 months, one patient was still on famciclovir showing a complete virological response. Sixteen patients were switched to lamivudine after 0.5-4 years of famciclovir therapy. Six of those showed a long-term response to lamivudine therapy lasting for up to 7 years. Lamivudine resistance developed in the remaining 10 patients (63%), in 4 of them successful rescue therapy (adefovir n = 3, tenofovir n = 1) could be initiated. Only one hepatocellular carcinoma developed, which was successfully treated by locoregional ablative therapy. Nine patients died (45%), with lamivudine-resistance-related liver failure as the cause of death in five cases. Significant improvement of Ishak fibrosis scores could be demonstrated in six of the seven patients with more than two sequential liver biopsies available. Long-term antiviral therapy of chronic hepatitis B can lead to regression of liver cirrhosis in patients after organ transplantation, unless viral resistance occurs. This study demonstrates the urgent need for further antivirals to overcome antiviral resistance.

In vivo echocardiographic imaging of transplanted human adult stem cells in the myocardium labeled with clinically applicable CliniMACS nanoparticles

OBJECTIVES

Intramyocardial transplantation of bone marrow-derived cells is currently under clinical evaluation as a therapy of heart failure. A major limitation of all clinical studies dealing with myocardial cell engraftment is the inability to track the fate of the transplanted cells. We present a clinically applicable technique using transesophageal echocardiography (TEE) of CliniMACS nanoparticle labeled transplanted CD133+ cells in ischemic hearts.

METHODS AND RESULTS

CD133+ cells were isolated from human bone marrow by CliniMACS magnetic bead selection. Positive (5 x 10(6) cells) cells were transplanted into porcine ischemic myocardium (n = 6). Control animals (n = 5) received medium injection. TEE was performed to demonstrate the distribution of the cells during and 8 weeks after the procedure. Accumulations of labeled CD133+ cells of adjacent injections in the myocardium were discriminatively identified by TEE.

CONCLUSIONS

TEE is an elegant method for real-time documentation of successful transplantation and cell colony localization of magnetically labeled CD133+ cells in the ischemic myocardium. Our method should be of special interest for TEE-guided transcatheter injection of cells.

Complete aortic root reimplantation facilitates preservation of the aortic valve

The optimal technique for preservation of a retainable aortic valve is yet to be defined. We present a new facilitated procedure allowing for reimplantation of the complete aortic root in selected patients with acute type A aortic dissection or ascending aortic aneurysm.

[Efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis: 10 cases]

Axilliary and palmar hyperhidrosis can become a considerable social and psychological handicap. Local treatments are not always effective and endoscopic thoracic sympathectomy is not without side effects. The efficacy of botulinum toxin has recently been demonstrated in axillary and palmar hyperhidrosis. Between June 2001 and June 2002, we treated all the patients presenting with axillary and palmar hyperhidrosis, resistant to classical treatments, with intradermal injections of botulinum toxin A (Dysport). The aim was to assess the interest of this technique at moderate doses, in a prospective, open, controlled study.

PATIENTS AND METHODS

The hyperhidrotic areas, revealed by Minor's test, were treated with intradermal injections of 100 U of Dysport in the axilliary form and 250 U in the palmar form. Patients were seen after 1 month and 6 months and underwent a Minor's test, photographic control and they filled-in a questionnaire to measure their satisfaction.

RESULTS

Ten patients: 9 women and 1 man aged 19 to 63, were included. Three of them consulted for palmar hyperhidrosis and 7 for auxiliary hyperhidrosis. Within 2 to 7 days, treatment was successful in all patients. The follow-up was of 3 to 12 months. The satisfaction index was comprised between 7/10 and 9/10. The relapse-free interval was of 2 to 9 months. Three patients were given a second injection, which doubled the relapse-free period. Side effects included pain with the palmar injections and moderate headaches.

DISCUSSION

This French study confirms the efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis with relatively low doses (100 U of Dysport per armpit and 250 U per palm). This is an easily reproducible, well tolerated, method without major side effects.

[Systemic necrobiotic xanthogranuloma with initial pericardial and pulmonary involvement]

INTRODUCTION

Necrobiotic xanthogranuloma is a rare disease, usually associated with a monoclonal gammapathy. We report a case with pericardial and pulmonary involvement that preceded the appearance of the cutaneous lesions.

OBSERVATION

A 58 year-old woman was hospitalized for cardiac tamponade. She has a past history of a ductal carcinoma of the right breast that had been completely cured. Pericardial and pulmonary samples showed a predominantly histiocyte monomorphous infiltrate. Twelve months later, indurated papular-like cutaneous lesions appeared around the eye orbits and on the thorax. The histological examination of the skin revealed a necrobiotic xanthogranuloma and the diagnosis of cutaneous and visceral necrobiotic xanthogranuloma was retained. The patient exhibited an IgG Kappa monoclonal gammapathy of undetermined significance. Sequential treatment with melphalan and general corticosteroids moderately improved the cutaneous lesions but did not modify the monoclonal peak.

DISCUSSION

To our knowledge, this is the first case of pericardial involvement of a necrobiotic xanthogranuloma. The discovery of the disease, revealed by a visceral manifestation at the onset is uncommon. The subsequent appearance of typical cutaneous lesions permits the retrospective diagnosis of systemic necrobiotic xanthogranuloma. Because its diagnosis is difficult in the absence of concomitant cutaneous involvement, visceral localizations of the disease must be recognized.