Selective use of OKT3 in heart transplantation with the use of risk factor analysis

Heart transplant patients who develop early (within 2 weeks after transplantation) severe renal dysfunction require an alternative to cyclosporine-based immunosuppressive induction therapy. In our experience, muromonab-CD3 (Orthoclone OKT3) is an excellent alternative for such patients. When compared with cyclosporine, however, it is associated with a higher incidence of infection. We conducted a retrospective analysis of a series of our patients to improve our ability to identify such patients. Selected risk factors for severe renal dysfunction included creatinine clearance less than 55 ml/min, hospitalization before transplant, perioperative cardiovascular compromise, and mechanical circulatory support. Of 50 adult patients (mean age 52 years), 35 (70%) completed full induction with intravenous (IV) cyclosporine (1 to 4 mg/kg/24 hr); 13 (26%) developed severe renal dysfunction; and two (4%) were excluded as a result of nonprotocol failures. Of the 13 patients in whom IV cyclosporine induction was precluded by severe renal dysfunction, 11 (85%) received IV OKT3 (5 mg/24 hr), and two (15%) received antithymocyte globulin (14 mg/kg/24 hr). Chi-square analysis showed perioperative cardiovascular compromise (p less than 0.001), hospitalization before transplant (p less than 0.001), and low creatinine clearance level (p less than 0.01) to be significantly associated with the development of severe renal dysfunction. The incidence of infection among patients treated with only IV cyclosporine versus OKT3 was 0.7 and 2.3 episodes per patient, respectively. This experience suggests that the selective use of OKT3 and IV cyclosporine with the use of risk factor analysis may improve individualization of induction therapy in heart transplant patients.

Mechanical circulatory support for perioperative donor heart failure

Perioperative acute donor heart failure can be caused by various factors, such as recipient pulmonary hypertension, marginal donor heart function, or immunologic mismatch. Of 265 patients who underwent orthotopic transplantation, four received mechanical support for acute perioperative donor heart failure. In two patients with reactive pulmonary hypertension, right heart bypass (RHB) with a centrifugal pump was used for 53 and 36 hr, respectively. One patient who experienced biventricular donor heart failure was supported for three days with an intraarterial, transvalvular, axial-flow left ventricular assist device (LVAD). Circulation was supported effectively with the LVAD, despite an initial absence of right ventricular function. The fourth patient, who had signs of heart failure, received intraaortic balloon pump support for 24 hr after transplantation. All four patients were weaned from circulatory support, and heart function was restored in each; the mean left ventricular ejection fraction was 63% (range from 57 to 71%). One patient died of fungal infection 14 days after being weaned from pump support, another died of lymphoma two months after support was discontinued, and the remaining two patients are well 9 and 18 months after transplantation. In cases of acute donor heart dysfunction, temporary mechanical assistance is a reliable option for supporting the circulation during heart recovery.

Clinical experience with Muromonab-CD3 monoclonal antibody (OKT3) in heart transplantation

Muromonab-CD3 (Orthoclone OKT3) monoclonal antibody was used as immunosuppressive therapy in 24 selected, cyclosporine-treated heart transplant recipients. Patients included 15 men, eight women, and one child. Mean age was 47 years. Eight patients (group 1) received OKT3 as rescue therapy for rejection, eight (group 2) as primary therapy for rejection, and eight (group 3) as induction therapy. Drug efficacy in the reversal or prevention of rejection in group 1 was 71%; in groups 2 and 3 it was 100%. Recurrent rejection occurred in three of 20 (15%) patients, despite optimal cyclosporine maintenance therapy after OKT3 therapy. Two patients were re-treated successfully for rejection with second courses of OKT3. Systemic side effects occurred in all patients, but in no case did they necessitate cessation of therapy. Infectious complications occurred in all except one patient, typically within the first month after therapy. On the basis of this experience, OKT3 therapy appears highly effective in reversing and preventing cardiac allograft rejection. Further research of the potential complications of such therapy is required to establish optimal dosing schedules and indications for its use after heart transplantation.

Clinical experience with the Hemopump

Complications associated with surgical procedures generally required for implantation of left ventricular assist devices (LVADs) may limit them from providing adequate circulatory support for patients suffering from profound left ventricular failure (LVF). Such problems are minimized with the use of the Hemopump, a recently developed intraarterial LVAD. This 7 mm transvalvular axial flow blood pump is percutaneously powered by an external console with a flexible drive cable. Since April 1988, we have used the device effectively in 12 patients. Indications for device application included postcardiotomy shock in eight patients, acute allograft rejection in two, severe allograft failure in one, and acute myocardial infarction in one. The Hemopump was inserted from the femoral approach in eight patients, the ascending aorta in three, and the abdominal aorta in one. During the first 12 hr of support, cardiac index (CI) ranged from 1.14-2.98 L/min/m2, and pump flow was 3.0 to 3.6 L/min. As the patients' hearts recovered, the pump speed was gradually reduced. Circulatory support ranged from 26 to 139 hr; 10 of 12 patients were successfully weaned. The mean CI before device removal was 2.74 +/- 0.4 L/min/m2, and the pump flow was 2.14 +/- 0.69 L/min. No device-related infections or thromboembolic episodes occurred. Plasma-free hemoglobin remained within acceptable levels during pumping. Six patients survived more than 30 days after pump removal. Thus, the Hemopump can provide safe, stable, temporary circulatory support and can be expeditiously applied with minimal complications.

Extended clinical support with an implantable left ventricular assist device

Clinical evaluations are under way of an intracorporeal (abdominally positioned) pulsatile left ventricular assist device (LVAD) that is capable of providing support for extended periods (greater than 30 days) in patients awaiting heart transplantation. The LVAD, developed by Thermo Cardiosystems Inc. (Woburn, MA), has uniquely textured blood contacting surfaces and requires only minimal antithrombotic therapy. It has been used at the Texas Heart Institute as a bridge to transplantation in 11 patients, including 2 who are currently receiving support. Four patients required extended LVAD support (35-132 days); of those, three are doing well at 1.5, 8.5, and 13 months, respectively, after transplantation, and one died of liver failure 49 days after transplantation. The LVAD was operated in a fixed-rate mode to maintain pump flows at 4-8 L/min, resulting in stabilization of hemodynamic and secondary organ function in all patients. Blood chemistry and hematologic values returned to normal during LVAD support in three of four patients. Postoperative anticoagulation was gradually reduced over the course of the trials. The two most recent patients (35 and 132 days) received only oral dipyridamole (75 mg X 3/day) and aspirin (80 mg/day) after the early recovery period (four-six days), resulting in normal prothrombin and partial thromboplastin times. Plasma hemoglobin levels remained within acceptable limits, and there was no evidence of thromboembolism. Blood contacting surfaces were coated with a thin, adherent, biologically derived lining. The initial results indicate that the intracorporeal LVAD, with textured blood contacting surfaces, can effectively support the failing heart for extended periods (greater than 30 days) with minimal antithrombotic therapy.

Cyclosporine A pharmacokinetics in a cardiac allograft recipient with a jejuno-ileal bypass

A 41-year-old man with a 13-year history of JI bypass for morbid obesity developed idiopathic cardiomyopathy. A pretransplant CsA pharmacokinetic profile demonstrated inadequate PO absorption with no appreciable enterohepatic recirculation. Inadequate levels occurred after three hours and became undetectable after 18 hours. The patient's status did not permit JI bypass reversal before transplantation. IV CsA was administered before cardiac transplantation, and a continuous IV CsA infusion was maintained for 72 days through episodes of CMV reactivation infection and complications common to the immunosuppressed patient. JI bypass reversal was subsequently performed and IV CsA converted to oral form as intestinal function improved. A repeat PO CsA pharmacokinetic profile demonstrated a threefold rise in peak concentration, delayed smaller peak concentrations representing enterohepatic recirculation, and a steady-state blood level that persisted for 23 hours. We have found that pretransplant CsA pharmacokinetic analysis predicts CsA bioavailability and serves as a guide for achieving optimal CsA serum concentrations; adequate PO absorption and enterohepatic recirculation of CsA depends on the anatomical and functional integrity of the jejunum and ileum; continuous IV CsA infusion can be precisely adjusted for optimal therapeutic efficiency; and long-term CsA infusion can benefit critically ill transplant patients without increased morbidity.

Cardiac transplantation in patients over 60 years of age

Cardiac transplant programs have routinely excluded patients over 55 years of age from consideration as transplant candidates. The Texas Heart Institute modified this policy of using age as a contraindication to transplantation. Between July, 1982, and August, 1987, a total of 200 cardiac transplants were performed, 28 (14%) of which were in patients over 60 years of age, the eldest being 66 years old at the time of transplant. Our immunosuppressive regimen consisted primarily of cyclosporine and prednisone. In 1985, azathioprine was added in an effort to decrease dosages of cyclosporine, thereby decreasing its associated nephrotoxicity. The incidences of rejection and infection were 1.2 and 1.4 episodes/patient, respectively, for those over 60 years of age versus 1.7 and 1.3 episodes/patient, respectively, for those less than 60 years of age. Of the 28 patients, 23 are alive and well. Four deaths were caused by infection, and the other by diffuse coronary arteritis. The one-year actuarial survival for patients over 60 years of age was 83%, compared with 75% for the other transplant patients. We conclude that persons over 60 years of age can undergo cardiac transplantation with results equal to or perhaps better than those of other heart transplant patients. Our experience suggests that advanced age should not be considered a major contraindication to cardiac transplantation.

Complications in cardiac transplant patients requiring general surgery

With the advent of cyclosporine A, heart transplantation has become a widely accepted treatment for patients with end-stage cardiac disease that is not amenable to medical or surgical treatment. Between July 1982 and December 1985, 86 heart transplantations were performed at the Texas Heart Institute with cyclosporine A and prednisone used for immunosuppression. Thirty patients had complications requiring general surgical consultation. The pancreas and biliary tracts were most commonly affected. Pancreatitis developed in sixteen patients; five patients required operative intervention, resulting in a 40% mortality rate. Five of nine patients with cholecystitis required cholecystectomy. All patients survived the procedures. Other gastrointestinal complications included colonic ileus, bowel perforation, gastrointestinal bleeding, gastric outlet obstruction, and perirectal abscess. Patients who have undergone cardiac transplantation are susceptible to life-threatening infections and are at risk of serious complications requiring general surgical intervention. Better results can be obtained in these complex clinical situations when complications are identified early and managed aggressively through the adjustment of immunosuppression, adequate selection of antimicrobial agents, and proper timing of surgical intervention.

Cardiac transplantation in a Jehovah's witness

Between July 1982 and October 1987, surgeons at our institution performed 215 cardiac transplantation procedures, 1 of which was in a 46-year-old Jehovah's Witness with congestive cardiomyopathy, who required preoperative intra-aortic balloon pump support. At surgery, the cardiopulmonary bypass system was primed with 1600 ml of Ringer's lactate solution and dextrose. In the 57 minutes during which the patient was on cardiopulmonary bypass, the intra-aortic balloon was removed and successful orthotopic heart transplantation was performed. No supplemental blood or blood product was used, either during or after the procedure. The estimated intraoperative blood loss was 300 ml, and the postoperative chest tube drainage amounted to 1495 ml. Postoperative hematologic abnormalities (mild hypoprothrombinemia, mild thrombocytopenia, mild platelet dysfunction, and moderate hypochromic microcytic anemia) were corrected with Imferon, vitamin K, and desmopressin acetate administered intravenously, and with ferrous sulfate administered orally. This case, which to our knowledge is only the 2nd cardiac transplant in a Jehovah's Witness, further establishes that these patients can undergo even the most major of open-heart procedures without supplemental blood.

Orthotopic cardiac transplantation in patients with large donor/recipient atrial size mismatch: surgical technique

A successful surgical technique is described that overcomes the problem of severe size mismatch between the recipient's atrial remnants and the donor heart atria in patients undergoing orthotopic cardiac transplantation. The circumferences of the atria are reduced by plicating the atrial remnants until the appropriate sizes are obtained.

The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.

Early experience with a new PTFE graft below the inguinal ligament

Between July 1984 and July 1985, 65 expanded polytetrafluoroethylene grafts (Vitagraft) were implanted in the infrainguinal position in 51 patients, including 41 men and 10 women, with an average age of 63 years. The indications for surgery were severe claudication (36 grafts) or ischemic necrosis of the extremities (29 grafts). Thirteen of the patients (25%) had had a previously placed infrainguinal graft of another type that had failed, requiring reoperation. Proximal vascular reconstruction (consisting of ten aorto-femoral and two femoro-femoral bypasses) was performed in 12 patients who had 16 grafts. Simultaneous aortocoronary bypass surgery was done in conjunction with a femoral-popliteal bypass in six patients. The site of distal anastomosis was the suprageniculate popliteal artery in 21 grafts (32%), the infrageniculate popliteal artery in 33 grafts (51%), tibio-peroneal trunk in seven grafts (11%), and the posterior tibial artery in four grafts (6%). The mean follow-up was 9.6 months (range, 1 to 16 months). Two grafts (3.0%) failed early (< 30 days). Another three grafts (4.6%) occluded between 1 and 6 months postoperatively, and five occluded after 6 months. The cumulative patency rate at 15 months was 78.8%. Limb salvage was not possible in three patients, who underwent amputation because of multiple previous operations and a lack of distal run-off. There were no operative deaths, graft infections, aneurysms, or untoward reactions (including seromas) along the graft tracts. At this early follow-up date, we have not encountered the complications normally associated with other grafts; our early results indicate that continued clinical use is warranted.

Heterotopic heart-single lung transplantation: report of a new technique

A new surgical technique for patients with end-stage pulmonary and cardiopulmonary disease is described. This technique, a heterotopic heart-single lung transplant, limits dissection in the vascular collateralized mediastinum and preserves the carina and left lung. Moreover, it preserves the recipient's heart when the predominant problem is pulmonary. We used this technique in a 34-year-old woman with end-stage cardiopulmonary disease, resulting from pulmonary hypertension, who was referred to the Texas Heart Institute for evaluation as a candidate for a heart-lung transplantation. She had undergone ligation of a large hypertensive patent ductus arteriosus in early childhood. We believe our technique is a potentially viable alternative for selected heart-lung transplant patients.

Ephedrine psychosis rediscovered

The use of ephedrine for medicinal purposes dates back over 5000 years, when native Chinese physicians Ma Huang in the late 1800s, but was considered too toxic for clinical use; it was rediscovered by Chen & Schmidt (1930), who demonstrated its sympatho mimetic action and introduced it into Western medicine, where it was found to be a big improvement on adrenaline in the treatment of asthma. That the structure of ephedrine is very similar to that of amphetamine is not a coincidence, since Alles (1933) synthesised the latter as a synthetic substitute for ephedrine.

Reconstruction of coronary artery anomaly in an infant using the internal mammary artery: 10-year follow-up

We report a case of tetralogy of Fallot with an unsuspected anomalous left anterior descending coronary artery arising from the right coronary artery and crossing the right ventricular outflow tract in a 16-month-old infant. During operation, the anomalous artery was severed. Successful repair of the intracardiac anomalies was performed, including left anterior descending-internal mammary artery reconstruction of the anomalous artery. This case illustrates the importance of delineation of coronary artery anatomy and even selective coronary arteriography in patients with tetralogy of Fallot, since anomalous coronary arteries occur most frequently in association with other cardiac anomalies. Arteriography 10 years later revealed a patent anastomosis to the left anterior descending artery, proving the durability of the internal mammary artery in a patient we believe to be the youngest to have undergone bypass with this particular conduit.

Durability and low thrombogenicity of the St. Jude Medical valve at 5-year follow-up

Between November, 1978, and December, 1983, 736 patients had valve replacement with the St. Jude Medical valve prosthesis. There were 478 patients with aortic valve replacement (AVR), 188 with mitral valve replacement (MVR), 63 with double valve replacement, and 7 with tricuspid valve replacement (they were not included in this study). The mean age at the time of operation was 46.7 years for patients having AVR and 48.6 years for those having MVR and AVR + MVR. Follow-up totaled 1,116 patient-years (range, 4 to 82 months). Early (30-day) mortality was lowest for isolated MVR (2.3%) and AVR (3.7%), and increased with reoperation or when associated procedures were combined with valve replacement. Patients undergoing reoperation or having associated procedures made up 49% of the AVR and 54% of the MVR groups. All patients were advised of the need for long-term anticoagulation with warfarin sodium. Nine patients (7 with AVR, 1 with MVR, 1 with AVR + MVR) had suspected or confirmed episodes of systemic thromboembolism, a linearized incidence of 0.99% per patient-year for AVR, 0.36% per patient-year for MVR, and 0.98% per patient-year for AVR + MVR. Eight patients with AVR underwent reoperation for prosthetic valve endocarditis (5 of the 8 patients had endocarditis prior to initial valve replacement). There were no instances of structural valve failure. There were 37 late deaths. Actuarial survival at 5 years (excluding early mortality, 95% confidence limits) was 89.8% for AVR, 84.8% for MVR, and 95.2% for AVR + MVR.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetically retained implant denture

This technique offers the following advantages: The disks allow the castings to be placed with a minimum amount of torque or tension. The casting can be removed from the frame for cleaning at scheduled appointments. Removal of the casting permits evaluation of the fixation of each implant.

Early and late results of coronary endarterectomy. Analysis of 3,369 patients

The effectiveness of coronary revascularization has been questioned in patients with diffuse coronary disease. Over a 14 year period (1970 to 1984), 30,464 patients underwent surgical revascularization at our institution. Coronary artery bypass alone was done in 27,095 patients and was combined with coronary endarterectomy in 3,369 patients (12.4%). Analysis of preoperative variables revealed an increased incidence of male sex, diabetes mellitus, low ejection fraction (less than 30) and multiple vessel disease in patients requiring endarterectomy. The early results after revascularization indicated a small increase in surgical risk after endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4% for coronary endarterectomy (p less than 0.01). Multivariate analysis identified independent predictors of operative risk: ejection fraction less than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and female sex. Early mortality was significantly increased by endarterectomy in the left anterior descending coronary artery (8.5%) compared to endarterectomy in arteries other than the left anterior descending (4.2%) (p less than 0.01). In a sample of 4,473 patients, myocardial complications were also found to be increased after coronary endarterectomy. The incidence of perioperative myocardial infarction in patients undergoing bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01). This suggests the failure mode of unsuccessful endarterectomy. Early mortality after coronary endarterectomy decreased substantially from 1970-1976 (6.4%) to 1977-1984 (3.5%; p less than 0.01). Actuarial analysis at 5 years and longer has shown very little difference in the long-term survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%), and freedom from reoperation (coronary artery bypass, 97%; coronary endarterectomy, 98%). Despite the small increase in surgical risk, the early and late results support the selective application of coronary endarterectomy in patients with diffuse distal disease and demonstrate the beneficial long-term effects.

Addition of papaverine to cardioplegia does not reduce myocardial necrosis

In a randomized, double-blind prospective study involving 495 patients, we investigated whether the addition of papaverine, 60 mg, to our existing regimen of cold cardioplegia would reduce myocardial necrosis during elective coronary artery bypass operations. Twenty-one (4.2%) patients sustained acute postoperative myocardial infarctions (MI), and 7 (1.4%) died during hospitalization. Neither MI nor death was related to papaverine supplementation. Among 469 patients without postoperative MI, levels of the myocardial-specific isoenzyme of creatine phosphokinase measured 10 hours after aortic cross-clamping were related to ischemic cross-clamp time, but not to papaverine supplementation of cardioplegia. At declamping after completion of distal anastomoses, ventricular fibrillation was more common after cardioplegia without papaverine (32% versus 9%). No other differences between the two groups were found in intraoperative and postoperative hemodynamics, difficulty of weaning from bypass, or postoperative volume requirements. We identified three risk factors for postoperative MI: ECG evidence of new ischemia prior to bypass, unusual technical difficulty with distal anastomoses for the surgeon, and prolonged time of ischemia. We conclude that addition of papaverine to our cardioplegia regimen did not affect outcome or nonspecific myocardial necrosis.