Heart-lung transplantation in a patient with pulmonary atresia and ventricular septal defect

Operation for pulmonary atresia and ventricular septal defect is challenging, as in most patients the pulmonary arteries are hypoplastic, nonconfluent, or in part absent. In these cases, combined heart-lung transplantation may be the surgical treatment of choice. In the described case, the morphology of pulmonary atresia and ventricular septal defect was present in combination with completely atretic main, left, and right pulmonary arteries. In this patient, successful heart-lung transplantation was performed.

Heart transplantation after Senning operation for transposition of the great arteries

In a 17.5-year-old boy and a 21-month-old girl orthotopic heart transplantation was performed after intractable right-heart failure had developed 14.5 years and 15 months respectively after Senning operation for TGA. Before the atrial repair, combined with closure of the VSD in each case, initial operation had involved a banding of the pulmonary artery in the boy and a modified Blalock-Taussig shunt in the girl. A coarctation of the first patient remained untreated. After resection of the diseased organ a new intraatrial septum of glutaraldehyde-fixed bovine pericardium was created. 15 and 3 months respectively after orthotopic heart transplantation both patients belong to NYHA classification I.

The influence of gastrointestinal agents on resorption and metabolism of cyclosporine after heart transplantation: experimental and clinical results

The clinical effectiveness of cyclosporine is limited by changes in resorption and metabolism of cyclosporine and by possible drug interactions. This study examined the influence of five gastrointestinal agents on duration and resorption of cyclosporine and dosage/level relations: cimetidine, famotidine, pirenzepine, aluminum hydroxide, and omeprazole. These gastrointestinal agents were studied in 64 rat experiments, in which the impact of each single drug and of drug combinations on cyclosporine resorption and metabolism was tested. A standardized dosage of cyclosporine was given orally, and the duration was calculated for the maximum whole blood level of cyclosporine to be achieved; the dosage/level quotient was calculated. Cimetidine, famotidine, pirenzepine, and combination treatment prolonged duration of cyclosporine resorption. Furthermore, cimetidine, famotidine, and omeprazole lowered the dosage/level quotient, thus leading to higher cyclosporine levels with the same dosage; pirenzepine increased the dosage/level quotient. For clinical comparison, 163 heart transplant patients who had received standard triple-drug immunosuppressive therapy were analyzed. The time interval until a therapeutic cyclosporine level was achieved and the dosage/level quotient were once again calculated. Similar to the results in the animal experiments, cimetidine and famotidine significantly delayed the resorption of cyclosporine; cimetidine, famotidine, and omeprazole lowered the cyclosporine dosage/level quotient, thus leading to higher cyclosporine levels with the same dosage. Aluminum hydroxide did not lead to any changes in the resorption or metabolism of cyclosporine. Most examined gastrointestinal agents, and particularly H2-blocking drugs, led to significant prolongation of cyclosporine resorption and cyclosporine level alterations. The initial prolongation of cyclosporine resorption was successfully avoided by intravenous administration of cyclosporine for the first 4 postoperative days in 40 consecutive patients.

Registration of thoracic electrical bioimpedance for early diagnosis of rejection after heart transplantation

In this study, registration of thoracic electrical bioimpedance was used for early detection of acute rejection after heart transplantation. Thirty-five heart transplant recipients were monitored by registration of thoracic electrical bioimpedance signals during the immediate postoperative period and during the outpatient follow-up. At the same time, endomyocardial biopsy specimens were taken. In addition to cardiac stroke volume index and ejection fraction, the acceleration index (seconds -2) was calculated. This acceleration index describes the acceleration of blood volume and represents a function parameter of the myocardial inotropy. Seventeen acute rejection episodes were diagnosed during the follow-up period. The average acceleration index value during the 17 rejection episodes was 92.5 +/- 11.7 sec-2 and thus significantly lower when compared with the nonrejection levels (p < 0.05). The acceleration index values decreased during acute rejections by an average of 36.4 +/- 19.3 sec-2 (28%). The sensitivity of this diagnostic parameter in the examined patients was 71%, and the specificity was 100%. Thus registration of thoracic electrical bioimpedance and calculation of the acceleration index represents a quick and noninvasive monitoring technique and can ideally be used in the outpatient clinic as a supplement to invasive endomyocardial biopsies.

Extended cardiopulmonary preservation: University of Wisconsin solution versus Bretschneider's cardioplegic solution

Application of the University of Wisconsin cold storage solution has rapidly expanded to include medium-term to long-term preservation of virtually all intraabdominal organs. Its use in intrathoracic organ transplantation has also been suggested. We therefore examined the efficacy of the University of Wisconsin solution in a primate allotransplantation model for preservation of hearts, and as a simple single-solution system for static preservation of heart-lung blocks, for periods of ischemia ranging from 6 to 24 hours. For comparison, we employed the histidine-tryptophane-ketoglutarate cardioplegic solution of Bretschneider. University of Wisconsin solution provided superior results with regard to clinical outcome and hemodynamic recovery of hearts after ischemic periods of up to 16 hours. This was in contrast to Bretschneider's solution, which allowed storage of hearts for periods of only up to 10 hours. Heart-lung blocks were equally well preserved with either University of Wisconsin or Bretschneider's solution after 6 to 12 hours, although the University of Wisconsin solution group exhibited a more notable increase in pulmonary water content. This was in accordance with histological data, which suggested that, although hemodynamic recovery of hearts stored for periods longer than 10 hours was poor, preservation of pulmonary ultrastructure was far superior using Bretschneider's solution as compared with University of Wisconsin solution after an ischemic period of up to 16 hours.

Myocardial preservation using HTK solution for heart transplantation. A multicenter study

Bretschneider HTK solution is commonly used for myocardial preservation. In order to evaluate its protective effect for heart transplantation, a retrospective study was initiated in cooperation with Eurotransplant and five heart transplant centers. Seventy-six female and 524 male patients who underwent cardiac transplantations between 1981 and 1991 were included in this study. Using standardized questionnaires, donor and recipient laboratory data, immunosuppressive therapy and the preoperative, intraoperative and postoperative organ function were documented. The average ischemic time of the donor hearts was 160 min, ranging from 75 min-304 min. Immediate postoperative graft failure was observed in 25 transplantations (4.2%). Within the first 30 days 71 organs (11.8%) failed. Using the chi2-test, a statistically significant increase of acute graft failure and early mortality was evident when they were correlated with the length of ischemic time (P = 0.01). In addition, a higher incidence of early graft failure was observed when the perfusion volume was less than 1500 ml. The 1- and 5-year survival rates were 72% and 63%, respectively. Organ preservation with HTK shows good results as long as the ischemic time does not exceed 4 h. The possibility that an increased perfusion volume allows longer ischemic times cannot be excluded with this study.

[Incidence, prevention and therapy of cytomegalovirus and pneumocystis carinii infection after heart transplantation]

Diseases caused by cytomegalovirus (CMV) and pneumonia due to pneumocytis carinii (PCP) are problematic complications after allogeneic heart transplantation. Recipients of CMV-seropositive donors have a higher morbidity of CMV. By using an anti-CMV-immunoglobulin preparation in routine prophylaxis the incidence of CMV disease after heart transplantation could be reduced significantly. Ganciclovir 10 mg/kg is administered for treatment of CMV disease for at least 14 days. Recent investigations show that a prophylactic administration of ganciclovir after heart transplantation is safe, and it reduces the incidence of CMV-induced illness in CMV-seropositive patients. The incidence of PCP after heart transplantation varies according to the literature between 1 and 13%. The onset of the disease is located mostly between the third and the fifth month after heart transplantation. An effective prophylaxis can be achieved by low dose cotrimoxazole (960 mg at two days per week in adults) within the first six postoperative months. Cases of PCP are treated by cotrimoxazole or pentamidine and are associated with a mortality up to 60%.

Histopathology of hyperacute rejection of the heart: experimental and clinical observations in allografts and xenografts

The histologic findings in a total of 112 experimental heart transplants comprising allografts (baboon to baboon: n = 37), concordant xenografts (vervet monkey to baboon: n = 52), and discordant xenografts (pig to baboon: n = 23), in which the roles of ABO blood group incompatibility, corcordance, and immunosuppression were evaluated, are described. Hyperacute (vascular, humoral) rejection was characterized by disruption of the microcirculation, with interstitial hemorrhage and edema, rather than by intravascular thrombosis; the features were basically similar whether hyperacute rejection occurred in an ABO-incompatible allograft, concordant xenograft, or discordant xenograft. Hyperacute rejection was noted in all 23 discordant xenografts, in 12 to 52 concordant xenografts, and in four of 17 ABO-incompatible allografts. A unique mixture of acute and hyperacute rejection was observed in three ABO-incompatible allografts and in 10 concordant xenografts. Intensive antirejection therapy was associated with a reduced incidence of hyperacute rejection in corcordant xenografts but also with a significant number of fatal treatment-related complications.

Adenosine cardioplegia: reducing reperfusion injury of the ischaemic myocardium?

Hyperkalaemia-induced hypopolarization of the sarcolemnal membrane during standard crystalloid cardioplegic arrest potentiates calcium influx during reperfusion and is associated with depletion of high-energy phosphate reserves. Adenosine has been shown to induce fast cardiac arrest whilst preserving membrane hyperpolarization in an isolated rat heart model. In this study we compared the efficacy of adenosine, both as an arresting agent and as an ultrastructural, haemodynamic and high-energy phosphate preserving agent, in an in situ global ischemia model in the baboon with St. Thomas' Hospital solution No. 2 (ST2; n = 8) and with Krebs-Henseleit buffer (KHB; n = 7). The addition of 10 mM adenosine to the non-cardioplegic KHB (ADO; n = 8) improved haemodynamic recovery significantly in terms of cardiac index (91.6% +/- 7.2 vs 59.9% +/- 9.9) and stroke volume index (101.6% +/- 8.9 vs 55.6 +/- 10.0) and was not statistically distinguishable from the ST2 with regard to cardiac index (91.6% +/- 7.2 vs 94.8% +/- 5.8), stroke volume index (101.6% +/- 8.9 vs 114.0% +/- 8.3) or left ventricular dP/dt (73.1% +/- 9.9 vs 87.0% +/- 12.4). Adenosine triphosphate was best preserved with ADO (103.5% +/- 21.1 vs 67.9% +/- 9.3 and 48.5% +/- 8.7) although this was not statistically significant. This suggests therefore that the mechanism of cardioprotection by adenosine occurs by means other than its role as high-energy phosphate precursor.

Heterotopic heart transplantation: mid-term hemodynamic and echocardiographic analysis--the concern of arteriovenous-valve incompetence

To assess the hemodynamic contribution of both hearts after heterotopic heart transplantation, we examined recipients by cardiac catheterization and Doppler echocardiography. Since September 1984, immunosuppression consisted of cyclosporine, azathioprine, methylprednisolone, and antithymocyte globulin. In this time interval, 55 orthotopic and 14 heterotopic transplants have been performed. The indications for heterotopic transplant were elevated pulmonary vascular resistance (greater than 4 Wood units), in 10 patients, or gross (greater than 20%) donor-recipient weight mismatch, in six patients. Two patients belonged to both groups. The 1-year survival rate was 63%; currently seven of the 14 patients are alive. Cardiac output (as measured by dye dilution curves and by the Fick method) increased from 4.2 L/min preoperatively to 6.1 L/min in both groups postoperatively (mean follow up, 5.3 months; p less than 0.0005); the transpulmonary gradient fell from 18.5 to 12.3 mm Hg, the pulmonary vascular resistance from 4.4 to 2.4 Wood units (p less than 0.01). The echocardiographic findings were as follows: left ventricular end-diastolic diameter (mm) in the recipient heart was 67.4 +/- 12 and in the donor heart, 42.6 +/- 8.7. Fractional shortening (%) in the recipient heart was 7.1 +/- 2.9 and in the donor heart, 30.4 +/- 10.4. The Doppler technique revealed a cardiac output contribution-ratio (CO donor/CO recipient) of 3.0 +/- 0.61 on average. In all recipient hearts mild and moderate mitral and tricuspid regurgitation was discovered. In the donor heart all mitral and tricuspid valves were found to be incompetent; this was severe in 66% and 11% of the mitral and tricuspid valves, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart-lung transplantation in 1990--indications, surgical technique, postoperative complications and outcome

Using cyclosporine A (CyA), long-term results after heart-lung transplantation became possible. Since 1981, 761 clinical heart lung transplantations have been registered at the International Society for Heart Transplantation. Candidates for this operation reveal signs of irreversible heart and lung diseases which are caused by cardiac lesions (e.g. valvular disease, Eisenmenger reaction due to congenital malformation) or pulmonary disorders (e.g. primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure necessitates three anastomoses which combine donor and recipient tracheae, right atria and aortae. Immunosuppression consists of CyA (blood levels of 300-500 ng/ml), azathioprine (1-2 mg/kg/d) and rabbit antithymocyte globuline (RATG) (IgG: 2-4 mg/kg/d). After the first 2 postoperative weeks, RATG is replaced by low dose methylprednisolone (0.3-0.1 mg/kg/d). As an alternative, RATG may be omitted completely. Postoperatively, a variety of complications may evolve. Early problems (within the first month) comprise acute pulmonary rejection, bacterial pneumoniae, and multiorgan failure. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances and cytoimmunological monitoring of the peripheral blood. Transbronchial lung biopsies are for precise diagnosis of similar value to endomyocardial biopsies after heart transplantation. Late postoperative complications comprise viral, bacterial, fungal, and protozoal infections and chronic obliterative bronchiolitis. With increasing experience, the 30 day mortality fell to below 20% according to the International Society for Heart Transplantation. The one-year survival rate between 1986 und 1988 was reported to be 61%. The results of some individual groups are even better.

15-Deoxyspergualin for induction of graft nonreactivity after cardiac and renal allotransplantation in primates

In order to assess the immunosuppressive potentials of 15-deoxyspergualin (15-DS) in a preclinical experiment, heterotopic cardiac (n = 27, group I) and classic renal (n = 25, group II) allotransplantations were performed in Chacma baboons. The following immunosuppressive regimens were applied: Groups IB and IIB were treated with 15-DS alone (4 mg/kg/day) for p.o. days 0-9. Groups IC and IIC were treated with cyclosporine A (10-40 mg/kg/day) for p.o. days 0-30. Groups ID and IID received a combination of 15-DS (for p.o. days 0-9) and CsA (for p.o. days 0-30). Groups IA and IIA served as control and received no medication. The mean graft survival was 11.0 days for group IA, 28.2 days for group IB (P less than 0.05; IB vs. IA), 32.4 days for group IC, and 43.1 days for group ID (P less than 0.025; ID vs. IA). After renal transplantation, the corresponding figures were 12.3 days for group IIA, 8.5 days for group IIB, 30.4 days for group IIC and 148.9 days for group IID (P less than 0.025; IID vs. IIA). After cardiac and renal transplantation, acute rejection was the main cause of graft failure. Treatment-related side effects, mainly gastrointestinal complications, were observed only in primates, who were treated with 15-DS alone. After cardiac transplantation, permanent graft non-reactivity was not achieved, but a delayed rejection occurred within a mean of 21.8 days after immunosuppression had been stopped. Following renal transplantation, graft nonreactivity was also not achieved in groups IIB and IIC. In group IID, however, 4 of 8 animals (50%) were graft-tolerant 340, 256, 244, and 164 days after treatment discontinuation. Thus, the combination of 15-DS and CsA led to a significant prolongation of graft survival in both groups. Long-term nonreactivity was achieved only after renal transplantation, when initially treated with 15-DS and CsA.

Heterotopic heart transplantation in 1988--recent selective indications and outcome

Considering a worldwide average 1-year survival rate of nearly 90% after orthotopic heart transplantation, the question arises as to whether there is still an indication for heterotopic heart transplantation. Since 1967, 132 heart transplantations have been performed at our institution. From 1974 to 1983 only heterotopic transplantations were performed. Since 1985, quadruple-drug therapy has been used for immunosuppression. This consists of low dose cyclosporine in combination with azathioprine, methylprednisolone (in lower dosages), and rabbit antithymocyte globulin (for the first 4 to 6 days after operation and as rescue therapy for severe rejections). Fifty-five transplantations have been performed with this therapy (44 orthotopic and 11 heterotopic). The indications for heterotopic transplantations were either elevated pulmonary vascular resistance (4 to 6 Wood units, n = 6), or a gross donor and recipient weight mismatch (more than 20%) in candidates who showed signs of severe cardiac decompensation (n = 6). One patient had both indications. The 1-year survival rate for those patients was 83%. Currently seven of the 11 patients are alive with life spans ranging from 6 months to 2.5 years after operation. Causes of deaths were infections (n = 3) and chronic graft rejection (n = 1). The recipients were restudied with right-sided heart catheterizations performed from 2 months to 2 years after transplantation. In all patients the cardiac output increased significantly from a mean of 4.0 to 5.8 L/min (p less than 0.0005). In patients with elevated pulmonary vascular resistance, this value decreased after heterotopic transplantation from a mean of 4.9 to 2.4 Wood units.(ABSTRACT TRUNCATED AT 250 WORDS)