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Suciu-Foca N, Liu Z, Colovai AI, Tugulea S, Reed EF, Mancini D, Cohen DJ, Benvenisty AI, Benstein JA, Hardy MA, Schulman LL, Rose EA. Role of indirect allorecognition in chronic rejection of human allografts. Transplant Proc 1996; 28:404-5. [PMID: 8644291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Chen JM, Weinberg AD, Rose EA, Thompson SM, Mancini DM, Ellison JP, Reemtsma K, Michler RE. Multivariate analysis of factors affecting waiting time to heart transplantation. Ann Thorac Surg 1996; 61:570-5. [PMID: 8572769 DOI: 10.1016/0003-4975(95)01031-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The growing clinical success of cardiac transplantation has resulted in a dramatic increase in the number of patients referred and subsequently listed for cardiac transplantation. Paradoxically, in the presence of a limited donor organ pool, such expansion has increased both the waiting time for transplantation and the number of patients dying while on the waiting list. METHODS We performed univariate and multivariate analyses of the waiting times of 301 patients listed for transplantation using a Cox proportional hazards model to evaluate the simultaneous effect of multiple variables on the waiting time of heart transplant candidates. Variables considered included age, sex, race, blood type, weight at listing, United Network for Organ Sharing (UNOS) status at listing, UNOS status at transplantation, and proportion of time on the waiting list as UNOS status 1. RESULTS The mean waiting time for patients ultimately having transplantation was 170.2 +/- 206.0 days; the median waiting time was 103.5 days. Age, sex, weight, blood type, and percent of time as UNOS status 1 all had a significant impact on waiting time in the univariate analysis. By multivariate analysis, proportion of time as UNOS status 1, lower weight at listing, and blood type AB were all highly associated as predictors of a shorter waiting time. Weight at listing represented a continuous variable whose risk ratio for a shorter waiting time correlated in such a way that the risk of a longer waiting time increased 2.3 per 22.5-kg (50-pound) increase in weight. Blood types A and B, although associated with a shorter waiting time, correlated less strongly than the other three variables. CONCLUSIONS Our findings from this multivariate analysis demonstrate that UNOS status, blood type, and weight were the variables that most strongly affected overall waiting time for transplantation. It is our hope to define more accurately a group of patients with both a high likelihood of a long waiting time and a prohibitive risk of death while on the waiting list, who therefore may benefit from surgical alternatives to transplantation.
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Schulman LL, Ho EK, Reed EF, McGregor C, Smith CR, Rose EA, Suciu-Foca NM. Immunologic monitoring in lung allograft recipients. Transplantation 1996; 61:252-7. [PMID: 8600633 DOI: 10.1097/00007890-199601270-00016] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To identify patients with increased risk of chronic lung allograft rejection, we assessed the utility of an in vitro biopsy-derived lymphocyte growth assay and serum anti-HLA antibody screening as a complement to currently available methods of monitoring lung allograft recipients. Lymphocyte growth assay was performed on bronchoscopic fragments of tissue cultured in medium with rIL-2. Seventy-nine biopsies from 31 lung transplant recipients were tested by lymphocyte growth assay, and results were correlated with histopathology findings. Positive lymphocyte growth was found in 12/26 (46%) episodes of acute rejection, 5/44 biopsies without rejection (11%), and 0/9 episodes of bronchitis. Positive lymphocyte growth was seen in 7/16 (44%) grade A1 rejections and in 5/10 (50%) grade A2 rejections, as opposed to only 5/44 (11%) grade A0 (no rejection) biopsies (P < 0.01 for both A1 and A2 with respect to A0). Actuarial probability of remaining free from obliterative bronchiolitis (OB)* tended to be higher in patients who did not exhibit lymphocyte growth in biopsies. Sequential samples of sera obtained at the time of the biopsy were screened for lymphocytotoxic anti-HLA antibodies. Twenty-two of 44 recipients (50%) developed anti-HLA antibodies during the first postoperative year, exhibiting greater than 10% reactivity to an HLA reference panel of lymphocytes in four or more consecutive serum samples. Actuarial survival of lung allograft recipients with anti-HLA antibodies (n = 22) was lower than in those without anti-HLA antibodies (n = 22; P = 0.03). Of the 22 antibody producers, 7/12 died as a consequence of OB. Of the 22 non-antibody-producers, 1/2 deaths occurred as a consequence of OB. Anti-HLA antibodies were present in 9/11 instances of OB (82% sensitivity) and in 13/33 patients without OB (61% specificity; P = 0.03). These data indicate that lung transplant recipients with positive lymphocyte growth and anti-HLA antibodies are at an increased risk of chronic allograft rejection.
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Kaplon RJ, Oz MC, Kwiatkowski PA, Levin HR, Shah AS, Jarvik RK, Rose EA. Miniature axial flow pump for ventricular assistance in children and small adults. J Thorac Cardiovasc Surg 1996; 111:13-8. [PMID: 8551757 DOI: 10.1016/s0022-5223(96)70396-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We investigated the efficacy of the Jarvik 2000 intraventricular assist device (Jarvik Research, Inc., New York, N.Y.) in an ovine model. The device is an axial flow pump measuring 1.8 cm in diameter by 5 cm long, has a displacement volume of 12 ml, and can deliver flow from 2 to 7 L/min. Seven devices were implanted through a left thoracotomy into the left ventricle with an outflow graft to the descending aorta. Animals were treated with warfarin sodium and aspirin to maintain prothrombin times approximately 1.5 times control. Animals were followed up for 3 to 123 days. Two animals died of operative complications at days 3 and 5. One device failed at 58 days because of thrombus formation at the inflow side of the impeller. The remaining four animals were killed at days 19, 42, 42, and 123, respectively, because of broken electric power cables. Hematocrit values rose significantly higher than preoperative levels (22.8% +/- 3.8% to 30.5% +/- 3.4%); premortem elevations of values higher than baseline values of plasma free hemoglobin (10.4 +/- 7.8 mg/dl to 17.1 +/- 7.4 mg/dl) and lactate dehydrogenase (391.5 +/- 113.7 units/L to 771.2 +/- 370.8 units/L) were statistically insignificant. Serum creatinine and bilirubin levels were normal. No end-organ dysfunction arising from long-term support was evident clinically or at postmortem examination, nor was there any evidence of embolism or damage to intracardiac structures. We found the Jarvik 2000 intraventricular assist device to be easily implantable, safe, nonhemolytic, and able to provide physiologic flow with power requirements under 10 watts.
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Michler RE, Chen JM, Itescu S, Mancini DM, Oz MC, Smith CR, Rose EA. Two decades of cardiac transplantation at the Columbia-Presbyterian Medical Center: 1977-1997. CLINICAL TRANSPLANTS 1996:153-165. [PMID: 9286565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Since its inception in 1977, the Cardiac Transplantation Service at Columbia-Presbyterian Medical Center has performed more than 900 heart transplant procedures, with a one-year survival rate of approximately 80%, and a 5-year survival rate of approximately 60%. Throughout our 20-year experience, the criteria for eligibility both donors and recipients has widened to include older and "reanimated" donors for selected recipients, as well as an extensive experience with recipients bridged to transplantation with mechanical assist devices. Of particular interest in recent years has been the need for additional therapy for the highly sensitized transplant candidate and ultimate transplant recipient, whose immunosuppressive regimen must be continuously monitored and modified to ensure graft survival. In light of the persistent donor organ crisis, continued efforts are being developed to more accurately characterize the transplant candidate waiting list in order to identify those patients who may be better served by either medical management or an alternative surgical procedure to transplantation, including high-risk coronary revascularization and mechanical or biological assistance. Current research interests at CPMC include left ventricular assist devices, xenotransplantation, and management of both transplant coronary artery disease and immunologic sensitization. Ongoing investigations in these and other areas of transplantation have been established to encourage continued growth both within the field and at CPMC through the 21st century.
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Rose EA, Goldstein DJ. Wearable long-term mechanical support for patients with end-stage heart disease: a tenable goal. Ann Thorac Surg 1996; 61:399-402; discussion 407. [PMID: 8561614 DOI: 10.1016/0003-4975(95)01003-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Increasing in frequency, and claiming more than 250,000 lives per year, heart failure represents a major public health problem. In spite of newer medical therapies, a significant proportion of patients progress to irreversible end-stage heart disease, for which cardiac transplantation remains the only long term hope. The inability to meet the demand for donor organs has led to the development of left ventricular assist devices as a temporizing measure while awaiting a transplantation. The "bridging to transplantation" experience has firmly established the efficacy of these devices as short-term and medium-term mechanical assistance and has provided valuable lessons applicable to long-term support. Mechanical cardiac assistance technology has dramatically improved and can provide reliable univentricular support with minimal thromboembolic and infectious complications. Although major obstacles remain, the potential benefits are great enough and the morbidity and mortality of end-stage heart disease high enough to warrant the evaluation of wearable left ventricular assist devices for long-term mechanical assistance.
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Chen JM, Levin HR, Rose EA, Addonizio LJ, Landry DW, Sistino JJ, Michler RE, Oz MC. Experience with right ventricular assist devices for perioperative right-sided circulatory failure. Ann Thorac Surg 1996; 61:305-10; discussion 311-3. [PMID: 8561595 DOI: 10.1016/0003-4975(95)01010-6] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Right-sided circulatory failure remains a significant source of morbidity and mortality for both cardiac transplant and left ventricular assist device recipients. METHODS We reviewed our experience with 11 patients who required a right ventricular assist device (RVAD) after either orthotopic heart transplantation or left ventricular assist device implantation. Variables analyzed included total time of RVAD support, hemodynamic and hematologic parameters, and parameters of end-organ perfusion. These were assessed at five time points: (1) at least 2 weeks before RVAD implantation, (2) intraoperatively just before RVAD insertion, (3) while on RVAD support, and, for those who survived, (4) just before RVAD explantation, and (5) off RVAD support. Survival was assessed as the ability to be weaned successfully from RVAD support. Urine output and serum transaminase levels were recorded throughout the period of RVAD support. RESULTS Five patients received an ABIOMED 5000 BVS RVAD, and 6 received a Bio-Medicus centrifugal pump. Nine patients in the study underwent orthotopic heart transplantation and had development of right-sided circulatory failure from 0 to 96 hours after donor organ insertion, and 2 patients underwent left ventricular assist device implantation 12 to 48 hours before RVAD support. The mean time of RVAD support for survivors was 133.6 +/- 33.6 hours (range, 107 to 190 hours). Six patients were successfully separated from RVAD support, and 5 patients died while on RVAD support. Causes of death included sepsis (2), biventricular failure (2), and coagulopathy (1). Continuous arteriovenous hemodialysis was employed in 3 of 6 survivors and 1 of 5 nonsurvivors. CONCLUSIONS Right ventricular assist devices work most effectively if implanted early enough to avoid significant, potentially irreversible end-organ injury. We liberally employ continuous arteriovenous hemodialysis, minimize the use of heparin immediately postoperatively, keep patients sedated, and continue RVAD support until the patient displays signs of hemodynamic and end-organ recovery as heralded by (1) a decrease in central venous pressure and, more importantly, a decrease in pulmonary artery diastolic pressure, (2) an increase in urine output, and (3) a decrease in serum transaminase levels.
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Heyer EJ, Delphin E, Adams DC, Rose EA, Smith CR, Todd CJ, Ginsburg M, Haggerty R, McMahon DJ. Cerebral dysfunction after cardiac operations in elderly patients. Ann Thorac Surg 1995; 60:1716-22. [PMID: 8787469 DOI: 10.1016/0003-4975(95)00719-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cerebral injury remains a significant complication of cardiac operations. We determined the incidence of cerebral dysfunction in a population of elderly patients undergoing open chamber cardiac operations (group 1) as compared with a younger population (group 2) and an age-matched group of elderly patients undergoing major noncardiac operations (group 3). METHODS Sixty-eight patients (55 for open chamber cardiac operations and 13 for noncardiac operations) were prospectively studied. Patients were evaluated preoperatively and postoperatively before hospital discharge using a complete neurologic examination and a battery of standard neuropsychometric tests, and at surgical follow-up with neuropsychometric tests only. RESULTS Postoperative changes detected by neurologic examination consisted of the appearance of new primitive reflexes in all groups. No statistically significant differences in incidence were found. The neuropsychometric performance of group 1 patients was statistically different from that of patients in groups 2 and 3 only in the early follow-up period. CONCLUSIONS Elderly patients having open chamber cardiac operations exhibit significantly more cerebral dysfunction in the early postoperative period than those undergoing major noncardiac operations and younger patients after open chamber procedures. These changes do not persist into the late follow-up period.
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Goldstein DJ, DeRosa CM, Mongero LB, Weinberg AD, Michler RE, Rose EA, Oz MC, Smith CR. Safety and efficacy of aprotinin under conditions of deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 1995; 110:1615-21; discussion 1621-2. [PMID: 8523871 DOI: 10.1016/s0022-5223(95)70021-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Aprotinin has been successfully used to reduce blood loss and blood product requirements in patients undergoing primary and reoperative cardiac operations. Its safety and efficacy during profound hypothermia and circulatory arrest have been questioned, however. A retrospective review compared 24 patients who received aprotinin during complex aortic procedures under profound hypothermia and circulatory arrest with 24 age-matched patients undergoing similar procedures without aprotinin. Activated clotting time was maintained at longer than 500 seconds (kaolin activating agent) or longer than 750 seconds (celite). We observed no statistically significant difference in the incidence of neurologic events (p not significant) or myocardial infarctions (p not significant), and there was a trend toward reduced in-hospital mortality rate in aprotinin-treated patients. A higher incidence of postoperative renal dysfunction was encountered in aprotinin-treated patients. Aprotinin recipients had a significant reduction in requirements for postoperative homologous erythrocytes (p = 0.01). We conclude that aprotinin may be safely and effectively used in patients undergoing deep hypothermia and circulatory arrest.
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Goldstein DJ, Williams DL, Oz MC, Weinberg AD, Rose EA, Michler RE. De novo solid malignancies after cardiac transplantation. Ann Thorac Surg 1995; 60:1783-9. [PMID: 8787481 DOI: 10.1016/0003-4975(95)00782-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND As long-term survival after cardiac transplantation improves, neoplastic complications are increasingly being discovered. Although lymphoproliferative disorders predominate, the incidence and clinical spectrum of solid tumors in a uniform population of heart transplant recipients remains uncertain. METHODS We reviewed our experience with 712 patients who underwent cardiac transplantation. Clinical charts were reviewed and telephone interviews were conducted, when possible. RESULTS De novo solid malignancies were identified in 3.3% of patients at risk (21 of 633 patients). Twenty patients were male; mean age was 51.5 +/- 8.6 years. Most patients reported a significant smoking history. Pulmonary, urologic, and Kaposi's sarcoma were the most common malignancies identified. Mean interval from transplantation to diagnosis was 35 months. Six patients were diagnosed within 6 months of transplantation. One-year and 5-year survival after transplantation were 90% and 49%, respectively. One-year and 3-year survival after cancer diagnosis were 60% and 52%, respectively. CONCLUSIONS De novo solid malignancy after transplantation occurred with about half the frequency of lymphoproliferative disorders. A striking male predominance was noted. The interval from transplantation to the appearance of cancer is variable, and no clustering was identified. A significant smoking history warrants aggressive search for occult malignancy during pretransplantation evaluation of potential heart recipients.
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Rafii S, Oz MC, Seldomridge JA, Ferris B, Asch AS, Nachman RL, Shapiro F, Rose EA, Levin HR. Characterization of hematopoietic cells arising on the textured surface of left ventricular assist devices. Ann Thorac Surg 1995; 60:1627-32. [PMID: 8787455 DOI: 10.1016/0003-4975(95)00807-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Textured biomaterial surfaces in implantable left ventricular assist devices induce development of a nonthrombotic neointimal surface and allow elimination of anticoagulation therapy in device recipients. Characterization of the hematopoietic cells formed within the neointimal surfaces of these devices will contribute to our understanding of this unique neointima. METHODS The blood-contacting surface of seven ThermoCardiosystems left ventricular assist devices was removed, washed with phosphate-buffered saline solution, and digested with 0.1% collagenase for 15 to 20 minutes. The hematopoietic cells released from the explants were isolated and analyzed by flow cytometry and immuno-histochemical staining. RESULTS More than 80% +/- 6% of hematopoietic cells isolated in this fashion are of myelomonocytic origin and express CD14, CD15, and CD33 surface molecules. Four percent of cells express the CD34 surface marker, which suggests that the neointima is colonized by pluripotent hematopoietic stem cells. Continuous culture of these hematopoietic cells in the presence of the cytokines interleukin-3, c-kit ligand, granulocyte colony-stimulating factor resulted in tenfold expansion by day 7 and 25-fold expansion by day 14. CONCLUSIONS Pluripotent hematopoietic cells with a high proliferative capacity colonize textured surfaces of left ventricular assist devices and may contribute to the development of a biologically nonthrombogenic neointima.
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Fisher PE, Suciu-Foca N, Ho E, Michler RE, Rose EA, Mancini D. Additive value of immunologic monitoring to histologic grading of heart allograft biopsy specimens: implications for therapy. J Heart Lung Transplant 1995; 14:1156-61. [PMID: 8719463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Currently the sole method available for diagnosis of heart allograft rejection is endomyocardial biopsy. Although this procedure offers important criteria for treatment, it cannot always discriminate between mild episodes of rejection which might be self-limiting and forms which may progress. In an effort to monitor rejection, we have implemented a cellular monitoring strategy aimed at identifying episodes of rejection in biopsy specimens which may evolve into higher grades of rejection. The lymphocyte growth assay is based on the capacity of interleukin-2 receptor-positive T cells to expand in the presence of interleukin-2 and antigen provided by the biopsy fragment. In this study we investigated whether a positive lymphocyte growth assay correlated with and was predictive of subsequent histologic allograft rejection and the development of anti-human leukocyte antigen antibodies. METHODS Lymphocyte growth assay was performed on 437 biopsy specimens from 76 patients. Patients with mild allograft rejection defined as grade 2 rejection were randomized to treatment according to the results of the lymphocyte growth assay. Anti-human leukocyte antigen antibodies was also measured monthly. Cells grown from the biopsy specimens were tested against the donor cells and allopeptides derived from the donor human leukocyte antigen-DR. RESULTS A highly significant correlation was observed between the histologic grade of rejection and growth of graft infiltrating cells (p < 0.0001). Lymphocyte growth occurred in 10% of grade 0 versus 60% of grade 3A biopsy specimens. Only 4% of histologically negative cases with negative lymphocyte growth assay progressed to rejection in the next month. In the randomized study in which treatment was based on the lymphocyte growth assay results, progressive rejection occurred in three of four cases with positive lymphocyte growth assay versus only 1 of 11 with a negative lymphocyte growth assay (p < 0.001). A highly significant correlation was found between a positive lymphocyte growth assay and subsequent development of antihuman leukocyte antigen antibodies (p < 0.0006). This finding indicates that cellular rejection evidenced by lymphocyte growth assay ultimately results in humoral antihuman leukocyte antigen antibody mediated rejection. Limiting dilution analysis showed that although the direct recognition pathway prevails in early rejection, cells participating in the indirect pathway also proliferate vigorously in the graft during rejection. CONCLUSIONS Monitoring of rejection with lymphocyte growth assay is a simple method which provides prognostic information on the outcome of cardiac allografts. Lymphocyte growth assay correlates with histologic rejection and is predictive of future histologic rejection episodes. Lymphocyte growth assay also predicts subsequent development of antihuman leukocyte antigen antibodies and thus may provide a useful method for ascertaining the onset of chronic rejection.
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Slater JP, Amirhamzeh MM, Yano OJ, Shah AS, Starr JP, Kaplon RJ, Burfeind W, Pepino P, Michler RE, Rose EA. Discriminating between preservation and reperfusion injury in human cardiac allografts using heart weight and left ventricular mass. Circulation 1995; 92:II223-7. [PMID: 7586413 DOI: 10.1161/01.cir.92.9.223] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Myocardial edema caused by injury during preservation or reperfusion can affect cardiac function after heart transplantation. This study was designed to distinguish these forms of injury in human allografts. METHODS AND RESULTS In 15 donor hearts preserved in University of Wisconsin solution, heart weight (HW) was obtained immediately after explantation and after transport before implantation. Left ventricular mass (LVM) was calculated separately in 18 patients with the use of epicardial two-dimensional echocardiograms obtained both before explantation from the donor and after transplantation and weaning from cardiopulmonary bypass. While changes in LVM could be due to preservation or reperfusion injury, changes in HW can only be due to edema occurring during transport. HW averaged 339 +/- 24 g (mean +/- SE) before and 340 +/- 24 g after transport (P = NS); however, LVM increased 14 g, from 164 +/- 8 to 178 +/- 11 g (P < .05, paired t test). LVM increased in 10 of 18 patients (56%). No correlation was demonstrated between duration of ischemia (mean, 172 +/- 13 minutes) and changes in HW or LVM. Two patients died as a result of primary graft failure. In the first, HW increased 54 g, 2 SD above the mean. In the second, LVM increased 66 g, 2 SD above the mean, but HW changed minimally. CONCLUSIONS While current preservation methods result in minimal change in HW during transport, reperfusion injury frequently increases LVM. LVM determination by two-dimensional echocardiography may prove valuable in detecting allograft injury.
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Oz MC, Liao H, Naka Y, Seldomridge A, Becker DN, Michler RE, Smith CR, Rose EA, Stern DM, Pinsky DJ. Ischemia-induced interleukin-8 release after human heart transplantation. A potential role for endothelial cells. Circulation 1995; 92:II428-32. [PMID: 7586450 DOI: 10.1161/01.cir.92.9.428] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Interleukin-8 (IL-8) secreted from endothelial cells is a powerful neutrophil chemoattractant and activator. We hypothesized that human endothelial cells deprived of oxygen would secrete IL-8, which might translate into elevated IL-8 production after cardiac ischemia. Furthermore, we hypothesized that coronary sinus (CS) IL-8 levels would be particularly high after cardiac preservation for transplantation, due to extended ischemic times. METHODS AND RESULTS Human saphenous vein endothelial cells exposed to a hypoxic environment (PO2 < 20 mm Hg) demonstrated a time-dependent release of IL-8 (measured by ELISA) into the culture supernatant as early as 4 hours after exposure. To determine whether cardiac preservation in humans was associated with IL-8 production, we obtained CS blood samples 5 minutes after reperfusion in a consecutive series of patients after they underwent cardiac transplantation (CTX, n = 20) or elective cardiac surgery (non-CTX, n = 21). CTX patients demonstrated significantly higher CS IL-8 levels than non-CTX patients (325 +/- 123 versus 50 +/- 17 ng/mL, respectively, P < .05). Further analysis of the CS samples revealed that a biochemical marker of myocyte injury (myoglobin) was similarly elevated in the CTX patients compared with the non-CTX patients (3340 +/- 625 versus 1151 +/- 525 ng/mL, respectively, P < .05). CONCLUSIONS These differences may reflect the longer ischemic times of CTX compared with non-CTX hearts (161 +/- 10 versus 80 +/- 6 minutes, P < .0001) and suggest that the neutrophil chemoattractant/activator IL-8 may contribute to myocyte injury after prolonged hypothermic cardiac ischemia, as occurs during human cardiac transplantation.
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Oz MC, Goldstein DJ, Pepino P, Weinberg AD, Thompson SM, Catanese KA, Vargo RL, McCarthy PM, Rose EA, Levin HR. Screening scale predicts patients successfully receiving long-term implantable left ventricular assist devices. Circulation 1995; 92:II169-73. [PMID: 7586403 DOI: 10.1161/01.cir.92.9.169] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although use of long-term implantable left ventricular assist devices (LVAD) is becoming more popular, further reduction of the mortality rate accompanying device insertion through improved patient selection would make this alternative even more appealing. We sought to develop a scoring system that was based on criteria obtainable at the time of evaluation and predictive of successful early outcome and simple to apply. METHODS AND RESULTS Patients (n = 56) undergoing LVAD insertion between 1990 and 1994 were screened for easily obtainable preoperative risk factors. To test the association between survival and each risk factor, a chi 2 analysis was performed, and relative risks were estimated. Oliguria, ventilator dependence, elevated central venous pressure, elevated prothrombin time, and reoperation stats had low probability values and high estimated relative risks. On the basis of these relations, a risk factor-selection scale (RFSS) (range, 0 to 10) was developed by computing appropriate weights for each risk factor. The distribution of patients for each scale score reveal that with RFSS > or = 5, most device recipients will die (P < .001). The average RFSS (+/- SD) of survivors (n = 42) was 2.45 +/- 1.73 compared with 5.43 +/- 2.85 in nonsurvivors (n = 14) (P < .0001). Univariate logistical regression was also significant (score statistic, 16.2; df = 1; P = .001). CONCLUSIONS The RFSS is simple, easy to apply, and statistically valid. Physicians could use the scale as a starting point in discussing the suitability for LVAD implantation in a specific patient and as a basis for comparing patient outcomes.
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Ascherman JA, Hugo NE, Sultan MR, Patsis MC, Smith CR, Rose EA. Single-stage treatment of sternal wound complications in heart transplant recipients in whom pectoralis major myocutaneous advancement flaps were used. J Thorac Cardiovasc Surg 1995; 110:1030-6. [PMID: 7475131 DOI: 10.1016/s0022-5223(05)80171-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Treatment of sternal wound complications is controversial, particularly in immunosuppressed heart transplant recipients. Regardless of the severity of infection, we combine immediate, aggressive débridement with bilateral pectoralis major myocutaneous advancement flaps in a single procedure. Compared with management with pectoralis major turnover flaps or distant pedicled muscle flaps, treatment of these sternal wounds with pectoralis major myocutaneous advancement flaps is simpler and quicker and provides better aesthetic results. Furthermore, because pectoralis major myocutaneous flaps are based on the thoracoacromial arteries, whether or not the internal mammary arteries have previously been harvested for coronary grafts is irrelevant. Twenty consecutive heart transplant recipients with sternal wound complications were treated with this technique. No intraoperative or perioperative deaths occurred. The morbidity rate was 30%, with seroma treated by needle aspiration in four patients (20%) being the most common complication. Only one patient had a postoperative wound infection. All patients had excellent functional and aesthetic results.
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Hsu DT, Quaegebeur JM, Michler RE, Smith CR, Rose EA, Kichuk MR, Gersony WM, Douglas JF, Addonizio LJ. Heart transplantation in children with congenital heart disease. J Am Coll Cardiol 1995; 26:743-9. [PMID: 7642869 DOI: 10.1016/0735-1097(95)00253-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The aim of this study was to describe heart transplantation in children with congenital heart disease and to compare the results with those in children undergoing transplantation for other cardiac diseases. BACKGROUND Reports describe decreased survival after heart transplantation in children with congenital heart disease compared with those with cardiomyopathy. However, transplantation is increasingly being considered in the surgical management of children with complex congenital heart disease. Present-day results from this group require reassessment. METHODS The diagnoses, previous operations and indications for transplantation were characterized in children with congenital heart disease. Pretransplant course, graft ischemia time, post-transplant survival and outcome (rejection frequency, infection rate, length of hospital stay) were compared with those in children undergoing transplantation for other reasons (n = 47). RESULTS Thirty-seven children (mean [+/- SD] age 9 +/- 6 years) with congenital heart disease underwent transplantation; 86% had undergone one or more previous operations. Repair of extracardiac defects at transplantation was necessary in 23 patients. Causes of death after transplantation were donor failure in two patients, surgical bleeding in two, pulmonary hemorrhage in one, infection in four, rejection in three and graft atherosclerosis in one. No difference in 1- and 5-year survival rates (70% vs. 77% and 64% vs. 65%, respectively), rejection frequency or length of hospital stay was seen between children with and without congenital heart disease. Cardiopulmonary bypass and donor ischemia time were significantly longer in patients with congenital heart disease. Serious infections were more common in children with than without congenital heart disease (13 of 37 vs. 6 of 47, respectively, p = 0.01). CONCLUSIONS Despite the more complex cardiac surgery required at implantation and longer donor ischemic time, heart transplantation can be performed in children with complex congenital heart disease with success similar to that in patients with other cardiac diseases.
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Frazier OH, Rose EA, McCarthy P, Burton NA, Tector A, Levin H, Kayne HL, Poirier VL, Dasse KA. Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system. Ann Surg 1995; 222:327-36; discussion 336-8. [PMID: 7677462 PMCID: PMC1234813 DOI: 10.1097/00000658-199509000-00010] [Citation(s) in RCA: 265] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This nonrandomized study using concurrent controls was performed to determine whether the HeartMate implantable pneumatic (IP) left ventricular assist system (LVAS) could provide sufficient hemodynamic support to allow rehabilitation of severely debilitated transplant candidates and to evaluate whether such support reduced mortality before and after transplantation. METHODS Outcomes of 75 LVAS patients were compared with outcomes of 33 control patients (not treated with an LVAS) at 17 centers in the United States. All patients were transplant candidates who met the following hemodynamic criteria: pulmonary capillary wedge pressure > or = 20 mm Hg with a systolic blood pressure < or = 80 mm Hg or a cardiac index < or = 2.0 L/minute/m2. In addition, none of the patients met predetermined exclusion criteria. RESULTS More LVAS patients than control patients survived to transplantation: 53 (71%) versus 12 (36%) (p = 0.001); and more LVAS patients were alive at 1 year: 48 (91%) versus 8 (67%) (p = 0.0001). The time to transplantation was longer in the group supported with the LVAS (average, 76 days; range, < 1-344 days) than in the control group (average, 12 days; range, 1-72 days). In the LVAS group, the average pump index (2.77 L/minute/m2) throughout support was 50% greater than the corresponding cardiac index (1.86 L/minute/m2) at implantation (p = 0.0001). In addition, 58% of LVAS patients with renal dysfunction survived, compared with 16% of the control patients (p < 0.001). CONCLUSIONS The LVAS provided adequate hemodynamic support and was effective in rehabilitating patients based on improved renal, hepatic, and physical capacity assessments over time. In the LVAS group, pretransplant mortality decreased by 55%, and the probability of surviving 1 year after transplant was significantly greater than in the control group (90% vs. 67%, p = 0.03). Thus, the HeartMate IP LVAS proved safe and effective as a bridge to transplant and decreased the risk of death for patients waiting for transplantation.
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Goldstein DJ, Mullis SL, Delphin ES, el-Amir N, Ashton RC, Gardocki M, Jordan DA, Catanese KA, Levin HR, Rose EA. Noncardiac surgery in long-term implantable left ventricular assist-device recipients. Ann Surg 1995; 222:203-7. [PMID: 7639586 PMCID: PMC1234779 DOI: 10.1097/00000658-199508000-00013] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The authors describe their experience with left ventricular assist-device (LVAD) recipients undergoing noncardiac surgery and delineate surgical, anesthetic, and logistic factors important in the successful intraoperative management of these patients. SUMMARY BACKGROUND DATA Left ventricular assist-devices have become part of the armamentarium in the treatment of end-stage heart failure. As the numbers of patients chronically supported with long-term implantable devices grows, general surgical problems that are commonly seen in other hospitalized patients are becoming manifest. Of particular interest is the intraoperative management of patients undergoing elective noncardiac surgical procedures. METHODS The anesthesia records and clinical charts were reviewed for eight ventricular assist-device recipients undergoing general surgical procedures between August 1, 1990 and August 31, 1994. RESULTS A total of 12 procedures were performed in 6 men and 2 women averaging 52.7 years of age. Mean time elapsed from device implantation to operation was 68 +/- 35 days. Conventional inhalational and intravenous anesthetic techniques were well tolerated in these patients undergoing diverse surgical procedures. No perioperative mortality was observed. Five of eight patients went on to successful cardiac transplantation. CONCLUSIONS Hemodynamic recovery after LVAD insertion has defined a new group of patients who develop noncardiac surgical problems often seen in other critically ill patients. Recognition of the unique potential problems that the LVAD recipient may encounter in the perioperative period--in particular patient positioning, device limitations, and fluid and inotropic management--will ensure an optimal surgical outcome for LVAD recipients undergoing noncardiac surgery.
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Downey RJ, Oz MC, Pepino P, Rose EA. Prosthetic abdominal fascial closure after ventricular assist device insertion. J Heart Lung Transplant 1995; 14:788-9. [PMID: 7578191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The requirement for adequate abdominal domain does not allow placement of left ventricular assist devices into patients with body surface areas less than 1.5 m2. We describe a technique for prosthetic abdominal wall closure that may allow placement of devices into smaller recipients, primarily children and women.
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Oz MC, Levin HR, Rose EA. Long term, implantable ventricular assist devices: what are they and who needs them? COMPREHENSIVE THERAPY 1995; 21:351-4. [PMID: 7554811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Oz MC, Goldstein DJ, Rose EA. Preperitoneal placement of ventricular assist devices: an illustrated stepwise approach. J Card Surg 1995; 10:288-94. [PMID: 7549184 DOI: 10.1111/j.1540-8191.1995.tb00613.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Improvement in left ventricular assist device (LVAD) implantation techniques may favorably impact on the significant perioperative morbidity and mortality that follows placement of these devices. Based on the difficulties faced and complications encountered during our 45 case experience, we developed a quick-reference illustrated guide which outlines in detail the steps and considerations critical for successful LVAD implantation.
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Levin HR, Oz MC, Chen JM, Packer M, Rose EA, Burkhoff D. Reversal of chronic ventricular dilation in patients with end-stage cardiomyopathy by prolonged mechanical unloading. Circulation 1995; 91:2717-20. [PMID: 7758175 DOI: 10.1161/01.cir.91.11.2717] [Citation(s) in RCA: 259] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Ventricular dilation, indexed by marked shifts toward larger volumes of the end-diastolic pressure-volume relation (EDPVR), has been considered to represent an irreversible aspect of ventricular remodeling in end-stage heart failure. However, we hypothesized that such dilation could be reversed with sufficient hemodynamic unloading, such as can be provided by a left ventricular assist device (LVAD). METHODS AND RESULTS The EDPVRs of hearts from seven patients with end-stage idiopathic cardiomyopathy and comparable baseline hemodynamics were measured ex vivo at the time of cardiac transplantation; these were compared with EDPVRs from three normal human hearts that were technically unsuitable for transplantation. Four of the patients received optimal medical therapy; three of the patients, who deteriorated on optimal therapy, underwent LVAD support for approximately 4 months. Compared with the normal hearts, EDPVRs of hearts from medically treated patients were shifted toward markedly larger volumes. In contrast, EDPVRs of hearts from LVAD patients were similar to those of normal hearts. CONCLUSIONS Chronic hemodynamic unloading of sufficient magnitude and duration can result in reversal of chamber enlargement and normalization of cardiac structure as indexed by the EDPVR, both important aspects of remodeling, even in the most advanced stages of heart failure.
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Rose EA, Ratner AJ. Cardiac allograft vasculopathy. Transplant Proc 1995; 27:1930. [PMID: 7792840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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