Intention to undergo prophylactic bilateral mastectomy in women at increased risk of developing hereditary breast cancer

PURPOSE

To assess intention to undergo prophylactic bilateral mastectomy and psychologic determinants in unaffected women at increased risk of developing hereditary breast cancer.

PATIENTS AND METHODS

Three hundred thirty-three women who were awaiting their initial appointments for risk assessment, advice about surveillance, and prophylactic options at one of 14 familial cancer clinics participated in a cross-sectional, questionnaire-based survey.

RESULTS

Nineteen percent of women would consider and 47% would not consider a prophylactic mastectomy, should genetic testing identify a mutation in a breast cancer-predisposing gene, whereas 34% were unsure and 1% had already undergone a prophylactic mastectomy. In a bivariate analysis, women at a moderately increased risk of developing breast cancer had the highest proportion of subjects reporting that they would consider a prophylactic mastectomy (25%), compared with women at high risk (16%) (chi(2) = 7.79; P =.051). In multivariate analyses, consideration of prophylactic mastectomy strongly correlated with high levels of breast cancer anxiety (odds ratio [OR] = 17.4; 95% confidence interval [CI], 4.35 to 69.71; P =. 0001) and overestimation of one's breast cancer risk (OR = 3.01; 95% CI, 1.43 to 6.32; P =.0036), whereas there was no association with objective breast cancer risk (P =.60).

CONCLUSION

A significant proportion of women at increased risk of developing hereditary breast cancer would consider prophylactic mastectomy. Although prophylactic mastectomy may be appropriate in women at high risk of developing breast cancer, it is perhaps less so in those who have a moderately increased risk. Such moderate-risk women are likely to benefit from interventions aimed at reducing breast cancer anxiety and correcting exaggerated breast cancer risk perceptions.

Psychological impact of genetic testing for adult-onset disorders. An update for clinicians

Testing for gene mutations that confer susceptibility to adult-onset disorders has potential benefits, but these must be balanced against the psychological harms, if any. We review published findings on the psychological effects of such testing, focusing on Huntington's disease, which has the most available data, and the hereditary cancer syndromes. Most of the evidence suggests that non-carriers and carriers differ significantly in terms of short-term, but not long-term, psychological adjustment to test results. The psychological impact of genetic testing depends more on pretest psychological distress than the test result itself.

IG-therasorb immunoapheresis in orthotopic xenotransplantation of baboons with landrace pig hearts

BACKGROUND

The major problem of xenotransplantation is, that hyperacute xenograft rejection (HXR) causes graft failure within minutes or a few hours because of natural antibodies and activation of the complement system. As a preclinical model we transplanted pig hearts orthotopically into baboons. To prevent HXR after orthotopic xenotransplantation (oXHTx), the immunoglobulins (Ig) and natural antibodies were adsorbed to reusable Ig-Therasorb immunoadsorption (IA) columns.

METHODS

We performed three oXHTx of landrace pig hearts into baboons (19+/-6.8 kg), using extracorporeal circulation (ECC) connected to the IA unit. After separating the recipient's blood into plasma and cellular fraction by a plasma filter, plasma flow was directed to the Ig-Therasorb column coated with polyclonal sheep-antibodies against human IgG, IgM, and IgA. Intraoperative treatment consisted of 4 cycles of IA. For a control, we transplanted one pig heart into a baboon (16.9 kg) without applying IA. Perioperatively, serum concentrations of Ig, anti-pig-antibodies, complement and cardiac enzymes were determined. Tissue samples of myocardium were collected at the end of the study for immunohistochemical examinations, light microscopic examination (LM) and electron microscopic examination (EM). For cardiac monitoring after oXHTx, we used ECG, echocardiography, and invasive measurement of cardiac output. To prevent a mismatch of donor and recipient heart size, the donor pig had a 30-40% lower body weight than the recipient baboon.

RESULTS

Four cycles of IA removed >80% of IgG, IgM, and IgA from plasma. The graft of the control animal failed after 29 min. The first oXHTx with IA was intentionally terminated after 100 min, the second oXHTx after 11 hr and the third oXHTx after 21 hr. All xenografts showed no histological signs of HXR. After weaning off ECC, these donor hearts worked in sinus rhythm without electrocardiographic ST-segment elevation. An excellent cardiac output was measured by echocardiography and thermodilution (2 L/min). Serological parameters indicating cardiac damage were significantly lower after IA if compared with the control experiment. Macroscopically, the xenograft of the control animal showed massive hemorrhage in comparison with the almost inconspicuous grafts after IA. The myocardium of the IA group demonstrated fewer deposits of Ig and complement components compared with the control animal.

CONCLUSION

Baboons do not hyperacutely reject a porcine xenograft after antibody depletion by the Ig-Therasorb column. In our experiment only 4 cycles of immunoapheresis effectively prevented HXR after oXHTx of baboons. The Ig-Therasorb column is a reusable device, which can be handled easily in combination with the ECC. IA must be tested in oXHTx longterm survival experiments, especially in combination with transgenic pig organs, which could be a reliable preclinical approach for future clinical xenotransplantation.

Cyclosporine versus tacrolimus (FK 506) for prevention of cardiac allograft vasculopathy

This study prospectively compared the impact of cyclosporine A and tacrolimus on the development of cardiac allograft vasculopathy. By using serial intravascular ultrasound examinations, a trend toward a more pronounced progression was noted in the tacrolimus group in the first year after heart transplantation.

Breast cancer screening uptake in women at increased risk of developing hereditary breast cancer

This multicenter study assessed breast cancer screening uptake in 461 unaffected women at increased risk of developing breast cancer on the basis of family history who approached familial cancer clinics for advice about surveillance options. At the time of attending the clinic, 89% and 90% of participants were vigilant with respect to age- and risk-specific recommendations for mammography and clinical breast examination, respectively, and 51% reported practicing breast self-examination monthly or more frequently. The degree to which health outcomes are perceived to be under one's personal control (chi2 = -2.09, p = 0.0037) and breast cancer anxiety (chi2 = 8.11, p = 0.044) were both associated with monthly or more frequent breast self-examination, while there were no associations with sociodemographic characteristics. A significantly lower percentage (56%) of women aged <30 were vigilant with respect to mammography recommendations, compared to 77%, 96% and 98% of women aged 30-39, 40-49 and >50, respectively (chi2 = 37.2, p < 0.0001). These relatively low rates of mammographic screening in young women may reflect concerns about increased cancer risk associated with early and repeated radiation exposure or lack of sensitivity in young women with radiographically dense breasts. If mammographic screening is ultimately shown to lower mortality in women at high risk, there will be a strong case to promote screening in young women. The need for regular mammographic screening would then need to be highlighted and reinforced amongst young women and their referring physicians. Awareness amongst general practitioners, who are largely responsible for referral to screening services, would also need to be increased.

Effects of prolonged cold storage time in xenotransplantation

BACKGROUND

Ischemia and reperfusion injury after prolonged ischemic time (IT) has a marked influence on hyperacute xenograft rejection (HXR). The aim of the study was to investigate the impact of different cold ischemic times on the HXR of ex vivo "working pig hearts" perfused with human blood. Xenoreactive natural antibodies (XNAb) as the trigger of HXR were reduced by immunoadsorption (IA) using an Ig-Therasorb column.

METHODS

Hearts of 24 Landrace pigs (13-31 kg) were harvested after cardioplegia with Celsior-solution and split into 4 groups. In Group C1 (n = 6) the short ischemic time (IT) lasted 48.9+/-10 minutes on the average prior to start of xenoperfusion, in Group I1 IT lasted 4 hours instead. Groups C2 and 12 experienced the same IT as C1 and I1, respectively, but underwent 2 cycles of IA in addition. IA removed immunoglobulins IgG, IgM and IgA from the perfusate. In the working heart mode hemodynamic parameters were measured in defined intervals. Blood samples were collected at the same time to determine myocardial enzymes, immunoglobulins, complement and anti-pig-antibodies. At the end of the study (cardiac arrest) tissue was sampled for histologic examination (light/electron microscopy (LM/EM) and immunohistochemistry).

RESULTS

Survival time of the control Group C1 was 125 minutes. IA resulted in an extension of perfusion time to 6.5 hours in C2. Four hours of IT (I1) prolonged the working time of hearts when compared with C1. IA had no additional impact (I2). Heart weight increased significantly in C1 without IA. Cardiac output and coronary flow in C1 were significantly lower when compared with the other 3 groups. IA improved cardiac output (CO) in C2 (vs C1, p < 0.001). Histologic signs of HXR (LM/EM) could be found in C1 in contrast to the other groups. Serologic parameters for myocardial damage were higher in groups with prolonged IT than in groups with short IT.

CONCLUSION

Prolonged ischemia and reperfusion injury showed controversial effects in this specific xenogeneic heart transplant model. In contrast to observations in allogeneic transplantation 4 hours of IT showed a beneficial behaviour of the xenografts. Reasons could be either a protective effect of the Celsior solution or changes of the endothelial cell surface (in terms of glycosylation or loss of alpha1-3Gal-epitopes). Tolerance of prolonged IT would allow transportation of xenografts over long distances.

Early experience with robotic technology for coronary artery surgery

BACKGROUND

To achieve an endoscopic coronary bypass anastomoses we performed a study with endoscopic robotic instrumentation and camera guidance using three-dimensional (3-D) visualization.

METHODS

The surgical robotic system ZEUS (Computer Motion Inc, Goleta, CA) consists of three interactive robotic arms and a control unit allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion Inc, Goleta, CA) positions the endoscope via voice control. The study had three phases. Phase I: In a phantom model, end-to-side anastomoses between vein grafts and the left anterior descending coronary artery (LAD) of 109 pig hearts were performed. Phase II: In 6 dogs (FBI, 20-25 kg) the left internal mammary artery (LIMA) was harvested endoscopically. During Port-Access (Heartport Inc, Redwood City, CA) cardiopulmonary bypass (CPB), LIMA and LAD were then anastomosed endoscopically with the help of telemetric ZEUS instruments (Computer Motion Inc). Phase III: A total of seven patients were operated on with help of the ZEUS system (Computer Motion Inc). After endoscopic LIMA harvesting and CPB using the Port-Access (Heartport Inc) system, the bypass graft (LIMA to LAD) was anastomosed endoscopically through three thoracic ports in 2 patients. Another 3 patients were operated on off-pump with regional stabilization and 2 patients with sternotomy and routine CPB.

RESULTS

The practice with the phantom model and the subsequent animal experiments allowed the surgeons to gain sufficient experience for the clinical setting. In the clinical cases, times for anastomoses ranged from 20 to 42 minutes. Median internal mammary artery flow rate was 74 mL per minute (range 36-110 mL per minute). One patient in the off-pump group was converted to CPB and routine anastomosis. All patients had an uneventful angiographic control and postoperative course.

CONCLUSIONS

Using telemetic technology, a completely endoscopic anastomosis of LIMA to LAD is possible on the arrested heart, as well as on the beating heart.

Attitudes toward prophylactic oophorectomy and screening utilization in women at increased risk of developing hereditary breast/ovarian cancer

OBJECTIVES

The aim of this study was to evaluate ovarian cancer screening uptake and attitudes toward prophylactic oophorectomy in women at risk of developing hereditary breast/ovarian cancer.

STUDY METHODS

Ninety-five unaffected women, who approached 1 of 14 familial cancer clinics for advice about their breast/ovarian cancer risk and surveillance and prophylactic options, were assessed in a cross-sectional design when they attended the clinic.

RESULTS

Among high-risk women ages 30 and over who had not had a prophylactic oophorectomy, 48% reported ever having had an ovarian ultrasound, and among women ages 50 and over 23% had had a serum CA 125 test. Twenty-three percent of women would consider, and 27% would not consider, a prophylactic oophorectomy should the genetic test indicate a germline mutation associated with hereditary breast/ovarian cancer, while 38% were unsure. Twelve percent had already undergone a prophylactic oophorectomy. Interest in prophylactic oophorectomy was associated with increased breast/ovarian cancer anxiety (chi(2) = 5.14, P = 0.023), but not objective cancer risk (chi(2) = 0.40, P = 0.53).

CONCLUSION

Findings demonstrate that breast/ovarian cancer anxiety, rather than objective risk, is the major factor which determines women's attitude to prophylactic oophorectomy. Women are likely to benefit from interventions aimed at reducing breast/ovarian cancer anxiety. Research on the impact of prophylactic oophorectomy would be helpful in the development of educational strategies and decision aids to assist women who are trying to make a decision under conditions of uncertainty.

Detection of humoral rejection in human cardiac allografts by assessing the capillary deposition of complement fragment C4d in endomyocardial biopsies

BACKGROUND

There are no well-established diagnostic criteria to detect humoral rejection in organ transplantation. The value of commonly used markers in immunohistochemistry, such as C1q, C3c, IgG, IgM and fibrinogen, is questioned by some groups. Complement fragment C4d is a more stable marker of complement activation as it is covalently bound to graft capillaries. C4d has been shown to identify clinically relevant, but otherwise undetectable humoral anti-graft reactions in human kidney transplants.

METHODS

Immunohistochemical techniques were used to evaluate 155 endomyocardial biopsies from 56 heart transplant recipients less than 3 months post transplantation for the presence of capillary C4d staining. In a subset of patients, C4d staining was compared with C1q, C3c, IgM and fibrin staining and was correlated with clinical outcome.

RESULTS

Within 3 months 9 of 56 patients died. Five of these nonsurvivors had prominent C4d staining (p < .05), whereas C1q, C3c and IgM showed no correlation with clinical outcome. Presence of fibrin correlated with clinical outcome and C4d staining (p < .05).

CONCLUSIONS

The capillary deposition of complement split product C4d in human endomyocardial biopsies was significantly associated with graft loss. Determination of fibrin deposition may yield additional information to establish a diagnosis of humoral rejection. The immunohistochemical assessment of capillary deposition of C4d and fibrin appears to be an appropriate tool for the identification of patients, who may require additional or alternative immunosuppressive therapy targeted against the humoral immune system.

Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting

OBJECTIVE

With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance.

METHODS

The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control.

PHASE I

In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization.

PHASE II

In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis.

PHASE III

Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports.

RESULTS

In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course.

CONCLUSIONS

With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.

The influence of antibody and complement removal with a Ig-Therasorb column in a xenogeneic working heart model

OBJECTIVE

Organ transplantation is limited by the number of brain-dead human donors. Xenotransplantation could be an alternative to guarantee a constant supply of organs. A major problem of xenotransplantation are xenogeneic natural antibodies (XNAb) directed against species-specific antigens of a discordant donor species (e.g. pig). They trigger the hyperacute xenograft rejection (HXR). Re-usable immunoapheresis (LA)-columns Ig-Therasorb (Therasorb, Baxter) were used to adsorb these XNAb. The effect of immunoapheresis of the perfusing human blood was investigated in ex vivo working pig hearts.

METHODS

Hearts of 12 landrace pigs (body weight 14-31 kg) were explanted after inducing cardiac arrest with 4 degrees C Celsior solution. Human blood (500 ml, heparinized) was obtained from healthy volunteers. In group 1 (G1, n = 6), blood as perfusate remained untreated. In group 2 (G2, n = 6), native blood was separated by plasmapheresis into cellular components and plasma. The latter passed through the Ig-Therasorb column for removal of immunoglobulins (so-called immunoadsorption or immunoapheresis). After back-table preparation the hearts were mounted to the working heart model. After 20 min of reperfusion in Langendorff mode, the working heart mode was established. Blood samples were taken isochronously for measurement of: CK(-MB), LDH, ASAT, troponin, immunoglobulins, complement activity, anti-pig antibodies and others. After cessation of the heart, atrial and ventricular tissue samples were taken for histological examinations (light/electron microscopy and immunohistochemistry).

RESULTS

Two cycles of immunoapheresis reduced the levels of IgG by 84%, IgM by 83.3% and IgA by 76%. In G2, the antibody immunoadsorption of blood prolonged the duration of the working heart mode significantly to 335+/-37.5 min. In contrast, hearts of group 1 (control) failed after 125+/-31.3 min. Heart rate was significantly different between both groups (G1, 77.3+/-6.1 beats/min; G2, 86.5+/-5.5 beats/min). In G2 cardiac output was 118% and mean coronary flow was 154.6% higher than in G1. CK, LDH and ASAT showed no differences in the two groups. Heart weight increased significantly more in group 1 than in G2. Histological examination indicated specific signs of HXR in G1 after 1.5 h, whereas in G2 only slight unspecific damages were found after 6 h.

CONCLUSION

Antibody removal by means of immunoapheresis results in a significantly improved xenogeneic cardiac function. Immunoapheresis may, therefore, become an important adjunct in future pig-to-man clinical xenotransplantation.

Attitudes and information needs of Chinese migrant cancer patients and their relatives

BACKGROUND

The information needs of ethnic minorities often differ from that of the dominant culture, leading to dissatisfaction among both patients and health professionals.

AIMS

This research project aims to identify attitudes towards cancer and associated information and communication needs of Chinese patients and their relatives in Sydney, thereby providing a framework for the provision of culturally appropriate cancer care for Chinese-Australians.

METHODS

A qualitative data collection strategy was selected as the most appropriate method, because no validated measures are available and no previous research has examined attitudes and needs of Chinese-Australian cancer patients. Patients were recruited from three major teaching hospitals in Sydney and from a Chinese cancer support organisation. Sampling was discontinued when informational redundancy was achieved. Four focus groups and 26 individual telephone interviews were conducted with a total of 36 cancer patients and 12 relatives born in China, Singapore and Malaysia.

RESULTS

While individual differences were observed, a majority view was expressed on a range of issues. Non-disclosure of a poor prognosis was favoured, and the role of the family in liaising between health professionals and the patient was emphasised. Patients preferred a confident and clear diagnosis and treatment recommendation. Most patients wished to incorporate Chinese culture-specific treatments into their care. The need for interpreters and psychological and spiritual support was emphasised.

CONCLUSIONS

Providing information in a culturally sensitive manner will assist doctors in providing optimum care and support for ethnic minority groups in this country.

[Pharmacological testing of the reversibility of increased pulmonary vascular resistance before heart transplantation with prostaglandin I2 (prostacyclin)]

An increased pulmonary vascular resistance (PVR) or an increased transpulmonary gradient (TPG) is a risk factor for increased 3-day and 3-month mortality after heart transplantation (HTx). The reversibility of increased PVR or TPG under pharmacologic testing is supposed to indicate a decreased probability of right ventricular failure/death after transplantation. We tested the response of an increased PVR (> 2.5 Wood units, WU) and/or of an increased TPG (> 15 mm Hg) in 29 right heart catheterizations (thermodilution catheter) of 23 patients (54 +/- 8 years, mean NYHA-class 3.1 +/- 0.6, ischemic n = 8, dilated cardiomyopathy n = 15). Increasing doses of prostaglandin I2 (PGI2, mean maximum dose 13.5 +/- 6.4 ng/kg/min) were applied stepwise over at least 10 min at the maximum dose level. We analyzed any dependence of the reversibility of PVR and TPG under prostaglandin I2 on hemodynamic values, echocardiographic parameters, demographic data, and laboratory findings. A decrease of PVR to a range usually accepted as no contraindication for HTx (< or = 4 WU) was found in each patient without symptomatic systemic hypotension during application of PGI2 (baseline value: 4.7 +/- 1.3 WU, during PGI2: 2.3 +/- 0.6 WU). An unresponsive, fixed increased PVR or TPG was not observed using PGI2. In 62% of investigations, both PVR and TPG decreased below 2.5 WU and 15 mmHg, respectively. The extent of reversibility of PVR and TPG was individually different and did not depend on the mean pulmonary artery pressure, mean capillary wedge pressure, cardiac output, mean systemic artery pressure or echocardiographic parameters (EDD, FS, ES-distance), sodium, urea or bilirubin levels, medication, age of the patients or the duration of the disease. The baseline PVR correlated inversely with its percentile value during PGI2 (r = -0.76, p < 0.05). In advanced heart failure, PGI2 decreases PVR in ranges of lower risk concerning orthotopic HTx, without causing an intolerable systemic hypotension. The individual extent of reversibility of PVR and TPG under PGI2 is not influenced by basic hemodynamic parameters or the patient's demographic profile.

Procalcitonin: a new marker for diagnosis of acute rejection and bacterial infection in patients after heart and lung transplantation

The aim of the study was to investigate the reliability of procalcitonin (PCT), a new potential marker for detection of bacterial, fungal and protozoal infections, in order to differentiate these from viral infections and early rejections in heart, heart-lung and lung transplanted patients. PCT is a propeptide of calcitonin with unknown origin which is not detectable in plasma of healthy subjects. It increases rapidly and significantly under severe microbial infections.

METHODS

PCT plasma levels were measured using an immuno-luminescence assay. C-reactive protein and white blood cells were quantified to validate the PCT values.

RESULTS

Increased levels of PCT were found in all transplant patients with bacterial, fungal and protozoal infections. The magnitude of the values were clearly associated with the severity of the infection. Trauma of operation or inflammatory events such as viral infections and rejections did not trigger PCT-production. The release of PCT did not depend on the type of pathogens even though Aspergillum resulted in the highest levels measured. Sensitivity, specificity and prognostic value of PCT for systemic infections were higher than of the other parameters investigated.

CONCLUSION

PCT is a highly specific analyte which shows significant diagnostic validities when nonviral infections are compared with rejection episodes. PCT discriminates between inflammatory events such as rejection or viral infections and nonviral-infections including bacterial, fungal and protozoal infections. The half-life of PCT is 24 h indicating clearly a competent antibiotic treatment. Unnecessary antibiotic therapy can be avoided due to the early exclusion of bacterial and fungal infections.

Minimally invasive coronary artery bypass grafting: port-access approach versus off-pump techniques

BACKGROUND

Within the past 5 years several surgical techniques have been developed for less invasive surgical treatment of coronary artery disease. The aim of this study was to define specific indications for the various minimally invasive coronary artery surgical procedures.

METHODS

Minimally invasive direct coronary artery bypass grafting through a minithoracotomy was performed in 67 patients. The left internal mammary artery was anastomosed on the beating heart with the use of a pressure or suction stabilizer without the use of extracorporeal circulation. In 58 other patients with multivessel disease, the off-pump coronary artery bypass grafting technique through a sternotomy was applied with a left internal mammary artery to left anterior descending artery and additional vein grafts without extracorporeal circulation. In a third group, Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting was performed through a left minithoracotomy with the use of an endovascular extracorporeal circulation system and cardioplegic arrest. Angiographic follow-up was complete in 64% of the patients.

RESULTS

There was minimal perioperative or postoperative mortality (0.5%). The medium surgical procedure time for all minimally invasive and off-pump procedures was 2.5 hours; it was 4.5 hours for Port-Access procedures. The median postoperative intensive care unit stay was 1.0 days, and the median hospitalization was 5.0 days. Overall graft patency was 97.3%; in 8 patients (4.1%) a stenosis either at or distal to the graft anastomosis was dilated with coronary angioplasty.

CONCLUSIONS

For single-vessel disease of the left anterior descending artery, the minimally invasive coronary artery bypass grafting procedure can be performed safely without the use of extracorporeal circulation. In case of hemodynamic instability or anatomic variation, the Port-Access procedure can be applied without additional necessity for sternotomy. For multivessel disease, the off-pump bypass grafting procedure with sternotomy can be recommended depending on the coronary arteries involved. In case of necessary grafts to the lateral marginal or circumflex branches, Port-Access grafting can be recommended and may play an important role in the future for the development of fully endoscopic robot-assisted coronary artery bypass grafting.

European Multicenter Tacrolimus (FK506) Heart Pilot Study: one-year results--European Tacrolimus Multicenter Heart Study Group

BACKGROUND

Tacrolimus (FK506) may represent a major advance in the management of allograft rejection after solid organ transplantation. In August 1994 a European heart transplantation pilot study was initiated to assess the efficacy and safety of tacrolimus when administered exclusively through an oral route.

METHODS

Eighty-two heart transplant recipients were randomized to treatment (2:1 ratio) with either tacrolimus- (n=54) or cyclosporine-based therapy (n=28).

RESULTS

No significant differences were evident between the two treatment groups in either rejection or survival rates at 1 year. Kaplan-Meier estimates of the freedom from rejection were 26.3% and 18.5%, respectively, for the tacrolimus and cyclosporine treatment groups (p=.444). Survival rates were 79.6% and 92.9% (p=.125). At 3 of the 5 centers, patients received antithymocyte globulin during the immediate postoperative period and fared better than those who did not (with acute rejection-free rates of 49.2% and 26.7% for tacrolimus and cyclosporine, respectively [p=.080], as opposed to 7.1% and 8.3% [p=.965]; patient survival rates of 84.6% and 93.3% [p=.382] vs 75.0% and 92.3% [p=.243]). The overall rates of infection, impaired renal function (31.5% vs 21.4%), and glucose intolerance (7.0% vs 4.3%) did not differ significantly between the tacrolimus and cyclosporine treatment groups. Tacrolimus seemed to possess an advantage with regard to a reduced requirement for antihypertensive therapy (59.5% vs 87.5%, p=.025).

CONCLUSIONS

Immunosuppression with oral tacrolimus provides a viable alternative to treatment with cyclosporine, particularly when administered in conjunction with antibody therapy. Further studies are warranted to optimize the administration of tacrolimus in this indication.

Adult human cardiomyocytes coexpress vimentin and Ki67 in heart transplant rejection and in dilated cardiomyopathy

BACKGROUND

The aim of this study was to investigate whether adult human cardiomyocytes may reexpress vimentin and whether this is linked to cellular activation.

METHODS

Myocardial samples of 81 heart transplant recipients (n=183) and patients with dilated cardiomyopathy (n=10) were investigated by immunohistochemistry with the use of the marker molecule vimentin, the muscle-specific protein desmin, and Ki67, a marker for cell activation.

RESULTS

Vimentin protein expression in cardiomyocytes was found in 28 samples of transplant recipients and 5 myocardial samples of patients with dilated cardiomyopathy. Coexpression of vimentin and Ki67 was found in 52 of 340 vimentin-positive cardiomyocytes.

CONCLUSIONS

We suggest that the vimentin/Ki67 coexpression indicates cell activation processes as the result of different growth stimuli.

Aggressive lowering of fibrinogen and cholesterol in the prevention of graft vessel disease after heart transplantation

BACKGROUND

A combined treatment of statins and extracorporeal H.E.L.P.-apheresis (Heparin-mediated Extracorporeal LDL/fibrinogen Precipitation) has already been shown to be beneficial for coronary artery disease (CAD). Presumably high levels of LDL cholesterol, Lp(a), and fibrinogen also increase the risk for graft vessel disease (GVD). Therefore, we studied whether this concept can be applied in GVD, based on the hypothesis that GVD is an accelerated form of CAD.

METHODS AND RESULTS

For comparison of statin treatment alone with the combined treatment, two matched groups of 10 cardiac transplant recipients were studied during a mean period of 3.6+/-1.0 years. Both groups were comparable in clinical characteristics, immunosuppressive medication, baseline plasma Lp(a), and high fibrinogen levels. Group I had normal LDL-C levels (3.36+/-0.60 mmol/L). Simvastatin alone was administered in this group to counteract the LDL-increasing effect of the immunosuppressive medication. Group II had marked hypercholesterolemia (LDL-C, 6.07+/-1.89 mmol/L), which was treated, in addition to simvastatin, with H.E.L.P.-apheresis weekly. GVD was assessed by coronary angiography. Simvastatin alone kept LDL-C levels within baseline limits but could not prevent GVD in 7 of 10 patients. In contrast, the combined treatment prevented GVD in 9 of 10 patients (P=.006) by simultaneous and drastic reduction of 48% LDL-C (P=.006), 35% fibrinogen (P=.002), and 47% Lp(a) (P=.006) below baseline. Both treatments were well tolerated and did not affect prevention of graft rejection and infections.

CONCLUSIONS

A strategy of early, drastic lowering of fibrinogen, LDL-C, and Lp(a) helps to prevent GVD.

[Prospective study of the frequency and extent of donor-transmitted coronary disease after heart transplantation by intravascular ultrasound]

PROBLEM AND OBJECTIVE

Cardiac allograft vasculopathy influences long-term survival of patients after heart transplantation. Donor-transmitted coronary artery disease may contribute to the further development of cardiac allograft vasculopathy. The aim of this study was to characterize by intracoronary ultrasound the extent and frequency of transmitted coronary artery disease.

PATIENTS AND METHODS

Intravascular ultrasound studies were performed at routine angiography in 33 patients (26 men, 7 women, mean age 51 [23-69] years) early after heart transplantation. Plaque morphology was analysed in 153 coronary segments of 52 epicardial coronary arteries.

RESULTS

Relevant atherosclerosis (defined as maximal plaque thickness > or = 0.5 mm in at least one coronary segment) was found in 17 patients (52%), while angiography showed irregularities in only 7 patients (21%). Maximal plaque thickness in patients with relevant atherosclerosis was 1.13 +/- 0.32 mm, mean plaque index was 19.2 +/- 10.2%. Plaque formation was eccentric, and plaques were predominantly located in proximal segments. Morphologic changes affecting more than one segment were found in 52% of the patients. Comparing clinical factors, only donor age predicted the degree of atherosclerosis.

CONCLUSIONS

In more than one half of the patients studied early after heart transplantation, Intravascular ultrasound revealed epicardial atherosclerotic lesions which were incompletely identified by coronary angiography. The degree of atherosclerosis was closely related to donor age. The potential influence of donor transmitted coronary artery disease on the progression of transplant coronary artery disease requires further longitudinal studies.

Simvastatin reduces graft vessel disease and mortality after heart transplantation: a four-year randomized trial

BACKGROUND

Accelerated graft vessel disease (GVD) represents the most serious long-term complication of heart transplantation. A possible cause underlying this progressive coronary vascular disease is believed to be post-transplantation hypercholesterolemia.

METHODS AND RESULTS

In a 4-year prospective randomized study with heart transplant recipients, the efficacy of primary antihypercholesterolemic therapy with simvastatin was compared with that of general dietary therapy. The aim of the treatment was to maintain post-transplantation LDL-cholesterol levels at <120 mg/dL. Seventy-two heart transplant recipients receiving standard triple immunosuppression were randomly assigned to an active-treatment group (low-cholesterol diet and simvastatin, n=35) or a control group (general dietary measures, n=37). In the course of 4 years after transplantation, the simvastatin group had significantly lower LDL-cholesterol concentrations than the control group (mean+/-SD, 115+/-14 versus 156+/-17 mg/dL,P=.002), a significantly better long-term survival (88.6% versus 70.3%,P=.05), and a lower incidence of GVD in the coronary angiographic findings (16.6% versus 42.3%,P=.045). The incidence of graft rejections did not differ between the two groups, although there was a tendency toward a lower number of serious rejections in the simvastatin group (2.8% versus 13.5%, P=.1). Intracoronary ultrasound performed after 4 years in a subgroup of 27 patients (simvastatin, 10; control, 17) showed less intimal thickening in patients with LDL-cholesterol levels of <110 mg/dL (170+/-84 versus 370+/-171 microm, P=.04) and a lower intimal index (13.8+/-7.1% versus 27.9+/-12.1%,P=.04).

CONCLUSIONS

In comparison with dietary measures alone, the combination of a low-cholesterol diet and simvastatin after heart transplantation led to a significant reduction in cholesterol levels, a significantly higher long-term survival rate, and a lower incidence of GVD.

Transfusion of platelet-rich plasma from the organ donor during cardiac transplantation

STUDY OBJECTIVE

To evaluate whether transfusion of platelet-rich plasma from the organ donor during cardiac transplantation can influence the amount of the needed homologous blood products.

DESIGN

Randomized, controlled study.

SETTING

University hospital.

PATIENTS

16 ASA physical status III patients undergoing orthotopic cardiac transplantation.

INTERVENTIONS

Eight patients received donor plasma, while another 8 patients served as a control group. Blood from the organ donor was acquired during cardiac explantation. Thereafter platelet-rich plasma was separated by plasmapheresis (2400 turns per minute). The plasma was then transfused to the organ recipient at the end of the cardiac transplantation. The control group received a similar amount of albumin 5%.

MEASUREMENTS AND MAIN RESULTS

In the patients who received donor plasma, the platelet count increased significantly from 98,000 +/- 49,000 mm-3 to 123,000 +/- 55,000 mm-3, the postoperative requirement of packed red blood cells (PRBCs) was 5.8 +/- 4.5 units, which was significantly lower as compared to the control group (10.8 +/- 5.9 units).

CONCLUSIONS

Transfusion of platelet-rich plasma from the organ donor to the recipient was confirmed to be feasible, the number of postoperatively transfused PRBCs was reduced.

Significance of prophylactic urodilatin (INN: ularitide) infusion for the prevention of acute renal failure in patients after heart transplantation

Acute renal failure is a serious problem following heart transplantation. In first uncontrolled clinical trials, Urodilatin revealed beneficial effects in the prophylaxis and therapy of acute renal failure following heart and liver transplantation. Here, we present the first randomized, placebo-controlled, double-blind study on 24 patients following heart transplantation to investigate whether prophylactic i.v. Urodilatin infusion can prevent acute renal failure requiring renal replacement therapy. Postoperative drug management was characterized by intravenous application of high furosemide, cyclosporine, and vancomycin doses. Urodilatin infusion was started postoperatively with a dose of 40 ng / kg bw / min for 6 days. 6 of the 12 patients in the Urodilatin group and 6 of the 12 patients in the placebo group had a stable diuresis (3 - 4 l / day) during the study period of 6 days. In contrast, the remaining 6 patients of each group developed oliguria / anuria and required subsequent hemofiltration / hemodialysis. Cumulative duration of hemofiltration (88 +/- 7.39 hours in the placebo treated patients versus 44 +/- 5.35 hours in the Urodilatin treated patients, p < 0. 05) as well as frequency of hemodialysis (3.0 +/- 0.49 times in the placebo group vs 1.2 +/- 0.29 times in the Urodilatin group, p < 0. 05) were significantly reduced using Urodilatin. Mean arterial blood pressure was stable during the Urodilatin infusion period and was not different to that observed in placebo patients. We conclude that Urodilatin does not reduce the incidence of acute renal failure and the subsequent requirement for hemofiltration / hemodialysis in our patient population, but seems to reduce the duration of hemofiltration and frequency of hemodialysis compared to the placebo group.

[Therapy of hypercholesterolemia after heart transplantation with the HMG-CoA reductase inhibitor simvastatin in long-term follow-up]

The problem of hypercholesterolemia following heart transplantation (HTx) is often underestimated. Up to now there is no concept of therapy allowing an optimal adjustment of lipid parameters. Therapeutical trials using ion exchange resins, derivates of nicotinic acids and fibrates were not successful due to Cyclosporin A interaction, hepatotoxicity and limited efficacy of the applied substances. In a prospective, randomized and controlled trial, we investigated the effects of monotherapy with the HMG-CoA-reductase inhibitor Simvastatin in heart transplant recipients. The study included 70 patients (Simvastatin n = 37, control group n = 33). Eight patients died within the first 3 month postoperatively following HTx. Purpose of the study was adjustment of LDL-cholesterol-values in the Simvastatin-treated group to < 110 mg/dl. Following 24 months of treatment a mean LDL-cholesterol-plasma level of 110 mg/dl was obtained. The corresponding mean value of the control group was 150 mg/dl. The difference between both groups was significant (p < .001). In the same period the mean HDL-cholesterol values increased by approximately 15% in both groups. The ratio of LDL-/HDL-cholesterol was significantly lower in the Simvastatin treated group (2.28) than in the control group (2.94) (p < .01). There was no significant difference in Lp(a)-values. No adverse effects were observed within the following period of 24 months, particularly no increase in the frequency of rejection episodes. The drug induced hypercholesterolemia following HTx could be treated safely and effectively by low-dose Simvastatin.

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.