Endomyocardial biopsy in cardiac transplant recipients using the femoral venous approach

A new method for right ventricular endomyocardial biopsy via the femoral veins: a novel approach employing a right ventriculography catheter (Nishiya type)

We have devised a new method for right ventricular endomyocardial biopsy, in which the use of a right ventriculography catheter (Nishiya Type) allows us to ensure the introduction of a guiding sheath (Cordis, right-angled long sheath) to the apical portion of the right ventricle by way of the femoral vein. With this method, we have biopsied the endomyocardium in 52 patients during the last 4 years. In each case, it only took us several minutes to complete the biopsy procedure. Neither failed applications nor significant complications were seen. We believe that this technique provides a clinically beneficial means as it enables us to readily and safely achieve right ventricular endomyocardial biopsy.

Renal function one year after switching from Sandimmun to Neoral

BACKGROUND

The replacement of Sandimmun by Neoral in 1995 was thought to cause subsequent renal function deterioration due to the better bioavailability of the new drug. We prospectively analyzed the effect of a dose-to-dose drug replacement on renal function over 12 months.

METHODS AND RESULTS

The renal function of 47 consecutive heart transplanted patients was prospectively evaluated before (T0), at 1 (T1), 3 (T3), and 12 (T12) months after drug replacement. Mean serum creatinine was not significantly different at T0 and T12 (142 +/- 55 and 154 +/- 60 micromol/L, p = 0.1). We were able to reduce cyclosporine total and weight-indexed doses by, respectively, 11% and 14% between T0 and T12 (274 +/- 86 to 244 +/- 72 mg/d, p = 0.0003; and 3.7 +/- 1.4 to 3.2 +/- 1.2 mg/kg/d, respectively, p = 0.0005).

CONCLUSIONS

This study demonstrates that the dose-to-dose replacement of Sandimmun by Neoral is feasible, with no direct influence on renal function over a 1-yr follow-up.

Extramediastinal surgical problems in heart transplant recipients

BACKGROUND

As heart transplantation has gained wide acceptance, a growing number of recipients are at risk of experiencing extramediastinal surgical problems.

STUDY DESIGN

We retrospectively reviewed our experience in the diagnosis and management of surgical problems occurring in 94 consecutive patients having heart transplantation. During the period of the study, we progressively adopted a policy of low-level immunosuppression, aiming toward monotherapy with cyclosporine.

RESULTS

Seventy-four extramediastinal surgical problems developed in 44 of 94 patients (47%). The type of problems were gastrointestinal in 17 of 74 (23%), vascular in 13 of 74 (17.5%), urogenital in 8 of 74 (11%), and neurologic in 4 of 74 (5.5%). There were also 9 of 74 cases of trauma (12%), 9 of 74 skin tumors (12%), and 14 of 74 miscellaneous diseases (19%). Sixty-two surgical diseases occurring in 40 patients required 75 surgical interventions, 11 of them (15%) on an emergency basis. Operations were performed for 12 of 74 neoplasms (16%) and 12 of 74 infectious or potentially infectious diseases (16%). Surgical diseases occurred most commonly within the first 6 months after transplantation (20 of 74; 27%). Complications occurred in 8 of 75 surgical interventions (9%). A high proportion of surgical disease was potentially related to immunosuppressive therapy (37 of 74; 50%) or to transplantation itself (7 of 74; 9%).

CONCLUSIONS

Extramediastinal diseases after heart transplantation involve most surgical specialties. Most of them are potentially linked with either the immunosuppressive therapy or the transplantation procedure, supporting our low-level immunosuppression policy. Expectant management is not justified in this population, who withstands operations well both early and late after transplantation.

Endomyocardial biopsy in heterotopic heart transplant recipients via the femoral vein

The results of endomyocardial biopsy (EMB) via the femoral vein in heterotopic heart transplant recipients were retrospectively analyzed and compared with those obtained using the right internal jugular vein approach. A total of 139 EMB were performed in 8 patients using the femoral (35) or the jugular (104) approach. Twenty three (64.7%) of the procedures performed via the femoral vein were part of the yearly hemodynamic and coronary artery study, and 12 (35.3%) constituted a routine postoperative evaluation of the myocardium rejection state in patients with imperviousness of the right internal jugular vein. Comparing the results obtained with the femoral approach, we observed a higher overall success rate (94.3 vs 88.5%, NS) and obtained more samples that were useful for histologic evaluation (95.5 vs 85.9%, NS); with the jugular procedure, the fragments were significatively larger in diameter (1.28 +/- 0.55 vs 1.61 +/- 0.85 mm, mean +/- SD) and in area (1.49 +/- 1.16 vs 2.28 +/- 2.24 mm2, mean +/- SD). No cardiac or local complications were noted when the femoral approach was used, while two attempts to perform biopsy via the jugular vein resulted in obstruction of this vessel. Our data suggest that the femoral venous approach for endomyocardial biopsy in heterotopic heart transplant recipients is a valid alternative to the more commonly used routes.

Failure of endocardial biopsy from the internal jugular vein due to endocardial scar: a new indication for the femoral venous approach

Following cardiac transplantation, patients undergo serial endomyocardial biopsies to evaluate rejection, usually by the internal jugular approach. A case report and data are presented that demonstrate that this approach becomes less efficient and occasionally impossible in the third year after transplant (53% success rate per biopsy attempt) as compared to the first year after transplant (80%) probably due to the development of endocardial scar in the area sampled by the bioptome. Alternatively, one can change to the femoral venous approach which continues to have a high success rate in the third year after transplant (83%) because a different area of the interventricular septum is sampled when this approach is used.

Tampa Bay catheter: a new guiding catheter for endomyocardial biopsy via femoral approach

Initially, endomyocardial biopsies were obtained almost exclusively using the jugular vein approach. Lately, the femoral vein route has gained popularity and in many centers, including ours, it is preferred. Despite this, guiding catheters specifically designed for endomyocardial biopsy via femoral vein approach are not available. Here, the experience with the Tampa Bay catheter, designed for endomyocardial biopsy using the femoral vein is described. From 1-1-89 to 1-31-90, a total of 486 endomyocardial biopsies were performed in 78 post-heart transplant patients (1-17, mean 6 per patient); 106 were performed via internal jugular vein (22%) and 380 (78%) via femoral vein. Of these, 100 were performed using the Tampa Bay catheter. The remaining 280 biopsies were done using a long sheath or a Judkin's right coronary angioplasty guiding catheter. Biopsy specimens were adequate for diagnosis of rejection in all 106 biopsies performed via internal jugular vein (100%) in 99 of 100 biopsies via femoral vein using the Tampa Bay catheter (99%) and in 274 of the 280 (98%) biopsies using the long sheath or the right Judkin's coronary angioplasty guiding catheter (NS). The femoral vein is larger and easier to find than the internal jugular vein. More important, complications such as right pneumothorax, Horner's syndrome, recurrent laryngeal nerve paralysis, and right phrenic nerve paralysis, known to occur when the internal jugular vein approach is used, can be completely avoided when the femoral vein approach is used.