An audit of a steriod withdrawal regimen in cardiac transplantation patients

BACKGROUND

Heart transplantation is optimal treatment for many patients with end-stage heart failure. Current data report 1-year graft survival rates of 85% after transplantation. The success of transplantation in large part is attributable to immunosuppression, including steroids, one of the mainstay agents. Despite its efficacy to treat acute graft rejection, steroids show numerous adverse effects. With newer immunosuppressive agents, steroid withdrawal is possible.

MATERIAL AND METHODS

We compared cardiac transplant patients who died versus survived between 2001 and 2006. We obtained Personal, transplant, occurrence of and cause of death data as well as postoperative intervals. Steroid therapy details were gathered, particularly whether the patient had been weaned off these agents. We calculated steroid doses and steroid-free years, as well as the steroid therapy status of posttransplant patients who remained alive in 2006.

RESULTS

Fifty cardiac transplant patients died between 2001 and 2006 excluding 6 who had graft failure and 2 who died of multiorgan failure before initial discharge. Of the 42 patient who died, 29 (69%) were on and 13 (31%) had been withdrawn from steroid therapy at time of death. There were 132 posttransplant patients currently alive in April 2006, including 43 (33%) on and 89 (67%) withdrawn from steroids. The percentages of patients who were on versus off steroids were compared for main causes of death. Thirty-eight percent of patients on steroids at the time of death died of graft vasculopathy compared with 46% of patients who had been weaned off steroids. Fifteen percent of deceased patients taking steroids at the time of death died of chronic rejection.

DISCUSSION

The current literature focuses on early withdrawal or reduction of steroids or steroid avoidance after organ transplantation. Although steroid avoidance remains controversial, steroid withdrawal has been generally incorporated into immunosuppressive protocols. Early steroid withdrawal has a positive influence on the emergence of de novo osteoporosis and cataracts. The benefits of steroid avoidance versus withdrawal are controversial topics being currently debated.

Skin-cancer awareness in Scottish cardiac transplant recipients

BACKGROUND

Cardiac transplant recipients have a greatly increased risk of nonmelanoma skin cancer, with a relative risk of up to 108. Skin cancer is more aggressive in transplant patients and results in substantial morbidity and mortality. It is therefore important that these patients understand this risk and take adequate sun-protection measures.

AIM

To assess awareness of skin cancer risk and sun protection measures used by cardiac transplant recipients and determine the impact of patient education.

METHODS

Using a detailed questionnaire, we surveyed 118 patients attending the cardiac transplant clinic at our centre to quantify knowledge of skin cancer risk (maximum total score 10) and behaviour in the sun (maximum total score 15). Of these patients, 50 were then seen by a dermatologist for education about skin cancer risk, sun protection measures and skin cancer screening. Six months later, we asked them to complete the same questionnaire again.

RESULTS

The mean knowledge score was 7.3/10 and the mean behaviour score was 11.2/15. In the group that received education, the mean knowledge score improved from 7.2/10 before the dermatology consultation to 7.8/10 after the consultation (P < 0.03). The mean score for the behaviour questions improved even more, from 11.2/15 before to 13.5/15 after the consultation (P < 0.0001). CONCLUSIONS. This study demonstrates that specialist advice can improve self-reported knowledge of skin cancer risk and sun protective behaviour in cardiac transplant recipients. It is hoped that this may reduce the risk of nonmelanoma skin cancer in these patients.

Comparison of survival following coronary artery bypass grafting vs. percutaneous coronary intervention in diabetic and non-diabetic patients: retrospective cohort study of 6320 procedures

AIM

To determine whether mortality following percutaneous coronary intervention vs. coronary bypass grafting varies according to whether or not patients have diabetes.

METHODS

We used the Scottish Coronary Revascularization Register to identify all patients undergoing revascularization in Scottish NHS hospitals since 1997. We excluded single-vessel disease, left main stem stenosis, and bypass grafting performed at the same time as other operations. We used death certificate data from the Registrar General to identify all subsequent deaths.

RESULTS

Of the 6320 eligible procedures, 5042 (80%) were bypass grafts and 1278 (20%) angioplasties. Overall 831 (13%) patients had diabetes with no significant difference by procedure (13% vs. 12%). A total of 382 deaths occurred over a mean follow-up of 2.3 years. Diabetic patients had a poorer prognosis following both surgery (adjusted hazards ratio (HR) 1.43, 95% confidence interval (CI) 1.08, 1.89) and percutaneous intervention (adjusted HR 2.58, 95% CI 1.43, 4.63). Among non-diabetic patients, no significant differences in mortality were detected between the two procedures. Among diabetic patients, no significant difference was detected in those with two-vessel disease. In those with impaired left ventricular function and triple-vessel disease, angioplasty was associated with a significantly higher risk of death (adjusted HR 3.58, 95% CI 1.40, 9.19).

CONCLUSIONS

This is the first study to demonstrate statistically significant results that support the BARI trial findings. Our study demonstrated a significant difference for triple-vessel disease but not two-vessel disease. The former may be due to incomplete revascularization using percutaneous intervention. Our results require corroboration from randomized trials.

Septal myotomy-myectomy and transcoronary septal alcohol ablation in hypertrophic obstructive cardiomyopathy. A comparison of clinical, haemodynamic and exercise outcomes

AIMS

Surgical myectomy has been successfully used to treat patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM). More recently, alcohol septal ablation has been advocated as a less invasive, but equally effective alternative therapy. The aim of this non-randomized cohort study was to compare subjective and objective outcomes in patients undergoing these therapies.

METHODS

Forty-four patients (25 male; age 41+/-15 years) with symptomatic drug-refractory obstructive HCM were studied. Twenty-four patients underwent surgical myectomy and 20 alcohol septal ablation. All patients underwent clinical evaluation, echocardiography and upright maximal cardiopulmonary exercise testing using a cycle ergometer before and following their intervention.

RESULTS

Peak gradient was reduced to a similar extent by both modalities (myectomy: 83+/-23 to 15+/-10 mmHg (P<0.000001); ablation: 91+/-18 to 22+/-14 mmHg (P<0.000002);P =0.48 for myectomy vs ablation) and led to similar improvements in NYHA class (myectomy: 2.4+/-0.6 to 1.5+/-0.7 (P<0.00001); ablation: 2.3+/-0.5 to 1.7+/-0.8 (P<0.0001);P=0.3 for myectomy vs ablation). Myectomy resulted in a greater improvement in peak oxygen consumption (myectomy: 16.4+/-5.8 to 23.1+/-7.1 ml.kg(-1) min(-1) (P<0.00002); ablation: 16.2+/-5.2 to 19.3+/-6.1 ml.kg(-1) min(-1) (P<0.05);P <0.05 for myectomy vs ablation) and work rate achieved (myectomy: 130+/-57 to 161+/-60 watts (P<0.04); ablation: 121+/-53 to 137+/-51 watts (P=0.11);P <0.05 for myectomy vs ablation).

CONCLUSION

Surgical myectomy and alcohol septal ablation are equally effective at reducing obstruction and subjective exercise limitation in appropriately selected patients. However, the superior effect of surgical myectomy on exercise test parameters suggests that surgery remains the gold standard against which new treatment modalities should be compared.

Parsonnet score is a good predictor of the duration of intensive care unit stay following cardiac surgery

OBJECTIVE

To investigate the value of the Parsonnet score (PS) in identifying preoperatively patients that are likely to spend < 24 hours on the intensive care unit (ICU) following cardiac surgery.

METHOD

Prospectively collected data on 5591 patients were analysed. PS, mortality, the length of stay on the ICU (ICU-LOS), number of patients with clinical evidence of stroke, need for haemofiltration, resternotomy for bleeding, tracheostomy, and use of intra-aortic balloon pump were documented as outcomes. A receiver operating characteristic (ROC) curve constructed using PS as a predictor of ICU stay < 24 hours identified a PS of 10 as the best cut off point that would predict ICU-LOS < 24 hours. The patients were therefore stratified by PS into two groups, those with a PS of 0 to 9 (PS 0-9) and those with a PS of 10 and above (PS 10+).

RESULTS

The ROC curve constructed using PS as a predictor of ICU stay < 24 hours had an area under the curve of 0.70 (0.01). The maximum efficiency of the test was at a sensitivity of 0.68. This corresponded to PS 10. The positive predictive value of the test at this score was 90.5%. Patients with PS 0-9 had a mean ICU stay of 1.49 days, while patients with PS 10+ had a mean ICU stay of 2.89 days (p = 0.01). The risk of stroke, use of intra-aortic balloon pump, requirement for haemofiltration, need for tracheostomy, and risk of resternotomy for bleeding were each significantly less in patients with PS 0-9 versus those with a score of PS 10+ (p < 0.01 in all cases). The risk of a single complication was 4.7% (PS 0-9) v 15.2% (PS 10+) (p < 0.01).

CONCLUSION

PS is an impartial and objective method of predicting postoperative complications and ICU stay < 24 hours. This is of value in selecting a cohort of patients likely to maintain a smooth flow of patients through the cardiothoracic unit when resources are limited to a few free ICU beds.

A controlled trial of substrate-enhanced, warm reperfusion ("hot shot") versus simple reperfusion

BACKGROUND

Modified reperfusion after aortic cross-clamping is claimed to reduce myocardial injury, thus improving postoperative myocardial performance.

METHODS

We measured perioperative release of creatine kinase-MB and troponin-T in 40 patients undergoing valve replacement (combined with coronary grafts in 12 cases) to determine whether infusion of a modified reperfusate before cross-clamp removal reduced myocardial injury. Patients were randomly allocated to one of two groups with minimization for age, surgeon, operation, and ventricular function. The control group received unmodified reperfusion, while the study group received a normothermic reperfusate, enhanced with glutamate and aspartate, for 5 minutes before removal of the cross-clamp. Serial determinations of troponin-T, creatine kinase-MB isoforms, and total creatine kinase-MB activity were made up to 5 days postoperatively. Requirements for inotropic support and evidence of myocardial infarction were documented.

RESULTS

Creatine kinase-MB activity, creatine kinase-MB isoforms, and troponin-T were not significantly different between the two groups. There were no differences in the incidence of postoperative myocardial infarction or in inotrope requirement.

CONCLUSIONS

Our study did not demonstrate any advantage in using modified reperfusion in this group of patients.

Excision of a false left ventricular aneurysm

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Myocyte loss in chronic heart failure

This study examined whether or not there is progressive loss of individual myocytes in established heart failure, accounting for the progressive left ventricular dysfunction; whether such loss is by necrosis or apoptosis; and whether such loss is more pronounced in ischaemic heart disease or idiopathic dilated cardiomyopathy. Tissue for patients undergoing cardiac transplantation for clinical end-stage heart disease was used. The clinical diagnosis was not known to the observer at the time of analysis. Indices of potential myocyte loss were: detection of apoptotic nuclei in situ, using the TUNEL method, immunohistochemistry for CD120a, CD120b, CD95, perforin and granzyme B; binding of C9 complex; and lipofuscin deposition within macrophages. Interstitial macrophages and T cells and their relationship to myocyte loss were also examined. There is indeed low grade myocyte loss in chronic heart failure, but there was no difference between the disease groups; rather, there was marked patient-to-patient variation within each category. Thus in chronic heart failure myocyte loss does occur, and both necrosis and apoptosis contribute to this loss, irrespective of the underlying nature of the disease. Any mechanism which accounts for myocyte loss must be common to both conditions, rather than specific for a pre-operative diagnosis.

Intermediate term results of total lymphoid irradiation for the treatment of non-specific graft dysfunction after heart transplantation

BACKGROUND

A proportion of heart transplant recipients develop poor graft function in the absence of cellular infiltrate in endomyocardial biopsies or transplant associated coronary artery disease. The condition has a poor prognosis and its aetiology is poorly understood. We report encouraging intermediate term results with total lymphoid irradiation (TLI) in the management of this condition.

METHODS

Eleven adult cardiac transplant recipients who developed severe allograft dysfunction (NYHA class-4) at a median period of 4 months after orthotopic heart transplantation were successfully treated with TLI. Endomyocardial biopsies and coronary angiography were normal in each patient and biventricular failure developed in spite of immunosuppression with Cyclosporin-A, Azathioprine, oral Prednisolone, Cyclophosphamide and intravenous Methylprednisolone therapy. Total lymphoid irradiation was given with standard Mantle and inverted Y-fields over ten treatments to achieve a cumulative dose of 8 Gy.

RESULTS

Each patient had a significant improvement in clinical response and in ventricular performance within 2 months of commencing TLI. Nine patients are currently well (four NHYA class-1, five NHYA class-2) at 4-48 (median 26) months following TLI. Two patients died; one from bacterial septicaemia and one as a consequence of chronic renal failure. Three patients developed opportunistic infection which was successfully treated with appropriate antimicrobial agents. An Ebstein-Barr virus associated lymphoproliferative disorder occurred in one patient and was successfully treated by reduction in immunosuppression and high dose Acyclovir. Two patients developed transient bone marrow suppression.

CONCLUSION

The intermediate term results of TLI in the management of poor graft function in cardiac transplant recipients with normal endomyocardial biopsies and coronary angiography are encouraging. Although complications of opportunistic infection, bone marrow suppression and lymphoproliferative disorder occurred, treatment was successful in each case.

Is routine post-operative surveillance for cytomegalovirus infection following heart transplantation necessary?

OBJECTIVE

Cytomegalovirus infection (CMV) is an important cause of morbidity and mortality following cardiac transplantation. The purpose of the present study was to ascertain whether routine post-operative screening for CMV infection influenced clinical management.

METHODS

Laboratory and case notes of 220 patients who received cardiac transplantation between November 1986 and October 1996 were reviewed. The range of follow-up was one to 120 (median 36) months. CMV surveillance involved blood tests for early antigen detection weekly for the first 6 post-operative weeks, fortnightly thereafter until the end of the third post-operative month and every 6 weeks to the end of the first post-operative year. Otherwise monitoring was performed if the patients had clinical symptoms suggestive of CMV infection. CMV sero-negative IgG recipients (R) of sero-positive IgG donor (D) organs and/or blood products received hyper-immune gammaglobulin for the first three post-operative months. Four patient groups were noted, namely R+D+ (59 patients), R+D- (70 patients), R-D+ (35 patients) and R-D- (56 patients).

RESULTS

CMV antigenaemia was present in 40% (89) of patients and 48% (43) of these patients developed clinical features of CMV infection and received ganciclovir therapy. The distribution of clinical CMV infection requiring treatment was 25% (9/35) in the R+D- group, 50% (16/32) in the R+D+ group and 85% (18/22) in the R-D+ group. None of the patients in the R-D- group developed CMV antigenaemia. Forty six (52%) patients who were CMV antigen positive but who did not develop symptoms were not treated with ganciclovir and have remained well.

CONCLUSION

Our results suggest that routine screening for CMV following cardiac transplantation is unnecessary. Surveillance did not result in the instigation of treatment for CMV unless there were associated clinical features of CMV infection.

Successful resection of obstructing airway granulation tissue following lung transplantation using endobronchial laser (Nd:YAG) therapy

OBJECTIVE

Airway obstruction due to an excessive growth of granulation tissue at the level of the anastomosis is an important complication following lung transplantation which requires early diagnosis and treatment. We report encouraging experience in the management of this condition using endobronchial Nd:YAG laser therapy.

METHODS

Four adult lung transplant recipients developed airway anastomotic obstruction secondary to granulation tissue formation at 9, 10, 32 and 32 days following bilateral sequential lung transplantation (2 patients), en bloc double lung transplantation (1 patient) and single lung transplantation (1 patient). The diameter of the airways at the level of the anastomoses was reduced by 75, 30, 60, 60, 50 and 90%, respectively. Endobronchial Nd:YAG laser was applied via a fiberoptic bronchoscope introduced through a rigid bronchoscope. The granulation tissue was visualised and resected with photocoagulation with the laser using between 1000-2000 J depending on the amount of tissue present. Necrotic tissue was removed with large forceps. If the obstruction extended to the orifice of a lobar bronchus resection was undertaken in a staged fashion.

RESULTS

Airway patency was fully restored at two anastomotic sites, and restored to 90% patency at two and 80 and 75% at one each, respectively. This was associated with a significant improvement in pulmonary function in 3 patients. One patient had a subsequent bougie dilatation of a stenotic area and 2 patients received an endobronchial stent for tracheo or broncho-malacia. One patient died from a gastrointestinal haemorrhage. Three patients are well at 10, 17 and 18 months following transplantation and have no further granulation tissue recurrence. There were no complications directly attributable to laser therapy.

CONCLUSION

Our encouraging early experience leads us to suggest that Endobronchial Nd-YAG laser therapy should be considered in the management of airway anastomotic obstruction due to excessive granulation tissue formation after lung transplantation.

Successful surgical repair of a false aneurysm of the ascending aorta following orthotopic cardiac transplantation: a case report

A 54-year-old male underwent orthotopic heart transplantation for valvular heart and developed a false aneurysm of the ascending aorta at the aortic suture line posteriorly 20 months after transplantation. This was successfully repaired using a patch of glutaraldehyde-fixed bovine pericardium. At the time of surgical repair there was no evidence of infection or atherosclerosis.

Absence of bradycardic response to apnea and hypoxia in heart transplant recipients with obstructive sleep apnea

In patients with obstructive sleep apnea, the vagal stimulation caused by inspiration against the upper airway obstruction results in sinus bradycardia during the apnea followed by a reflex tachycardia at apnea termination. We report on five heart transplant recipients with obstructive sleep apnea who demonstrated no change in baseline heart rate in spite of marked hemoglobin oxygen desaturation, presumably on account of parasympathetic denervation of the allograft. Heart transplant recipients with obstructive sleep apnea may be at an increased risk of development of potentially fatal ventricular arrhythmias if the allograft is unable to respond appropriately to hypoxia. Should cardiac parasympathetic reinnervation occur, prospective polysomnography may be a marker for this process in these patients.

Partial resolution of acute interstitial pneumonia in native lung after single lung transplantation

The case of a 49 year old man presenting with rapidly progressive interstitial lung disease is described. Radiological findings and the lung biopsy specimen were compatible with an acute interstitial pneumonia, as was the relentless clinical course culminating in hypoxic respiratory failure. After right single lung transplantation there was considerable improvement in lung function and radiographic clearing of disease in the native left lung.

Total lymphoid irradiation as rescue therapy after heart transplantation

BACKGROUND

Allograft dysfunction develops in a proportion of heart transplant recipients without significant cellular infiltrate in endomyocardial biopsies and with normal coronary arteries at angiography. The mechanisms responsible for this presentation are unclear, and the prognosis is poor. We report encouraging experience with total lymphoid irradiation given in addition to cyclosporine A, cyclophosphamide, and prednisolone therapy in three heart transplant recipients with poor graft function with normal endomyocardial biopsies and coronary angiography.

METHODS

Three patients who had severe allograft dysfunction after orthotopic heart transplantation, with normal endomyocardial biopsies and coronary angiography, were successfully treated with total lymphoid irradiation. Biventricular failure developed in each patient despite immunosuppression with cyclosporine A, azathiaprine, oral prednisolone, cyclophosphamide, and intravenous methylprednisolone therapy. Total lymphoid irradiation was given with standard mantle and inverted y fields over 10 treatments to achieve a cumulative dose of 8 Gy.

RESULTS

Each patient had a significant improvement in clinical response and in ventricular performance after total lymphoid irradiation, which was well tolerated in each case. The patients remain well at 8, 9, and 12 months after completion of treatment.

CONCLUSIONS

Total lymphoid irradiation should be considered as adjunct therapy to conventional immunosuppression for heart transplant recipients with poor graft function in the absence of cellular rejection or coronary artery disease.

Myocyte nuclear area as a measure of left ventricular hypertrophy in transplant patients

Transplanted hearts have been reported to increase in size/weight in the first few months after transplant and to remain stable thereafter. An indirect way of assessing the changes in heart weight is through the changes in the area of the myocyte nucleus (MNA). We studied 20 patients who had undergone orthotopic heart transplantation more than 12 months previously; 10 had become hypertensive, and the remaining 10 were normotensive. Myocardial biopsies taken the first week after transplant and 6, 12, 24, and 52 weeks after transplant were assessed. Myocyte nuclear area was measured in 200 myocytes/biopsy with an image analyzer. Individual measurements showed a wide variation in MNA, with significant overlaps among the different biopsies. Assessment of MNA at one year showed increased MNA in 4 10 patients in the hypertensive group and 5 10 in the normotensive group. The remaining patients showed either no statistically significant changes in MNA or a significant (p < 0.0001) decrease in MNA. The presence of systemic hypertension was not a predictive factor for significant hypertrophy and, in some cases, not even for hypertrophy itself. We conclude that although there is often an increase in MNA of the transplanted heart at one year posttransplant, this increase is not systematic, and isolated morphometric results should be viewed cautiously.

Mitral valve repair

The greatest service that surgeons can provide for patients is to restore the function of diseased or injured parts. The principle followed is that once anatomical form is restored, then physiological recovery will follow, thus surgeons must understand the anatomy, physiology and pathology involved. They must also know the limits of the technology available and their own practical skills, so that judgment as to what is and is not possible allows avoidance of mistakes.

Association of cytomegalovirus infection with post-transplantation cardiac rejection as studied using the polymerase chain reaction

The relationship between cytomegalovirus (CMV) infection and cardiac allograft rejection is controversial, some authors reporting a significant association, others not, on the basis of the results of conventional virological diagnosis by culture or serology. This problem was reinvestigated in 88 patients using a semi-quantitative nest polymerase chain reaction (PCR) procedure for detecting CMV DNA in endomyocardial biopsy specimens. Significantly more positive biopsies were obtained from patients with moderate (grade 2; P = 0.02) or severe (grade 3a-4; P = 0.03) rejection than with no or mild (grade 0-1b) rejection, whereas there was no significant association between rejection and CMV as diagnosed by virus isolation from urine, throat or blood, or by the detection of CMV-IgM. PCR-positive biopsies originated most frequently from CMV-antibody positive recipients (R+) of hearts from seropositive donors (D+), in association with moderate or severe rejection rather than with mild or no rejection The detection of CMV in the heart thus seemed to be related more to R+D+ serological status than to severity of rejection, that is, to circumstances that favoured co-infection with strains of CMV from both donor and recipient. Studies on sequential biopsy specimens from selected patients also provided evidence that CMV infection and rejection were not always related events. The PCR was able to differentiate latent from active CMV infection; moreover, some seronegative individuals gave repeatedly positive biopsies, thereby supporting the work of others that some patients undergo CMV infection without mounting a detectable antibody response.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood pressure and endocrine responses to changes in dietary sodium intake in cardiac transplant recipients. Implications for the control of sodium balance

BACKGROUND

The role of cardiac extrinsic innervation in the regulation of sodium balance and blood pressure is controversial.

METHODS AND RESULTS

We performed a double-blind study of endocrine and blood pressure responses to 5 days of low- (LS, 10 mmol/d) and 5 days of high- (350 mmol/d) sodium intake in 12 cardiac transplant recipients, 12 matched healthy subjects, and 12 matched subjects with untreated essential hypertension. In transplant recipients on low sodium, supine blood pressure was 137/94 +/- 8/4 (mean +/- SEM) mm Hg and plasma atrial natriuretic peptide (ANP) was 59.3 +/- 6.3 pg/mL; on high sodium, blood pressure was 148/97 +/- 5/3 mmHg (P < .05 for systolic pressure versus LS), and ANP was 94.3 +/- 10.6 pg/mL (P < .01 versus LS), respectively. Plasma ANP for those on each diet was significantly higher in the cardiac transplant recipients than in healthy or hypertensive controls; relative changes in plasma ANP in changing from low- to high-sodium diet were similar in each group. Urinary sodium excretion by the fifth day of each diet was similar in each group. Suppression of plasma renin activity and aldosterone by high-sodium diet was blunted in cardiac transplant recipients compared with healthy subjects (respectively, plasma renin activity: 1.41 +/- 0.30 versus 0.68 +/- 0.21 ng.mL-1 x h-1, P < .05; aldosterone: 391 +/- 35 versus 166 +/- 21 pmol/L, P < .05).

CONCLUSIONS

These results suggest that extensive denervation of the heart does not result in major abnormalities in regulation of large changes in sodium intake and that intact cardiac innervation is not required for plasma ANP responses to altered sodium intake. Blood pressure after cardiac transplantation is sensitive to reduced sodium intake.

Slide tracheoplasty for congenital funnel-shaped tracheal stenosis

Congenital funnel-shaped trachea is a serious condition, and the survival rate in infants is poor. A slide tracheoplasty is described, with a brief review of other methods of repair. Two cases that demonstrate the operability of congenital funnel-shaped trachea in infancy are reported.

Clastogenic factor in ischemia-reperfusion injury during open-heart surgery: protective effect of allopurinol

The hypothesis tested was that free radicals generated following ischemia and reperfusion in cardiac operations can produce clastogenic factor that results in chromosomal aberration. Fourteen randomized patients undergoing coronary artery bypass grafting were divided into two groups. In Group 1 (7 patients), myocardial protection was achieved using a cardioplegic solution without allopurinol. In Group 2 (7 patients), 100 mg of allopurinol (xanthine oxidase inhibitor) was added to the solution. In both groups, blood samples were taken from the coronary sinus before the aorta was clamped and 20 minutes after myocardial reperfusion was achieved. The blood samples were used to study the patients' chromosomes. The results were given as the percentage of chromosomal aberrations observed in 100 mitoses. There were no significant differences between the preischemic values in both groups and the postischemic values in Group 2. On the other hand, there was a significant difference between the postischemic values in Groups 1 and 2 (p less than 0.01). In conclusion, reperfusion following myocardial ischemia in cardiac operations can produce clastogenic aberrations. This clastogenic activity can be reduced by adding allopurinol to the cardioplegic solution.

Local thrombolysis in peripheral arteries and bypass grafts

Sixty-two patients hospitalized for recent angiographically documented arterial occlusion in the legs (46 femoropopliteal arteries and 16 grafts) benefited from local fibrinolytic therapy delivered at the site of the occlusion with a No. 4F or No. 5F catheter. This therapy combined a continuous urokinase (UK) infusion of 1000 U/kg/hr and a lysyl plasminogen (LYS-PLG) infusion of 15 mukat every 30 minutes. Angiographically confirmed lysis was obtained in 77% of the cases. Five percent of the patients had major and 8% had minor groin hematomas. Only two patients had concentrations of fibrinogen as low as 100 mg/dl. Intravascular infusion of UK and LYS-PLG is as effective as streptokinase but produces lower systemic fibrinolysis. However, local fibrinolysis remains a potentially hazardous procedure (10% suffered major complications) and must only be applied to patients with severe ischemia and little or no possibility of surgical intervention.

A nasal adhesion following prolonged nasotracheal intubation

A patient who presented with nasal obstruction 4 months after prolonged pernasal tracheal intubation is described. The cause of the obstruction was an adhesion which extended from the septum to the inferior turbinate. The evidence in support of long-term pernasal tracheal intubation is presented and the aetiology of this complication is discussed.