Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation

BACKGROUND

Despite advances in heart transplantation and mechanical circulatory support, mortality among transplant candidates remains high. Better ways are needed to ensure the survival of transplant candidates both inside and outside the hospital.

METHODS

In a prospective, multicenter clinical trial conducted at 24 centers in the United States, 280 transplant candidates (232 men, 48 women; median age, 55 years; range, 11-72 years) unresponsive to inotropic drugs, intra-aortic balloon counterpulsation, or both, were treated with the HeartMate Vented Electric Left Ventricular Assist System (VE LVAS). A cohort of 48 patients (40 men, 8 women; median age, 50 years; range, 21-67 years) not supported with an LVAS served as a historical control group. Outcomes were measured in terms of laboratory data (hemodynamic, hematologic, and biochemical), adverse events, New York Heart Association functional class, and survival.

RESULTS

The VE LVAS-treated and non-VE LVAS-treated (control) groups were similar in terms of age, sex, and distribution of patients by diagnosis (ischemic cardiomyopathy, idiopathic cardiomyopathy, and subacute myocardial infarction). VE LVAS support lasted an average of 112 days (range, < 1-691 days), with 54 patients supported for > 180 days. Mean VE LVAS flow (expressed as pump index) throughout support was 2.8 L x min(-1) x m(-2). Median total bilirubin values decreased from 1.2 mg/dL at baseline to 0.7 mg/dL (P =.0001); median creatinine values decreased from 1.5 mg/dL at baseline to 1.1 mg/dL (P =.0001). VE LVAS-related adverse events included bleeding in 31 patients (11%), infection in 113 (40%), neurologic dysfunction in 14 (5%), and thromboembolic events in 17 (6%). A total of 160 (58%) patients were enrolled in a hospital release program. Twenty-nine percent of the VE LVAS-treated patients (82/280) died before receiving a transplant, compared with 67% of controls (32/48) (P <.001). Conversely, 71% of the VE LVAS-treated patients (198/280) survived: 67% (188/280) ultimately received a heart transplant, and 4% (10/280) had the device removed electively. One-year post-transplant survival of VE LVAS-treated patients was significantly better than that of controls (84% [158/188] vs 63% [10/16]; log rank analysis P =.0197).

CONCLUSION

The HeartMate VE LVAS provides adequate hemodynamic support, has an acceptably low incidence of adverse effects, and improves survival in heart transplant candidates both inside and outside the hospital. The studies of the HeartMate LVAS (both pneumatic and electric) for Food and Drug Administration approval are the only studies with a valid control group to show a survival benefit for cardiac transplantation.

Long-term use of a left ventricular assist device for end-stage heart failure

BACKGROUND

Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated.

METHODS

We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure.

RESULTS

Kaplan-Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent (P=0.09), respectively. The frequency of serious adverse events in the device group was 2.35 (95 percent confidence interval, 1.86 to 2.95) times that in the medical-therapy group, with a predominance of infection, bleeding, and malfunction of the device. The quality of life was significantly improved at one year in the device group.

CONCLUSIONS

The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life. A left ventricular assist device is an acceptable alternative therapy in selected patients who are not candidates for cardiac transplantation.

Long-term outcomes after cardiac transplantation: an experience based on different eras of immunosuppressive therapy

BACKGROUND

Constantly changing practices in heart transplantation have improved posttransplant survival in patients with end-stage heart disease. The objective of this study was to evaluate long-term outcomes in different eras of immunosuppressive therapy after cardiac transplantation at a single center during a two-decade period.

METHODS

A retrospective review of 1,086 consecutive cardiac allograft recipients who underwent transplantation between 1977 to 1999 was performed. Patients were divided into four eras based on type of immunosuppressive therapy: era 1 = steroids, azathioprine (n = 26, February 1977 to March 1983), era II = steroids, cyclosporine (n = 43, April 1983 to April 1985), era III = cyclosporine, steroids, azathioprine (n = 752, April 1985 to December 1995), era IV = cyclosporine, steroids, mycophenolate mofetil (n = 315, January 1996 to October 1999).

RESULTS

The actuarial survival of the entire cohort of 1,086 patients undergoing cardiac transplantation was 79%, 66%, and 49% at 1, 5, and 10 years, respectively. There were significant trends in recipient age and gender distribution among the four eras with increasing proportion of older age (> 60 years) and female recipients in eras III and IV (p = 0.001 and 0.02). Early mortality and long-term survival improved significantly over all eras (p < 0.001). Rejection as a cause of death decreased over time (era I, 24%; era II, 21%; era III, 15%; era IV, 9%; p = 0.02), whereas the contribution of transplant coronary artery disease as a cause of death remained unchanged.

CONCLUSIONS

Cardiac transplantation provides satisfactory long-term survival for patients with end-stage heart failure. The improving outcomes in survival correlate with improved immunosuppressive therapy in each era. Although the reasons for improvement in survival over time are multifactorial, we believe that changes in immunosuppressive therapy have had a major impact on survival as evidenced by the decreasing number of deaths due to rejection.

Use of a template to improve documentation and coding

BACKGROUND AND OBJECTIVES

Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions.

METHODS

Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note.

RESULTS

Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors.

CONCLUSIONS

The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes.

The development and initial validation of the Exercise Causality Orientations Scale

Deci and Ryan's causality orientations theory suggests that there are individual differences in motivational orientation towards initiating and regulating behaviour. They described three causality orientations: autonomy, control and impersonal. The aim of this paper is to describe the development and concurrent validity of the Exercise Causality Orientations Scale (ECOS), which was designed to measure the strength of these three orientations within exercise. Altogether, 592 working adults aged 35.0 +/- 11.4 years (mean +/- s) completed the ECOS and measures of self-determination, self-consciousness and social desirability. The analysis was conducted in two parts. First, the data were subjected to confirmatory factor analysis using a multi-trait, multi-method framework. The original model resulted in a poor fit to the data. On the basis of its modification indices, three scenarios with ambiguous items were removed successively, resulting in a scale with good psychometric properties. Secondly, Pearson's correlations were conducted between the subscales of the ECOS and those of the questionnaires used for validation. Most of the results supported a priori hypotheses. In conclusion, our results show the ECOS to have good psychometric properties and they provide some support for its concurrent validity.

Role of cardiopulmonary bypass in single vessel coronary revascularization: implications for MID-CABG

BACKGROUND

Minimally invasive direct coronary artery bypass grafting (MID-CABG) is being utilized for the treatment of coronary artery disease in selected patients. This innovative procedure has generated numerous technical issues relating to coronary revascularization, including whether to perform the revascularization with or without cardiopulmonary bypass (CPB).

METHODS

We addressed this issue indirectly by analyzing the 1995 New York State CABG registry, comparing patients who had single vessel bypass without CPB (Non-CPB Group) to a similar cohort of patients who had CABG performed on CPB (CPB Group). The database showed stratification of patients selected for bypass grafting without CPB to a significantly higher risk group, as shown by increased age, higher incidence of reoperation, transmural MI, congestive heart failure, carotid/cerebrovascular disease, and peripheral vascular disease.

RESULTS

Patients in the Non-CPB Group had a higher incidence of postoperative malignant ventricular arrhythmias and heart block requiring pacemaker insertion. Otherwise, the incidence of postoperative complications was similar between the two groups.

CONCLUSIONS

There were no statistical differences in the hospital mortality or the length of hospitalization between the two groups. In conclusion, the data showed a definite trend toward doing higher risk cases off CPB. These cases had an acceptable early morbidity and mortality outcome. The results were comparable to a group of lower risk patients with single vessel CABG done on cardiopulmonary bypass. However, further follow-up are required to evaluate long-term outcomes and confirm the utility of this surgical option.

The cost of long-term LVAD implantation

BACKGROUND

With increasing use of left ventricular assist devices (LVAD) worldwide, the economics of LVAD implantation have become an important focus of concern. Although these devices have high unit costs, they are the only hope for survival for a large group of terminally ill patients and are likely to have an expansion in indications for use.

METHODS

We calculated the costs associated with long-term LVAD implantation. We used the ratio of cost-to-charges method to calculate hospital costs per resource category, market prices for drugs and device, and payments for physician services.

RESULTS

Based on our experience with "bridge-to-transplantation" patients, we estimated average first-year costs to be $222,460 including professional fees and $192,154 excluding professional fees. The latter figure is comparable to average first-year costs for cardiac transplantation, which is $176,605 without professional fees at our institution.

CONCLUSIONS

The costs of LVAD therapy will change after the first year of implantation, and device reliability and longevity will be important factors in determining these costs. Should the costs of LVAD therapy continue to track those of cardiac transplantation, devices will be cost-effective only if they offer similar efficacy to cardiac transplantation.

Factors affecting long-term survival (>10 years) after cardiac transplantation in the cyclosporine era

OBJECTIVES

The aim of this study was to determine long-term survival (>10 years) after cardiac transplantation in the cyclosporine era and identify risk factors influencing long-term survival.

BACKGROUND

Despite the availability of newer modalities for heart failure, cardiac transplantation remains the treatment of choice for end-stage heart disease.

METHODS

Between 1983 and 1988, 195 patients underwent heart transplantation at a single center for the treatment of end-stage heart disease. Multivariable logistic regression analysis of pretransplant risk factors affecting long-term survival after cardiac transplantation included various recipient and donor demographic, immunologic and peritransplant variables.

RESULTS

Among the group of 195 cardiac transplant recipients, actuarial survival was 72%, 58% and 39% at 1, 5 and 10 years respectively. In the 65 patients who survived >10 years, mean cardiac index was 2.91/m2 and mean ejection fraction was 58%. Transplant-related coronary artery disease (TRCAD) was detected in only 14 of the 65 patients (22%). By multivariable analysis, the only risk factor found to adversely affect long-term survival was a pretransplant diagnosis of ischemic cardiomyopathy (p = 0.04).

CONCLUSIONS

Long-term survivors maintain normal hemodynamic function of their allografts with a low prevalence of TRCAD. It is possible that similar risk factors that lead to coronary artery disease in native vessels continue to operate in the post-transplant period, thereby contributing to adverse outcomes after cardiac transplantation. Aggressive preventive and therapeutic measures are essential to limit the risk factors for development of coronary atherosclerosis and enable long-term survival after cardiac transplantation.

Pica: common but commonly missed

BACKGROUND

Pica is the compulsive eating of nonnutritive substances and can have serious medical implications. Although it has been described since antiquity, there has been no single agreed-upon explanation of the cause of such behavior.

METHODS

Databases from MEDLINE and PSYCH-Lit were searched from 1964 to the present to find relevant sources of information using the key words "pica," "obsessive-compulsive disorder," "iron-deficiency anemia," and "nutrition."

RESULTS AND CONCLUSIONS

Pica is observed most commonly in areas of low socioeconomic status and is more common in women (especially pregnant women) and in children. To our knowledge, the prevalence of pica is not known. Numerous complications of the disorder have been described, including iron-deficiency anemia, lead poisoning, and helminthic infestations. Pica is probably a behavior pattern driven by multiple factors. Some recent evidence supports including pica with the obsessive-compulsive spectrum of disorders. Many different treatment regimens have been described, with variable responses. It is important to be aware of this common, but commonly missed, condition.

Impact of current management practices on early and late death in more than 500 consecutive cardiac transplant recipients

OBJECTIVE

To study risk factors for early and late death after heart transplantation in the current era.

SUMMARY BACKGROUND DATA

The current cardiac transplant population differs from earlier periods in that an increasing number of sicker patients, such as those with ventricular assist device (LVAD) support, prior cardiac allotransplantation, and pulmonary hypertension, are undergoing transplantation. In addition, sensitized patients constitute a greater proportion of the transplanted population. Emphasis has been placed on therapies to prevent early graft loss, such as the use of nitric oxide and improved immunosuppression, in addition to newer therapies.

METHODS

Five hundred thirty-six patients undergoing heart transplantation between 1993 and 1999 at a single center were evaluated (464 adults and 72 children; 109 had received prior LVAD support and 24 underwent retransplantation). The mean patient age at transplantation was 44.9 years. Logistic regression and Cox proportional hazard models were used to evaluate the following risk factors on survival: donor and recipient demographics, ischemic time, LVAD, retransplantation, pretransplant pulmonary vascular resistance, and immunologic variables (ABO, HLA matching, and pretransplant anti-HLA antibodies).

RESULTS

The rate of early death (less than 30 days) was 8.5% in adults and 8.8% in children. The actuarial survival rate of the 536 patients was 83%, 77%, and 71% at 1, 3, and 5 years, respectively, by Kaplan Meier analysis. Risk factors adversely affecting survival included the year of transplant, donor age, and donor-recipient gender mismatching. Neither early nor late death was influenced by elevated pulmonary vascular resistance, sensitization, prior LVAD support, or prior cardiac allotransplantation.

CONCLUSIONS

Previously identified risk factors did not adversely affect short- or long-term survival of heart transplant recipients in the current era. The steady improvement in survival during this period argues that advances in transplantation have offset the increasing acuity of transplant recipients.

History of mechanical circulatory support

End-stage heart failure exerts a tremendous impact on individuals and society in terms of personal and economic suffering. The development of mechanical circulatory support devices has been driven by the shortage of donor organs for heart transplantation. Collaborative efforts in the fields of surgery, medicine, and biomedical engineering, sponsored by both government and industry, have led to devices capable of providing reliable circulatory support. Future mechanical cardiac assist devices will likely play an important role in the treatment of an ever-growing population of patients with end-stage heart failure.

Susceptibility of Vespula vulgaris (Hymenoptera: vespidae) to generalist entomopathogenic fungi and their potential for wasp control

The pathogenicity of Vespula vulgaris wasp workers and larvae to a range of fungi was determined. All fungi were isolated in New Zealand and included isolates from Vespula, known generalist insect pathogens, and isolates generally nonpathogenic to insects. Workers and larvae were highly susceptible to pathogenic isolates at high spore concentrations (>1.75 x 10(5) cfu/individual). Eight isolates, two of Metarhizium anisopliae, five of Beauveria bassiana, and one of Aspergillus flavus were pathogenic while a single isolate of M. flavouiride var. novazealandicum, Cladosporium sp., and Paecilomyces sp. were not. The transfer of spores between workers, and between workers and larvae, was also investigated using several different application methods. Transfer of spores occurred between treated and untreated individuals, and for some of the application methods sufficient spores were transferred to cause mortality of the nontreated individuals. These findings are related to the potential of fungi for the control of wasps.

Prophylactic photopheresis and chronic rejection: effects on graft intimal hyperplasia in cardiac transplantation

BACKGROUND

Despite the decreased incidence of acute rejection episodes and improvements in short and intermediate term graft survival with current immunosuppressive agents, there has been little progress in decreasing the morbidity and mortality from chronic rejection. This phenomenon may, in part, be related to the development of a humoral immune response with increases in anti-HLA antibodies, which presents as accelerated graft arteriopathy with intimal hyperplasia.

METHODS

Based on prior experimental work, a pilot, prospective, randomized study was performed in 23 primary cardiac transplant recipients to determine whether the addition of prophylactic photopheresis to a cyclosporine, azathioprine and prednisone regimen was safe and resulted in decreased levels of panel reactive antibodies (PRA) and transplant arteriopathy.

RESULTS

There was no difference between the two groups in regard to infection or acute rejection incidence. The photopheresis group had a significant reduction in PRA levels at two time points within the first 6 postoperative months. Coronary artery intimal thickness was significantly reduced in the photopheresis group at 1-yr (0.23 vs. 0.49 mm, p < 0.04) and 2-yr (0.28 vs. 0.46 mm, p < 0.02) follow-up compared with the control group.

CONCLUSION

In this small pilot study, photopheresis is a safe, well-tolerated immunomodulatory technique that is capable of decreasing the severity of chronic rejection manifesting as post-transplant graft intimal hyperplasia.

Using faculty development to solve a problem of evaluation and management coding: a case study

Compliance with billing and coding rules put forth by the Health Care Finance Administration (HCFA) is a challenge for practicing physicians, including those in academic settings. The authors, members of the academic practice at Wayne State University School of Medicine, Department of Family Medicine, designed and delivered a comprehensive curriculum as part of the practice's faculty development initiative surrounding the coding challenge. The authors defined outcomes expected on the way to achieving 100% compliance with HCFA's guidelines. Their curriculum covered topics of coding theory, chart auditing for coding, team building, effective meetings, and structured problem solving. The curriculum was delivered from January to May 1998. Chart audits of 251 charts (office notes) from before the intervention and 263 charts from after the intervention were performed to evaluate differences in coding accuracy. Errors were significantly reduced. The total error rate dropped from 50.2% to 31.1% (p < .05). Overcoding errors were reduced by one third (29.1% versus 19.7%), while undercoding errors were reduced by half (16.3% versus 8.4%). Other errors fell from 4.7% to 3%. The approach of defining and developing work teams and then using standard quality improvement tools may be an effective way to improve compliance with HCFA billing and coding rules. In addition, faculty development can be incorporated into the process of solving a problem that faces a faculty.

The effects of self-hypnosis on quality of life following coronary artery bypass surgery: preliminary results of a prospective, randomized trial

The effects of complementary techniques and alternative medicine on allopathic therapies is generating much interest and research. To properly evaluate these techniques, well controlled studies are needed to corroborate the findings espoused by individuals practicing complementary medicine therapies. To this end, we evaluated the role of one of these therapies, self-hypnosis relaxation techniques, in a prospective, randomized trial to study its effects on quality of life after coronary artery bypass surgery. Subjects were randomized to a control group or a study group. Study group patients were taught self-hypnosis relaxation techniques the night prior to surgery. The control group received no such treatment. Patients then underwent routine cardiac management and care. The main endpoint of our study was quality of life, assessed by the Profile of Moods Scale. Results demonstrated that patients undergoing self-hypnosis the night prior to coronary artery bypass surgery were significantly more relaxed than the control group (p = 0.0317). Trends toward improvement were also noted in depression, anger, and fatigue. This study demonstrates the beneficial effects of self-hypnosis relaxation techniques on coronary surgery. This study also identifies endpoints and a study design that can be used to assess complementary medicine therapies. Results of this preliminary investigation are encouraging and demonstrate a need for further well-controlled studies.

Incidence of atrial fibrillation after mild or moderate hypothermic cardiopulmonary bypass

OBJECTIVES

Atrial fibrillation remains a significant source of morbidity after coronary artery bypass grafting (CABG). Whether cardiopulmonary bypass (CPB) temperature influences the occurrence of postoperative atrial fibrillation in CABG patients has not been specifically examined. In the present study, we reviewed postoperative data from patients who were prospectively randomized to mild or moderate hypothermic CPB for elective CABG to determine the incidence of postoperative atrial fibrillation.

DESIGN

Randomized, single center, observational study.

SETTING

Tertiary university medical center.

PATIENTS

Adults undergoing elective CABG surgery.

INTERVENTIONS

Enrolled patients were prospectively randomized to mild (34 degrees C [93.2 degrees F]) or moderate (28 degrees C [82.4 degrees F]) hypothermic CPB.

MEASUREMENTS AND MAIN RESULTS

The incidence of postoperative atrial fibrillation was determined by review of ICU and hospital records. There was a significantly higher incidence of atrial fibrillation in the moderate compared with the mild hypothermic CPB group. Patients who had postoperative atrial fibrillation were significantly older than those without atrial fibrillation. Furthermore, a significant increase in the relative risk of developing postoperative atrial fibrillation was found for both age and CPB temperature.

CONCLUSIONS

Our results indicate that the temperature of systemic cooling during CPB is an important factor in the development of atrial fibrillation after CABG surgery. In addition, this study confirms that increasing age is a significant determinant of postoperative atrial fibrillation.

Six-year experience of caring for forty-four patients with a left ventricular assist device at home: safe, economical, necessary

OBJECTIVE

With increasing numbers of implantations, left ventricular assist device programs can put a financial strain on a hospital unless an efficient and safe outpatient program is developed. However, the left ventricular assist device is not widely recognized in the medical community as being reliable enough to support a patient at home. We reviewed our experience with these patients at home to assess the safety and the benefits of such a program.

METHODS

Our institutional 6-year experience with 90 consecutive recipients of a wearable left ventricular assist device was analyzed.

RESULTS

Forty-four (49%) of the 90 patients who received TCI vented-electric left ventricular assist devices (Thermo Cardiosystems, Inc, Woburn, Mass) were discharged, spending a total of 4546 days (12.5 years) at home with an average of 103 +/- 16 days of outpatient support (range 9-436 days). Of these 44 patients, all were successfully bridged to transplantation (42 patients, 96%) or planned explantation (2 patients, 4%). None of the outpatients died. The cumulative events per outpatient month were 0.020 for bleeding, 0.053 for device infection, 0.0068 for thromboembolus, and 0.020 for major malfunctions. Our estimated average cost to bridge a patient to transplantation or explantation once discharged is $13,200 and as an inpatient over the same length of time, including only room and board, is $165,200. Thirty percent of outpatients were able to return to work or school, 33% to sexual activity, and 44% to driving. All outpatients performed activities of daily living.

CONCLUSION

Current left ventricular assist device technology provides effective and economical outpatient support and is associated with limited morbidity and a satisfactory quality of life.

Multicenter review of preoperative risk factors for stroke after coronary artery bypass grafting

BACKGROUND

Stroke complicates the postoperative course in 1% to 6% of patients undergoing coronary revascularization. There has been no large scale mandatory database reporting on the incidence of stroke after coronary revascularization.

METHODS

A multicenter regional database from the Bureau of Health Care Research Information Services, New York State Department of Health, on 19,224 patients who underwent coronary revascularization in 31 hospitals within New York State during 1995 was analyzed to determine the risk factors for postoperative stroke.

RESULTS

The incidence of postoperative stroke was 1.4% (n = 270). Hospital mortality for patients who had a stroke was 24.8%, compared with 2.0% for the rest of the patient population. Postoperative stroke increased the hospital length of stay threefold (27.9+/-1.9 versus 9.1+/-0.9 days, p<0.0001). Multivariable logistic regression identified the following variables to be significantly associated with a postoperative stroke: calcified aorta (p<0.0001; odds ratio [OR], 3.013), prior stroke (p = 0.0003; OR, 1.909), age (p<0.0001; OR, 1.522 per 10 years), carotid arterial disease (p = 0.002; OR, 1.590), duration of cardiopulmonary bypass (p = 0.0004; OR, 1.27 per 60 minutes), renal failure (p = 0.0062; OR, 2.032), peripheral vascular disease (p = 0.0157; OR, 1.62), cigarette smoking (p = 0.0197; OR, 1.621), and diabetes mellitus (p = 0.0158; OR, 1.373).

CONCLUSIONS

Postoperative stroke increases mortality and length of stay after coronary revascularization. Several risk factors can be identified, and some of these factors are potentially amenable to intervention, either before or during coronary revascularization, and should also influence patient selection.

Risk stratification for coronary bypass surgery in patients with left ventricular dysfunction: analysis of the coronary artery bypass grafting patch trial database

BACKGROUND

Preoperative characteristics may influence morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). The CABG Patch Trial was designed to assess the impact of prophylactic insertion of an implantable cardioverter-defibrillator in patients undergoing high-risk CABG. This database was used to investigate the influence of symptomatic congestive heart failure (CHF) and angina on morbidity and mortality in CABG patients with ventricular dysfunction.

METHODS AND RESULTS

Data were analyzed for 900 randomized patients with an ejection fraction </=35% and an abnormal signal-averaged ECG. Single-variable and stepwise multiple logistic regression analyses were used for mortality and length-of-stay (LOS) data. Severity of CHF and angina was graded by the New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications, respectively. Perioperative mortality was 3.5% in 454 patients without clinical signs of heart failure versus 7.7% in 443 patients with NYHA class I to IV heart failure (P=0.018). By multiple logistic regression analysis, mortality was significantly higher in patients with preoperative symptomatic (NYHA class I to IV) heart failure (odds ratio, 2.4; P=0.01) or reoperation (odds ratio, 3.8; P<0.0001). Mortality was not significantly influenced by age, sex, the presence or severity of angina, hypertension, left main coronary artery disease, pulmonary disease, or severity of CHF (although LOS was increased 0.7 days per NYHA class). Patients with a history of stroke had a higher rate of perioperative stroke (16.4% versus 3.6%, P=0.001) and an increased LOS (by 3.5 days).

CONCLUSIONS

Symptomatic heart failure and reoperation are predictors of increased operative mortality in patients with ventricular dysfunction and a positive signal-averaged ECG. Conversely, patients without heart failure symptoms may undergo CABG with relatively low mortality despite low ejection fraction. LOS is prolonged significantly by advanced age, history of stroke, and the presence and severity of heart failure.

Quantitative changes in T-cell populations after left ventricular assist device implantation: relationship to T-cell apoptosis and soluble CD95

BACKGROUND

Left ventricular assist devices (LVADs) are currently being evaluated as permanent therapy for end-stage heart failure. Because life-threatening infections limit successful long-term device implantation, we investigated the relationship between quantitative T-cell defects in LVAD recipients and CD95-mediated T-cell apoptosis.

METHODS AND RESULTS

Immunological studies were performed in NYHA class IV patients awaiting cardiac transplantation who received either a TCI Heartmate left ventricular assist device (LVAD) or medical management. Fluorochrome-labeled Mabs were used in T-cell phenotypic analyses. T-cell apoptosis was measured by annexin V binding of T cells cultured in medium for 24 hours. Circulating serum levels of soluble CD95 were measured by ELISA. LVAD recipients had a relative lymphopenia and reduction in CD4 T-cell levels compared with NYHA class IV heart failure controls. These observations were confirmed in a longitudinal study in LVAD recipients, which showed that device implantation was accompanied by progressive and sustained reductions in circulating CD4 T-cell levels. These abnormalities in LVAD recipients were accompanied by increased levels of circulating soluble CD95 and by excessive CD4 and CD8 T-cell apoptosis. Susceptibility to induction of apoptosis was >2-fold greater for CD4 T cells than for CD8 T cells.

CONCLUSIONS

These results suggest that the reduction in CD4 T-cell levels accompanying LVAD implantation is a consequence of an augmented pathway of CD95-mediated apoptosis. The clinical consequences of these abnormalities may include increased prevalence of systemic infections.

Cardiac transplantation for end-stage heart disease

In the nearly 30 years since the first successful human heart transplant, a variety of developments have allowed this form of cardiac replacement therapy to flourish. These have included improvements in surgical and critical care technology, as well as breakthroughs in immunosuppressive pharmacology, the most notable of which was the introduction of cyclosporine in 1980. Subsequently, indications and exclusion criteria for heart transplantation have evolved, guided by the constraints of a limited donor supply and facilitated by an improved understanding of prognostic risk factors. Current 1- and 5-year survival estimates are encouraging, and despite the frequency of acute rejection, current management strategies have, for the most part, limited the fatal consequences of this complication. Graft atherosclerosis, however, has continued to complicate the posttransplant course of many patients, and despite therapeutic strategies aimed at a variety of potential pathogenic mechanisms, this entity remains the most common cause of late death after transplantation. In these patients and other victims of allograft failure, retransplantation remains a viable option. Finally, the recent trend of selecting increasingly critically ill transplant recipients, although not associated with inferior survival, has driven the costs of this form of cardiac replacement therapy to unprecedented levels. These issues, as well as current developments in the fields of mechanical cardiac assistance, xenotransplantation, and cardiac gene therapy, will certainly result in a continually evolving role for cardiac transplantation in the treatment of end-stage heart disease.

Left ventricular assist device bridge-to-transplant network improves survival after failed cardiotomy

BACKGROUND

Postcardiotomy cardiogenic shock has been reported to occur following 2% to 6% of cardiac surgical procedures. Both the mandatory New York state cardiac surgery database and a voluntary ventricular assist device registry have reported hospital discharge rates of only 25% in postcardiotomy patients supported with ventricular assist devices. Although many centers have access to short-term mechanical cardiac assist devices, most lack a dedicated team which can resuscitate these critically ill patients. Equally important, these centers do not have easy access to effective cardiac replacement options, including implantable left ventricular assist devices (LVADs) and heart transplantation.

METHODS

A referral network based upon the use of implantable LVADs as a bridge to transplantation in patients with postcardiotomy heart failure was established in the New York City region. Cardiac surgery centers were encouraged to contact our center early following any failed cardiotomy.

RESULTS

Forty-four patients entered our postcardiotomy network: 12 recovered without an implantable LVAD, 23 received implantable LVADs, and six expired without long-term LVAD support. Of the 44 referrals, 29 (66%) survived to hospital discharge. Of the 23 patients receiving implantable LVADs, two recovered myocardial function and underwent LVAD explant, 14 were bridged to heart transplant, one underwent an emergent heart transplant, and six expired. Of the 23 implantable LVAD patients, 17 (74%) survived to hospital discharge.

CONCLUSIONS

Regional networks centered around bridge-to-transplant facilities that have an aggressive approach to implantable LVAD placement may substantially improve the survival rate of patients with postcardiotomy heart failure.

Reduction of retrosternal and pericardial adhesions with rapidly resorbable polymer films

BACKGROUND

The formation of postoperative cardiac adhesions makes a repeat sternotomy time consuming and dangerous. Many attempts have been made to solve this problem by using either drugs to inhibit fibrinolytic activity or different types of pericardial substitutes. The results have not been satisfactory.

METHODS

The efficacy of bioresorbable film prototypes made of polyethylene glycol (EO) and polylactic acid (LA) (EO/LA = 1.5, 2.5, and 3.0) in the prevention of adhesions after cardiac operations in canine models was tested. After desiccation and abrasion of the epicardium, a transparent bioresorbable film was placed over the heart. The pericardium was closed to allow intrapericardial adhesions (n = 32) or left open and attached to the chest wall to induce retrosternal adhesions (n = 17). Postoperative recovery was similar among the groups. Retrosternal and pericardial adhesions were evaluated at necropsy 3 weeks later by assessing area, tenacity, and density of the adhesions.

RESULTS

In the control dogs, tenacious, dense adhesions were observed. In contrast, adhesion formation was reduced at all sites covered by the films. The bioresorbable films were efficacious in the reduction of adhesion formation between epicardium and pericardium or between epicardium and sternum after cardiac operation. The EO/LA 1.5 film most effectively prevented the early adhesions.

CONCLUSIONS

The bioresorbable films (EO/LA = 1.5, 2.5, and 3.0) significantly reduced adhesion formation, with EO/LA = 1.5 (Repel CV) being optimal. As the barrier was rapidly resorbed, the capsule formation induced by permanent barriers was avoided.

Time-dependent cellular population of textured-surface left ventricular assist devices contributes to the development of a biphasic systemic procoagulant response

OBJECTIVE

Textured-surface left ventricular assist devices (LVAD) have been shown to enhance ventricular function and survival in patients with end-stage heart failure. Furthermore, we have described a procoagulant physiology in our LVAD population with sustained thrombin generation (elevated thrombin-antithrombin III complex and prothrombin fragment 1+2) and fibrinolysis (D-dimers), even up to 335 days after LVAD placement. To explain such sustained activation of coagulation, we speculated that the LVAD surface selectively adsorbed and promoted activation of circulating blood cells.

METHODS

In a prospective study of 20 patients with LVADs, we examined samples of peripheral blood as well as cells harvested from the surface of the LVADs at the time of their explantation for procoagulant proinflammatory markers.

RESULTS

Analysis of the cells populating the LVAD surface revealed the presence of pluripotent hematopoietic CD34(+) cells, as well as cells bearing monocyte (CD14)/macrophage (CD68) markers, which also expressed procoagulant tissue factor. Reverse transcriptase-polymerase chain reaction confirmed cellular activation on the LVAD surface, revealing transcripts for interleukin 1alpha, interleukin 2, and tumor necrosis factor alpha, in addition to vascular cell adhesion molecule-1 consistent with their capacity to continually recruit and activate circulating cells, thereby propagating their response. In the periphery, elevated levels of tissue factor were found in the plasma of patients with LVADs, along with enhanced procoagulant activity.

CONCLUSION

These observations suggest that the LVAD surface selectively absorbs and activates circulating hematopoietic precursor and monocytic cells, thereby creating a sustained prothrombotic and potentially proinflammatory systemic environment.

Activation-induced T-cell death and immune dysfunction after implantation of left-ventricular assist device

BACKGROUND

Cardiac transplantation is a limited option for end-stage heart failure because of the shortage of donor organs. Left-ventricular assist devices (LVADs) are currently under investigation as permanent therapy for end-stage heart failure, but long-term successful device implantation is limited because of a high rate of serious infections. To examine the relation between LVAD-related infection and host immunity, we investigated immune responses in LVAD recipients.

METHODS

We compared the rate of candidal infection in 78 patients with New York Heart Association class IV heart failure who received either an LVAD (n=40) or medical management (controls, n=38). Fluorochrome-labelled monoclonal antibodies were used in analyses of T-cell phenotype. Analysis of T-cell function included intradermal responses to recall antigens and proliferative responses after stimulation by phytohaemagglutinin, monoclonal antibodies to CD3, and mixed lymphocyte culture. We measured T-cell apoptosis in vivo by annexin V binding, and confirmed the result by assessment of DNA fragmentation. Activation-induced T-cell death was measured after T-cell stimulation with antibodies to CD3. All immunological tests were done at least 1 month after LVAD implantation. Between-group comparisons were by Kaplan-Meier actuarial analysis and Student's t test.

FINDINGS

By 3 months after implantation of LVAD, the risk of developing candidal infection was 28% in LVAD recipients, compared with 3% in controls (p=0.003). LVAD recipients had cutaneous anergy to recall antigens and lower (<70%) T-cell proliferative responses than controls after activation via the T-cell receptor complex (p<0.001). T cells from LVAD recipients had higher surface expression of CD95 (Fas) (p<0.001) and a higher rate of spontaneous apoptosis (p<0.001) than controls. Moreover, after stimulation with antibodies to CD3, CD4 T-cell death increased by 3.2-fold in LVAD recipients compared with only 1.2-fold in controls (p<0.05).

INTERPRETATION

LVAD implantation results in an aberrant state of T-cell activation, heightened susceptibility of CD4 T cells to activation-induced cell death, progressive defects in cellular immunity, and increased risk of opportunistic infection.

Arginine vasopressin in the management of vasodilatory hypotension after cardiac transplantation

Vasodilatory hypotension requiring the administration of catecholamine pressors may occur following cardiopulmonary bypass. We investigated the hemodynamic response to arginine vasopressin (AVP) in 20 patients who developed vasodilatory hypotension after cardiac transplantation. In this cohort, AVP infusion (0.1 U/min) significantly increased mean arterial pressure and decreased norepinephrine requirements, allowing rapid discontinuation of norepinephrine infusions in 7 patients. Judicious use of this novel agent in appropriately selected patients may minimize end-organ sequelae of hypotension and high-dose catecholamine therapy.

100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience

BACKGROUND

The use of left ventricular assist devices (LVADs) as bridge to transplantation is now accepted as a standard of care for a subset of end-stage heart failure patients. Our interim experience with both pneumatically and electrically powered ThermoCardiosystems LVADs is presented to outline the benefits and limitations of device support as well as discuss its potential role as bridge to recovery and as destination therapy.

METHODS AND RESULTS

Detailed records were kept prospectively for all patients undergoing LVAD insertion. One hundred LVADs were inserted over 7 years into 95 patients, with an overall survival rate of 75% and a transplantation rate of 70%. Four patients underwent device explant for recovered myocardial function. Three patients received LVADs as destination therapy in the ongoing REMATCH (Randomized Evaluation of Mechanical Assist Treatment for Congestive Heart failure) trial. Overall mean patient age was 51 years, and mean duration of support was 108 days. There were 25 device-related infections including the drive line, device pocket, and blood-contacting surfaces. Cerebral vascular accidents and other embolic events occurred in 7 patients with six deaths. There were four device malfunctions and nine graft-related hemorrhages, resulting in six reoperations and three deaths.

CONCLUSIONS

The use of long-term implantable LVADs will likely not be limited to bridge to transplantation. The REMATCH trial has commenced to study the role LVADs may have as an alternative to medical management. Furthermore, as the issues of myocardial recovery are examined, the "bridge to recovery" may be an important additional role for these assist devices.

A randomized double-blind study of the effect of triiodothyronine on cardiac function and morbidity after coronary bypass surgery

BACKGROUND

Although triiodothyronine deficiency has been described after cardiopulmonary bypass, data supporting its use have been conflicting. A double-blind, randomized, placebo-controlled study was undertaken to further define the effect of triiodothyronine on hemodynamics and outcome after coronary artery bypass grafting.

METHODS

A total of 170 patients undergoing elective coronary artery bypass grafting were enrolled and completed the study from November 1996 through March 1998. On removal of the aortic crossclamp, patients were randomized to receive either intravenous triiodothyronine (0.4 microgram/kg bolus plus 0.1 microgram/kg infusion administered over a 6-hour period, n = 81) or placebo (n = 89). Outcome variables included hemodynamic profile and inotropic drug/pressor requirements at several time points (mean +/- standard error of the mean), perioperative morbidity (arrhythmia/ischemia/infarction), and mortality.

RESULTS

Despite similar baseline characteristics, patients randomized to triiodothyronine had a higher cardiac index and lower inotropic requirements after the operation. Subjects receiving triiodothyronine demonstrated a significantly lower incidence of postoperative myocardial ischemia (4% vs 18%, P =.007) and pacemaker dependence (14% vs 25%, P =.013). Seven patients in the placebo group required postoperative mechanical assistance (intra-aortic balloon pump, n = 4; left ventricular assist device, n = 3), compared with none in the triiodothyronine group (P =.01). There were 2 deaths in the placebo group and no deaths in the triiodothyronine group.

CONCLUSIONS

Parenteral triiodothyronine given after crossclamp removal during elective coronary artery bypass grafting significantly improved postoperative ventricular function, reduced the need for treatment with inotropic agents and mechanical devices, and decreased the incidence of myocardial ischemia. The incidence of atrial fibrillation was slightly decreased, and the need for postoperative pacemaker support was reduced.

The REMATCH trial: rationale, design, and end points. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure

BACKGROUND

Because left ventricular assist devices have recently been approved by the Food and Drug Administration to support the circulation of patients with end-stage heart failure awaiting cardiac transplantation, these devices are increasingly being considered as a potential alternative to biologic cardiac replacement. The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial is a multicenter study supported by the National Heart, Lung, and Blood Institute to compare long-term implantation of left ventricular assist devices with optimal medical management for patients with end-stage heart failure who require, but do not qualify to receive cardiac transplantation.

METHODS

We discuss the rationale for conducting REMATCH, the obstacles to designing this and other randomized surgical trials, the lessons learned in conducting the multicenter pilot study, and the features of the REMATCH study design (objectives, target population, treatments, end points, analysis, and trial organization).

CONCLUSIONS

We consider what will be learned from REMATCH, expectations for expanding the use of left ventricular assist devices, and future directions for assessing clinical procedures.

Long-term survival after cardiac retransplantation: a twenty-year single-center experience

OBJECTIVE

To identify risk factors for survival after cardiac retransplantation and compare the survival after retransplantation with that after primary cardiac transplantation.

METHODS

A retrospective analysis of 952 patients undergoing cardiac transplantation for the treatment of end-stage heart disease at a single center between 1977 and October 1997. Of these, 43 patients (4.5%) underwent cardiac retransplantation for cardiac failure resulting from transplant-related coronary artery disease, rejection, and early graft failure.

RESULTS

No significant difference in actuarial patient survival was found by Kaplan-Meier analysis at 1, 2, and 5 years between patients undergoing primary transplantation and those undergoing retransplantation 76%, 71%, and 60% versus 66%, 66%, and 51%, respectively (P =.2). Multivariable analysis identified a shorter interval between transplants and an initial diagnosis of ischemic cardiomyopathy as significant risk factors for death after retransplantation (P =.04 and.03, respectively). Since 1993, when our criteria for patient selection for retransplantation were revised on the basis of earlier experience to exclude patients with allograft dysfunction as a result of primary graft failure and those with intractable acute rejection occurring less than 6 months after transplantation, the survival has been significantly better (<1993 = 45%, 45%, and 33% versus >/=1993 = 94%, 94%, and 94% at 1, 2, and 4 years, respectively, P =.003).

CONCLUSION

The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation, especially in patients with transplant-related coronary artery disease. Patient characteristics and other preoperative variables should assist in the rational application of retransplantation to ensure optimal use of donor organs.

Teaching practice management during residency

BACKGROUND AND OBJECTIVES

Practice management is a required component in family practice residency education. A few studies have reported that recently graduated primary care physicians indicated that their practice management training was inadequate. Our study describes the current nature of practice management education in family practice residencies and the perceptions of residency directors about the effectiveness of their program's practice management curriculum.

METHODS

Surveys were mailed to 421 family practice residency directors, who were asked about their program's curriculum approach to teaching practice management, as well as their evaluation of the effectiveness of the curriculum. After two mailings, 213 surveys (51%) were returned.

RESULTS

Eighteen percent of the respondents provided less than the required 60 hours of practice management curricular time. Residency directors indicated that managed care has had a significant effect on their curriculum. Directors' ratings of the effectiveness of their curriculum were associated with more curricular time and specifically with active learning activities. Although directors reported that managed care had affected how they teach practice management, managed care penetration was not associated with perceived curriculum effectiveness.

CONCLUSIONS

Family practice residency program directors described a variety of approaches to teaching practice management. Active learning strategies seem to be important curricular components, although further study is needed about the most-effective methods to prepare physicians for post-residency practice.

Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use of a novel pressor agent

BACKGROUND

Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure.

METHODS

Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m2, and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively.

RESULTS

Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 +/- 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements.

CONCLUSIONS

Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.

Evidence for unconscious memory processing during elective cardiac surgery

BACKGROUND

Many anesthetic drugs have been shown to disrupt conscious recall (explicit memory) in volunteers. However, unconscious processing (implicit memory) of intraoperative auditory material may occur during general anesthesia and may provide an opportunity for intraoperative therapeutic intervention. In this study, we examined patients undergoing elective cardiac surgery for evidence of intraoperative implicit and explicit memory.

METHODS AND RESULTS

Twenty-five subjects provided written informed consent and underwent general anesthesia and cardiopulmonary bypass for cardiac surgery. During the operation, patients were randomized to receive 1 of 2 different audiotapes of associated word pairs. Postoperatively, a blinded observer conducted a standardized interview to determine the extent of intraoperative implicit and explicit memory. With the use of free association, significant intraoperative implicit memory was found. In contrast, no patient had spontaneous or directed recall of intraoperative events, and we did not find evidence of intraoperative explicit memory with a recognition task.

CONCLUSIONS

Patients undergoing general anesthesia for cardiac surgery were reliably able to reinforce associations between word pairs solely on the basis of their intraoperative presentation. This provides further evidence that patients are capable of processing intraoperative auditory information.

Selective anticoagulation with active site-blocked factor IXA suggests separate roles for intrinsic and extrinsic coagulation pathways in cardiopulmonary bypass

BACKGROUND

Multiple stimuli converge in cardiopulmonary bypass to create a tremendous prothrombotic stimulus. The ideal anticoagulant for cardiopulmonary bypass should selectively target only the intravascular stimuli, thereby eliminating pathologic clotting in the bypass circuit while preserving hemostasis in the thoracic cavity. We propose the inhibition of factor IX as such a targeted anticoagulant strategy.

METHODS

We prepared an inhibitor of activated factor IX and applied it to a primate model of cardiopulmonary bypass to confirm the anticoagulant efficacy of activated factor IX in this setting and to assess more subtle markers of thrombin generation, macrophage procoagulant activity, and cellular tissue factor expression. Seven baboons that received activated factor IX (460 microg/kg) and 7 that received heparin (300 IU/kg) and protamine underwent cardiopulmonary bypass for 90 minutes and were followed after the operation for 3 hours.

RESULTS

Analysis of plasma factor IX activity demonstrated adequate inhibition (<20%) of factor IX throughout cardiopulmonary bypass. Activated factor IX-treated baboons demonstrated similar circuit patency to heparin-treated baboons but had significantly diminished intraoperative blood loss. Preservation of extravascular hemostasis was further demonstrated in activated factor IX-treated animals by (1) significantly increased levels of thrombin-antithrombin III complex and prothrombin activation peptide (F1+2) without intravascular thrombosis, (2) significantly greater macrophage procoagulant activity in pericardial-derived monocytes, and (3) immunohistochemical evidence of tissue factor expression in pericardial mesothelial cells and macrophages.

CONCLUSIONS

Anticoagulation with activated factor IX allows for intravascular anticoagulation with maintenance of extravascular hemostasis. These findings suggest activated factor IX as an agent that not only exemplifies a targeted approach to selective anticoagulation in cardiac surgery but also further characterizes the procoagulant milieu during cardiopulmonary bypass.

Treatment of chronic suppurative otitis media with topical ciprofloxacin

To date, only ofloxacin has been approved by the US Food and Drug Administration for treatment of ears with a nonintact tympanic membrane. The purpose of this study was to determine the safety and efficacy of topical ciprofloxacin hydrochloride in the treatment of experimental chronic suppurative otitis media caused by Pseudomonas aeruginosa infection in cynomolgus monkeys. Forty adult cynomolgus monkeys were divided into 4 equal groups, and their ears were challenged with P aeruginosa, drained for 3 weeks, then treated twice daily for 4 weeks with 1 of 4 randomly assigned agents: 1) ciprofloxacin, 2) saline, 3) Cortisporin, or 4) vehicle. The animals were followed up with auditory brain stem response testing, culture, otoscopy, and histopathology. Both ciprofloxacin and Cortisporin treatment resulted in a significantly more rapid rate of clearance of P aeruginosa as compared to treatment with saline (100% versus 20%). Eradication was not associated with resolution of otorrhea after a 4-week period of treatment. There were no significant changes in auditory brain stem response wave latencies for any of the treatment groups. Histopathologic data revealed that there was no statistically significant difference in the amount of outer hair cell loss for the ciprofloxacin group as compared to the control ear and other treatment groups. We conclude, therefore, that topical ciprofloxacin is not ototoxic and is effective in sterilizing the otorrhea, but does not promote resolution of the drainage, in this animal model.

Cost-effectiveness of coronary artery bypass surgery in octogenarians

OBJECTIVE

The objective of this retrospective cohort study was to determine whether coronary artery bypass graft (CABG) surgery is effective and cost-effective relative to medical management of coronary artery disease (CAD) in the elderly.

SUMMARY BACKGROUND DATA

The aging of the U.S population and the improvements in surgical techniques have resulted in increasing numbers of elderly patients who undergo this surgery. The three randomized, controlled trials (RCTs) that established the efficacy of CABG surgery completed patient enrollment from 19 to 24 years ago excluded patients older than 65 years. Although information regarding outcomes of CABG in this population is mainly available in case series, a major lacuna exists with respect to information on quality of life and cost effectiveness of surgery as compared with medical management.

METHODS

The authors retrospectively formed surgical and medically managed cohorts of octogenarians with significant multivessel CAD. More than 600 medical records of patients older than 80 years who underwent angiography at our institution were reviewed to identify 48 patients who were considered reasonable surgical candidates but had not undergone surgery. This cohort was compared with 176 patients who underwent surgery.

RESULTS

The cost per quality-adjusted life year saved was $10,424. At 3 years, survival in the surgical group was 80% as compared with 64% in the entire medical cohort and 50% in a smaller subset of the medical cohort. Quality of life in patients who underwent surgery was measurably better than that of the medical cohort with utility index scores, as measured by the EuroQoL, (a seven-item quality of life questionnaire) of 0.84, 0.61, and 0.74, respectively.

CONCLUSIONS

Performing CABG surgery in octogenarians is highly cost-effective. The quality of life of the elderly who elect to undergo CABG surgery is greater than that of their cohorts and equal to that of an average 55-year-old person in the general population.

Preformed IgG antibodies against major histocompatibility complex class II antigens are major risk factors for high-grade cellular rejection in recipients of heart transplantation

BACKGROUND

Preformed anti-HLA antibodies reacting specifically with donor lymphocytes have been associated with acute vascular rejection and early cardiac allograft failure. However, the effect of preformed anti-HLA antibodies directed against allogeneic major histocompatibility complex (MHC) class I or II antigens of a donor panel on heart transplantation outcome has not been extensively studied.

METHODS AND RESULTS

The study group consisted of 68 patients who received cardiac transplants between 1989 and 1996 and who were at high risk for developing anti-HLA antibodies before transplantation. The effect of preformed antibodies against allogeneic MHC class I or class II antigens on the development of early high-grade cellular rejection and on cumulative annual rejection frequency was determined. Both patients with left ventricular assist devices and retransplantation candidates had a similar increase in the frequency of IgG anti-MHC class II antibodies (IgG anti-II) compared with control subjects (P<0.0001), whereas the frequency of IgG anti-MHC class I antibodies (IgG anti-I) was elevated only in patients with left ventricular assist devices. Pretransplantation IgG anti-II predicted early development of high-grade cellular rejection (P=0.006) and higher cumulative annual rejection frequency (P<0.001) in both of these sensitized patient groups. Among retransplantation recipients, a match between donors 1 and 2 at HLA-A additionally predicted an earlier time to a high-grade cellular rejection.

CONCLUSIONS

These results emphasize the importance of specifically screening heart transplantation candidates for the presence of IgG antibodies directed against MHC class II molecules and suggest that strategies aimed at their reduction may have an impact on the onset and frequency of high-grade cellular rejections after transplantation.