Development and usability testing of a multi-criteria value clarification methods for patients with localized prostate cancer

Current guidelines for the development of decision aids recommend that they have to include a process for helping patients clarify their personal values, for example, by using values clarification methods. In this article, we extensively described the development process of the web-based values clarification method for patients with localized low- to intermediate-risk prostate cancer based on the analytic hierarchy process. With analytic hierarchy process, the relative importance of different attributes of available treatments can be determined through series of pairwise comparisons of potential outcomes. Furthermore, analytic hierarchy process is able to use this information to present respondents with a quantitative overall treatment score and can therefore give actual treatment advice upon patients’ request. The addition of this values clarification method to an existing web-based treatment decision aid for patients with localized prostate cancer is thought to improve the support offered to patients in their decision-making process and their decision quality.

Developing a shared decision support framework for aortic root surgery in Marfan syndrome

OBJECTIVE

The study is an early phase of development of a decision support framework for people with Marfan syndrome who are anticipating prophylactic aortic root surgery. Implications of the timing and the nature of the operation chosen were previously elicited in focus groups. In this step, we explored the range of relative values placed by individuals on the implications of decisions made about surgery.

METHODS

Following the principles of the Ottawa Decision Support Framework, eight questions in the general form 'How important is it to you …' were framed by a panel. Marfan people, families and specialist doctors answered online. Quantitative and qualitative analyses were performed.

RESULTS

Worldwide, 142 responses were received including 25 specialist doctors. Respondents were 55% female and 46% had previous aortic root surgery. Overall, active lifestyle was more important to males (p=0.03). Patients placed more importance than doctors on not deferring surgery (p=0.04) and on avoidance of anticoagulation in the interests of childbearing (p=0.009). Qualitative analysis showed differing but cogently reasoned values that were sometimes polarised, and mainly driven by the wish to maintain a good quality of life and active lifestyle.

CONCLUSIONS

Given the cogency of these viewpoints, people anticipating root replacement surgery should have ample opportunity to express them and to have them acknowledged ahead of a consultation when they can then be fully explored in a mutually informed forum. If they differ from local medical practice, they can then be discussed in the process of reaching shared and individualised decisions.

Specific requirements for bloodless cardiopulmonary bypass in neonates and infants; a review

A miniaturized cardiopulmonary bypass circuit enables the safe performance, in selected pediatric patients, of bloodless open heart surgery. As the latest survival rates in neonatal and infant cardiac surgery have become satisfactory, investigators have concentrated upon the improvement of existing procedures. Institutional guidelines and multidisciplinary efforts undertaken in the pre- and postoperative periods are of great importance, concerning bloodless CPB and should be seriously pursued by all involved caregivers.

This review reflects upon the selective, most relevant requirements for success of asanguinous neonatal and infant CPB: acceptable level of hemodilution during the CPB, patient preoperative hematocrit value and volume of CPB circuit. We present an assessment of practical measures that were also adapted in our institution to achieve an asanguinous CPB for neonatal and infant patients.

New Trends and Developments in Patients with Severe Aortic Stenosis – Towards Optimal Treatment?

Over the next few decades the number of patients diagnosed with aortic stenosis is expected to rise as the population ages and the use of several diagnostic tools expands. This will result in a growing need for both medical and surgical treatment and stimulate the development of new diagnostic and surgical techniques. This article briefly describes the prevalence, pathogenesis and clinical presentation of patients with aortic stenosis and focuses on developments in diagnostic tools, treatment strategies and treatment modalities: the use of echocardiography, tissue Doppler imaging, stress testing and biomarkers is discussed, as well as timing of surgery and the role microsimulation can play in prosthesis selection. Furthermore, newly developed transcatheter valve implantation techniques and their possible role in treating ‘inoperable’ or ‘elderly’ patients are discussed.

The effect of open lung ventilation on right ventricular and left ventricular function in lung-lavaged pigs

INTRODUCTION

Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and high positive end-expiratory pressure, aiming at minimizing atelectasis. The minimization of atelectasis reduces the right ventricular (RV) afterload, but the increased intrathoracic pressures used by OLC ventilation could increase the RV afterload. We hypothesize that when atelectasis is minimized by OLC ventilation, cardiac function is not affected despite the higher mean airway pressure.

METHODS

After repeated lung lavage, each pig (n = 10) was conventionally ventilated and was ventilated according to OLC in a randomized cross-over setting. Conventional mechanical ventilation (CMV) consisted of volume-controlled ventilation with 5 cmH2O positive end-expiratory pressure and a tidal volume of 8-10 ml/kg. No recruitment maneuvers were performed. During OLC ventilation, recruitment maneuvers were applied until PaO2/FiO2 > 60 kPa. The peak inspiratory pressure was set to obtain a tidal volume of 6-8 ml/kg. The cardiac output (CO), the RV preload, the contractility and the afterload were measured with a volumetric pulmonary artery catheter. A high-resolution computed tomography scan measured the whole lung density and left ventricular (LV) volumes.

RESULTS

The RV end-systolic pressure-volume relationship, representing RV afterload, during steady-state OLC ventilation (2.7 +/- 1.2 mmHg/ml) was not significantly different compared with CMV (3.6 +/- 2.5 mmHg/ml). Pulmonary vascular resistance (OLC, 137 +/- 49 dynes/s/cm5 versus CMV, 130 +/- 34 dynes/s/cm5) was comparable between groups. OLC led to a significantly lower amount of atelectasis (13 +/- 2% of the lung area) compared with CMV (52 +/- 3% of the lung area). Atelectasis was not correlated with pulmonary vascular resistance or end-systolic pressure-volume relationship. The LV contractility and afterload during OLC was not significantly different compared with CMV. Compared with baseline, the LV end-diastolic volume (66 +/- 4 ml) decreased significantly during OLC (56 +/- 5 ml) ventilation and not during CMV (61 +/- 3 ml). Also, CO was significantly lower during OLC ventilation (OLC, 4.1 +/- 0.3 l/minute versus CMV, 4.9 +/- 0.3 l/minute).

CONCLUSION

In this experimental study, OLC resulted in significantly improved lung aeration. Despite the use of elevated airway pressures, no evidence was found for a negative effect of OLC on RV afterload or LV afterload, which might be associated with a loss of hypoxic pulmonary vasoconstriction due to alveolar recruitment. The reductions in the CO and in the mean pulmonary artery pressure were consequences of a reduced preload.

Is the use of albumin in colloid prime solution of cardiopulmonary bypass circuit justified?

BACKGROUND

Albumin in the priming solution precoats the surface of the cardiopulmonary bypass circuit, supposedly causing delayed adsorption of fibrinogen and reduced activation and adhesion of platelets. This action may result in lower transoxygenator resistance. Because our institution uses a colloidal prime solution (Gelofusine), questions were raised about the value of albumin in the prime solution. We decided to focus on the clinical effects of transoxygenator resistance.

METHODS

Sixty adults undergoing elective cardiac operations were randomly divided into three groups: a group with 20-g albumin (n = 20), a group with 2-g albumin (n = 20), and a group with no albumin (n = 20) in the 1,600-mL colloidal prime. Patients older than 75 years and patients with a preoperative serum albumin level of 30 g/L or less were excluded. The transoxygenator resistance was measured throughout cardiopulmonary bypass. Beta-thromboglobulin levels were used to study contact activation of platelets. Measures of prothrombin F1,2 fragments were used as a marker of thrombin generation. Body surface area, age, preoperative albumin, hematocrit, hemoglobin, fibrinogen, platelet count, and colloid osmotic pressure levels were compared between groups.

RESULTS

Base line characteristics and chosen control measurements were similar for all three populations. When comparing the observed transoxygenator resistance among the three different groups, no significant differences were noted. Prothrombin F1.2 fragments remained low for all the groups without significant differences. In the no-albumin group the level of beta-thromboglobulin appeared to be higher, but the difference was not statistically significant.

CONCLUSIONS

Addition of albumin to prime solution in a cardiopulmonary bypass circuit that already contains colloids does not affect the transoxygenator resistance of the COBE Duo flat sheet oxygenator and does not affect prothrombin F1.2 and beta-thromboglobulin levels. Therefore additional costs for the albumin are not justified. Measurement of transoxygenator resistance is a reliable, simple method to determine the effects of a prime solution on the oxygenator surface in vivo.

Is there a place for pediatric valvotomy in the autograft era?

OBJECTIVE

Valvotomy and the autograft procedure are the most common surgical treatment options for children with valvular aortic stenosis. We evaluated the results of these surgical procedures in our institution.

METHODS

Retrospective analysis was done of all patients presenting with aortic stenosis and operated upon before the age of 18. In 11 patients a valvotomy was performed and in 36 an autograft procedure.

RESULTS

There was no hospital mortality. Mean follow-up in the valvotomy group was 4.8 years (SD 3.3), in the autograft group 4.5 years (SD 3.3). During follow-up one patient died suddenly 2 months after valvotomy. Two patients in the autograft group died (not valve-related). After valvotomy three patients underwent a balloon valvotomy, in one followed by an autograft procedure and one patient had a repeat valvotomy. In the autograft group one patient was reoperated for severe aortic regurgitation and moderate pulmonary stenosis. At last echocardiography after valvotomy (eight remaining patients) in only two patients (25%) no aortic stenosis or regurgitation was present. In the remaining six patients aortic stenosis is mild in two and moderate in three, including one with moderate aortic regurgitation. In one patient without stenosis, moderate aortic regurgitation was seen. No pulmonary stenosis or regurgitation is present. Echocardiography after autografting (33 remaining patients) showed no aortic stenosis. Aortic regurgitation was mild in seven patients, moderate in two, severe in one. Pulmonary stenosis was present in two patients (16%). Pulmonary regurgitation was mild in three patients and moderate in one.

CONCLUSIONS

In selected patients with valvular aortic stenosis who are beyond infancy, valvotomy may be adequate and may postpone further surgery for a significant length of time. After valvotomy the main problem is residual aortic stenosis while after autografting a shift occurs to aortic regurgitation and problems related to the pulmonary valve. Careful clinical and echocardiographic follow-up is therefore warranted in young patients after the autograft procedure.

Estimated event-free life expectancy after autograft aortic root replacement in adults

BACKGROUND

Autograft aortic root replacement is an established therapeutic option for young adults with aortic valve disease. Unfortunately, most series are small with a limited follow-up. Meta-analysis and microsimulation modeling were used to predict long-term outcome based on currently available midterm data.

METHODS

We combined our center's experience with autograft aortic root replacement in 85 adult patients in a meta-analysis with reported results of three other hospitals. The outcomes of this meta-analysis were entered in a microsimulation model, calculating (event-free) life expectancy after autograft aortic root replacement.

RESULTS

The pooled results comprised 380 patients with a total follow-up of 1,077 patient-years. Mean age was 37 years (range 16 to 68 years). Male/female ratio was 2.7. Operative mortality was 2.6% (n = 10); during follow-up 6 more patients died. Linearized annual risk estimates were 0.5% for thromboembolism, 0.3% for endocarditis, and 0.4% for nonstructural valve failure. Structural autograft failure requiring reoperation occurred in 5 patients, and a Weibull function was constructed accordingly. Using this information, the microsimulation model predicted age- and gender-specific mean, reoperation-free, and event-free life expectancy.

CONCLUSIONS

Based on current evidence the calculated average autograft-related reoperation-free life expectancy is 16 years. The combination of meta-analysis and microsimulation provides a promising and powerful tool for estimating long-term outcome after aortic valve replacement.

Human tissue valves in aortic position: determinants of reoperation and valve regurgitation

BACKGROUND

Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography.

METHODS AND RESULTS

In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age <40 years was the only independent predictor of aortic regurgitation.

CONCLUSIONS

Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults.

Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation

BACKGROUND

Bioprostheses are widely used as an aortic valve substitute, but knowledge about prognosis is still incomplete. The purpose of this study was to provide insight into the age-related life expectancy and actual risks of reoperation and valve-related events of patients after aortic valve replacement with a porcine bioprosthesis.

METHODS AND RESULTS

We conducted a meta-analysis of 9 selected reports on stented porcine bioprostheses, including 5837 patients with a total follow-up of 31 874 patient-years. The annual rates of valve thrombosis, thromboembolism, hemorrhage, and nonstructural dysfunction were 0.03%, 0.87%, 0.38%, and 0.38%, respectively. The annual rate of endocarditis was estimated at 0.68% for >6 months of implantation and was 5 times as high during the first 6 months. Structural valve deterioration was described with a Weibull model that incorporated lower risks for older patients. These estimates were used to parameterize, calibrate, and validate a mathematical microsimulation model. The model was used to predict life expectancy and actual risks of reoperation and valve-related events after implantation for patients of different ages. For a 65-year-old male, these figures were 11.3 years, 28%, and 47%, respectively.

CONCLUSIONS

The combination of meta-analysis with microsimulation enabled a detailed insight into the prognosis after aortic valve replacement with a bioprosthesis for patients of different ages. This information will be useful for patient counseling and clinical decision making. It also could serve as a baseline for the evaluation of newer valve types.

Right ventricular outflow tract reconstruction with an allograft conduit

BACKGROUND

Allograft conduits are used for reconstruction of the right ventricular outflow tract in patients with congenital heart disease and in the pulmonary autograft procedure. A retrospective evaluation of our experience with the use of allograft conduits for reconstruction of the right ventricular outflow tract was conducted.

METHODS

Between August 1986 and March 1999, 316 allografts (246 pulmonary, 70 aortic) were implanted in 297 patients for reconstruction of the right ventricular outflow tract. Main diagnostic groups were aortic valve pathology (n = 112, 35%), tetralogy of Fallot (n = 71, 22%), and pulmonary atresia with ventricular septal defect (n = 46, 14%). Kaplan-Meier analyses were done for survival, valve-related reoperation, and valve-related events. In addition, Cox regression analysis was used for evaluation of potential risk factors.

RESULTS

Mean age at operation was 18 years (range, 7 days to 61 years). Mean follow-up was 4 years (range, 2 days to 12 years). Twelve patients (4%) died within 30 days after operation. Patient survival was 90% (95% confidence interval [CI], 86% to 94%) at 5 years and 88% (95% CI, 83% to 94%) at 8 years. Twenty-four reoperations were required for allograft dysfunction in 23 patients; 21 allografts were replaced. Freedom from valve-related reoperation was 91% (95% CI, 86% to 95) at 5 years and 87% (95% CI, 81% to 93%) at 8 years. Twenty-nine valve-related events were reported (2 deaths, 24 reoperations, 2 balloon dilatations, and 1 endocarditis). Freedom from valve-related events was 90% (95% CI, 85% to 94%) at 5 years after implantation, and 84% (95% CI, 77% to 91%) at 8 years. Risk factors for accelerated allograft failure were extra-anatomic position of the allograft (p = 0.03; hazard ratio, 9.7) and the use of an aortic allograft (p = 0.02; hazard ratio, 2.4).

CONCLUSIONS

Right ventricular outflow tract reconstruction with an allograft conduit has good medium-term results, although progression of allograft degeneration is noted. Aortic allografts should preferably not be used for reconstruction of the right ventricular outflow tract.

Results of primary two-patch repair of complete atrioventricular septal defect

OBJECTIVE

The policy of primary repair of complete atrioventricular septal defect (CAVSD), using a two-patch technique, was evaluated with special attention to the risk of implantation of a prosthetic atrioventricular (AV) valve.

METHODS

From 1986 to 1999, all 97 patients who underwent primary repair for CAVSD were included in a retrospective analysis. Seventy-five patients (75%) had Down's syndrome. Preoperative echocardiographic AV valve regurgitation was absent or limited in 85 (88%), moderate in seven (7%) and severe in five (5%). Fifty-six patients (58%) were on diuretics, six (6%) on artificial ventilation and four (4%) were on inotropic support. The mean age at operation was 10.2 months (SD, 16.4), with a mean weight of 5.9 kg (SD, 3.7).

RESULTS

Early mortality comprised three patients (4%), and late mortality two patients. Follow up was complete and comprised 402 patient-years (mean, 4.5 years; SD, 3.2). The cumulative survival at 10 years was 93% (95% CI, 89-97%). Multivariate analysis with regard to mortality revealed no associations with any of the analyzed factors. Eight patients were reoperated, all for regurgitant left AV valve. The reoperation-free survival at 10 years was 83% (95% CI, 75-91%). Multivariate analysis with regard to reoperation showed being on preoperative diuretics to be a decreasing risk factor (Odd's Ratio (OR), 0.13; 95% CI, 0.00-0. 99; P=0.005) and significant postoperative left AV valve regurgitation to be an increasing risk factor (OR, 9.90; 95% CI, 1. 90-53.0; P=0.001). Only one prosthetic valve was implanted (annual linearized risk of 0.002/patient-year). At the latest follow up of the surviving patients, left AV valve regurgitation was absent or limited in 83 (90%) and moderate in nine (10%). Right AV valve regurgitation was absent or limited in all 92 (100%) patients. All surviving patients are thriving well, seven (8%) of whom are on diuretics.

CONCLUSIONS

Primary repair of CAVSD with a two-patch technique, including cleft closure of the left AV valve, has good clinical and functional results without problems for the right-sided AV valve. The need for prosthetic valve implantation for the left AV valve is minimal.

Progressive pulmonary autograft root dilatation and failure after Ross procedure

We present a case of progressive pulmonary autograft root dilatation and subsequent failure after a Ross procedure. The explanted autograft vessel wall revealed striking histologic findings indicative of chronic media rupture. Examination of another explanted pulmonary autograft root showed similar histologic changes, suggesting a common phenomenon in pulmonary autograft roots. It may be the cause of progressive root dilatation as observed after Ross operations.

Left coronary pressure-flow relations of the beating and arrested rabbit heart at different ventricular volumes

OBJECTIVE

To study the effect of cardiac contraction on left coronary artery pressure-flow relations at different vascular volumes and to compare these relations in the beating heart with those in the heart arrested in systole and diastole.

METHODS

Maximally vasodilated, Tyrode perfused, rabbit hearts (n = 6) with an intra-ventricular balloon were used. The left coronary artery was separately perfused via a cannula in the left main coronary artery. The slopes and the intercepts of left coronary pressure-flow relations were determined in the beating and arrested heart at different chamber volumes. A 3-factor design with repeated measures was used to compare the effect of three factors: phase of contraction (systole and diastole), chamber volume (V0 and V1, left ventricular end-diastolic pressure 1.4 and 20 mm Hg, respectively) and the type of contraction (beating and arrested; a measure of capacitive effects).

RESULTS

The phase of contraction has a significant effect on the intercepts (> 40 mmHg, p = 0.00032) but not on the slopes of the pressure-flow relations. Chamber volume had a small effect on the intercepts (< 5 mm Hg, p = 0.037), but not on the slopes of the pressure-flow relations. The type of contraction has a significant effect on the slopes (approximately 10%, p = 0.00021) but not on the intercepts of the pressure-flow relations.

CONCLUSIONS

In the isolated Tyrode perfused rabbit heart left coronary pressure-flow relations are mainly determined by contraction, while left ventricular chamber volume and capacitive effects contribute little.

Heart transplantation with bicaval and pulmonary venous anastomoses. A hemodynamic analysis of the first 117 patients

BACKGROUND

A new surgical technique for orthotopic heart transplantation has been introduced into clinical practice. It accomplishes total atrioventricular transplantation as the recipient's atria are completely excised and the allograft is implanted using bicaval and pulmonary venous anastomoses.

MATERIALS AND METHODS

We retrospectively analyzed post-transplant hemodynamic and patient survival in our first 117 patients transplanted with this new operative approach and compared them with 64 patients transplanted with the standard biatrial technique.

RESULTS

Patients transplanted with the bicaval technique had a significantly lower right atrial mean, pulmonary arterial systolic, pulmonary arterial mean, and pulmonary capillary wedge pressures. In addition, a significant reduction in post-transplant tricuspid regurgitation and a trend towards less severe mitral regurgitation was observed. The need for permanent pacemaker implantation due to sinus node dysfunction after transplantation was completely eliminated with this new technique. Thirty-day operative survival and actuarial survival at 1, 2, 3, and 4 years was significantly greater in patients transplanted with the bicaval technique.

CONCLUSIONS

Orthotopic heart transplantation performed with bicaval and pulmonary venous anastomoses offers improved post-transplant hemodynamics, eliminates the need for permanent pacemaker, and has improved patient survival when compared with the standard biatrial technique. These differences can be related in part to improved hemodynamic function of the cardiac allograft due to preservation of the anatomic configuration and physiologic function of the atria.

The effect of chronic alcohol use on the heart before and after transplantation in an experimental model in the rat

BACKGROUND

Alcohol has potential deleterious effects on donor heart function. This study was conducted in rats to determine whether long-term alcohol ingestion produces impaired hemodynamic performance while maintaining a normal left ventricular ejection fraction in donor hearts before transplantation and whether donor cardiac function is affected after heart transplantation.

METHODS

Rats fed 30% alcohol in their drinking water for 12 weeks were compared with rats fed a normal diet. Left ventricular ejection fraction was measured by echocardiography with Simpson and single plane Dodge formulas in living sedated rats after 10 and 12 weeks of alcohol feeding. Explanted heart function was assessed before and 3 days after heterotopic heart transplantation (no immunosuppression) with a Langendorff preparation.

RESULTS

Blood ethanol levels at 4 and 8 weeks were 0.08 +/- 0.04 and 0.08 +/- 0.09 gm/dl. Left ventricular ejection fraction was similar in the group fed an alcohol diet for 12 weeks when compared with the control group (65.4% +/- 1.6% vs. 66.5% +/- 2.9%, p = 0.33). Explanted alcohol-fed hearts before transplantation had significantly lower maximum and developed pressures and had a blunted response to 0.1 ml 10(-9) mol/L isoproterenol. After transplantation alcohol-fed hearts had significantly lower maximum and developed pressures and decreased maximum rates of pressure rise and pressure decline. Allografts (ACI to Lewis) exhibited decreased function in comparison with isografts (ACI to ACI).

CONCLUSIONS

Alcohol feeding for 12 weeks in rats does not affect pretransplantation left ventricular ejection fraction, but it impairs explanted heart function, both before and after transplantation, resulting in a subclinical cardiomyopathy that is worsened by the presence of allograft rejection. Long-term alcohol exposure and rejection have independent, additive detrimental effects on left ventricular performance of the transplanted heart. Alcohol-exposed hearts may not be suitable donors.

The duration of administration of monoclonal antibody OKT3 for induction immunosuppression after heart transplantation

The effective treatment of refractory allograft rejection with murine antihuman monoclonal antibody muromonab-CD3 (OKT3) and of patients with renal dysfunction has led to its use as induction therapy. The optimal protocol for OKT3 prophylaxis remains to be established. We compared 59 patients consecutively transplanted with the total orthotopic technique between 1/92 and 5/94. The first 21 patients were treated with OKT3 for 14 days, the next 19 for 10 days, and the last 19 for 7 days. Patients operated with different surgical techniques or other induction treatment were excluded. We compared length of stay (total and ICU), time to first rejection, rejection incidence and infection incidence (cytomegalovirus separately), and survival. Preoperative characteristics were similar except for significantly younger age in the 10-day group (p = 0.04). Preoperative hemodynamic parameters were similar except for a significantly higher left-ventricular ejection fraction (21%) in the 7-day group. Length of stays in the ICU and hospital were similar for the three groups (p = NS). Freedom from cellular rejection was lower with the 7 days course (p = 0.02), but freedom from humoral rejection was slightly higher (p = 0.11). However, patients in the 7-day group required treatment for rejection less frequently than patients in the other two groups (95% untreated at 2 months vs. 43% in the 14-day and 53% in the 10-day group; p = 0.002). There were no differences in incidence of infections, including cytomegalovirus. Survival was similar between the groups. There was one death in the 14-day and 1 in the 10-day group, both due to rejection. In conclusion, OKT3 therapy can be reduced safely to 7 days with a higher overall incidence of rejection but no increased necessity to treat for rejection, and no difference in infection incidence.

Resting hemodynamics after total versus standard orthotopic heart transplantation in patients with high preoperative pulmonary vascular resistance

OBJECTIVE

Pretransplant pulmonary vascular resistance > or = 4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires longer ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemodynamics in pts with high preoperative pulmonary vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart transplantation transplanted between 12/88 and 7/94. Of these, 18 with total and 15 with standard orthotopic heart transplantation had a preoperative pulmonary vascular resistance > or = 4 Wood-units.

METHODS

Right heart catheterization data were obtained at each endomyocardial biopsy. All data from biopsies at both 2 weeks and 1 year posttransplant that were free from humoral or greater than 1A cellular rejection (9 versus 13 pts) were included in a two way ANOVA. Pts with postop pacemakers, atrial fib or beta-blocker therapy at the time of biopsy were excluded.

RESULTS

Ischemic time was different (172 +/- 44 versus 142 +/- 28 min, P = 0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output and index were higher in the total orthotopic group at 2 weeks (6.5 +/- 1.7 versus 5.1 +/- 1.0 l/min; 3.4 +/- 0.9 versus 2.8 +/- 0.6 l/min per m2) and 1 year (7.1 +/- 2.0 versus 4.9 +/- 1.1 l/min, P = 0.002; 3.6 +/- 1.1 versus 2.6 +/- 0.5 l/min per m2, P = 0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orthotopic heart transplantation at 2 weeks (6 +/- 4 versus 9 +/- 5, P = 0.04; 22 +/- 3 versus 25 +/- 7, P = 0.1) and 1 year (5 +/- 2 versus 7 +/- 3, P = 0.02; 19 +/- 4 versus 25 +/- 7, P = 0.03). Pulmonary capillary wedge pressure (mmHg) was borderline nonsignificant (11 +/- 4 versus 13 +/- 7 at 2 weeks, 8 +/- 3 versus 14 +/- 5 at 1 year, P = 0.055), as well as pulmonary vascular resistance (1.9 +/- 1 versus 2.5 +/- 1 at 2 weeks, 1.5 +/- 0.6 versus 2.7 +/- 1.7 WU at 1 year, P = 0.051).

CONCLUSIONS

Total orthotopic heart transplantation improves cardiac output and index in pts with high preoperative pulmonary vacular resistance. There is a lower mean RA and PA pressure perhaps due to less tricuspid and mitral regurgitation. In view of the frequently observed restrictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsided by preserving atrioventricular synchrony and offering better atrial transport.

Heart transplantation in patients with diabetic end-organ damage before transplantation

Diabetes mellitus with preexisting end-organ damage (EOD) is considered a contraindication for heart transplantation. The outcome of such patients has not been well characterized. Among 138 patients transplanted between 12/88 and 7/94, 29 were diabetic (11 insulin-dependent); of these, 12 had preexisting EOD, defined as a creatinine clearance < or = 50 ml/min, a 24-hour urine protein concentration > or = 500 mg/L or typical symptoms of peripheral or autonomic polyneuropathy, and 17 had no EOD. We compared diabetics with and without EOD and non-diabetics (n = 109) for operative mortality, length of stay, serum creatinine, fasting glucose levels, and postoperative prednisone doses at 1,6, and 12 months. Actuarial survival and freedom from rejection and infection were analyzed. Both diabetic groups were significantly older than nondiabetics, Ischemic time, operative mortality, surgical technique, ICU- and total length of stay were similar. Actuarial survival and freedom from rejection were similar among the three groups. Infection rates including CMV did not differ. Serum creatinine levels increased in all groups compared to pretransplant levels (p = 0.001), but without significant differences among the groups. Post-transplant glucose levels at 6 and 12 months were higher for diabetic patients with EOD than for those without or for nondiabetics (183, 153, and 94 mg/dl at 6 months, p = 0.01; 202, 161, and 102 mg/dl at 12 months, p = 0.0001). Prednisone dosage was lower in diabetics with EOD at 6 months, but did not differ among the three groups at 12 months. The incidence of angiographically proven transplant vasculopathy did not differ at 1 and 2 years. Diabetics with preexisting EOD undergoing heart transplantation experience similar short- and intermediate-term results when compared to diabetics without EOD and nondiabetics. Metabolic control is more difficult to achieve, as indicated by higher fasting glucose levels. Larger and longer-term prospective studies have to confirm our findings, since the shortage of donor organs would increase if such patients were transplanted routinely.

Heart transplantation in patients 70 years of age and older: initial experience

BACKGROUND

Heart transplantation has become a highly successful therapeutic option for patients with end-stage cardiomyopathy. Consequently, the criteria for patient selection, particularly regarding recipients' upper age limits, have been expanded, with an increasing number of people older than 60 years of age now undergoing transplantation.

METHODS

A retrospective analysis of 6 patients 70 years of age and older who underwent heart transplantation was done; their clinical courses and outcomes were compared with those of younger patients, with a special emphasis on their posttransplantation quality of life.

RESULTS

All 6 patients are alive and clinically well at a mean follow-up of 12 months. No age-related complications have been observed, and their quality of life is excellent. There has been a very low incidence of rejection, as well as few episodes of rejection.

CONCLUSIONS

Heart transplantation in selected people 70 years of age and older can be performed successfully with a morbidity comparable to that seen in younger patients and excellent short-term survival. This initial experience is encouraging, but further studies and long-term follow-up are needed to validate the more routine application of this therapy.

Heart transplantation in patients 65 years of age and older: a comparative analysis of 40 patients

BACKGROUND

Advanced age has traditionally been considered a relative contraindication to heart transplantation because of the potential for increased morbidity and decreased long-term survival.

METHODS

We analyzed the results in 40 patients 65 years of age and older who underwent heart transplantation and compared them with those in 138 patients younger than 65 years.

RESULTS

The older age group had a higher incidence of diabetes mellitus (p = 0.01), donor-recipient weight mismatch (< 0.80) (p = 0.004), lower donor-recipient weight ratio (p = 0.02), and longer allograft ischemic time (p = 0.008), among other differences. However, the 30-day operative mortality was similar in both groups (2.5% in older versus 2.2% in younger patients). Actuarial survival at 12, 24, and 36 months was not statistically different between the older and younger patients (86% +/- 6% versus 93% +/- 2%, 78% +/- 8% versus 89% +/- 3%, and 72% +/- 9% versus 81% +/- 4%, respectively; p = 0.26). The posttransplantation intensive care unit stay, total hospital stay, and associated hospital costs were also similar. The incidence of rejection during the first posttransplantation year was similar in both groups.

CONCLUSIONS

Heart transplantation in selected patients 65 years of age and older can be performed successfully, with a morbidity and mortality comparable with those seen in younger patients. Advanced age should not be an exclusion criterion for heart transplantation, but selective criteria should be applied that identify risks and benefits individually.

Resting hemodynamics after total versus standard orthotopic heart transplantation

Total orthotopic heart transplantation (TOHT) requires longer surgery than standard orthotopic heart transplantation (SOHT), but offers normal anatomy and synchronous atrial contraction. We endeavored to test whether TOHT improves resting hemodynamics. We analyzed 60 patients with SOHT and 66 with TOHT transplanted between 12/89 and 7/94. Age, preoperative NYHA class, ejection fraction, and donor characteristics were similar. After applying exclusion criteria at 2 weeks postoperatively, 53 SOHT and 58 TOHT patients were accepted for further study. Right-heart hemodynamics were examined at 2 weeks and 6 months posttransplant. Despite a longer ischemic time (161 +/- 36 vs. 142 +/- 37 min, p = 0.004), cardiac output and index were higher in the TOHT group at 2 weeks (6.1 +/- 1.4 vs. 5.4 +/- 1.0 L/min, TOHT vs. SOHT, p = 0.01; and 3.3 +/- 0.7 vs. 2.9 +/- 0.6 L/min/m2, p = 0.005) but similar at 6 months (5.9 +/- 1.2 vs. 5.6 +/- 1.4 L/min; and 3.0 +/- 0.6 vs. 2.9 +/- 0.7 L/min/m2). Right-atrial pressure was lower with TOHT at both time points (7 +/- 4 vs. 9 +/- 4 mmHg, p = 0.02: and 5 +/- 2 vs. 7 +/- 3, p = 0.0006). Wedge pressure was similar at 2 weeks (12 +/- 5 vs. 13 +/- 5, p = 0.045). Heart rate (bpm) was higher at both time points with TOHT (84 +/- 10 vs. 75 +/- 12, p = 0.0003: and 90 +/- 12 vs. 82 +/- 9, p = 0.0006). Pulmonary vascular resistance was similar at both time points. Despite a longer ischemic time, total orthotopic heart transplantation does not impair postoperative cardiac function. There is an early improvement in cardiac output, a sustained higher heart rate reflecting preservation of donor sinus node function, and a lower right-atrial pressure.

Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation

BACKGROUND

Careful donor and recipient selection are important factors for the success of heart transplantation. Currently, donors with a history of alcohol use are routinely accepted despite the potential deleterious effects of alcohol on the heart.

METHODS

We examined the frequency of chronic alcohol use (> 2 ounces of pure alcohol daily for > or = 3 months) among organ donors and the outcome of the receipients after heart transplantation. Of 99 consecutive patients who underwent transplantation between December 1988 and August 1993 with an adequate donor history, 17 (17%) had a history of chronic alcohol use (alcohol group), and 82 (83%) did not (nonalcohol group). All recipients received triple-drug immunosuppression, and 10 to 14 days of OKT3.

RESULTS

Survival rates at 1 and 2 years were significantly lower in the alcohol group (61% +/- 13% and 61$ +/- 13%) than in the nonalcohol group (95% +/- 3% and 91% +/-4%, p = 0.0001). Most deaths in the alcohol group occurred within 3 months after transplantation. The incidence of rejection episodes did not differ significantly. Fatal rejection occurred more frequently in the alcohol group and was associated with severe ventricular dysfunction before death. Cox multiple regression analysis identified donor alcohol use as an independent risk factor for death after heart transplantation.

CONCLUSIONS

A substantial proportion (17%) of heart donors have a history of chronic alcohol use. The unfavorable early outcome of patients receiving hearts from alcoholic donors suggests the presence of a subclinical alcoholic cardiomyopathy before transplantation and poor tolerance of rejection episodes after transplantation. Larger prospective studies are needed to determine the mechanism of fatal rejection and whether such hearts can be used safely for transplantation.

Survival of acute intestinal infarction after cardiac transplantation

We report the case of a 52-year-old male who underwent total orthotopic heart transplantation for end-stage ischemic cardiomyopathy. The postoperative course was complicated by acute intestinal infarction which was diagnosed after surgical exploration, and treated with a subtotal colectomy with Brooke ileostomy and closure of the distal sigmoid three days posttransplant. The patient survived with nutritional support and broad antibiotic prophylaxis. Review of the literature on acute abdominal complications after operations involving cardiopulmonary bypass suggests that such complications are usually fatal. Detection and diagnosis may be obscured and treatment complicated by immunosuppression after cardiac transplantation. Because of the poor prognosis without appropriate management, a high level of suspicion, early and aggressive diagnostic measures, and swift surgical intervention are essential to survival.

Heart transplantation after repair of postinfarction ventricular septal defect

A 68 year-old man underwent surgical repair of a ventricular septal defect following an acute myocardial infarction. Recurrent interventricular septal rupture with significant left-to-right shunting led to progressive deterioration in cardiac function and intractable heart failure. The patient underwent orthotopic heart transplantation three months after his initial operation, and he is clinically well sixteen months after transplantation.

Heart transplantation for Chagas' cardiomyopathy

We present 2 patients who underwent orthotopic heart transplantation for end-stage Chagas' cardiomyopathy. Despite immunosuppressive therapy, postoperative prophylaxis with nifurtimox appeared to prevent Trypanosoma cruzi reactivation. Neither patient has shown signs of Chagas' myocarditis, and both are clinically well 12 and 72 months after transplantation. The successful outcome of our patients suggests that heart transplantation is a reasonable therapeutic option in patients with end-stage Chagas' cardiomyopathy.

Permanent pacemaker for rejection episodes after heart transplantation: a poor prognostic sign

BACKGROUND

The development of arrhythmias early or late after heart transplantation has been associated with acute and chronic rejection. This study aims to document the importance of this relationship and its value as a prognostic sign in those patients who required a permanent pacemaker for rejection episodes.

METHODS

A retrospective analysis of 158 orthotopic heart transplantations performed in 157 patients between December 1988 and April 1995 was done. The clinical course and the outcome of 6 patients who underwent insertion of a permanent pacemaker for bradyarrhythmias caused by acute or chronic allograft rejection were compared with the course and outcome of 9 patients who had pacemaker placement as a result of sinus node dysfunction not associated with rejection.

RESULTS

The mortality rate was 100% for patients whose indication for permanent pacing was severe acute or chronic rejection. Conversely, 8 of the 9 patients who underwent pacemaker placement for sinus node dysfunction not associated with rejection are long-term survivors; the one late death was due to a noncardiac cause.

CONCLUSIONS

We observed a strong relationship between bradyarrhythmias requiring a permanent pacemaker and severe acute or chronic allograft rejection. This association suggests a poor prognosis and indicates that these patients should be managed aggressively. Such management includes close immunologic surveillance for cellular and humoral rejection, increased frequency of endomyocardial biopsies and coronary angiography, and early consideration for retransplantation.

[Cholelithiasis in children. Case report and literature review]

A case of a child with asymptomatic, idiopathic cholelithiasis is presented. Epidemiologic features, etiology, symptoms, diagnosis and therapy of gallstones in childhood are discussed.