Listeria grayi bacteremia in a heart transplant recipient

Bacteria belonging to the genus Listeria have been isolated from food products of animal, plant, and fish origin, and are associated with infections in immunocompromised hosts, pregnant women, and infants. The species Listeria grayi has rarely been reported as a human pathogen. It has a unique antibiotic sensitivity profile. We describe a case of L. grayi bacteremia in a heart transplant recipient. The organism demonstrated a reduced sensitivity to ampicillin. The patient was successfully treated with a combination of vancomycin and ciprofloxacin.

Extrinsic compression of the left main coronary artery in pulmonary hypertension

Compression of the left main coronary artery by a dilated pulmonary artery can be a life-threatening condition. It can present with angina, symptoms of left ventricular dysfunction, and sudden death. Diagnosis and treatment of this condition is very important. We demonstrate significant compression of the left main coronary artery on coronary angiography and thorax CT examinations.

Development of an ambulatory artificial lung in an ovine survival model

We are developing an artificial lung (AL) as an eventual bridge to lung transplant or recovery. The device is rigidly housed, noncompliant, and has a very low resistance to blood flow. In eight sheep, arterial cannulae were anastomosed end-to-side to the proximal and distal main pulmonary artery, and attached to the AL. A pulmonary artery snare between anastomoses diverted full pulmonary blood flow through the AL. Eight of eight sheep survived the preparation. Mean pressure gradient across the AL was 8 mm Hg (3 Wood units; 8 mm Hg/2.8 L/min). Four of eight sheep tolerated immediate full diversion of blood flow and died at 24 and 40 hours (exsanguination) or 168 and 168 hours (elective sacrifice). Four of eight sheep were intolerant of full flow: two died of right heart failure at <8 hours with full flow through the device (full snare); the other two survived with partial device flow (partial snare), but the device clotted. These two then underwent successful closed-chest cannula thrombectomy and device change-out at 53 and 75 hours, and subsequently tolerated full flow. Long-term (up to 7 day) survival with complete diversion of pulmonary blood flow through a non-compliant, low-resistance AL is possible. Initial right heart failure in this model was 50% (4 of 8).

Improved right heart function with a compliant inflow artificial lung in series with the pulmonary circulation

BACKGROUND

We previously reported a 50% incidence of immediate right heart failure using a rigidly housed, noncompliant inflow artificial lung in series with the pulmonary circulation in a healthy ovine survival model. Three device modifications resulted: (1) an inflow cannula compliance chamber, (2) an inlet blood flow separator, and (3) modification of the artificial lung outlet geometry, all to reduce resistance and mimic the compliance of the pulmonary vascular bed.

METHODS

In 7 sheep, arterial grafts were anastomosed end-to-side to the proximal and distal main pulmonary artery, with the paracorporeal artificial lung interposed. A pulmonary artery snare between anastomoses diverted full pulmonary blood flow through the artificial lung for up to 72 hours.

RESULTS

Six of 7 sheep exhibited good cardiac function throughout the test period: mean central venous pressure was 6.8 mm Hg (range, 4 to 11 mm Hg), mean cardiac output, 4.17 +/- 0.12 L/min (range, 2.4 to 6.3 L/min); before and after device mean pulmonary arterial pressure, 21.8 and 18.5 mm Hg, and left atrial pressure, 10.8 mm Hg.

CONCLUSIONS

This modified artificial lung prototype with an inflow compliance chamber, blood flow separator, and modified outlet geometry has greatly improved cardiac function and initial survival in our healthy ovine model.

Development of an implantable artificial lung: challenges and progress

Unlike dialysis, which functions as a bridge to renal transplantation, or a ventricular assist device, which serves as a bridge to cardiac transplantation, no suitable bridge to lung transplantation exists. Our goal is to design and build an ambulatory artificial lung that can be perfused entirely by the right ventricle and completely support the metabolic O2 and CO2 requirements of an adult. Such a device could realize a substantial clinical impact as a bridge to lung transplantation, as a support device immediately post-lung transplant, and as a rescue and/or supplement to mechanical ventilation during the treatment of severe respiratory failure. Research on the artificial lung has focused on the design, mode of attachment to the pulmonary circulation, and intracorporeal versus paracorporeal placement of the device.

Anatomic study of the pulmonary artery as a conduit for an artificial lung

Our group is developing an artificial lung as a bridge to transplant. We evaluated the sheep pulmonary artery (PA) for the presence or absence of a septum, which may increase PA resistance and affect artificial lung flow. We also measured the PA size to determine whether it is a suitable conduit for artificial lung implantation using a PA-PA shunt. Adult Suffolk ewes in two groups were studied. Group 1 consisted of animals (n = 12, 30-43 kg) prepared for thoracotomy. Group 2 (n = 21, 30-43 kg) consisted of postmortem dissections. In both groups, the length and girth of the PA was measured. The heart and lungs were removed on all postmortem animals (group 2), the ductus arteriosum was crosscut, and the common PA was incised. The average length of the PA in live animals was 5.5 cm and the average diameter was 2.2 cm. The average length of the PA in postmortem animals was 4.8 cm and the average diameter was 2.0 cm. All pulmonary arteries were aseptate, and the ligamentum arteriosum in each PA was not patent. We conclude that the PA is not a source of increased resistance and is a suitable conduit for artificial lung implantation in the PA-PA configuration.

Technique of controlled reperfusion of the transplanted lung in humans

BACKGROUND

Reperfusion injury remains a significant and sometimes fatal problem in clinical lung transplantation. Controlled reperfusion of the transplanted lung using white cell-filtered, nutrient-enriched blood has been shown recently to significantly ameliorate reperfusion damage in a porcine model. We modified this experimental technique and applied it to human lung transplantation.

METHODS

Approximately 1,500 mL of arterial blood was slowly collected in a cardiotomy reservoir during the lung implant, and mixed to make a 4:1 solution of blood:modified Buckberg perfusate. This solution was passed through a leukocyte filter and into the transplant pulmonary artery for 10 minutes, at a controlled rate (200 mL/min) and pressure (less than 20 mm Hg), immediately before removal of the vascular clamp.

RESULTS

Five patients underwent lung transplantation (1 bilateral, 4 single lung) using this technique. All patients were ventilated on a 40% fraction of inspired oxygen within a few hours and extubated on or before the first postoperative day.

CONCLUSIONS

Controlled reperfusion of the transplanted lung with white cell-filtered, nutrient-enriched blood has given excellent functional results in our small initial clinical series.

Heart donation after lightning strike

We present the first reported case of heart donation after lightning strike. Approximately 150 to 300 generally young and healthy people die from lightning strike in the United States each year. These unfortunate victims may make good heart donors. Pertinent pathophysiology of lightning strike is briefly reviewed.

Automatic internal cardioverter-defibrillator patch erosion into the upper airway presenting as a cavitary lesion

Erosion of an automatic internal cardioverter-defibrillator (AICD) patch into the lingular bronchus occurred 4 years after implantation; the erosion presented as a cavitary mass associated with hemoptysis and weight loss. On bronchoscopy to evaluate for suspected carcinoma, a cavity was entered through a bronchial defect and the AICD patch clearly identified. The complication was successfully treated with patch removal and fistula closure.

Torn ascending aorta missed by transesophageal echocardiography

Transesophageal echocardiography has become a commonly used screening tool for traumatic tears of the descending aorta. The role of transesophageal echocardiography for ascending aortic tears is not yet well-defined. We report an ascending aortic tear imaged by aortography but missed on transesophageal echocardiography.

Adverse effects of postoperative infusion of shed mediastinal blood

BACKGROUND

Postoperative infusion of shed mediastinal blood has been used in an effort to decrease blood usage after cardiac operations. Recent experience has suggested that this practice may actually lead to a delayed increase in bleeding.

METHODS

In a prospective, randomized study, 40 patients undergoing coronary artery bypass grafting with shed mediastinal blood collected in a cardiotomy reservoir were divided into two equal groups and studied during their first 4 hours in the intensive care unit. Shed mediastinal blood was directly infused in group I (n = 20), whereas in group II (n = 20), it was not. In group II, if a sufficient volume of red cells was present to allow processing (n = 5), washed red cells were infused. Variables studied before and after infusion were the amount of blood lost and infused, homologous blood transfused, complete blood count and differential, serum fibrinogen, fibrin split products, D-dimers, clotting factors, prothrombin time, activated partial thromboplastin time, thromboelastograms, plasma-free hemoglobin, complement factors C3 and C4, creatine kinase and its MB isoenzyme, and body temperature.

RESULTS

After infusion of shed mediastinal blood, elevated levels of fibrin split products and D-dimers were found in significantly more patients in group I. The thromboelastogram index was normal in 76% of patients in group II but in only 12.5% in group I. Group I also had an increase in band neutrophils, a greater number of febrile patients, higher serum levels of creatine kinase, its MB isoenzyme, and plasma-free hemoglobin, and greater blood loss during hours 3, 4, and 5 in the intensive care unit. The volume of red cells in shed mediastinal blood (hematocrit, 9% to 10%) was small, resulting in clinically insignificant autotransfusion when infused directly, and insufficient for cell processing in most patients.

CONCLUSIONS

These data support those in previous studies that direct infusion of shed mediastinal blood does not save substantial amounts of autologous red cells and can cause a delayed coagulopathy and other adverse effects that may be harmful to patients postoperatively.

Transient ischemia cannot precondition the rabbit heart against postischemic contractile dysfunction

BACKGROUND

The rat heart is preconditioned against postischemic contractile dysfunction by a brief period of transient ischemia before a prolonged ischemic period. However, the rabbit heart does not receive such cardio-protection from pretreatment with a single transient ischemia periods. We hypothesized that in the rabbit heart, a multiple cycle of transient ischemia is required to reach a threshold necessary to precondition against postischemic contractile dysfunction.

METHODS

To test this hypothesis, we subjected isolated, perfused rabbit hearts to either one 5-minute transient ischemic period or three 5-minute transient ischemic periods followed by a 40-minute period of warm ischemia and 30 minutes of reperfusion. Control hearts (no pretreatment with transient ischemia) were examined simultaneously. Left ventricular developed pressure was measured with an intraventricular balloon.

RESULTS

Postischemic recoveries (expressed as percent of preischemic values) of left ventricular developed pressure for the group with one ischemic period and the group with three ischemic periods were 43% +/- 5% (n = 5) and 38% +/- 6% (n = 6), respectively. These values were not significantly different from control values.

CONCLUSIONS

Neither one nor three periods of transient ischemia protect the isolated, perfused rabbit heart from postischemic contractile dysfunction. Therefore, the rabbit heart may not have the capacity to be ischemically preconditioned against postischemic contractile dysfunction.

Simple technique of left heart bypass

Left heart bypass is typically established by left atrial appendage cannulation. We report a technique using inferior pulmonary vein cannulation, which is technically simpler. We have used this technique in 20 cases with reliable venous inflow.

Simplified technique of heart-lung transplantation

Well-known complications of heart-lung transplantation include mediastinal bleeding and phrenic nerve injury. Conventional technique places the hila behind the phrenic nerves. We have placed the hila in front of the phrenic nerve in our last 10 patients, using direct caval anastomoses when feasible. This minimizes traction on and dissection around the phrenic nerves, and allows anterior rotation of the heart-lung block for easier hemostasis of the posterior mediastinum after implantation.