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Reperfusion is the key strategy in acute ST-segment elevation myocardial infarction (STEMI) care, and it is time-dependent. Shortening the time from symptom to reperfusion and choosing the optimal reperfusion strategy for STEMI patients are great challenges in practice. We need to improve upon the problems of low reperfusion rate, non-standardized treatment, and economic burden in STEMI care. This article briefly reviews the current status of reperfusion strategy in STEMI care, and also introduces what we will do to bridge the gap between the guidelines and implementation in the clinical setting through the upcoming China STEMI early reperfusion program.

Objective: To study the effect and implication of nonmyeloablative donor specific bone marrow (DSBM) infusion on the immunoreaction of liver allotransplantation., Methods: Orthotopic liver transplantation model was used in this study. Groups were set as follows: Group I, syngeneic control (Wistar-to-Wistar); Group II, acute rejection (SD-to-Wistar); Group III, acute rejection treated with cyclosporine A (CsA) by intramuscular injection (SD-to-Wistar+CsA); Group IV, bone marrow infusion at 7 d pretransplantation followed by short-term CsA treatment (SD-to-Wistar+DSBM); Another group of short-term CsA treatment preoperatively without bone marrow infusion was also set as control. General characteristics and survival time were observed. Histological grades of rejection were determined by pathological examination. IL-2 and IFN-gamma level in peripheral blood and donor liver were detected respectively by Enzyme-Linked Immuno-Sorbent Assay (ELISA) and Western blot. Chimerism of donor cells was measured by PCR for a male-specific marker (Y-chromosome-specific sequence, Sry)., Results: No signs of rejection were found in Group I. Acute rejection occurred in both Group II and the short-term CsA treated group. All the recipients died at (9-15) d posttransplantation with a median survival time of (10.7+/-0.5) d and (11.2+/-2.4) d, respectively. Only mild rejection could be seen in Group III. In Group IV, 4 out of 6 recipients had long-term survival (>100 d), the histological grade of rejection was significantly lower than that of Group II, so did the expression level of IL-2 and IFN-gamma in both peripheral blood and grafted liver. Y-chromosome-specific sequence (Sry) of male SD rats could be detected in the bone marrow, spleen and thymus of female recipients at 15 d after bone marrow infusion., Conclusion: Mild preconditioning nonmyeloablative donor specific bone marrow infusion can enhance chimerism formation in recipients, alleviate the rejection of liver allotransplantation and prolong survival of liver allotransplantation.

Objective: To investigate the gene expression of 4-1BB in peripheral blood mononuclear cells (PBMCs) and its possible significance in clinical liver transplantation., Methods: Reverse transcription-polymerase chain reaction (RT-PCR) was used to determine the gene expression of 4-1BB in PBMCs from 22 patients receiving liver transplantation, 13 patients with primary liver carcinoma (PLC), and 12 healthy controls. To determine whether 4-1BB molecule is also expressed on the surface of CD4+ and CD8+ T cell, flow cytometry was used to analyse the phenotype of T cell subsets from the blood of liver transplantation patients., Results: 4-1BB mRNA was detected in PBMCs from stable survivors after liver transplantation, but almost not detected in PBMCs from PLC patients and healthy controls. Meanwhile, 4-1BB was almost not expressed on the surface of CD4+ and CD8+T cells in healthy controls and PLC patients. A low level of 4-1BB expression, however, was found on the surface of CD4+ and CD8+ T cells from the stable survivors after liver transplantation., Conclusions: This study demonstrates that although patients are stable after liver transplantation, effector T-cells can also be activated through the signal of 4-1BB molecule and persistent immune response to grafts. Blockage of 4-1BB/4-1BBL pathway may benefitially reduce the clinical dosage of immunosuppressive agents and prolong the survival of grafts.

Objective: To summarize our clinical experience in liver transplantation while considering the background in this field in China., Methods: Ninety-five patients who had received liver transplantation from April 1993 to March 2002 were analyzed retrospectively. Three periods were defined objectively as period I (1993 - 1997), II (1999) and III (2000 - 2002). Operative techniques, recipients, original diseases, complications and survival rates were compared among the three periods., Results: Malignant liver lesions were the main cause for liver transplantation in period I and II. The ratio of number of malignant disease to total recipients decreased gradually from period I to III (100%, 53% and 35%, respectively). The 1-year survival rate in patients with benign liver disease was 85% and the total operative mortality was 5% in period III. The incidence of hepatitis B virus reactivation or reinfection was 24% twelve months after liver transplantation. Vascular complication decreased but biliary complications did not and remained a major long-standing problem. No veno-venous bypass technique was used in period III, and its advantages were obvious when comparing with those with veno-venous bypass in period I and II., Conclusions: Strict selection of recipients, fine operative technique, familiarity with various complications and correct therapeutic methods, prophylaxis of recurrence of hepatitis B and hepatocellular carcinoma are necessary to improve long-term results of liver transplantation in China.

Objective: To sum up the experience in liver transplantation in a period of ten years at a single center., Methods: We retrospectively reviewed the clinical records of 120 patients receiving liver transplantation from April 1993 to October 2002. The patients' clinical characteristics, surgical techniques, complications and survival were compared in the phases of 1993-1997 (phase I), 1999 (phase II), and 2000-2002 (phase III)., Results: Malignant liver diseases were major indications for liver transplantation in phase I (100%) and II (53.3%), but decreased markedly in percentage in phase III (34.0%). When compared with recipients in phase I and II, the survival of recipients with benign liver diseases in phase III was significantly improved with the 3-month, 6-month and 1-year survival rates of 85.7%, 84.5% and 83.1%, respectively. For patients with malignant liver diseases, the 3-month, 6-month and 1-year survival rates were 87.4%, 81.1% and 46.0%, respectively. The reinfection rate of hepatitis B virus was 24% 12 months after transplantation. With technical refinements, the incidence of postransplantation vascular complications has significantly decreased from 29.4% in phase I and II to 4.9% in phase III. Biliary complications remained one of the major obstacles to long-term survival. No veno-venous bypass was applied in phase III, providing a promising outcome., Conclusion: Strict selection of potential recipients, technical refinement, appropriate management of vascular and biliary complications, and prophylaxis of recurrences of hepatitis B and malignant liver diseases are important to obtain long-term survival of patients receiving liver transplantation in China.

Soluble major histocompatibility complex (MHC) class I antigens released from hepatocytes and the passenger leukocyte population of the liver allograft have both been considered as important contributors for spontaneous liver tolerance upon allogeneic transplantation into fully MHC-mismatched hosts. This study was conducted to delineate the role of "passenger leukocytes" (PL) as well as local intra-graft defence mechanisms of long-term accepted liver allografts in more detail. Orthotopic liver transplantation was performed in male inbred rats as follows (n = 4-6): (i) Lewis (LEW; RT1.(l)) --> LEW; (ii) DA (RT1.(av1)) --> DA; (iii) DA --> LEW; (iv) LEW --> DA; (v) LEW (10-Gy whole body irradiation [WBI], d-7) --> DA; (vi) LEW (10-Gy WBI, d-7) --> LEW; (vii) LEW (10-Gy WBI, d-7) --> LEW (parked for 36 hours) --> DA; and (viii) LEW (10-Gy WBI, d-7) --> DA (parked for 36 hours) --> DA. The model specifically investigated the role of PLs as potential contributors to liver tolerance as WBI destroys this nonresident liver population. Characterization of Fas/FasL expression and the frequency of apoptotic cell death was performed by immunohistochemistry and TUNEL staining. Reverse transcriptase-polymerase chain reaction, by the use of Fas and FasL-specific cDNA probes, was performed on isolated hepatocytes of tolerized and rejected livers at various time points after transplantation. Animal survival in the various experimental groups was calculated using Kaplan-Meier survival statistics and related log-rank statistics as follows: (i) < 100 days; (ii) > or = 100 days; (iii) > 100 days; (iv) 11.3 +/- 1.0 day; (v) 9.0 +/- 0.5 days; (vi) > 100 days; (vii) 5/6 > 100 days; and (viii) 8.0 +/- 1.5 days. Immunohistochemistry revealed high numbers of proliferating cells in tolerized liver allografts. Apoptotic cell death of hepatocytes could be detected in both rejecting and to a lower extent in tolerized animals. Conversely, only tolerized but not rejected liver allografts revealed upregulation of FasL-expression on hepatic parenchymal cells from day 3 onwards. Irradiated LEW livers, in turn, lose their ability to survive in allogeneic DA hosts (group v) whereas they survive in syngeneic hosts (group vi), indicating that irradiation itself does not destroy the liver parenchyma. Reconstitution of irradiated LEW livers with syngeneic (group vii) but not with allogeneic (group viii) PLs restored tolerance induction. The underlying mechanisms of immune-privilege observed with liver allografts appear to share characteristics of clonal exhaustion suggesting that alloreactive lymphocytes are depleted by AICD via the FasL/Fas signal transduction pathway. The high frequency of apoptotic lymphocytes found in the portal tract of tolerized (but not rejected) LEW grafts supposes that functional FasL expression on graft hepatocytes mediates specific elimination of graft-directed effector lymphocytes. This mechanism constitutes peripheral deletion as one of the possible tolerogenic mechanisms involved. Chimerical liver grafts consisting of donor (LEW) parenchyma and host (DA) passenger leukocytes lose their tolerogenic capacity. In contrast, syngeneic reconstitution with LEW-PLs, restores liver graft acceptance upon transplantation into allogeneic DA hosts. This phenomenon is not relying on the induction of micro- or macrochimeric hosts, as no LEW PLs were found in spleen, thymus or the blood compartment from long-term surviving DA rats. Thus, non-resident liver cells contribute significantly to liver graft acceptance. Subsequently, liver tolerance appears to be mainly induced in the graft itself.

Objective: To investigate the variation of functions of the heart and lung during orthotopic liver transplantation (OLT)., Methods: Pulmonary artery cannula and right radial artery cannula were indewelled before anaesthesia and the parameters of hemodynamics in different periods were monitored. Analysis of variance was used to reveal the variation among the groups. T hypothesis test in paired data was used to compare the preoperative parameters with those in each period during operation and after operation respectively, and to compare the parameters immediately after operation with those in each period after operation respectively., Results: During the operation, heart rate increased, but blood pressure decreased significantly at the beginning of no-liver period, increased again in a short period and then increased progressively 12 h after operation. Pulmonary artery pressure (PAP) increased from before the no-liver period to 60 h after operation. Pulmonary wedge pressure changed in accordance with the variation of PAP. Cardiac output was maintained at a high-output level from before operation to 60 h after operation. Systemic vascular resistance (SVR) was within the normal limits before operation, whereas pulmonary vascular resistance (PVR) was lower than normal. In the no-liver period during the operation, SVR decreased significantly. Both SVR and PVR increased progressively and returned to normal postoperatively., Conclusions: The patients undergoing OLT have a high cardiac output and low resistance obstacle before and during the operation, and will recover gradually after operation. Monitoring hemodynamics during the peri-operative period is of significance in the prevention and treatment of pneumonedema and cardiac functional insufficiency.

Objectives: To prevent and early diagnose hepatitis B virus reinfection and recurrent hepatitis B following liver transplantation, and to discuss the further treatment of recurrent hepatitis B., Methods: Liver transplantation recipients received lamivudine for prophylaxis of HBV reinfection. Virological and biochemical data, serum HBV DNA, and immunohistological staining for HBsAg and HBcAg in liver biopsy specimens were tested in due time., Results: Five patients with hepatitis B virus reinfection and two patients with hepatitis B recurrence were observed after liver transplantation. One patient with recurrent hepatitis B developed chronic severe hepatitis B despite treatment. One patient improved after a series of treatment., Conclusions: Hepatitis B virus reinfection or recurrent hepatitis B following liver transplantation occurs mostly 6-12 months after operation. The diagnosis of hepatitis B recurrence should be taken into account when liver biochemical data becomes poor during this period. The treatment for recurrent hepatitis B after liver transplantation includes increased dosage of lamivudine, application of famciclovir, and other liver protection measures.

Objective: To sum up the preliminary experience in living related liver transplantation (LRLT)., Methods: A 9-month-old male infant with biliary atresia (BA) who had undergone an unsuccessful Kasai operation was defined as a candidate for LRLT. The donor was his 30-year-old mother. Her lateral lobe of the left liver was transplanted into the infant's body as the graft. The left branches of the portal vein, left hepatic artery and left hepatic vein of the graft were end-to-end anastomosed to the portal vein, hepatic artery proper and hepatic vein of the recipient respectively. Biliary drainage was reestablished via Roux-en-Y operation., Results: The donor retained her liver function within 2 weeks after the operation. Steroid and FK506 were prescribed in immunosuppressive therapy for the recipient. The blood bilirubin level of the infant decreased to normal 2 weeks after operation. No acute rejection occurred. Biliary leakage in the early period after the transplantation was controlled by drainage, and E.coli infection was effectively treated with antibiotics. The donor and recipient are in satisfactory condition to the present., Conclusion: LRLT is advisable for children with biliary atresia.

Objective: To explore cytomegalovirus (CMV) infection in recipients of liver transplantation (LT)., Methods: 30 recipients of LT were screened for the appearance of CMV infection by using ELISA to test anti-CMV-Ab from serum samples and using immunohistochemistry method to test CMV antigen expression and nested-PCR to amplify CMV-DNA from blood samples., Results: Four of 243 samples taken from 30 recipients came out positive of anti-CMV IgG and anti-CMV IgM with a positive rate of 100% and 1.6% respectively. 85 samples resulted in CMV antigen expression (35.0%) with the average antigen index being 4.2+/-3.1/5 X 10(4) WBC. Besides, 99 samples were found to be positive by nested-PCR with a positive rate of 40.7%. 61 samples were found to be simultaneously positive in test of CMV antigen and DNA, with a rate of 25.1%., Conclusions: Infection of CMV is common in recipients of LT. Simultaneous screening of anti-CMV-Ab, CMV-Ag and CMV-DNA after liver transplantation is very important for early diagnosis of CMV infection.

Objective: To summarize the experience of human orthotopic liver transplantation (OLTx) in treatment of patients with end-stage hepatic disease and their perioperative management., Methods: A retrospective analysis was made on OLTx performed in 77 patients from April 1993 to September 2001 in our department included combined liver-kidney transplantation (6 patients) and living related liver transplantation (2). Among them, 76 were adults and 1 was infant (67 males and 10 females). The donors included 75 non-heart beating donors and 2 living related donors. Veno-venous bypass was used only in 45 cases during the operation. immunosuppressive agents consisted of cyclosporine, cellcept, ALG corticosteroids and FK506., Results: The one-year survival rates of grafts and recipients with benign hepatic disease were 75%. The recipients this year are surviving with good function of grafts., Conclusion: Liver transplantation is the best therapeutic method for a large number of patients with end-stage hepatic disease in China.