Search

Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens.Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage.Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the anterior leaflet of the mitral valve is reported. Excision of the tumor and mitral valve repair was performed. Four years later the child remains asymptomatic with no recurrence of the tumor or regurgitation.

Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy in whom a left ventricular tumour was discovered during on diagnostic work-up for a syncope. The tumour was removed and histology confirmed the diagnosis of myxoma.

Patients with severe angina pectoris, refractory to medical treatment, in which conventional revascularization (PTCA or bypass surgery) is not possible because they present advanced coronary artery disease with a poor distal bed, account for an important clinical problem due to an increasing incidence, combined with poor quality of life, an elevated risk of severe complications, repeated hospital admissions and high mortality rate. Laser transmyocardial revascularization provides a new therapeutic alternative for these patients. Although up to now there are only a few published series, with a small number of patients, the results obtained in the two ongoing multicentric studies in Europe and the United States (including more than 500 patients at present) are quite promising. It is a simple surgical procedure, but its associated mortality is not to be dismissed (in the beginning 12% and currently 5%), because patients are in an advanced evolutionary stage. In Spain this procedure has been available since April 1996 and the results have been encouraging. In our small series we have noted a significant symptomatic improvement and better quality of life.

We present four patients with intramural hematomas in the ascending aorta. Diagnostic suspicion was aortic dissection in two of them. Prompt surgical procedures were performed in all of them. After reviewing other series, we conclude that ascending aorta hematomas should be treated as true aortic dissections.

Four surgical procedures are proposed to achieve an efficient remodelling of the ventricles with a low injury to heart muscle, for the treatment of the dilated cardiomyopathy. Those procedures are based the partial ventriculectomy technique of Batista an on the new conception of the macroscopical myocardium structure of the ventricles evidenced in the second half of the present century.

This study describes a patient who had fulminant infectious myocarditis as a result of methicillin-resistant Staphylococcus aureus after receiving a heart transplant from an infected donor. There was complete concordance of typing results between donor and recipient strains that were different from the 20 isolates with which they were compared. Molecular epidemiologic study provided compelling evidence that a transplanted organ can transmit a bacterial infection from the donor to the recipient.

Objectives. We sought to determine the prevalence, intensity and evolving changes of myocardial damage detected by myocardial uptake of antimyosin antibodies in patients with alcohol-induced dilated cardiomyopathy, alcohol addicts attending a detoxification unit and healthy subjects with short-term alcohol consumption.Background. Evidence of alcohol-induced myocardial damage may be provided by myocardial uptake of indium-111–labeled monoclonal antimyosin antibodies. The spectrum of such damage in patients who are heavy drinkers (>100 g for >10 years), with or without cardiomyopathy, and the impact of short-term alcohol ingestion on antimyosin antibody uptake have not been adequately explored.Methods. One hundred twenty antimyosin studies were performed in 56 patients with dilated cardiomyopathy (group I), 15 alcohol addicts attending a detoxification unit (group II) and 6 volunteers for short-term alcohol ingestion (group III). Estimation of antibody uptake was calculated through a heart/lung ratio (HLR) (normal

A patient with a localized severe stenosis of his lower thoracic aorta is described. He presented a coarctation like syndrome with hypertension, pulseless legs and left ventricular failure. At surgery a biopsy of the lesion and bypass graft were performed. Pathology diagnosed intimal hyperplasia. Twenty eight months later he developed a sarcoma.

The performance of peroperative transesophageal echocardiography on a 60 year old woman with mitral and tricuspid valve disease discovered a previously undiagnosed thrombus in the right pulmonary artery that completely occluded the inferior lobar branches. Following valvular surgery, a successful thromboendarterectomy was performed.

Anomalous origin of left coronary artery from pulmonary artery is a rare congenital anomaly (0.25-0.46%). Mortality is high in the first months (65%). Paradoxically, some patients reach adulthood because of a net made of collaterals from the right coronary artery. Thus, we classify the entity in two ways of clinical onset: childhood and adulthood. Ideally, the best surgical approach is the arrangement of a double coronary system. The most well-known technique is the one described by Takeuchi, that links the aorta and the left coronary artery by a tunnel through the pulmonary artery, made from a pulmonary artery frontal wall flap (closing the defect with a pericardial patch). We present a case of anomalous origin of the left coronary artery in an adult, treated in our institution using a modified Takeuchi technique.

Aprotinin reduces blood loss in operations done with cardiopulmonary bypass, whereas the use of desmopressin remains controversial. We compared aprotinin, desmopressin, and placebo in a double-blind, randomized trial to evaluate bleeding and transfusion requirements.One hundred forty-nine patients (48 received aprotinin, 50 desmopressin, 51 placebo) were included. Blood loss and transfusion requirements were recorded and levels of Factor VIII coagulant activity, von Willebrand's factor, thrombin-antithrombin complexes, and D-dimer were measured. Overall blood loss was 195 +/- 146 ml/m2 in the aprotinin group, 400 +/- 192 ml/m2 in the desmopressin group, and 489 +/- 361 ml/m2 in the placebo group (95% confidence intervals: difference between desmopressin and aprotinin 98 to 312 ml/m2, p0.001; difference between placebo and aprotinin 190 to 398 ml/m2, p0.001). Twenty-six percent of patients treated with aprotinin, 66% of those treated with desmopressin, and 56% of those treated with placebo were given transfusion (95% confidence intervals: difference between aprotinin versus placebo plus desmopressin 51% to 71%, p0.001). Fibrinolytic activation throughout cardiopulmonary bypass was markedly higher with placebo or desmopressin administration. D-dimer level correlated with overall blood loss in patients receiving desmopressin or placebo, but not in those receiving aprotinin.Aprotinin administration reduces blood loss and transfusion requirements in cardiopulmonary bypass. This benefit may be explained by a lower activation of fibrinolysis.

A 39-years-old male patient with chronic venous insufficiency, deep venous thrombosis and recurrent pulmonary embolism in the past medical history. After syncopal event was diagnosed of bilateral chronic pulmonary embolism, pulmonary hypertension and right ventricular failure. Fibrinolytic treatment was no effective therapeutic modality. Under cardiopulmonary bypass, bilateral pulmonary thromboendarterectomy with extension into lobe arteries, plus insertion of caval filter was performed. We present our experience with this case and a review of the literature.

Takayasu's disease (TD) is a chronic inflammatory arteritis which affects the aorta and its main branches and occasionally the pulmonary artery. Its cause is not known. Clinical manifestations are due to the intensity and location of arterial inflammation in the acute phase, as well as chronic arterial stenosis over time; 50% of patients have hypertension. Although TD appears to be more common in Asia, increasing numbers of patients of different races are observed in Western countries. The most important pathogenetic mechanism of hypertension seems to be through renal artery stenosis. We show here seven Caucasian hypertensive patients with TD and renovascular stenosis and arterial hypertension. One case was diagnosed in the acute phase of the disease, while in the others diagnosis was established in an advanced occlusive phase. Basic diagnosis was established by angiographic study, with biopsy confirmation in two cases. All patients had at least three of the six criteria listed as diagnostic of TD (by the American College of Reumatology). All patients had the following criteria: age of disease onset before 40 years (symptoms or findings related to TD), vascular bruits in different areas and all patients also had aortic and renal arterial stenosis with some lesions of the main aortic branches. Six of them had claudication of the extremities. We describe their clinical, analytical and angiographic features and also the therapeutic approach. We discuss the aetiopathogenic mechanisms of hypertension in this disease and suggest that TD is not an unusual cause of vasculorenal hypertension.

A novel noninvasive sensitive mean to detect cardiac rejection is described: myocardial uptake of 111In-labeled monoclonal antimyosin antibodies (MAA). All patients showing rejection at cardiac biopsy disclosed positive MAA studies. However, a large percentage of positive studies in the presence of negative biopsies were detected. This discrepancy can be ascribed to a false-negative biopsy result. During the first year posttrasplantation MAA studies are useful to predict severe rejection-related complications, but due to high sensitivity of MAA, treatment for rejection in this period must be based on biopsies, as criterium to treat for rejection on the basis of MAA scans would lead to excessive immunosuppression. After the first year of transplantation, individual patient management can ben implemented on the basis of risk stratification using MAA scans: Negative MAA scans entail an almost nil probability of detecting rejection during long-term follow-up (low-risk group), whereas positive MAA scans imply a probability of detecting near 1 episode of rejection and requirement for treatment per year. In summary, at our institution biopsies are avoided as from the first year after transplantation; after such period, MAA scans allow risk stratification and treatment for rejection based on the results of MAA scans in individual patients.

A 66[correction of 60]-year-old female patient was admitted to hospital for clinical signs of pericardial tamponade. The pericardiocentesis revealed an hematic effusion and a left appendage mass was diagnosed by transesophageal echocardiography. At surgery, a left atrial tumour was resected which histological examination showed to be an undifferentiated angiosarcoma-endothelioma with difficult histological classification. The tumoral screening was negative and the patient was discharged from the hospital. Seven months later the patient was readmitted for two parasternal tumours which anatomopathologic study revealed to be subcutaneous metastases. The rare localization in the left atrium and subcutaneous metastatic spread were discussed.

A 31-year-old male patient, underwent Mustard operation in childhood for complete transposition of the great arteries. He required a sequential (DDD-mode) pacemaker due to a complete symptomatic auriculoventricular block, 25 years after the operation. Wires were inserted through the left cephalic vein and placed in the systemic atrium and ventricle, achieving correct sensing and stimulating thresholds. Atrial rhythm disturbances, specially sinus node dysfunction, are frequent after Mustard's operation and increase through the years following the surgical procedure. Atrioventricular conduction disturbances are rare. Treatment by endocavitary pacemaker implies a correct knowledge of the special anatomy in this congenital disease and its surgical correction.

A case of a 32-year-old woman who developed acute mitral insufficiency after percutaneous mitral dilatation is presented. In spite the fact of having torn both leaflets, successful plastic repair of her valve was performed.

A 46-year-old female, who underwent an orthotopic heart transplantation 5 years ago, presented an occlusive coronary artery disease with severe stenosis of the left anterior descending artery and a large septal perforator. An isonitrile scintigraphy showed a decreased uptake involving the anterior and inferior segments of the left ventricle. Percutaneous transluminal coronary angioplasty was successfully performed in both lesions. Three months after dilatation, improvement of the uptake in both myocardial segments was detected. The results of the percutaneous transluminal coronary angioplasty published in the literature are reviewed.

Thirteen patients with ages between 53 and 74 years had development of free wall left ventricular rupture after a myocardial infarction (mean interval, 3.8 days). All patients showed clinical signs of cardiac tamponade. Diagnosis was established by bedside multiple pressure monitoring and echocardiography, which showed pericardial effusion with compression of the right ventricle. Cardiac catheterization was not performed. A new surgical technique was employed for the repair. After the pericardium was opened and cardiac tamponade was relieved, the myocardial tear was identified. A Teflon patch was applied over the area and glued to the heart surface with a surgical glue (cyanoacrylate). Cardiopulmonary bypass was not used except in a patient with a posterior tear. The method was consistently effective in controlling bleeding from the myocardial tear. All patients survived the operation and were discharged from the hospital a mean of 15 days after the operation. Follow-up extending up to 5 years (mean, 26 months) shows a 100% survival, 11 asymptomatic patients, and 2 patients with mild exertional angina. The technique is a simple, effective, and safe method for repair of subacute cardiac rupture and obviates the need for suturing on an infarcted ventricle.

A case of a 47-year-old white male who developed an aortobronchial fistula eleven years after resection of a posttraumatic aneurysm of the descending aorta is presented. The clinical picture, the diagnostic problems as well as the treatment are presented and commented.

The results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

Patients with mitral stenosis and some degree of right ventricular failure may benefit from inotropic or pulmonary vasodilator drugs in the early postoperative period. Thirty patients undergoing an operation for mitral stenosis were randomized into three groups. In group I (n = 10), isoproterenol (5 micrograms/kg/min) was started in the immediate postoperative period. In group P (n = 10), prostaglandin E1 (0.08 microgram/kg/min) was given, and in group C, the control group (n = 10), no drugs were used. After the operation and before drug therapy was begun, basal measurements of cardiac index, mean pulmonary arterial and mean arterial pressures, and pulmonary vascular resistance were taken. Measurements were repeated at 6, 12, and 24 hours. Mean measurements of cardiac index (basal up to 24 hours) were as follows: 1.39 +/- 0.3, 1.92 +/- 0.4, 2.4 +/- 0.5, and 2.34 +/- 0.3 L/min/m2 for group C; 1.54 +/- 0.5, 2.64 +/- 0.4, 2.68 +/- 0.7, and 2.2 +/- 0.6 L/min/m2 for group I, and 1.57 +/- 0.3, 2.2 +/- 0.6, 2.72 +/- 0.7, and 2.27 +/- 0.4 L/min/m2 for group P (p less than 0.05 between groups C and I at 6 and 12 hours). Mean pulmonary artery pressures were as follows: 19.5 +/- 3.2, 24.8 +/- 7, 27.7 +/- 7.3 and 28.8 +/- 5.7 mm Hg in group C; 21.4 +/- 8.7, 25.7 +/- 7.2, 26.4 +/- 7, and 29.4 +/- 8.6 mm Hg in group I, and 19.1 +/- 4, 19.2 +/- 3, 20.4 +/- 6, and 20.7 +/- 5 mm Hg in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). Mean pulmonary vascular resistances were as follows: 3.9 +/- 2.4, 3.9 +/- 1, 3.36 +/- 2, and 3.2 +/- 1.4 Wood units in group C; 4.84 +/- 4, 3.37 +/- 2.2, 3.69 +/- 3, and 4.69 +/- 4.1 Wood units in group I, and 3.29 +/- 1.3, 1.71 +/- 0.5, 1.61 +/- 0.5, and 1.96 +/- 0.8 Wood units in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). There was no difference in mean systemic arterial pressure among the three groups. Our results indicate that patients subjected to mitral valve operations have a low cardiac index. Isoproterenol increases cardiac index but has little effect on pulmonary resistance. At low doses, prostaglandin E1 effectively decreases pulmonary vascular resistance without altering systemic arterial pressure or heart rate.

The Peritoneal Equilibration Test (PET) as standardized by Twardowski (T) and simplified Mass Transfer Coefficients (MTC) as per Garred (G) and Krediet (K) have been employed in our patients to assess: 1) the reproducibility of results, 2) correlation between methods, and 3) usefulness of patient categorization by simplified methods in contrast to PET patterns. We have performed 29 standardized PET (Dianeal 2.5%) in 24 stable CAPD patients. We have collected dialysate samples at 0, 30, 60, 120, 180 and 240 minutes. With this data we were able to calculate the dialysate/plasma ratio for PET, MTC as per Garred and MTC as per Krediet. Our results were not significantly different from data reported by the original authors, except for PET D/P urea at 240': 0.91 +/- 0.07(T) vs. 0.87 +/- 0.08 (our), p0.05. In our patients, good correlation was found between PET and MTC for urea, creatinine, and glucose, using both formulae (G and K). Patient categorization as High, High Average, Low Average, and Low by MTCs can well predict PET categorization with acceptable sensitivity and good specificity. We conclude there is good reproducibility of the methods. There is also a close correlation between PET, K and G methods for solute transport evaluation and patient categorization. Simplified methods can be substituted for the more complex ones.

We analyze retrospectively the short- and long-term results of coronary artery bypass surgery in 50 patients with severe left ventricular dysfunction operated in a period of 11 years. Sixty-six percent of patients had unstable angina and 12% of total presented angina post-acute postmyocardial infarction. Thirty-eight percent of patients were in preoperative functional class III-IV of NYHA. Three-vessel disease was present in 70% of the patients, two-vessel in 30%, and the main trunk was affected in 12% of the global. Hospital mortality was 4% (2/50) due to low cardiac output syndrome. Follow-up was available in all the survivors and ranged 6 months-11 years (mean: 4.8 +/- 3.1). During follow-up, 13 patients died, but in only six was due to cardiac cause. The 35 patients followed were in functional class I-II of NYHA. Eighty-eight percent of the patients were angina free at follow-up. Actuarial analysis, after exclusion of 3 patients who died of causes no directly related to the heart, showed an intrahospital survival rates of 96%; at first year was 92, at 3rd was 78%, and 5th year survival rates were 75%. In conclusion, patients with symptomatic angina and preoperative severe left ventricular dysfunction, coronary artery bypass graft has a low hospital mortality, is effective in improving angina and heart failure, and the long-term survival is acceptable.

A child with a membranous obstruction of the inferior vena cava (MOIVC) is presented. The diagnosis was confirmed by angiography. The clinic significance, the evolution, the surgical treatment and the possible complications are described.

A simple method to obtain a motionless surgical field with excellent exposure and access to perform internal thoracic or radial artery composite grafts for myocardial revascularization is described.

A retrospective study was undertaken to evaluate the results achieved by treatment of renal tumor in 6 patients with solitary kidney. Two were treated conservatively, three were submitted to radical nephrectomy, and one patient underwent heminephrectomy. The mean follow-up was 28 months, the mortality rate was 33%, and metastasis was observed in another 33% of this patient group during follow-up.

A retrospective study was undertaken of 31 patients submitted to tricuspid valve replacement between 1977 and 1988, either alone or associated to mitral or aortic replacement. The cause of the tricuspid lesion was rheumatic in 19 patients, congenital in seven, prosthetic valve thrombosis in two and miscellaneous in the remaining 3 patients (endocarditis, carcinoid syndrome, iatrogenic operative tricuspid regurgitation). Of the 31 tricuspid prostheses reviewed, 26 were mechanical (St Jude, Björk-Shiley) and five of the biological type (Ionescu, Hancock). Results showed that 25% of patients died in the hospital; 75% of them had been operated previously. With a follow-up averaging 3.9 years the complications related with the prosthesis were: thrombosis of the tricuspid prostheses in 1 patient (1.2% patients-year) and hemolytic anemia in another. Ninety percent of patient included in the follow-up were in NYHA class I or II. Three patients (14%) died due to a cause not directly related to the prosthesis. An actuarial analysis showed intrahospital survival rates of 55%, 100% and 75% in patient with 3, 2 and 1 prostheses, respectively; at 6 months postoperatively the figures were 55%, 87% and 75%, and at a follow-up of 3 years, 55%, 67% and 66%. In conclusion, in patients submitted to a tricuspid valve replacement mortality is high before hospital discharge, and is related to the clinical situation. A sustained improvement is observed in survivors once discharged, independently of the number of prostheses implanted. Complications related to the tricuspid prosthesis are comparable to those observed with prostheses in mitral or aortic position.

A case of a 29 year old man with congenital aortic stenosis who developed a subvalvular annular aneurysm of the left ventricle after being run by a car is presented. At surgery his aortic valve was replaced and the opening of the aneurysm was closed with a patch of Dacron. Due to the dense adhesions to the aorta and left atrium no attempts were made to excise the sac, that was not compromising the dynamics of any one of these structures.

Two cases of athero-embolic nephropathy unrelated with known precipitating factors such as aortic surgery, angiography, anticoagulation or pharmacological fibrinolysis are reported. In one, the histological study additionally disclosed endo-extracapillary proliferative glomerulonephritis. Hypocomplementemia or hypereosinophilia, which some authors consider very characteristic findings, could not be demonstrated in any of the two patients. The difficulties in the diagnosis of athero-embolic nephropathy and the possible indications of renal biopsy are discussed. Emphasis is made on prevention as the best approach to management, no specific treatment being available.