Search

Celsior solution has already proved effective in heart graft preservation because it reduces myocardial edema, prevents free radical damage, and limits calcium overload. The aim of this study was to evaluate the effectiveness of Celsior solution as myocardial protection in high-risk transplantation. Hospital charts and follow-up data of 200 consecutive heart recipients (162 males, 38 females, mean age 47.4 +/- 12.6 years) were reviewed. Patients were divided into two groups: group A (73 patients) included recipients of high-risk grafts (at least two of the following: age >45; female sex; high preretrieval inotropic support, viz. dobutamine or dopamine >10 microg/kg per minute and/or infusion of norepinephrine regardless of its dosage; size mismatch >20%; ischemia time >180 min) and group B (127 patients) included recipients of standard grafts. Quality of preservation was assessed through enzyme release, echocardiographic evaluation, the need for inotropic support or pacemaker, and histology of biopsy samples. Hospital and 1-year mortality were also evaluated. Comparisons between the two groups were made through univariate analysis. Study groups proved homogeneous as to recipient age, pretransplant cardiomyopathy, status at transplantation, mean panel reactive antibodies, and redo cardiac surgery. Hospital mortality was 8% (11% vs 6.3%, P = 0.18) while 1-year mortality reached 12% (15.1% vs 10.2%, P = 0.6) without significant difference between groups. Graft performance as described by the need for inotropic support and/or pacemaker as well as echocardiography (left and right ventricular ejection fraction) proved comparable. There were no significant differences as to histology findings and patterns of enzyme release. Celsior provides optimal myocardial preservation in both standard and high-risk procedures. Such advances help to enhance donor pool expansion.

Objective: This retrospective single-center report sought to evaluate the relation of immunosuppressive regimen with the incidence and characteristics of cytomegalovirus (CMV) infection from 1999 to 2003., Patients and Methods: Immunosuppression consisted of cyclosporine microemulsion (Neoral), azathioprine (AZA), and prednisolone associated with either thymoglobulin or ATG high-dosage induction from 1999 to 2000 (AZA, 64 patients [AZA-Thymo = 38 patients and AZA-ATG 26 patients]), or cyclosporine microemulsion (Neoral), mycophenolate mofetil (MMF), and prednisolone with low-dose thymoglobulin induction from 2001 onward (n = 52 patients). Ganciclovir preemptive therapy was guided by pp65 antigenemia monitoring without CMV prophylaxis., Results: The study groups were homogeneous with respect to major perioperative risk factors. Comparing the two AZA subgroups no difference emerged as to percentage of pp65 antigenemia-positive, preemptively treated patients reflecting CMV disease incidence and relapses. AZA-Thymo patient showed significantly shorter time to first positive pp65-antigenemia and higher viral load (AZA-Thymo vs AZA-ATG, P = .004 and P = .009). The two subgroups did not differ with regard to incidence of rejection, superinfection, and graft coronary disease. By shifting from AZA to MMF no difference emerged as to incidence and characteristics of CMV infections, but there was a significant reduction in acute rejection and superinfection (AZA vs MMF P = .001 and P = .008)., Conclusions: The distinct immunological properties of thymoglobulin versus ATG significantly altered the pattern of CMV expression. MMF with reduced-dose induction did not engender a higher CMV morbidity.

Objective: To evaluate the mid-term results of endovascular stent-grafting for type B aortic dissection, in comparison with those of standard medical therapy in uncomplicated cases., Methods: Between January 1999 and 2004, among 56 patients (mean age 59.5+/-11.5 years) with type B aortic dissection, hypotensive medical therapy was the only treatment in 28 uncomplicated cases, (group A), while stent-graft implantation was performed in 28 patients with uncontrolled hypertension, persistent pain or evidence of dissection progression or complication (group B). In 14 cases (50%) the procedure was performed in an acute setting. Stent-grafting procedures were monitored with intraoperative trans-esophageal echocardiography and cine-angiography. CT scan and trans-esophageal echocardiography were performed before hospital discharge, at 6 and 12 months and then yearly., Results: Follow-up (range 1-61 months, average 18.1+/-16.9 months) was 100% complete. In-hospital mortality was 10.7% (three patients, all belonging to Group B; P=0.24). No spinal cord injuries were observed. Early endoleak occurred in one patient (3.5%). Mid-term mortality was lower in Group B, although the difference was not significant (10.7 versus 14.3% in Group A, P=0.71). Follow-up CT scans evidenced complete thrombosis of the false lumen in 75% cases in Group B, 10.7% in Group A (P=0.0001), and an aneurismal dilatation of the descending aorta in 3.5% cases in Group B, 28.5% in Group A (P=0.02)., Conclusions: Although with still considerable early mortality, endovascular stent-graft implantation is an effective option for the treatment of complicated type B aortic dissection. Endovascular treatment achieved a better mid-term fate of the descending thoracic aorta than medical therapy alone, even in patients with worse preoperative conditions.

This prospective randomized study compared the effects in heart transplant recipients of thymoglobulin and ATG, two rabbit polyclonal antithymocyte antibodies available for induction therapy. Among 40 patients (29 men and 11 women, mean age: 40.7 +/- 14 years) undergoing orthotopic heart transplantation, 20 were randomly allocated to receive induction with thymoglobulin (group A) and 20 to ATG-fresenius (group B). Comparisons between the two groups included early posttransplant (6 months) incidence of acute rejection episodes (grade >/= 1B), bouts of steroid-resistant rejection, time to first rejection, survival, graft atherosclerosis, infections, and malignancies. The study groups displayed similar preoperative and demographic variables. No significant difference was found with regard to actuarial survival (P =.98), freedom from rejection (P =.68), number of early rejections > 1B (P =.67), mean time to first early cardiac rejection (P =.13), number of steroid-resistant rejections (P =.69). Cytomegalovirus reactivations were more frequent among group A (65%) than group B (30%; P =.028). New infections due to cytomegalovirus occurred only in group A (four patients; 20%; P =.05). No cases of malignancies were observed at a mean follow-up of 32.8 +/- 8.9 months. Although thymoglobulin and ATG showed equivalent efficacy for rejection prevention, they have different immunological properties. In particular, thymoglobulin seems to be associated with a significantly higher incidence of cytomegalovirus disease/reactivation.

To evaluate the impact of early ischemic necrosis (IN) on the early and late outcome of heart transplantation, we reviewed our 11-year experience. Between January 1988 and June 1999, 207 heart transplants were performed in 205 patients (174 male and 31 female). Criteria for donor and recipient selection, and protocols for postoperative immunosuppression and rejection monitoring have remained unchanged over this period. Three different cardioplegic solutions were employed in graft preservation: St. Thomas Hospital solution in the earliest 31 cases (15%), University of Wisconsin solution in 96 cases (46.4%), and Celsior solution in the last 80 cases (38.6%). All patients who underwent at least one endomyocardial biopsy (176 patients) were divided into two groups according to the findings of IN within the early 3 postoperative months (group A, 49 patients with IN; group B, 127 patients without IN). The following variables were estimated in each group: donor and recipient age, ischemic time, type of cardioplegia, late mortality for cardiac causes, incidence of grade >2 rejection within the first 6 postoperative months, late incidence of grade >2 rejection, late incidence of NYHA class >II. No significant difference was found in any parameter between the two groups, except for the type of cardioplegic solution. A significantly higher incidence of ischemic necrosis in hearts preserved with St. Thomas solution was found (P < 0.001). Although pathology findings show that extracellular solutions carried a higher risk of early IN, no associated significant impairment in terms of late survival and event-free rate was observed in recipients with early IN.

Three hundred eighty-five valve prostheses were implanted between 1974 and 1981 in patients with isolated mitral disease: 157 caged-ball valves (156 Starr-Edwards; 1 Smeloff-Cutter) (group A), 107 tilting-disc valves (44 Bjork-Shiley, 49 Sorin, 14 Lillehei-Kaster) (group B), 121 porcine bioprostheses (45 Carpentier-Edwards, 66 Liotta, 10 Hancock) (group C). Perioperative mortality was 9.5% in group A, 11.2% in group B and 6.6% in group C. The follow-up was 86% complete. Actuarial freedom from complications was calculated as follows (linearised rates in brackets) in groups A, B and C, respectively: survival: 47.01% +/- 0.11 (3% patient/yr), 53.37% +/- 0.08 (1.8% patient/yr), 61.24% +/- 0.05 (2.2% patient/yr); thromboembolism: 67.94% +/- 0.09 (1.18% patient/yr); 73.07% +/- 0.06 (1% patient/yr); 97.43% +/- 0.02 (0.02% patient/yr); anticoagulation-related hemorrhage: 84.10% +/- 0.13 (0.18% patient/yr), 97.21% +/- 0.01 (0.12% patient/yr), 100%; prosthetic valve endocarditis: 100% in groups A and B, 95.76% +/- 0.02 (0.18% patient/yr) in group C; valve-related mortality: 87.52% +/- 0.03 (0.75% patient/yr), 87.96% +/- 0.03 (0.56% patient/yr), 82.53% +/- 0.04 (0.93% patient/yr); valve failure: 81.22% +/- 0.07 (0.56% patient/yr), 63.36% +/- 0.1 (1.06% patient/yr), 14.31% +/- 0.05 (4% patient/yr); treatment failure: 78.81% +/- 0.05 (1.12% patient/yr), 76.44% +/- 0.09 (0.62% patient/yr), 80.97% +/- 0.04 (1% patient/yr); all valve-related morbidity and mortality: 40.43% +/- 0.13 (1.93% patient/yr), 57.76% +/- 0.08 (1.43% patient/yr), 14.96% +/- 0.05 (4.18% patient/yr); all valve-related morbidity and mortality at 5 years: 91.97% +/- 0.02 (7.8% patient/yr), 87.06% +/- 0.03 (3.6% patient/yr), 90.27% +/- 0.03 (2.6% patient/yr); at 10 years: 80.4% +/- 0.03 (4.6% patient/yr), 75.91% +/- 0.03 (2.6% patient/yr), 37.44% +/- 0.05 (4.18% patient/yr).(ABSTRACT TRUNCATED AT 250 WORDS)

The CarboMedics cardiac prosthesis (CarboMedics, Inc., Austin, Tex.) is a relatively new, low-profile bileaflet prosthesis. We report the results of a prospective mid-term evaluation of 426 CarboMedics prostheses implanted at our institution. Three hundred fifty patients had CarboMedics prostheses implanted in the mitral (n = 125), aortic (n = 149), or aortic and mitral positions (n = 76). Hospital mortality was 5.2%. Follow-up was 98% complete, with 478 patient/years and a mean follow-up of 19 months (range 1 to 42 months). Actuarial freedom from complications were calculated as follows (linearized rates in parentheses): late mortality 97% +/- 0.77% (2.7%), thromboembolism 98% +/- 0.4% (0.5%), anticoagulation-related hemorrhage 98.6% +/- 0.4% (0.4%), nonstructural dysfunction 98.5% +/- 0.6 (0.2%), valve-related mortality 91.5% +/- 0.7 (0.5%), valve failure 90.9% +/- 1% (0.7%), treatment failure 92.8% +/- 0.8% (0.7%), and all valve-related morbidity and mortality 90% +/- 2% (2.6%). According to our results, the CarboMedics valve has a low rate of complications that further improves the quality of life in patients with heart valve prostheses.

The surgical treatment of 6 patients affected by right cardiac tumors is reported. Three of them showed a right atrial myxoma, 1 metastases from an occult embryonal carcinoma and 1 a leiomyosarcoma of the pulmonary artery. While clinical diagnosis was not reliable, the echocardiographic examination was able to assess the site of the tumor, supplying useful information for the anatomy and surgery in 5 cases out of 6; in one case, the diagnosis was reached intraoperatively. All the patients survived the surgical treatment: while those with atrial myxoma recovered completely, the others with malignant tumors died from metastases 5 to 10 months postoperatively. The importance of early diagnosis is stressed together with the role of surgery, which permits the recovery of cases with benign tumors and a longer survival of cases with malignant tumors.

The coexistence of a coronary artery obstructive disease (CAOD) with aorto-iliac obstructive disease (AIOD) often represents a surgical problem. Because of left main coronary disease (LMCOD) the contemporary correction of AIOD should be performed with a simple non traumatic procedure. The case of a high risk patient in whom aortoiliac obstructive disease has been corrected with the implantation of a bifurcated vascular prosthesis from the ascending aorta to the bilateral common femoral arteries, and with a double aorto-coronary by-pass, is reported.

A ten-year experience with reoperations for failure of cardiac bioprostheses is reported. 362 patients were operated for valve replacement with 412 bioprostheses. There were 35 (9.64%) reoperations for valve failure. Mean time between operation and reoperation was of 64.4 months. Operative mortality was 14.28%: 3 patients died for cardiac and 2 for extra-cardiac causes. Long-term mortality after reoperation was 6.25%. Morphological examination of the explanted bioprostheses confirmed the cause of bioprosthetic valve failure, due to calcific degeneration in 88.88% of case, to post-endocarditic rupture in 5.55% and to prosthetic thrombosis in 2.77%. The importance of timing reoperation is stressed in order to reduce the operative mortality. The conditions suitable for implantation of bioprostheses are listed.

The mechanical valve produced by Sorin is a modified tilting disc device. Between March 1979 and November 1985, 763 Sorin prostheses were implanted in 710 patients. The study has been restricted to 504 isolated mitral or aortic valves. There were 238 females and 266 males whose ages ranged from 2 to 71 years (mean 43.8). Follow-up is 99.23% and covers 1045 patient-years. No structural failure has been observed. In the aortic position, 282 Sorin prostheses were implanted with the large orifice orientated towards the right coronary sinus. Hospital mortality was 5% (14/282). Actuarial survival at 78 months was 94.68% +/- 1.6% with a linearized mortality rate of 1.7% patient-years. There were 11 late deaths (9 valve-related and 2 non valve-related). The linearized rate of occurrence of embolic events was 0.32 patient-years (2/268). Actuarial survival complication-free at 78 months was 90.88% +/- 2.83%. Preoperatively, 19.8% patients were in NYHA class II, 68.5% in III and 11.7% in IV; postoperatively, 79.3% patients were in NYHA class I, 19.5% in II and 1.2% in III. In the mitral position, 222 Sorin prostheses were implanted with the large orifice orientated anteriorly in 46 patients (group 1) and posteriorly-in 176 patients (group 2). Hospital mortality was 4.5% (10/222). Actuarial survival at 66 months was 93.25% +/- 2.1% with a linearized mortality rate of 2.8 patient-years. There were 12 late deaths (9 valve-related and 3 non valve-related). The 66-month actuarial freedom from embolic events was 95.8% +/- 1.89% with a linearized rate of occurrence of 1.44 patient-years.(ABSTRACT TRUNCATED AT 250 WORDS)

The mechanical valve produced by Sorin is a modified tilting disc device. Over about a 6-year period, 763 Sorin Prostheses were implanted in 710 patients. No structural failure has been observed. 282 prostheses were implanted in aortic position with the large orifice oriented towards the right coronary sinus. Hospital mortality was 5% (14/282). Actuarial survival at 78 months was 94.68% +/- 1.6%, with a linearized mortality rate of 1.7% pt-years. There were 11 late deaths (9 valve related and 2 non valve-related). The linearized rate of occurrence of embolic events was 0.32 pt-years (2/268). Actuarial survival complication free at 78 months was 90.88% +/- 2.83%. Preop. 19.8% patients were in class II N.Y.H.A, 68.5% in III, 11.7% in IV; postop. 79.3% patients were in class I, 19.5% in II, 1.2% in III. The durability and satisfactory complication-free survival rate indicate the Sorin prosthesis as a fully reliable device for aortic valve replacement.