Neurologic outcome after heart transplantation in Chagas' disease. Preliminary results

OBJECTIVE

To evaluate the neurologic morbidity after orthotopic heart transplantation (OHT), we examined consecutive Chagas' (Ch) and non-Chagas' (NCh) patients, before and after surgery.

MATERIAL AND METHODS

We undertook neurological and neuropsychological evaluations in Ch and NCh patients with end-stage cardiac failure, from September 1993 to September 1995.

RESULTS

Of 10 Ch patients (mean age = 33.6 years; 7 male; mean follow-up = 10.8 months) and 13 NCh patients (mean age = 50.9 years; 12 male; mean follow-up = 15 months) 3 died (rejection and sepsis) without neurologic symptoms. Neurologic complications occurred in 4 Ch and 5 NCh patients. Two Ch patients had skin and myocardial Chagas' reactivation successfully treated, without CNS involvement. NPS performance and return to work rates were similar in both groups.

CONCLUSION

Although Ch patients are potentially at a higher risk of Trypanosoma cruzi reactivation, in addition to all known neurologic complications of OHT, early neurologic complications detected in this sample were similar in Ch and NCh patients and could not be specifically related to Chagas' disease.

Salmonella gastroenteritis outbreak among workers from a tertiary care hospital in Mexico City

OBJECTIVE

To describe an outbreak of Salmonella gastroenteritis among employees of the National Institute of Nutrition (INNSZ) of Mexico City during July, 1994.

METHODS

Employees who developed diarrhea or fever associated with gastrointestinal symptoms starting on July 14th were included for study as well as 50 healthy controls. A questionnaire was applied to all, and they also provided a stool sample, along with other 80 asymptomatic people (included the kitchen workers) in whom only stool culture was done.

RESULTS

Ninety-seven employees that ate regularly at the Hospital's cafeteria were affected by the outbreak, and 67 of them (69%) could be evaluated. Most of them were nurses (34%), and handymen (27%). Most common symptoms were abdominal pain (97%), diarrhea (95%), nausea (91%), and fever (89%). Cultures from suspicious food items were all negative, but stool cultures from 10/70 cases were positive for Salmonella enteritidis vs. 0/133 in the controls. The ten S. enteritidis isolates resulted identical either by serotyping and by rapid amplified polymorphic DNA (RAPD) analysis. Cultures from all kitchen employees were negative for S. enteritidis. Breakfast meal on July 14th was associated with the development of gastroenteritis (61/67 cases vs 26/50 controls, p < 0.001), and particularly with an egg-covered meat plate (61/62 vs 13/26 controls, p < 0.0001).

CONCLUSIONS

This outbreak was probably caused by eggs contaminated with Salmonella, since no one of the kitchen personnel was found to be an asymptomatic carrier, and the implicated recipe allows for inappropriate cooking. Recommendations to improve cooking procedures must be added to the usual regulations to diminish the frequency of foodborne disease outbreaks in hospitals.

[Prognostic value of stress echocardiography by dobutamine combined with atropine]

PURPOSE

To determine the prognostic value of dobutamine-atropine stress echocardiography (DASE).

METHODS

We studied 452 consecutive patients at high risk for coronary artery disease, using DASE. They were followed during a mean period of 23 months.

RESULTS

There were 9 cardiac deaths and 2 acute myocardial infarctions in the group of patients with positive tests, and there were 2 myocardial infarctions and 1 cardiac death in patients with negative DASE.

CONCLUSION

We conclude that DASE reliably identifies patients at high risk for hard cardiac events.

[Prognostic value of stress echocardiography by dobutamine combined with atropine]

PURPOSE

To determine the prognostic value of dobutamine-atropine stress echocardiography (DASE).

METHODS

We studied 452 consecutive patients at high risk for coronary artery disease, using DASE. They were followed during a mean period of 23 months.

RESULTS

There were 9 cardiac deaths and 2 acute myocardial infarctions in the group of patients with positive tests, and there were 2 myocardial infarctions and 1 cardiac death in patients with negative DASE.

CONCLUSION

We conclude that DASE reliably identifies patients at high risk for hard cardiac events.

[Partial atrioventricular septal defect associated with right atrioventricular valve Ebstein's disease]

The association of Ebstein's disease and atrioventricular septal defect is extremely rare with only 13 cases described in the literature and none in our country. We described a 15 year-old girl with echo and angiographic diagnosis confirmed by surgery. The non-identification of one of the lesions could impair planning and surgical results.

Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk)

BACKGROUND

The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates.

METHODS

Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures.

RESULTS

The mean arrest time was 31.4 +/- 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line.

CONCLUSIONS

The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.

[Heart surgery in Brazilian Indians]

PURPOSE

Our experience with surgical treatment of heart diseases in Indians living in the Amazon rain forest in primitive stages was reviewed.

METHODS

From 1988 to 1995, 18 patients underwent cardiovascular surgical procedures at the São Paulo Hospital of the Escola Paulista de Medicina. Seven patients had valvar disease, nine congenital heart defects, one submitral aneurysm and one arrhythmia. Thirteen Indians came from tribes of the Amazon rain forest area: three from the Xavante, two from Waiapi, two from Tucano, two from Macuxi, two from Mayoruna, and one of each tribe of Xikrin, Guajajara, Terena, Surui, Galibi, Cinta-Larga and Pataxó.

RESULTS

We performed 22 operations, with two hospital deaths. Follow-up was possible in 87.5% of cases, with one late death. The majority of cases were due to congenital heart defects and in this series it was noted the absence of operations to treat coronary artery disease. The incidence of valve disease was higher in accultured or semi-accultured Indians.

CONCLUSION

The surgical treatment of cardiovascular disease has made possible to the surviving indians to return to and be accepted by their fellow tribesmen.

Resting and reflex heart rate responses during cholinergic stimulation with pyridostigmine in humans

Dysfunction of the autonomic nervous system is of prognostic value for sudden death after acute myocardial infarction. Although the use of beta-blockers to counteract the adrenergic hyperactivity has been shown to decrease mortality in these patients, there have been no reports on the role of cholinomimetic drugs in the prognosis of patients after myocardial infarction. The present study was designed to investigate the effect of the administration of pyridostigmine bromide, a reversible anti-cholinesterase agent, on cardiac cholinergic activity assessed by the resting and reflex heart rate responses. Eight healthy volunteers were submitted to a conventional 12-lead electrocardiogram to obtain resting heart rate, and to three non-invasive cardiovascular tests: respiratory sinus arrhythmia, Valsalva maneuver and 4-sec exercise test. On two different days and following a randomized cross-over double-blind protocol, the experiments were performed before and 120 min after oral administration of either pyridostigmine bromide (30 mg) or placebo. Pyridostigmine increase (P < 0.05) the duration of the R-R intervals at rest (pre: 898 +/- 30 msec; post: 1019 +/- 45 msec; pre-placebo: 916 +/- 26 msec; post: 956 +/- 28 msec; P > 0.05). Although the duration of the R-R intervals during the autonomic tests was also increased (P < 0.05), the derived indexes of maximal fluctuation during the maneuvers did not change. These results indicate that oral pyridostigmine produces tonic cardiac cholinergic stimulation while exerting no effect on its reflex changes. Further studies are needed to address the potential role of the administration of pyridostigmine in the prognosis of patients with acute myocardial infarction.

Chagas' disease reactivation after heart transplantation: efficacy of allopurinol treatment

BACKGROUND

Chagas' disease is a parasitic infection that provokes a severe form of dilated cardiomyopathy. In the initial experience with heart transplantation with Chagas' disease, a high rate of acute reactivation has been reported. Although benzinidazole and nifurtimox are effective in the treatment of reactivation or of the acute phase of the disease they are associated with important adverse effects. Allopurinol has substantial activity against Trypanosoma cruzi in vitro, in the experimental laboratory and in chronic human Chagas' disease; however, there is no information regarding its action in Chagas' reactivation after heart transplantation.

METHODS AND RESULTS

We describe two patients with Chagas' disease who underwent heart transplantation. The first one had asthenia, anorexia, and several painful subcutaneous nodules in the legs after transplantation; biopsy showed an inflammatory infiltrate with intracytoplasmatic nests of Trypanosoma cruzi, confirmed by immunohistochemical stains with monoclonal antibodies specific to parasitic antigens. Allopurinol (600 mg/day) produced complete regression of the symptoms and the nodules with a negative control biopsy within 2 weeks. Treatment was maintained for 2 months. Mild leukopenia developed which improved after azathioprine reduction, and no further side-effects were noted. The second patient had sudden heart failure months after transplantation; endomyocardial biopsy showed myocardial fibers infested with Trypanosoma, and a concomitantly performed right heart catheterization showed a low cardiac index and highfilling pressures. The patient received allopurinol at a daily dose of 900 mg and conventional treatment for heart failure. Echocardiogram showed improved wall motion and decreased left ventricular dimensions, and control biopsy showed no inflammatory activity; cardiac index and filling pressures normalized. Treatment was maintained for 2 months without side effects. The two patients have not had recurrences and were in New York Heart Association functional class I 12 and 3 months, respectively, after discontinuation of allopurinol.

CONCLUSIONS

Allopurinol seems to be safe and effective in treating Chagas' disease reactivation after heart transplantation. A larger number of case studies seems to be necessary to properly evaluate its role in the treatment of Chagas' disease reactivation.

Effect of acute volume expansion associated with salt load on the profile of plasma angiotensins in rats

We measured the changes produced in renin and the peptide components of the circulating renin-angiotensin system by acute volume expansion alone or associated with salt load in rats. With both maneuvers, there was a decrease of plasma renin activity (PRA) and plasma angiotensin (Ang) concentrations, but the changes were more pronounced in the salt-load group. In contrasting to Ang I and Ang II, plasma Ang-(1-7) concentration decreased significantly only within 60 min of 5.0% NaCl infusion (19.5 +/- 2.9 vs 30.5 +/- 1.9 pg/ml in the control group). As expected, plasma vasopressin increased markedly in the animals submitted to acute salt load (144.0 +/- 42.0 vs 5.0 +/- 0.2 pg/ml in the control group). The dissociation between the changes in plasma Ang-(1-7) and that of other plasma angiotensins is consistent with our previous studies using chronic salt load, and suggests that during acute volume expansion associated with salt load Ang I is preferentially converted to Ang-(1-7). In contrast to vasopressin, however, plasma Ang-(1-7) concentration increased only after chronic salt load, suggesting that this angiotensin may be more involved with long-term mechanisms of control of hydromineral balance.

[Pregnancy after heart transplantation]

A 25-year old female patient, with peripartum cardiomyopathy was submitted to heart transplantation and became pregnant two years after. Pregnancy was uneventful and a baby-girl was born completely healthy. Six years after pregnancy, the mother remains well with preserved ventricular function and the girl has had a normal development. Although considered a high-risk situation and not indicated, pregnancy after heart transplantation is possible, without any apparent deterioration of the transplanted graft and with healthy babies being delivered.

Neurological outcome in coronary artery surgery with and without cardiopulmonary bypass

INTRODUCTION

The neurological complications of coronary artery surgery with cardiopulmonary bypass (CPB) have been extensively studied, but to our knowledge those without CPB (NCPB) have not been defined.

PATIENTS & METHODS

We prospectively examined 81 patients, before and up to seven days after surgery, to compare the neurological morbidity between patients subjected to coronary artery bypass graft (CABG) surgery with and without CPB. We analyzed demographic variables, risk factors and neurological examination including neuropsychological (NPS) tests using chi-square and non-parametric analysis (Mann-Whitney and Kruskal-Wallis).

RESULTS

Forty-eight patients (34M; median age = 62 yrs; median number of grafts = 3 and median total surgery duration = 300 min) operated with CPB and 33 without CPB (23M; median age = 64 yrs; median number of grafts = 2 and median total surgery duration = 240 min) differed only in relation to number of grafts (p = 0.0001) and surgery duration (p = 0.0001).

CONCLUSION

We found no difference in early neurological outcome in patients subjected to CABG with or without CPB.

[Acute hemodynamic effects of ibopamine, captopril, and placebo in patients with severe heart failure]

PURPOSE

To evaluate the acute hemodynamic effects of ibopamine (IBO), captopril (CAP) and placebo (PLA) in patients with severe congestive heart failure at rest.

METHODS

Twelve male patients in sinus rhythm with dilated cardiomyopathy and NYHA class IV were studied with Swan-Ganz hemodynamics. Drugs were given in a blinded fashion. Rest, 30 min and every hour for 5 h measurements were made after oral ingestion of 100 mg IBO, 25 mg CAP or PLA. Prior to the study, patients were on diuretics as the only medication for at least 48 h. Comparisons were made with analysis of variance of repeated measurements and Duncan's multiple comparisons procedure.

RESULTS

Significant increase in cardiac index and stroke volume index and reduction in systemic vascular resistance were observed with IBO and CAP for 2 h after ingestion. IBO however increased right and left filling pressures in the first hour after its administration. Ventricular tachycardia occurred in 2 patients 1 h after IBO administration.

CONCLUSION

Both IBO and CAP improved hemodynamic parameters in the first two hours after oral ingestion in patients with dilated cardiomyopathy in class IV.

Successful use of deep hypothermic circulatory arrest in pregnancy

A woman pregnant for 21 weeks underwent an emergency operation because of an aortic arch aneurysm that had ruptured into her left lung. Cardiopulmonary bypass and deep hypothermia were used and she needed 37 minutes of circulatory arrest at a core temperature of 19 degrees C. Both the mother and fetus survived, and a normal baby was delivered by cesarean section at the 39th week of gestation.

[Supravalvar aortic stenosis complicated by aortic endarteritis and formation of mycotic aneurysm]

A 11 years-old male child, with supravalvar aortic stenosis who had as complications aortic endarteritis and mycotic aneurysm formation in the ascending aorta. The aneurysms were diagnosed by a control echocardiogram at the end of an apparently successful clinical treatment of endocarditis. Angiography confirmed the diagnosis and the aneurysms were surgically resected. Six months after surgery the patient is doing well.

[Emergency valvuloplasty with a balloon catheter of a tricuspid bioprosthesis in Ebstein's anomaly]

A case of severe stenosis of a tricuspid bioprosthesis was successfully dilated in a 13 year old young male with Ebstein's anomaly. The patient had congestive heart failure and developed cardiogenic shock; angiography revealed absence of emptying of the right atrium. Multiple size balloons (#4 to 23) were sequentially introduced with successful bioprosthesis dilation and shock resolution. Tricuspid bioprosthesis can be dilated even in critical conditions and, although a palliative procedure, balloon valvuloplasty can be a lifesaving procedure in patients with cardiogenic shock.

[Comparative study of transthoracic Doppler echocardiogram, computed tomography and aortography in the diagnosis of thoracic aortic dissection]

PURPOSE

Comparative and prospective evaluation of three methods (transthoracic echo-Doppler (TTE), computerized tomography (CT) and aortography (AORT) utilized for aortic dissection diagnosis.

METHODS

The 39 patients with confirmed aortic dissection (surgery or autopsy) underwent, within a few hours of each other, all three methods scrutinized. There were 19 cases of type A and 20 of type B dissection.

RESULTS

In type A dissection the methods were equivalent (TTE = 73.7%, CT = 84.2%, AORT = 73.7% p = NS) but for type B, TTE was significantly inferior to the other two methods (TTE = 60%, TC 90%, AORT = 80%, p < 0.05 for TTE, for TC and AORT p = NS). In three occasions, even though all three methods were performed, the diagnosis was not obtained.

CONCLUSION

The methods which were evaluated make the diagnosis in the majority of cases. In type A all methods are similar, however, in type B, TC and AORT are superior to TTE. Even performing all three methods in each patient, in three instances the diagnosis was not made.

[A cerebrovascular stroke in a child with an anomalous origin of the left coronary artery]

A two-year-old male child presenting anomalous origin of the left coronary artery diagnosed by Doppler echocardiography and confirmed by angiography developed an ischemic stroke, which is a rare event in this situation. He [correction of She] had good recovery of the neurological deficit and his anomalous artery was successfully reimplanted.

[Late development of congestive heart failure in interventricular communication caused by penetrating wound, with pulmonary hypertension resolution after surgical correction]

Male, 33 years-old, with onset of heart failure and edema; he used to be completely asymptomatic but mentioned he underwent previously a pleural drainage, after a hemothorax provoked by a stab wound. His physical examination confirmed he was in heart failure and showed a harsh holosystolic murmur between mitral and tricuspid areas. Cardiac catheterization demonstrated a large apical ventricular septal defect (VSD) and systemic pulmonary arterial pressures. With oxygen there was an increase in the left to right shunt and normal pulmonary vascular resistance. The clinical diagnosis was that of a traumatic VSD provoking pulmonary hypertension although a congenital etiology could not be completely ruled out. At surgery there was a sharp cut at the pericardium and an apical epicardial lesion; the VSD was patch sutured and the patient did well with control of his heart failure. A control hemodynamic study performed within the first postoperative month showed no residual shunt and complete normalization of the pulmonary pressures and resistance.