Large left ventricular metastasis causing left ventricular outflow tract obstruction and haemolysis

Although post-mortem studies would suggest that cardiac metastases occur frequently, many of these metastases remain clinically silent. However, symptomatic lesions may also remain unrecognized due to overshadowing by other symptoms of the primary malignancy. Patients undergoing treatment for cancer are not routinely screened using echocardiography, unless their chemotherapeutic regimen includes cardiotoxic agents. The current era of research and development of targeted biological agents (such as trastuzumab and epidermal growth factor receptor inhibitors) for cancer may lead to prolonged survival of oncology patients. In future, metastases that were once rare may become increasingly recognized as these new treatments augment the natural history of the disease. There have been several case reports of small, asymptomatic left ventricular metastases, but clinically significant ventricular metastases are very rare. There are no reports in the current literature of a symptomatic ventricular metastasis, occurring in the absence of other metastatic disease. We report an unusual case of a large solitary ventricular metastasis, leading to left ventricular outflow tract obstruction and haemodynamic compromise. Echocardiographic imaging led to the diagnosis of a recurrence of soft-tissue fibrosarcoma 9 years after original resection.

Outcomes following de novo CNI-free immunosuppression after heart transplantation: a single-center experience

Renal impairment at the time of heart transplantation complicates the choice of subsequent immunosuppressive therapy. Calcineurin (CNI)-free regimens utilizing proliferation signal inhibitors (PSI) may mitigate against nephrotoxicity in this group; however, their effectiveness remains unclear. We present our 7-year experience with de novo CNI-free, PSI-based immunosuppression after heart transplantation. Of the 152 patients transplanted between July 1999 and July 2006, de novo immunosuppression regimens were 49 CNI-free, PSI-based, 88 CNI, 15 combination of CNI+PSI. Pretransplant creatinine clearance improved within 6 months in the PSI group (0.69 +/- 0.34 mL/s vs. 1.00 +/- 0.54 mL/s, p < 0.05) but not the CNI (1.32 +/- 0.54 mL/s vs. 1.36 +/- 0.53 mL/s, p = ns) or CNI+PSI (1.20 +/- 0.24 mL/s vs. 1.20 +/- 0.41 mL/s, p = ns) groups. The PSI group had more episodes of early (<or=6 months) acute rejection, bacterial or fungal infections and pleural effusions but less CMV infection (p < 0.05 for all comparisons). Early CNI addition occurred in 37% of the PSI group for acute rejection. 33% of the entire cohort changed immunosuppression regimens over 3.6 +/- 2.2 years follow-up. De novo CNI-free, PSI-based immunosuppression in patients with significant renal dysfunction allowed significant posttransplantation renal recovery but with increased early acute rejection, bacterial and fungal infections and pleural effusions.

Mitochondrial respiratory chain activity in idiopathic dilated cardiomyopathy

BACKGROUND

Cardiomyopathy is well recognized in mitochondrial diseases in which it has been associated with defects of mitochondrial function, including cytochrome-c oxidase (COX) deficiencies. This study explores the respiratory chain activity, particularly of COX, in patients with cardiomyopathy to determine whether a relationship exists between respiratory enzyme activity and cardiac function.

METHODS AND RESULTS

Myocardial specimens from the left ventricular wall of explanted hearts were obtained from subjects with ischemic (n = 6) or nonischemic dilated (n = 8) cardiomyopathy. Assays for citrate synthase (CS) and complexes II/III and IV activity were performed on cardiac mitochondria and homogenate. Enzyme activities were normalized to CS activity and compared with control activities (n = 10). A significant reduction in COX and/or CS activity was identified in mitochondrial preparations from the transplant group and correlated significantly with ejection fraction (P < .05), although this does not prove a causal relationship. Significantly reduced CS activity in homogenate was identified, suggesting decreased mitochondrial volume in addition to decreased COX activity. Measurements in cardiac homogenates failed to show a significant reduction in COX activity (P > .05) in the transplant group, suggesting that the use of prefrozen tissue homogenates may underestimate existing mitochondrial respiratory defects in cardiac tissue.

CONCLUSIONS

Mitochondrial function is altered at a number of levels in end-stage cardiomyopathy. Defective COX activity resulting in deficient adenosine triphosphate generation may contribute to impaired ventricular function in heart failure. Agents capable of improving mitochondrial function may find an adjuvant role in the treatment of cardiac failure.

Risk factors for surgical wound infection and bacteraemia following coronary artery bypass surgery

BACKGROUND

There has been no consensus from previous studies of risk factors for surgical wound infections (SWI) and postoperative bacteraemia for patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

Data on 15 potential risk factors were prospectively collected on all patients undergoing CABG surgery during a 12-month period.

RESULTS

Of 693 patients, 62 developed 65 SWI using the Centres for Disease Control definition: 23 were sternal wound infections and 42 were arm or leg wound infections at the site of conduit harvest. There were 19 episodes of postoperative bacteraemia. Multivariate analysis revealed that: (i) diabetes, obesity and previous cardiovascular procedure were independent predictors of SWI; and (ii) obesity was an independent risk factor for postoperative bacteraemia.

CONCLUSIONS

These findings suggest that improved diabetic control and pre-operative weight reduction may result in a decrease in the incidence of SWI. But further prospective studies need to be undertaken to examine (i) whether the increased SWI risk in diabetes occurs with both insulin- and non-insulin-requiring diabetes, and whether improved peri-operative diabetes control decreases SWI; and (ii) what degree of obesity confers a risk of SWI and postoperative bacteraemia, and whether pre-operative weight reduction, if a realistic strategy in this patient group, results in a decrease in SWI.

Preoperative and postoperative comparison of patients with univentricular and biventricular support with the thoratec ventricular assist device as a bridge to cardiac transplantation

OBJECTIVES

The goal of this study was to determine whether there are differences in populations of patients with heart failure who require univentricular or biventricular circulatory support.

METHODS

Two hundred thirteen patients who were in imminent risk of dying before donor heart procurement and who received Thoratec left (LVAD) and right (RVAD) ventricular assist devices at 35 hospitals were divided into three groups: group 1 (n = 74), patients adequately supported with isolated LVADs; group 2 (n = 37), patients initially receiving an LVAD and later requiring an RVAD; and group 3 (n = 102), patients who received biventricular assistance (BiVAD) from the beginning.

RESULTS

There were no significant differences in any preoperative factors between the two BiVAD groups. In the combined BiVAD groups, pre-VAD cardiac index (BiVAD, 1.4 +/- 0.6 L/min per square meter, vs LVAD, 1.6 +/- 0.6 L/min per square meter) and pulmonary capillary wedge pressure (BiVAD, 27 +/- 8 mm Hg, vs LVAD, 30 +/- 8 mm Hg) were significantly lower than those in the LVAD group, and pre-VAD creatinine levels were significantly higher (BiVAD, 1.9 +/- 1.1 mg/dl, vs LVAD, 1.4 +/- 0.6 mg/dl). In addition, greater proportions of patients in the BiVAD groups required mechanical ventilation before VAD placement (60% vs 35%) and were implanted under emergency conditions than in the LVAD group (22% vs 9%). The survival of patients through heart transplantation was significantly better in patients who had an LVAD (74%) than in those who had BiVADs (58%). However, there were no significant differences in posttransplantation survival through hospital discharge (LVAD, 89%; BiVAD, 81%).

CONCLUSION

Patients who received LVADs were less severely ill before the operation and consequently were more likely to survive after the operation. As the severity of illness increases, patients are more likely to require biventricular support.

Pulmonary allograft ischemic time: an important predictor of survival after lung transplantation

BACKGROUND

Traditionally organ availability in human lung transplantation has been limited by aiming to keep the graft ischemic time under 6 hours. To maximize organ supply in a country with a widely spread population, we have routinely procured organs beyond this time. Our experience outlines the clinical consequences of a prolonged allograft ischemic time.

METHODS

Between 1990 and 1994 we performed 106 lung or heart-lung transplantations. The average graft ischemic time was 323 +/- 93 minutes. Lung preservation included a prostacyclin infusion (40 to 80 ng/kg/min for 10 minutes) and cold modified Euro-Collins solution flush. Organs were stored and transported on ice at 6 degrees to 10 degrees C. Graft ischemic time, transplant type, age, gender, cytomegalovirus status, and anesthetic time were subject to multivariate Cox regression analysis.

RESULTS

Survival and graft ischemic times for heart-lung (n = 38), single lung (n = 33), and bilateral lung transplantation (n = 35) were not significantly different. Graft ischemic time was an independent predictor of survival (p < 0.01). Subgroup analysis notes the effect to be most pronounced beyond 5 hours (p = 0.02, hazard ratio 3.44, confidence interval 1.12 to 9.8).

CONCLUSIONS

Pulmonary allograft ischemic time beyond 5 hours does not result in acceptable outcomes although survival is reduced. Attempts should be made to minimize graft ischemic times with careful coordination of transport and personnel.

Analysis of proliferating cell nuclear antigen expression aids histological diagnosis and is predictive of progression of human cardiac allograft rejection

A quantitative immunohistological analysis was undertaken of 558 sequential paraffin-embedded and 22 snap-frozen endomyocardial biopsies (EMBs) from nine consecutive patients undergoing cardiac transplantation and followed for up to 1 year post-surgery. Serial monitoring was performed to assess whether 1) the phenotypic characteristics, 2) level of immune activation, or 3) expression of proliferation-associated antigens by intragraft leukocytes were useful in determining the grade of rejection or predicting further rejection episodes. Particular attention was given to those patients whose most recent EMBs showed grade 2 rejection, because these patients present a common problem in clinical management wherein a decision must be made as to whether or not to increase immunosuppression. Comparison of EMBs displaying various grades of rejection showed that whereas the absolute number of leukocytes (CD45), memory T cells (UCHL1/CD45RO), helper T cells (OPD4), and macrophages (Mac387) increased with increasing grade of rejection, the proportions of each subset remained similar. Cell proliferation was determined by labeling with monoclonal antibodies to proliferating cell nuclear antigen (cyclin) and Ki-67, and immune activation was assessed using an anti-interleukin-2 receptor (CD25) monoclonal antibody. The numbers of intragraft proliferating cell nuclear antigen-positive Ki-67+ or interleukin-2 receptor-positive cells were found to increase with increasing grades of rejection. Moreover, comparison of EMBs with equivalent histological features of rejection (grade 2) showed significantly (P < 0.0001) greater numbers of proliferating cell nuclear antigen-positive cells in EMBs preceding an episode of higher grade or persisting rejection versus EMB from patients whose rejection resolved, as seen on subsequent biopsy, without increased immunosuppression. These data suggest that the identification of proliferating or immunologically activated cells may aid in the histological diagnosis of clinical rejection and provide a valuable indicator predictive of likely further rejection episodes of increasing severity if grade 2 rejection is left untreated.

Epstein-Barr virus-specific cytotoxic T cell response in cardiac transplant recipients

PBLs from 10 normal seropositive donors, 15 precardiac transplant patients, and 17 postcardiac transplant patients have been assayed for their ability to mount a cytotoxic T cell response to both A- and B-type EBV. Compared with the results obtained with healthy seropositive donors, pre- and posttransplant patients had significantly weaker T cell responses against both A-type and B-type EBV. Analysis of individual patients showed a preferential T cell response to B-type EBV in 4/15 pre- and 6/17 posttransplant patients and a preferential T cell response to A-type EBV in 1/15 pretransplant and 2/17 posttransplant recipients. PBMCs were obtained from patients and analyzed for the presence of A- and B-type EBV using polymerase chain reaction. EBV types detected in the PBMCs of each individual were correlated with their EBV-specific CTL response. The results obtained indicated that the EBV-specific cytotoxic T cell response of these patients matched the EBV types with which they were infected.

Value of postoperative assessment of cardiac allograft function by transesophageal echocardiography

Heart transplantation now provides an acceptable therapy for patients with severe end-stage heart disease. Although patient outcome has significantly improved both early and late after heart transplantation, early morbidity and mortality continues to affect overall survival and may be unpredictable. In an attempt to identify factors that may assist in predicting early outcome after orthotopic heart transplantation, we assessed allograft function in 16 patients in the immediate postoperative period, 30 minutes after weaning from cardiopulmonary bypass by measuring the fractional shortening of the left ventricle with transesophageal echocardiography. In addition, standard hemodynamic indexes of allograft function (arterial blood pressure, pulmonary capillary wedge pressure, mean pulmonary artery pressure, and cardiac output) were obtained at this early time point. Early outcome was assessed by the duration and peak dose of inotrope support required after transplantation, requirement for mechanical support, and the duration of stay in the intensive care unit. Left ventricular fractional shortening 30 minutes after cardiopulmonary bypass was significantly lower in those patients requiring inotropic support (28.4% +/- 4.6% versus 43.7% +/- 3.5%, p < 0.05), whereas hemodynamic variables failed to distinguish these groups. In those patients requiring inotropes, there was a significant negative correlation of fractional shortening with the peak dose (r = -0.87, p < 0.01) and the duration of inotropic support (r = -0.62, p < 0.05). The total ischemic time of the allograft (206 +/- 22 minutes, range 77 to 359) did not correlate with the subsequent fractional shortening, but patients requiring inotrope support after the operation had significantly longer ischemic times (259 +/- 22 versus 138 +/- 22 minutes, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Functional and neurochemical evidence for partial cardiac sympathetic reinnervation after cardiac transplantation in humans

BACKGROUND

The presence of cardiac reinnervation in humans after cardiac transplantation has been widely debated, based on the application of differing methods for the assessment of neuronal function. Some of these techniques have been rather indirect; consequently, the time course and extent of cardiac reinnervation remains uncertain.

METHODS AND RESULTS

To test for the presence of cardiac reinnervation after transplantation, we examined neurochemical (radiolabeled norepinephrine [NE] kinetics) and functional markers (power spectral analysis, heart rate response to exercise) of cardiac sympathetic nerve integrity in 15 cardiac transplantation recipients and 25 healthy control subjects of similar age. Cardiac transplantation subjects were studied 9 weeks to 8 years after cardiac transplantation (10 "early" patients < 18 months and 5 "late" patients > 2 years after cardiac transplantation). At rest, cardiac NE spillover was markedly attenuated early after transplantation (11.2 +/- 18.3 pmol/min) compared with subjects late after transplantation (105 +/- 11 pmol/min, P < .01) or in healthy control subjects (103 +/- 15 pmol/min, P < .01). Heart rate variability (measured by total spectral power) was significantly reduced in cardiac transplantation recipients compared with control subjects (59.4 +/- 30 vs 1673 +/- 516 milliseconds squared; P < .05), with evidence of a trend toward increasing spectral power late after transplantation. During exercise, the cardiac NE spillover was significantly lower in early cardiac transplantation recipients when compared with control subjects (163 +/- 50 vs 1876 +/- 418 pmol/min, P < .01). Late cardiac transplantation subjects showed a response intermediate (1080 +/- 254 pmol/min) between that of the early cardiac transplantation and control groups. However, measurements of the neuronal reuptake process for NE (assessed by the fractional extraction of plasma labeled NE across the heart and tritiated dihydroxyphenylglycol release) were significantly depressed in both early and late cardiac transplantation subjects.

CONCLUSIONS

The present study demonstrates a partial restoration of cardiac sympathetic nerve function in humans up to 8 years after heart transplantation.

Expression of B-type Epstein-Barr virus in HIV-infected patients and cardiac transplant recipients

In the present study, peripheral blood mononuclear cells (PBMCs) were obtained from HIV+ subjects as well as cardiac transplant recipients, and the presence of A- and B-type Epstein-Barr virus (EBV) was determined using the polymerase chain reaction (PCR). Of the HIV+ patients studied, 24% were found to be infected with A-type EBV, 27% with B-type EBV, and 39% with both A and B virus types. Analysis of PBMCs from cardiac transplant recipients revealed that 39% were infected with A-type EBV, 33% with B-type EBV, and 28% with both EBV types. These results demonstrate a higher prevalence of infection with B-type EBV in HIV+ patients, than had been found previously by an analysis of spontaneously generated lymphoblastoid cell lines. The data indicated that it is not HIV per se which is responsible for the high incidence of B-type EBV in HIV+ individuals.

Cardiopulmonary transplantation service establishment in the 1990s: Australia--a developing country?

1. A National Transplantation Service has been established at the Alfred Hospital performing more than 50 transplants per year. 2. Increased access to transplantation technology has facilitated an improvement in national population servicing from 2.7 to 6.2 transplants per million population per year. National funding of A$4.062 million per year has been secured. 3. Basic research into organ preservation has facilitated transcontinental organ procurement. 4. An active lung transplantation program has been established synchronous with the cardiac transplant service activities. 5. MCS program establishment has paralleled clinical transplantation activities. 6. Budget management and cost containment has been achieved through rationalisation of management protocols.

Coronary artery to middle cardiac vein fistula following endomyocardial biopsy in a heart transplant patient

Coronary artery fistulas draining directly into the right ventricle have been recognised as a complication of transvenous endomyocardial biopsy procedures performed in heart transplant recipients. We report a case where a fistula drained into the middle cardiac vein and outline the possible mechanism of occurrence and its prevention. The diagnostic and therapeutic aspects of these "acquired" fistulas are reviewed.

Heart transplantation in females

To confirm reports of a higher rate of rejection in female recipients of cardiac allografts and to determine whether infection rates and actuarial survival differ from that in males, we reviewed the results of 150 consecutive heart transplant procedures. Of these, 27 were in females and 123 were in males. Three different regimens were used over a 5-year period: group 1 (n = 37), cyclosporine and prednisolone; group 2 (n = 61), cyclosporine, azathioprine, and prednisolone; group 3 (n = 52), cyclosporine and azathioprine. All groups received a 7- to 10-day induction course with antithymocyte globulin. Female recipients had significantly more rejection episodes than male recipients to 3 months after transplantation (females 2.3 vs males 1.5 episodes/patient, p less than 0.01) and to 12 months (females 2.4 vs males 1.5 episodes/patient, p less than 0.02). These differences were largely caused by higher rates of rejection in females in both "double" therapy groups (groups 1 and 3). All surviving females in group 3 required the addition of maintenance steroids to control rejection. Gender mismatching of donors (male donor, female recipient) was identified as a factor associated with this requirement for conversion. Augmented treatment for rejection resulted in a higher rate of infection at 12 months in female recipients (females 1.5 vs males 0.7 episodes/patient, p less than 0.02), yet no female died of infection, and actuarial survival was comparable to that in male recipients. In view of the propensity of females to reject more frequently and earlier than males, triple therapy is currently the regimen of choice for female patients in the first 3 to 6 months after heart transplantation. Steroid withdrawal may be possible at a later time in those in whom this is indicated.

Psychological adjustment after cardiac transplantation

Cardiac transplantation is viable therapeutic alternative for patients with end-stage heart disease, which offers a favourable short- and medium-term prognosis. The survival has improved from 20% of patients who survived at one year after transplantation in the 1960s to the present figures of 80%-85% of patients who are alive at one year, and 50%-70% of patients who are alive at five years, after transplantation. Therefore, it seems timely to focus attention on the psychological well-being of cardiac-transplant recipients. The medical literature is scant in regard to the psychiatric and the psychosocial impact of cardiac transplantation on recipients, and a systematic and prospective study of the psychosocial adaptation of recipients is lacking. Since 1984, we have been studying the emotional impact of cardiac transplantation on recipients and their families. This article presents the results for a group of recipients who have been assessed before transplantation, then followed-up at discharge from hospital and at four, eight and 12 months after transplantation. The study attempted to quantitate the recipients' anxiety, depression, body image and subjective quality of life by way of standardized self-assessment questionnaires. The recipients' satisfaction with relationships or their marital situation also was reported, as were their degree of rehabilitation at 12 months and their attitudes to various aspects of treatment after the transplantation. Before the transplantation, 53% of patients reported an increase in anxiety and 34% of patients recorded scores that indicated mild-to-moderate levels of depression. Thirty-seven per cent of patients showed a deterioration in the quality of their lives and 34% of patients had a negative body image. After the transplantation, significant improvements occurred in all parameters, which were maintained at follow-up.

Effects of low-dose cyclosporine A on toxicity and rejection in cardiac transplantation

In conclusion, the low doses of CsA have significantly reduced nephrotoxicity and infectious complications. The patient survival has been acceptable, but there has been a disappointing incidence of rejection and graft loss in patients who have survived the first 3 months. We feel our experience would indicate that by targeting our CsA dosages to such low serum levels some of our patients receive suboptimal immunosuppression. Perhaps the best way of overcoming this is add a third maintenance immunosuppressive agent such as azathioprine to supplement immunosuppression. In fact, we have now changed our immunosuppressive protocol to include azathioprine while maintaining our CsA therapy at its current level.