Outcomes from paired single-lung transplants from the same donor

BACKGROUND AND METHODS

Simultaneous, paired single-lung transplants from a single organ donor is one way to maximize lung transplant opportunities. Paired transplants allow comparison between left and right single-lung transplants and also provide insight into the relevance of donor vs recipient factors in rejection outcomes.

RESULTS

Of 76 paired transplants (38 pairs) performed at the Alfred Hospital, 68 patients have survived >30 days. We observed no significant differences between left and right single-lung transplants in ICU stay (median, 3.1 vs 3.0 days; range, 0.5 to 83 vs 0.5 to 76 days), hospital stay (median, 19.5 vs 24.0 days; range, 1 to 118 vs 11 to 144 days), airway complications (5 vs 3), and 5-year survival (60% vs 50%). The 6 month, and 1- and 2-year survivals were lower in left single-lung transplant recipients, primarily related to increased mortality from airway complications. In 28 pairs, both recipients survived 90 days, and the incidence, frequency, and time of onset of acute rejection and chronic rejection (bronchiolitis obliterans syndrome [BOS]) were not significantly different. When sequentially performed lung transplants were separately analyzed, the incidence of acute rejection was not related to graft ischemic time.

CONCLUSIONS

The general outcomes of right and left transplants are similar, although we observed increased 6-month to 2-year mortality associated with left lung transplantation. The lack of correlation between the incidence of acute rejection episodes or the severity of BOS in paired allograft recipients suggests that "donor factors" are not the dominant cause.

Post-cardiac transplantation gout: incidence of therapeutic complications

OBJECTIVE

To study the clinical impact of gout treatment following cardiac transplantation.

METHODS

We performed an audit of all cardiac transplant recipients of the Alfred Hospital before August 1998 who lived in Victoria.

RESULTS

We studied 225 patients (81% men), with a mean post-transplant follow-up of 50.8 months (SD 36). Forty-three (19%) had pre-transplant gout, 19 recurring post-transplantation. Twenty-three patients developed gout de novo. Of the 24 patients who received allopurinol, 6 developed pancytopenia and required hospitalization. Fourteen received a change in immunosuppression: in 5 patients following pancytopenia, and in 9 to enable safe use of allopurinol. Thirty-two patients received colchicine; 5 developed neuromyopathy. Impaired renal function, diuretic use, and hypertension were more common in this sub-group. Non-steroidal anti-inflammatory agents, used in 16 patients, caused serious complications in 1 patient (life-threatening peptic ulceration and hemorrhage, precipitating dialysis-dependent chronic renal failure).

CONCLUSIONS

Cardiac transplant recipients, when treated for gout, are at high risk of therapeutic complications. Thus, gout treatment significantly affects care, health, and immunosuppression of these patients.

A simplified method of harvesting and dilating the radial artery achieves acceptable clinical outcomes

BACKGROUND

The recent successful revival of the radial artery as a coronary-bypass conduit has been attributed to a minimally traumatic harvesting technique without diathermy, combined with long-term oral calcium antagonist therapy. We describe a simplified technique of harvesting the radial artery, which reduces procurement time and maintains conduit relaxation.

METHODS

Radial arteries were harvested using diathermy and topical glyceryl trinitrate-verapamil dilator solution. Postoperatively, intravenous glyceryl trinitrate, but no calcium antagonist was used. The clinical results in the first 100 consecutive patients receiving radial artery grafts (RA group), procured using this technique, were compared with a group of 100 patients receiving saphenous vein conduits (SV group) immediately prior to the introduction of the radial artery at our institution.

RESULTS

There were no demographic differences between the two groups, other than the SV group being slightly older. There was one intraoperative death in each group. There was no difference in the rate of peri-operative myocardial infarction or length of stay in the intensive care unit. At a median follow-up time of 16 months for the RA group, and 25 months for the SV group, the survival rates were 97 and 94%, respectively. All survivors were in the New York Heart Association class I. In the SV group, two postoperative angioplasties were performed.

CONCLUSIONS

These early results suggest that this method of procuring the radial artery using diathermy, glyceryl trinitrate and no postoperative calcium antagonists, is rapid, safe and effective. The continued use of this technique is justified, while awaiting the results of long-term angiographic studies.

Outcomes of coronary artery bypass grafting: A 3 year analysis using the society of thoracic surgeons database

BACKGROUND

Accurate risk factor analysis is a critical element in contemporary cardiac surgical practice. In the USA, the Society of Thoracic Surgeons Database allows institutions and individual surgeons to carry out detailed patient risk assessment and to review their cardiac surgical outcomes in a comparative fashion.

METHODS

To evaluate outcomes of isolated coronary artery bypass grafting, data from all patients operated upon at the Alfred Hospital, Melbourne, Australia, over a 3 year period were entered into the Society of Thoracic Surgeons Database.

RESULTS

Our results (mortality and morbidity) compared favourably with those contained within this large international database.

CONCLUSION

It is hoped that a similar Australasian database can be established to facilitate a meaningful local risk assessment and a comparative analysis of outcomes of cardiac surgical procedures.

Maximizing thoracic organ transplant opportunities: the importance of efficient coordination

BACKGROUND

In Australia, despite large distances and one of the world's lowest multiorgan donor rates (11.4/million population/year), the thoracic organ transplant (TOTx) rate of 9.6/million population/year is one of the world's highest.

METHODS

As an example of the Australian approach, a system of transplant coordination and organ allocation has evolved at the Alfred Hospital. Donor organs are assigned locally, or between the 4 major TOTx units on rotation. The recipient team then selects appropriate recipients, matching by blood group, size, cytomegalovirus (CMV) status, prospective cross matching and clinical status. An experienced recipient coordinator takes responsibility for organization of the retrieval and transplant process, including all operating room staff, all medical personnel, and transport for the donor team and the potential TOTx recipients.

RESULTS

Between February 1989 and February 1999, 307 hearts, 48 heart/ lung, 124 single and 116 bilateral lung transplants were performed from 452 donor offers (52% beyond 500 miles). This represents 1.74 organs transplanted/thoracic donor and compares favourably to American United Network for Organ Sharing (1.43) and European (1.3) figures.

CONCLUSIONS

The Australia TOTx model has enabled high transplant rates by efficiently using the available donor organs. This has been achieved through an enlarged, experience TOTx team, the optimizing of donor acceptance criteria and improving coordination logistics to allow multiple thoracic procedures simultaneously.

Bilateral sequential single lung transplantation for pulmonary hypertension and Eisenmenger's syndrome

BACKGROUND

Lung transplantation, with and without intracardiac repair for pulmonary hypertension (PH) and Eisenmenger's syndrome (EIS), has become an alternative transplant strategy to combined heart and lung transplantation (HLT).

METHODS

Thirty-five patients with PH or EIS underwent either bilateral sequential single lung transplantation (BSSLT, group I, n = 13) or HLT (group II, n = 22). Another 74 patients, who underwent BSSLT for other indications, served as controls (group III). Immediate allograft function, early and medium-term outcomes, lung function, and 2-year survival were compared between the groups.

RESULTS

Comparisons between groups I and II showed no significant difference in any variables except percent predicted forced vital capacity. Immediate allograft function was significantly inferior (p < 0.05) and the blood loss was greater (p < 0.01) in group I when compared with those in group III. However, this resulted in no significant difference in early and medium-term outcomes, and 2-year survival between the 2 groups.

CONCLUSIONS

BSSLT for PH and EIS can be performed as an alternative procedure to HLT without an increase in early and medium-term morbidity and mortality. Results are comparable with BSSLT performed for other indications.

Bridge to recovery with a left ventricular assist device for fulminant acute myocarditis

Acute fulminant myocarditis frequently causes circulatory collapse that is resistant to conventional therapy. We describe a case in which a patient with histologically confirmed viral myocarditis was supported by a left ventricular assist device (LVAD) as a bridge to recovery. The LVAD was successfully weaned 3 weeks later.

Increased temperature reduces the protective effect of University of Wisconsin solution in the heart

BACKGROUND

The protective effect of University of Wisconsin solution (UW) for hypothermic storage of donor hearts has been demonstrated in the laboratory. However, clinical usage is associated with occasional primary graft failures. We postulated that this could be related to adverse effects of UW on the coronary vasculature during cardiac implantation and rewarming. We therefore assessed recovery of contractile function and coronary flow in rat hearts after cardioplegic arrest using UW compared with St. Thomas' solution (ST) at 4 degrees C or 25 degrees C.

METHODS

Cardioplegia was induced in isolated rat hearts using either UW or ST at 4 degrees C. Hearts were then maintained at 4 degrees C or 25 degrees C. In some hearts, UW at 4 degrees C was used for inducing arrest followed by flushing with ST at 4 degrees C and then rewarming to 25 degrees C. After 40 minutes of arrest, recovery of function and coronary flow were measured. Nuclear track emulsion was used to assess microvascular competence.

RESULTS

Compared with ST-treated hearts, UW-treated hearts showed significant reduction in recovery of function at 25 degrees C (76.2% +/- 4.0% versus 25.0% +/- 4.1%; p < 0.01) but not at 4 degrees C (88.0% +/- 1.6% versus 87.1% +/- 2.6%). Recovery of coronary flow in the UW-treated hearts at 25 degrees C was significantly lower than that in the ST-treated hearts at 25 degrees C (71.7% +/- 3.0% versus 94.5% +/- 6.3%; p < 0.01). At 25 degrees C, microvascular competence was reduced in the UW group compared with the ST group. At 25 degrees C, flushing out UW with ST resulted in greater recovery of function compared with UW throughout (73.4% +/- 7.1% versus 25.0% +/- 4.1%; p < 0.01).

CONCLUSIONS

University of Wisconsin solution provides effective donor heart protection under hypothermic conditions but can be deleterious at warmer temperatures.

Coronary artery disease in potential lung transplant recipients > 50 years old: the role of coronary intervention

STUDY OBJECTIVES

To review the experience of the Alfred Hospital in the systematic assessment of coronary artery disease (CAD) using coronary angiography (CA), and the subsequent management of CAD, in potential lung transplant recipients.

DESIGN

Retrospective study.

SETTING

The Alfred Hospital Lung and Heart Transplant Service.

PATIENTS

CAD risk factors were sought in potential recipients of lung transplantation (LTx) who were > 50 years old, including a history of smoking, male gender, hypertension, diabetes, hypercholesterolemia, angina, and a family history of CAD. When feasible, and in the presence of more than one cardiac risk factor, CA was performed.

RESULTS

From 243 referral patients who were > 50 years old, 97 were listed for LTx, and 77 underwent LTx. Four patients were refused LTx on the basis of CAD. Of 101 patients undergoing a detailed cardiac assessment for LTx, 83 had smoked, 56 were male, 48 had hypercholesterolemia, 22 had hypertension, 4 had diabetes, and 3 had a history consistent with angina. Eighty-five patients underwent CA. In 32 cases, CA revealed CAD, and half of these cases were significant stenoses. Eight patients who were assessed required intervention. Five patients of this group have been transplanted; of these, three patients underwent coronary artery grafting at the time of LTx, and two patients underwent preoperative angioplasty or stenting. Only one of these five patients died < 90 days postoperatively.

CONCLUSION

Significant CAD is a common finding in older patients who are presenting for LTx. Coronary revascularization for severe large vessel stenoses can allow safe LTx. CAD risk factors may predict who should undergo CA, but further studies of clinical and noninvasive assessments of CAD are needed if CA is to be safely avoided in patients at low risk of CAD.

Maximizing the utilization of donor organs offered for lung transplantation

The number of patients awaiting lung transplantation (LT) and waiting time for surgery is increasing. In Australia, LT rates are 4. 6/million population/yr, which despite low organ donation rates, are the highest published in the world. The Australian organ allocation system allows identification of marginal donors and therapeutic manipulation where appropriate. This study aims to assess the impact of utilization of marginal donors and aggressive donor management. A comparison between published donor criteria and local practice is made, allowing assessment of the effect of using marginal donors on outcome. Donor management included antibiotic therapy, strict fluid management, physiotherapy, bronchoscopy and bronchial toilet, and alteration of ventilatory settings including initiation of pressure support. Blood gases were repeated to assess the results of interventions. Between January 1, 1995 and May 31, 1998, we performed 140 transplants from 112 of 219 (51%) lung donor offers. Of these donors, 48 (43%) satisfied all published criteria for suitable donor organs (Group 1 = ideal donors) and 64 (57%) did not (Group 2 = marginal donors). Criteria breached by the marginal donors were: an initial ratio of arterial oxygen pressure to fraction of inspired oxygen (PaO2/FIO2) < 300 mm Hg (n = 20), abnormal radiology (n = 39), pulmonary infection (n = 24), 20 pack-years smoking (n = 5) and age > 55 yr (n = 4). Therapeutic manipulation resulted in improvement in the PaO2/FIO2 ratio in 20 donors (Group 3) who would not otherwise have been used. Immediate and 24 h postoperative gas exchange and length of intensive care unit (ICU) stay was not different for recipients from donors from all three groups. Overall survival was 94% at 30 d, 83% at 1 yr, 70% at 2 yr, and 62% at 3 yr and was not significantly different from the three groups. We conclude that organ utilization can be maximized by therapeutic manipulation and utilization of marginal donors without compromising results from transplantation.

Impact of graft ischemic time on outcomes after bilateral sequential single-lung transplantation

BACKGROUND

Graft ischemic time (GIT) is a potential limiting factor in lung transplantation.

METHODS

Seventy-four patients who underwent bilateral sequential single-lung transplantation were divided into three groups: group I, GIT less than 5 hours (n = 20); group II, GIT between 5 and 8 hours (n = 39); and group III, GIT more than 8 hours (n = 15). We compared early allograft function (ratio of arterial oxygen tension to inspired oxygen fraction and alveolar-arterial oxygen gradient), blood loss, the need for tracheostomy, the duration of ventilation, intensive care unit stay, and hospital stay. We also compared prevalences of acute and chronic rejection, airway complications, lung function test, and 2-year survival.

RESULTS

Early allograft function in group III was significantly worse than those in groups I and II. However, there was no significant difference in any other variables of early and medium-term outcomes among the three groups. No significant correlation was detected between GIT and duration of intensive care unit stay or hospital stay.

CONCLUSIONS

The limitation of acceptable GIT could be extended from the traditionally approved 4 to 5 hours, to 5 to 8 hours or even longer.

Clonidine and cardiac surgery: haemodynamic and metabolic effects, myocardial ischaemia and recovery

Clonidine may have beneficial effects in patients undergoing major surgery. We enrolled 156 patients having elective CABG surgery in a double-blind, randomized trial. Patients were randomized to receive either two doses of placebo (Group PP) or clonidine 5 micrograms/kg (Group CC). Perioperative measurements included haemodynamics, anaesthetic and analgesic drug usage, creatinine clearance, cortisol excretion, recovery times and quality of life (SF-36) after surgery. Overall, there was no significant difference with time to tracheal extubation (median [10-90 centile]): CC 7.1 (3.4-18) h vs PP 8.0 (4.3-17) h, P = 0.70; but there was a higher proportion of patients extubated within four hours: CC 20% vs. PP 8%, P = 0.038. Clonidine resulted in a number of significant (P < 0.05) haemodynamic changes, particularly pre-CPB: less tachycardia and hypertension, more bradycardia and hypotension. Clonidine was associated with a significant (P < 0.05) reduction in anaesthetic drug usage, higher creatinine clearance, lower cortisol excretion and improvement in some aspects of quality of life. This study lends support to consideration of clonidine therapy in patients undergoing CABG surgery.

The limited role of myocardial fluorine-18 fluorodeoxyglucose imaging in candidates for cardiac transplantation: a planar imaging study

This study compares the incidence and extent of hibernating myocardium (defined by myocardial perfusion/metabolism mismatch) in 28 cardiac transplant candidates with ischaemic cardiomyopathy and in 16 other patients with coronary artery disease (CAD) undergoing viability assessment. It then reviews the impact of myocardial perfusion metabolism imaging on management decisions in the transplant candidates at 6 months after scintigraphy. Each patient underwent a planar myocardial thallium-201 and fluorine-18 fluorodeoxyglucose scan on a modified gamma camera. Perfusion/metabolism mismatch was sized semi-quantitatively and each patient was assigned a global mismatch score. Transplant candidates had a lower left ventricular ejection fraction (LVEF) (P < 0.0002) and extent of hibernation myocardium (lower global mismatch score: P = 0.005) than other CAD patients but the difference in respect of mismatch frequency (8/28 vs 9/16 patients) did not reach statistical significance. Transplant candidates with LVEF < 20% had a lower global mismatch score (P < 0.02) than those with an LVEF > or = 20%. Interestingly two of three other CAD patients with LVEF < 20% had a moderate mismatch. Follow-up studies revealed the lack of impact of metabolic imaging as none of the three transplant candidates who eventually underwent revascularisation had hibernating myocardium and transplantation was offered to one of only two candidates with more than one minor mismatch. Thus metabolic imaging in potential transplant candidates may be of limited value because of the very low extent of hibernating myocardium, particularly if LVEF is below 20% and where clinical decisions are often based on many other factors.

Lung volume reduction surgery for emphysema

OBJECTIVE

To report the results of lung volume reduction surgery (LVRS) for severe emphysema in Australia.

SETTING

A tertiary teaching hospital.

DESIGN

A prospective study of a consecutive case series.

PARTICIPANTS

20 patients (mean age, 56 years) with severe emphysema--mean forced expiratory volume in one second (FEV1), 0.72 L (28% of predicted) and severe gas trapping (mean residual volume, 286% of predicted).

INTERVENTION

Bilateral apical LVRS was performed via a median sternotomy with a linear stapler; bovine pericardial strips were used to reinforce the staple line.

RESULTS

There was a 95% survival, and a mean (range) inpatient stay of 17 (8-45) days. No complications occurred in nine patients; a further six patients had only minor complications. Five patients had major complications (sputum retention requiring reintubation, persistent air leak requiring reoperation, duodenal perforation, and epidural haemorrhage); one patient died from multiorgan failure at 28 days. Intercostal drainage was left in situ for a mean of eight days. The results of FEV1, Medical Research Council (MRC) Dyspnoea Score and six-minute walk test improved in more than 90% of patients. FEV1 improved an average of 0.35 L (54% over baseline) (P < 0.001). Mean MRC Dyspnoea Score decreased from 3.4 to 2.1 (P < 0.001). Mean distance for the six-minute walk test increased from 306 to 431 metres (P < 0.001).

CONCLUSION

Our experience confirms that LVRS produces worthwhile early outcomes for a subgroup of patients with severe emphysema. The clinical, economic and ethical questions raised by this new therapy will need to be assessed.

Quantitative detection of human cytomegalovirus DNA in lung transplant recipients

Human cytomegalovirus (HCMV) disease remains a major cause of morbidity and mortality after lung transplantation. Currently, routine diagnostic tests for HCMV are inefficient and insensitive or nonspecific for HCMV disease. We describe an efficient, highly sensitive, quantitative polymerase chain reaction (PCR) assay for HCMV using competitive PCR and fluorescently labeled primers, and we have used this to measure HCMV DNA load in donor and recipient tissues of six lung transplant recipients at the time of transplantation, and 2 wk after transplantation when clinically stable. Total DNA yield was adequate for analysis in transbronchial biopsy, bronchoalveolar lavage, and peripheral blood leukocytes, but the endobronchial biopsy specimens did not consistently produce sufficient DNA for analysis. There was a large intersubject and intrasubject variability between tissues in HCMV DNA load, with a tendency for greater levels in lung tissue compared with BAL or peripheral blood cells. All six HCMV IgG seronegative donors or recipients were found to have HCMV DNA present. One of the three seronegative matched transplant recipients developed histopathologically proven HCMV disease, and HCMV DNA levels were shown to increase at that time point and subsequently decrease with ganciclovir treatment. This assay will allow prospective studies to confirm the predictive value of HCMV DNA load in donor and recipient tissues for HCMV disease.

Early hemodynamic effects of left atrial administration of epinephrine after cardiac transplantation

We studied the hemodynamic effects of left atrial (LA) administration of epinephrine in 10 patients after cardiac transplantation, using a prospective, randomized, double-blind, cross-over design. After allograft implantation, a LA catheter was inserted and epinephrine infusion commenced at 100 ng.kg-1.min-1. Each trial period consisted of 20 min, with the LA and right atrial (RA) lines switched over between each period; hemodynamic measurements were taken after each time period. Whether epinephrine was administered via the RA or LA did not significantly alter hemodynamics (RA versus LA): mean (SD) arterial blood pressure 67 (7.5) vs 64 (9.5) mm Hg (P = 0.16), mean pulmonary artery pressure 22 (4.0) vs 21 (9.4) mm Hg (P = 0.67), cardiac index 3.2 (1.1) vs 3.2 (1.1) L.min-1.m-2 (P = 0.83), pulmonary vascular resistance index 308 (157) vs 345 (157) dynes.s.cm-5/m-2 (P = 0.30) or right ventricular ejection fraction 35% (11%) vs 32% (9.8%) (P = 0.23). Arterial epinephrine plasma levels were similar (P = 0.16). There was no significant pulmonary extraction of measured catecholamines. We observed no hemodynamic benefit of LA epinephrine administration. It may be that the cardiac transplantation population reacts differently compared with other cardiac surgical patients (possibly because pulmonary extraction of catecholamines is reduced). Because we did not observe a hemodynamic advantage in patients immediately after cardiac transplantation, we would not recommend the use of LA epinephrine at the dose studied.

Improved sternal fixation in the transsternal bilateral thoracotomy incision

The success of bilateral sequential single-lung transplantation has led to the rebirth of the transsternal bilateral thoracotomy incision. Despite the multiple advantages of this incision over a median sternotomy for this operation, one distinct disadvantage is the high prevalence of sternal disruption at the transverse sternotomy site, which is traditionally closed with sternal wires. This disruption rate is between 20% and 40% in most institutions and can lead to significant pain and deformity in addition to slowing the postoperative recovery and increasing the risk of sternal infection. To overcome this problem we have designed and manufactured a device that provides a sound method of fixating the sternum. The device is composed of two plates, one anterior and one posterior to the sternum, that are fixed to each other and to the sternum by means of screws into internally threaded posts positioned in predrilled holes through the bone on either side of the sternotomy. All components of the device are made from titanium and a range of post lengths are available to accommodate variability in sternal thickness. The structure of the device is demonstrated. The device has now been inserted into a total of 20 patients after bilateral lung transplantation and the preliminary results suggest this is a superior technique for closure of a transverse sternotomy and support continued and routine use.

Cytolytic therapy for the bronchiolitis obliterans syndrome complicating lung transplantation

The bronchiolitis obliterans syndrome (BOS) is the major cause of late morbidity and mortality after lung transplant (LTx). Previous studies suggest cytolytic therapy may be effective for the BOS but this therapy has not been proved effective or safe.

METHOD

A retrospective study of a predetermined treatment regimen to determine if the rate of fall in FEV1 can be reduced by corticosteroids and cytolytic therapy. Since August 1992, 10 to 65 long-term survivors of LTx (5 men, 5 women; mean age 36 +/- 10 years) developed BOS. All had previously had lymphocyte immune globulin, antithymocyte globulin (equine) (ATGAM sterile solution; Upjohn Pty Ltd; Sydney, Australia) induction therapy and corticosteroid avoidance for the first 7 to 10 days post-LTx. Therapy for the BOS was initiated with pulse methylprednisolone and ATGAM (aiming for an absolute CD3 count of < or - 100 cells per microliter for 5 days). ATGAM therapy was initiated at a mean 657 +/- 323 days post-LTx. Subsequent follow-up has been for 310 +/- 110 days (range, 163 to 530 days).

RESULTS

Nine of ten patients had a response with tolerable side effects. Preintervention, there was a linear fall in FEV1 of 0.22 +/- 0.15% predicted FEV1 per day (mean +/- SD) (range, 0.06 to 0.56%) compared with a postintervention linear fall of 0.036 +/- 0.019% predicted per day (range, 0 to 0.13%) (paired t test; p<0.005). This effect is sustained over the follow-up period.

CONCLUSION

The fall off in FEV1 that characterizes the BOS may be altered usefully by augmented immunotherapy. This effect can be rapid and sustained although it is neither completely arrested nor ever reversed. These data are preliminary but encourage a randomized control trial in the BOS.

Reverse telescope anastomotic technique reduces the incidence of bronchial stricture

BACKGROUND

Bronchial stricture remains a major problem after lung transplantation. We hypothesized that a "reverse" telescope anastomosis, where the donor bronchus is sleeved external to the recipient bronchus, would be associated with a lower incidence of anastomotic stricture.

METHODS

Over a 12-month period our Unit performed 35 consecutive single and bilateral sequential lung transplantations. The 56 bronchial anastomoses were constructed as a conventional (n = 27) or as a reverse (n = 29) telescope.

RESULTS

Bronchial strictures developed in 48% of the conventional anastomoses but in only 7% of the reverse anastomoses (p < or = 0.05). Furthermore, the reverse telescope anastomosis eliminated the need for stenting.

CONCLUSIONS

This technique greatly reduced the need for dilatation, debridement, and stent placement and may reduce the morbidity and mortality associated with anastomotic complications.

Successful long-term outcome with prolonged ischemic time cardiac allografts

BACKGROUND

The limited availability of cardiac allografts together with the increasing number of patients on the waiting list restricts treatment of this population with heart transplantation. An increase in the available donor pool has been facilitated by the use of allografts with prolonged ischemic time (> 240 minutes).

METHODS

Short- and long-term outcomes were compared in 150 heart transplant recipients on the basis of allograft ischemic time (< 241 minutes, 241 to 300 minutes, and > 300 minutes).

RESULTS

No difference was found in allograft functional capacity, the development of transplant-associated coronary disease, or actuarial survival in the short and long term.

CONCLUSIONS

Improved population treatment with prolonged ischemic time cardiac allografts can be safely undertaken without long-term risk to heart transplant recipients.

Preliminary experience with inhaled nitric oxide for acute pulmonary hypertension after heart transplantation

BACKGROUND

Substantial interest has developed in the physiologic and therapeutic role of nitric oxide in the last few years. In patients with pulmonary hypertension it appears to be a useful selective pulmonary vasodilator; however, many issues of both staff and patient safety remained unanswered.

METHODS

This study examines further safety issues and also presents preliminary clinical experience in patients after orthotopic heart transplantation with pulmonary hypertension and right-sided ventricular failure.

RESULTS

Atmospheric levels of nitric oxide and nitrogen dioxide are 100 times less than occupational health standards. When nitric oxide is used at 70 parts per million in the presence of a fraction of inspired oxygen greater than 0.60, nitrogen dioxide levels in the circuit exceed the published short-term exposure limit of the American Conference of Government Industrial Hygienist of 5 parts per million.

CONCLUSION

Staff safety appears confirmed, but despite encouraging clinical results, further longer term safety and efficacy studies are indicated.

Inhaled nitric oxide used as a bridge to heart-lung transplantation in a patient with end-stage pulmonary hypertension

We describe a 40-yr-old woman who received inhaled nitric oxide (NO) as a therapeutic bridge to heart-lung transplantation for end-stage primary pulmonary hypertension. After 10 yr of increasing disability, the patient presented in October 1993 with severe dyspnea, right ventricular angina, and syncope. As predicted by a prior vasodilator trial, prostacyclin produced as initial favorable clinical and hemodynamic response. With the recurrence of severe symptoms and hemodynamic compromise, inhaled NO was successfully tried at 40 ppm, initially via a face mask and later via a transtracheal Scoop catheter. The patient was "bridged" to heart-lung transplant after 68 d of therapy (mean dose of NO, 50.4 +/- 23 ppm). The explanted lungs revealed no evidence of significant NO toxicity, and the explanted heart was successfully transplanted into another patient. Inhalation of NO via a transtracheal catheter is a useful and practical treatment of refractory pulmonary hypertension. The limits of NO therapy in terms of duration and dosage have not been determined.

Exercise, potassium, and muscle deconditioning post-thoracic organ transplantation

Although muscle deconditioning appears to significantly limit peak exercise performance post-thoracic organ transplantation, few confirmatory data exist. Potassium (K+) regulation during exercise may reflect muscle deconditioning, since both peak plasma K+ concentration ([K+]) and the increase in plasma [K+] relative to energy expenditure (delta [K+]/W) are reduced in healthy individuals after training. This study compares delta [K+]/W during graded exercise and the change in [K+] (delta [K+]) during both exercise and recovery in 12 heart transplant (HT) recipients, 14 lung transplant (LT) recipients, and 7 healthy subjects. Plasma [K+] was determined from arterial blood sampled at rest; during the final 15 s of each power output; and at 1, 2, and 5 min postexercise. Peak oxygen consumption was significantly lower (P < 0.0001), whereas delta [K+]/W was significantly higher (P < 0.002) among the HT and LT groups. When delta [K+] during recovery was expressed relative to delta [K+] detected during activity, no difference at 1, 2, or 5 min postexercise was detected, although the absolute fall in plasma [K+] was greater among the healthy subjects in the 1st min (P < 0.0001). The rate of delta [K+] during recovery appears to reflect the rise seen during activity in all groups. These results suggest that [K+] regulation is altered during exercise in both HT and LT recipients and may reflect muscle deconditioning.

Techniques and results in bilateral sequential single lung transplantation. The National Heart & Lung Replacement Service

Lung transplantation continues to evolve as a therapeutic option for patients with end-stage lung disease. Bilateral sequential single lung transplantation (BSSLTx) is a recent addition to the lung transplant surgeon's armamentarium that incorporates the benefits of single lung transplantation in patients who require double lung replacement while avoiding the morbidity inherent in the en bloc double lung transplant procedure. Between November 1992 and October 1993, 17 recipients underwent 18 bilateral BSSLTx procedures for a variety of indications. In 53% of patients, the procedure was completed without the requirement for cardiopulmonary bypass. Telescoping of the bronchial anastomosis has proved satisfactory. Induction cytolytic therapy has not been utilized. Patients received methyl prednisolone from day 1 and as maintenance prednisolone therapy. Actuarial 1-year survival is 87%; 12 of the 15 survivors are in Functional Class I. BSSLTx is an evolving transplant option for patients who require double lung replacement. Definitive clinical diffusion of the procedure will depend upon intermediate and long-term outcomes for specific recipient pathologies.

Clinicopathological correlates of cardiac myxomas: a 30-year experience

Between 1961 and 1991, 23 patients (eight men and 15 women, with a mean age of 50 (range 25-72) years) with cardiac myxomas were managed at the Alfred Hospital, Prahran, Victoria, Australia. Symptoms of mitral valve obstruction were present in 13 patients and of systemic embolism in nine. In the patients, 21 myxomas were confined to the left atrium. In the other two patients, one myxoma was confined to the right atrium and the other was a dumb-bell-shaped biatrial myxoma. Most tumours were diagnosed with echocardiography. Removal was achieved via a median sternotomy and by entering the involved chamber. Those myxomas presenting with systemic embolism were always soft and friable, whereas those with obstructive symptoms were large and of variable consistency. There was one operative death early in the series. The 22 surviving patients have been assessed as functional class I of the New York Heart Association at follow-up, ranging from 2 months to 23 years (mean 9 years). There were no episodes of tumour recurrence. Excellent short, intermediate and long-term results can be achieved by excision of cardiac myxomas.

Successful heart transplantation with cardiac allografts exposed to carbon monoxide poisoning

The procurement of cardiac allografts from brain-dead donors who have suffered acute carbon monoxide poisoning has, in the past, been considered inadvisable. Two patients have recently undergone successful transplantation at our institution with cardiac allografts from donors who had suffered acute carbon monoxide poisoning. Carbon monoxide poisoning is not a contraindication to cardiac allograft procurement in the setting of clinical and objective evidence of satisfactory cardiac function.

Circadian rhythms of heart rate and blood pressure after heart transplantation

Blood pressure and heart rate were recorded over 24-hour periods on 39 occasions in 20 subjects 5 to 72 weeks after heart transplantation. All patients were receiving cyclosporine, azathioprine, and prednisolone. In 38 of the 39 records the mean nighttime heart rate was lower than the mean daytime rate, with a peak difference of 20.1 +/- 1.8 beats/min. Blood pressure responses were, however, of two patterns. In 15 of the 39 recordings (approximately 50% of patients) the mean nighttime systolic pressure was higher than the mean daytime systolic pressure; in the remainder the converse was observed. The pattern was generally consistent on repeated recordings from the same patient and was not related to time since transplantation, renal function, or other therapy. Echocardiographic/Doppler studies were available at the time of 31 of these recordings. No differences in left ventricular diameters, systolic function, or transmitral filling patterns were present between patients whose blood pressure was higher or lower at night. Left ventricular posterior wall thickness and the ratio between wall thickness and ventricular diameter at end diastole were greater in the group showing nighttime pressure falls. Blood pressure responses after heart transplantation show the presence of nighttime "dippers" and "nondippers." At least early after transplantation, however, nondipper status is not preferentially associated with the development of left ventricular hypertrophy. The mechanisms accounting for the different circadian blood pressure responses in heart transplant recipients are not known.

The "domino-donor" operation in heart and lung transplantation

OBJECTIVE

To report the first "domino-donor" operation performed in Australia; review the results of the first five combined procedures at the Alfred Hospital; and discuss the advantages of the procedure and its place in transplantation.

PATIENTS AND OUTCOME

The first domino-donor was a 25-year-old man with cystic fibrosis and pulmonary hypertension, receiving a heart-lung transplant, whose heart was transplanted into a 20-year-old woman with end-stage cardiomyopathy. The cardiac recipient's initial course was satisfactory, but at eight months she developed severe rejection, with failure of the donor heart, and required retransplantation. Subsequently four further combined procedures were performed. All 10 patients are alive and well. Four patients have had cytomegalovirus infection but without major complications. Improved function of the donor right ventricle has been observed when the ventricle is working against a lower resistance.

CONCLUSIONS

Four advantages of the domino procedure are evident: an increased pool of donor allografts; the use of a heart with an hypertrophied ("prepared") right ventricle; absence of the adverse effects of brain-death in the live donor; and improved ability to match the donor and recipient before the operation.

Technique and results of cardiac transplantation using "domino-donor" hearts

Heart-lung transplantation is now well established for treatment of patients with terminal cardiopulmonary disease. More than 50% of heart-lung transplant recipients have normal or near normal hearts, with the majority having some degree of right ventricular hypertrophy. This potential source of "prepared" cardiac allografts remained untapped until the introduction of the "domino-donor" operation, a procedure in which the heart-lung recipient serves as a cardiac donor. The implantation of these available allografts contributes to the alleviation of the short supply of donor organs for cardiac transplantation. Aspects of the surgical technique, results, and potential benefits of this procedure are presented.

Aortic distensibility in patients with isolated hypercholesterolaemia, coronary artery disease, or cardiac transplant

The stiffness of the thoracic aorta can be assessed non-invasively. If aortic stiffness can be shown to be related to coronary heart disease, perhaps it can be used to identify which patients with hypercholesterolaemia are most likely to have atheromatous changes and thus to be selected for intensive cholesterol-lowering treatment. Hence the distensibility of the transverse aortic arch was measured by echocardiography of the aortic arch in four groups of patients--symptom-free patients with normal serum cholesterol; symptom-free patients with raised serum cholesterol; patients with coronary heart disease (all with raised serum cholesterol), and post-heart-transplant patients. In all groups distensibility fell with age. The regression slope was steeper (p less than 0.05) for patients with known coronary disease than for either of the disease-free groups, and among cardiac transplant recipients there was also a segregation of distensibility values between those with and without atheroma in their native hearts. The results indicate that aortic distensibility might be an indicator of coronary heart disease and that it might be useful in identifying which symptom-free subjects with modest hypercholesterolaemia should be treated aggressively.

Initial clinical experience with the Haemopump left ventricular assist device

The Haemopump is an intra-arterial, axial flow, temporary left ventricular assist device. The intra-cardiac pump assembly is connected by a flexible drive shaft to a high speed motor and a drive console. The pump is placed in the left ventricle via the femoral artery, iliac artery or abdominal aorta. Blood is withdrawn from the left ventricle and pumped in a continuous, non-pulsatile fashion into the descending thoracic aorta. We report the use of the Haemopump to provide circulatory assistance in 2 patients with severe graft dysfunction following cardiac transplantation. Both patients were successfully weaned from the Haemopump after 6 and 3 days of support. The first patient subsequently died of overwhelming fungal sepsis and the other remains well 3 months after transplantation with normal left ventricular function. The Haemopump is an effective temporary cardiac assist device for application in severe left ventricular failure.

Right ventricular assist and prostacyclin infusion for allograft failure in the presence of high pulmonary vascular resistance

The presence of high pulmonary vascular resistance (PVR) greater than 4 Wood units contributes to significant early posttransplant mortality, and remains a negative predictor of long-term survival. Current trends have been toward exclusion of the recipient with high PVR from the orthotopic procedure; elective heterotopic allograft placement is increasingly advocated. A patient with a PVR of 6 Wood units underwent orthotopic transplantation; the cardiac allograft from a 12 kg heavier donor was implanted after an ischemic time of 115 minutes. Early graft failure at 4 hours and subsequent cardiac arrest were followed by reinstitution of cardiopulmonary bypass, during which time optimal pharmacologic manipulation of the pulmonary vasculature was undertaken, including the use of high-dose prostacyclin. Refractory right heart failure indicated the requirement for right ventricular assistance (RVA) for patient survival. RVA with a Bio-Medicus pump was instituted in association with high-dose prostacyclin; an intraaortic balloon pump was inserted 12 hours later. Maintenance immunosuppression consisted of cyclosporine and azathioprine alone. RVA was maintained for 3 days; during this time the patient was totally pump dependent. Over an 18-hour period the patient was weaned and successfully withdrawn from RVA. Intraaortic balloon pump counterpulsation and the prostacyclin infusion were continued for 6 and 10 days, respectively. The clinical implications of the various interventions that resulted in the patient's survival are discussed.

Reproducibility of radionuclide left ventricular ejection fraction in patients awaiting cardiac transplantation

Radionuclide-derived left ventricular ejection fraction (LVEF) is used to assess LV systolic function, to follow trends in the natural history of dilated cardiomyopathy, and to prioritize patients waiting for cardiac transplantation. Reproducibility of LVEF at extremely low levels has not, however, been reported. To assess the reproducibility of radionuclide LVEF at levels below 0.30 EF U, 17 highly symptomatic patients (NYHA Class III/IV) with dilated cardiomyopathy were studied on two occasions, 72 hours apart. Sequential scans were analyzed by two independent observers. Mean LVEF was 0.18 +/- 0.06 U (scan 1) and 0.17 +/- 0.06 U (scan 2). Interoperator reproducibility (SD) was 0.03 U (R = 0.76), interscan reproducibility (SD) was 0.03 U (R = 0.62), and overall reproducibility (SD) was 0.04 U (R = 0.50). The interobserver variation of 0.03 (actually 0.027) was just over one half that seen in normal volunteers (variation 0.05, n = 29) studied previously in this department. A change of greater than or equal to 0.08 U (2SD) in either direction is highly likely to represent a real change in LV function in those with LVEF less than or equal to 0.30 units, compared with the change of at least 0.10 units required in those with normal LV function. Lower interobserver and interscan reproducibility should be taken into account when interpreting sequential scans in patients with severe LV dysfunction.

Ascending aortic aneurysms associated with aortic valve regurgitation: St Vincent's Hospital's experience

This report represents a retrospective analysis of the St Vincent's Hospital experience with combined replacement of the aortic valve and ascending aorta using a composite conduit and coronary artery reimplantation, in 44 patients, from 1 January 1981 to 30 June 1988. The mean age at operation was 48 years. Annuloaortic ectasia was the most common indication for operation in 24 patients (54%). There were three hospital deaths (7%). Forty-one patients were discharged from hospital and were followed up for a total of 1,106 patient months (mean = 26.5 months). There were three late deaths (7%). One death was due to a new dissection, one to a cerebrovascular accident and one to a drug overdose. So far, no patients have required reoperation. Of the 36 surviving patients available for follow-up, 28 are in New York Heart Association class I, seven patients are in class II and one in class III. Composite graft replacement reduces the risk of recurrent dissection and aneurysm formation and of periprosthetic leak. In the present experience, it is the method of choice in patients with degenerative lesions in the ascending aorta and aortic valve and particularly for annuloaortic ectasia. The exact surgical technique currently used has been the result of an evolution of different techniques.

Repeat myocardial revascularization surgery: an analysis of 169 cases

One hundred and sixty-nine patients who underwent repeated myocardial revascularization surgery between 1982 and 1987 were studied. The mean interval between operations was 91.6 +/- 7.3 months. The indications for repeated surgery were graft failure in 37.2% of patients, progressive coronary atherosclerosis in 40.2% of patients and a combination of the two causes in 22.5% of patients. The mean number of grafts that were inserted was 2.74 +/- 0.61 grafts per patient at the second operation. Coronary endarterectomy as an adjunctive procedure was necessary in 17.1% of patients. The hospital mortality rate was 4.1%, with a 1.8% incidence of perioperative myocardial infarctions. Of the surviving patients, 96.3% were available for follow-up at a mean of 19 +/- 6.4 months. Of these patients, 68.5% were well and could be categorized into the New York Heart Association's functional class I. We conclude that both progression of coronary atherosclerosis in native vessels and obstruction of venous grafts cause recurrent angina and that repeated myocardial revascularization surgery is a feasible treatment option in these patients.

Cyclosporine and azathioprine immunosuppression without maintenance steroids: a prospective randomized trial

Since the commencement of the St. Vincent's Transplant Programme, 41 patients have undergone orthotopic heart transplantation, with low-dose cyclosporine and prednisolone as maintenance immunosuppression. An actuarial survival rate of 75% at 1 year resulted. To reduce early rejection-related death, azathioprine was chosen as an augmenting immunosuppressive agent to be administered as a prospective randomized trial. Sixty patients were randomized; 29 received low-dose cyclosporine plus azathioprine plus prednisolone (group A). Thirty-one patients received cyclosporine and azathioprine alone (group B). Both groups received a 7-day course of antithymocyte gamma globulin. One group B patient who underwent retransplantation was not analyzed. Actuarial survival for group A was 92% and group B 93%. The overall incidence of rejection for group A was 1.1 per patient and group B, overall, 2.3 episodes per patient. Group B patients who had persistent rejections were converted to group A protocol. Nine group B patients (30%) required conversion to maintenance steroids (group C). The overall incidence of infection was 1.6 episodes per patient and 1.3 episodes per patient for group A and group B, respectively. Two early deaths in group B and one in group A were unrelated to immunosuppressive protocol. One group A patient died at day 280 of multiorgan failure. There were no rejection- or infection-related deaths in the series. Hypertension occurred with equal frequency in both study groups. The cyclosporine and azathioprine protocol produces actuarial survival and morbidity rates comparable to those of a matched triple-therapy group. Thirty percent of patients in this protocol, however, will require maintenance steroids.