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This article describes four years' experience with heart transplantation using conventional immunosuppression. Twenty of 32 patients are alive. The one-year survival rates were 75% (1979), 67% (1980), and 75% (1981). Actuarial survival rates for operative survivors were 70% at one year, 60% at two years, and 51% at three years. Patients in the 50- to 55-year age group have survived as well as younger recipients. Rejection resulted in six deaths, infection in three, donor heart failure in two, and multiple organ failure in one. There were 1.5 acute rejections per patient and one infection per patient in the first three posttransplant months. Postoperative hospital stay averaged 62 days and cost a total of $58,351.

Eighteen serious pulmonary infections have been encountered in 10 of 16 surviving cardiac transplant recipients. Fourteen of 18 infections (78%) occurred within the first six months after transplant and the remaining 4 (22%) after the first six months (p less than 0.05). There was no correlation between the number of rejections per patient and propensity toward infection. Transtracheal aspiration or percutaneous lung aspiration established the diagnosis in all but two episodes. Percutaneous lung aspiration appeared more accurate as a diagnostic tool but was associated with 6 complications in 13 attempts (46%), while no complications occurred in 17 attempts with transtracheal aspiration (p less than 0.05). Five of the 10 patients had multiple episodes of pulmonary infection; 2 of these 5 (40%) had concurrent infections. Nocardia organisms were encountered most frequently, accounting for 7 of 18 (39%) infections; 6 of 10 patients (60%) were infected with Nocardia at some point after transplant. Nine of 10 patients (90%) were cured of infection. Eight are still alive without evidence of infection. We conclude from these data that pulmonary infection is common in transplant recipients, that early definitive diagnosis, in spite of the potential complications, is warranted, and that cure of infection and long-term survival are possible if treatment is timely and aggressive.

The present study evaluated (1) the influence of the collection of autologous platelet-rich plasma intraoperatively in addition to intraoperative autotransfusion on homologous blood usage and bleeding in cardiac operations; (2) the influence of age, sex, body surface area, type of operation, and reoperations on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively; and (3) the influence of the preoperative administration of aspirin, Persantine (dipyridamole), heparin sodium, thrombolytic agents, Coumadin (crystalline warfarin sodium), and nonsteroid, antiinflammatory drugs on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively. The results demonstrated a decrease in homologous blood use and bleeding when autologous platelet-rich plasma is collected in addition to the use of intraoperative autotransfusion. All of the patient and procedural variables influenced homologous blood usage and bleeding to some extent. Only the thrombolytic agents affected blood usage by increasing homologous plasma usage. All other drugs evaluated did not influence blood utilization or the amount of bleeding intraoperatively or postoperatively.

Eighteen drug addicts with left-sided valvular endocarditis requiring operation are reviewed. Gram-positive bacteria were the most common organisms cultured (61%), with Staphylococcus aureus present in 7 of 11 patients. Gram-negative bacteria, exclusively Pseudomonas aeruginosa, were cultured in the remaining 39%. Indications for operation included sepsis (61%), heart failure (78%), and systemic emboli (22%). Abscesses formed in 6 of 11 patients with gram-positive endocarditis, while only one abscess was present with gram-negative endocarditis. Normal valves were infected in 17 of 18 patients (94%). Early surgical mortality (less than 30 days) was 11%. There were major complications in 79% of these patients, including persistent sepsis (50%), valvular dehiscence, prosthetic endocarditis or perivalvular leakage (37%), and mycotic aneurysms (22%). These complications were directly related to a late mortality of 44%, yielding an overall mortality of 50% in the first nine months after operation. Contrary to previous reports of acceptable surgical survival for valvular endocarditis, these data suggest that endocarditis involving the aortic or mitral valve in a drug addict is a highly lethal disease due to the virulence of the organisms, the severity of the complications encountered, and the predisposition to continued addiction.

The Southern Arizona Red Cross Blood program, in conjunction with participating hospitals and cardiac surgeons, evaluated the effect of a program to harvest autologous platelet-rich plasma (PRP) from patients immediately prior to undergoing cardiopulmonary bypass surgery. The PRP was transfused back to the patient after heparin neutralization was achieved at the completion of cardiopulmonary bypass. The effect of this autologous PRP product on homologous plasma and platelet usage was examined. The study demonstrates a significant decrease in homologous plasma and platelet usage when autologous PRP is used in cardiac surgery.

We studied 37 consecutive patients, all drug addicts, who underwent 48 valve operations from 1976 through 1981. GN bacteria were the major organisms in 25 patients (64%), compared with a previous reported incidence of 10%. Operative indications were uncontrolled sepsis in 49%, embolism in 27% and heart failure in 24% of the patients. Primary operations included nine tricuspid valvectomies and 14 aortic, 10 mitral and four aortic/mitral valve replacements. Early (30-day) mortality was 2.7% (one of 37 patients); five of nine patients who had 11 reoperations survived. Long-term follow-up revealed a late mortality of 39% (11 of 28) in patients with left-sided disease; eight of the 11 patients who died had GN infection with perivalvular abscess. Thus, the subgroup with GN sepsis and left-sided disease had a combined early and late mortality of 50%, with all deaths occurring within 8 months postoperatively. We conclude that valve replacement in the presence of active sepsis can be safely performed, but GN sepsis in addicts increases the risk of early reinfection and late mortality.

Minocycline hydrochloride was used to treat pulmonary infections with Nocardia asteroides in five cardiac allograft recipients. In three patients, minocycline was successfully used as the only antinocardial agent. Two other patients were found to have leukopenia after initial therapy with sulfisoxazole. These two patients were subsequently treated with minocycline. The clinical success with minocycline in these highly immunosuppressed patients suggests that minocycline is an effective antinocardial agent. These data did not allow any conclusion regarding which drug, minocycline or sulfisoxazole, is superior in the treatment of this disease.

The Southern Arizona Regional Red Cross Blood Program, in cooperation with two cardiac surgery groups, examined the effect of intraoperative autotransfusion on red cell, plasma, and platelet usage during and after cardiac operations. The study evaluated whether intraoperative autotransfusion influenced intraoperative or postoperative blood usage and whether regular use was more effective than selective use. The study demonstrated that intraoperative autotransfusion reduces intraoperative and postoperative blood use and that regular use of intraoperative autotransfusion is more effective than selective use.

Simultaneous measurements of pulmonary capillary wedge pressure (PCWP) and left atrial pressure (LAP) were obtained before and after cardiopulmonary bypass and for a period of 16 hours postoperatively in 20 consecutive patients undergoing electric cardiac operations. In contrast to several previous reports that PCWP accurately reflects left-sided hemodynamics, we found that the PCWP significantly exceeded the LAP in the early postbypass period and was most significantly in error at 4, 8, and 12 hours after operation (p less than .02) (95% confidence limit). The magnitude of this discrepancy differed in individual patients; however, it was consistent for each patient for the time period studied and independent of the procedure performed. The disparity between PCWP and LAP may be due to an increase in lung interstitial water as a result of hemodilution, or it may be related to the differing effects of afterload reducing agents on the pulmonary versus the systemic circulation. We conclude from these data that LAP more accurately reflects left ventricular filling and performance in the early postoperative period and should be used instead of PCWP to monitor the hemodynamics of postsurgical patients.

The purpose of this study was to investigate the changes in serum and urine potassium before, during, and after the administration of potassium cardioplegia using a solution containing 28 mEq/L of potassium chloride in 20 consecutive patients with acquired heart disease. The data obtained suggest that the concentration of potassium administered does not result in inordinately elevated serum potassium levels (peak, 4.6 +/- 0.18 mEq/L at 2 hours of multidose hypothermic potassium cardioplegia) during or after infusion. Additionally, the urinary excretion of potassium increased during infusion and eventually exceeded the amount of potassium infused. While hypothermic potassium cardioplegia appears to be a safe and efficient method of myocardial protection, continued surveillance of postoperative potassium levels remains necessary to detect obligatory urinary potassium excretion following cardiopulmonary bypass and operation.