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Combined heart and renal transplantation from the same donor is an uncommon procedure. We describe the case of a patient with prior kidney transplantation whose renal graft had to be removed a few years later because of chronic rejection. The patient then developed severe hypertensive and ischemic left ventricular dysfunction. Combined heart and kidney transplantation was performed several years after the first renal transplantation. This observation is the first description of a combined heart and kidney transplantation after removal of a former renal graft whose failure was due to chronic rejection. Great care was taken to avoid identical MHC antigens (HLA-A; -B; -DR) between the two donors, to prevent recurrent rejection of the grafted organs. After 18 months, no rejection was detected in either organ. This case report confirms the feasibility of this complex procedure, provided care is taken to avoid identical HLA groups between the two donors so as to reduce immunological complications.

Prognosis of heart transplant patients has dramatically improved in the last decade thanks to the use of cyclosporine as immunosuppressive treatment. Optimal follow-up and early recognition of complications and side effects of treatment lead to longer survival and marked improvement of these patients' quality of life. However, the incidence of complications remains high and their management calls for particular care. We review our experience of heart transplantation in Lausanne and describe in detail the results and complications such as rejection, transplant coronary artery disease, hypertension, renal failure, metabolic disorders, cancer and conduction problems. Cooperation of the medical team (cardiologist, surgeon, anesthetist, general practitioner) is essential to long term success of the transplant program.

Infectious complications, a major cause of morbidity and mortality after heart transplantation, were reviewed in 49 heart transplant patients at Lausanne. The follow-up lasted 32 months on average. 43 patients (88%) presented 108 infections (2.20 episodes of infection/patient). 38 severe infections (0.78 episodes/patient) were diagnosed in 27 patients (55%). 2 of the 9 deaths which occurred were due to infection. The viruses, principally of the herpes group, were responsible for 37% of all the infections, and bacteria for 28%. About a third of the viral and bacterial infections were severe. The other documented infections were caused by fungi (13%), which were most often responsible for superficial infections, and rarely by protozoa (5%). Finally, in 17% of infectious episodes, the pathogen could not be identified. Cytomegalovirus was the pathogen the most frequently responsible in severe infections. The highest incidence of infections occurred during the first 2-3 months after transplantation and was reduced considerably after the 6th month. The distribution of different pathogens was related to specific periods after the transplant. Our results confirm that infection is a major complication of heart transplantation. Clinical and prophylactic aspects of some infections are reviewed.

Background: In a retrospective analysis of 653 consecutive patients who underwent heart valve replacement by one single type of mechanical prosthesis (St. Jude Medical) at three Swiss university medical centers (Basel, Bern, Lausanne), the outcome was judged on the basis of preoperative variables. These variables should facilitate the timing of heart valve replacement., Methods: Preoperative evaluation includes NYHA classification of symptoms, chest X-ray, ECG, and LVEF on angiography. Postoperative outcome was assessed clinically at yearly intervals by NYHA classification, documentation of complications and mortality., Results: Five-year-survival rates were 96 and 88%, and complication-free rates were 82 and 76% respectively in patients after isolated aortic and mitral valve replacement. An unsatisfactory outcome with death or persistent severe symptoms was more frequent when preoperative symptoms at rest and atrial fibrillation were present., Conclusion: Heart valve replacement should not be postponed until severe symptoms and functional impairment occur. Clinical criteria are at least as important for the timing of operation as the findings of more complex investigations.

Subaortic pressure gradient in hypertrophic obstructive cardiomyopathy (HOCM) is the consequence of a dynamic obstruction of the left ventricular outflow tract linked to the presence of a hypertrophied septum. We tried to induce an altered septal motion electrically by physiologic pacing. We studied 8 patients (6 men, 2 women, mean age 60 +/- 13 years) with symptomatic HOCM, resistant to optimal drug treatment. During a hemodynamic study, dual chamber pacing significantly reduced the preexistent subaortic pressure gradient, from 69 +/- 39 to 34 +/- 26 mm Hg (p less than 0.004), without concomitant reduction of aortic pressure or cardiac output. This reduction was dependent upon a optimized AV interval. A dual chamber pacemaker (PM) was then implanted and programmed to VDD mode and optimized AV delay interval (50-90 ms), warranting full ventricular capture. The follow-up of 3 to 30 months showed a significant reduction of both angina (from NYHA class 3 to 1: p less than 0.009) and dyspnea (from 3 to 2: p less than 0.03). An echo-doppler study in 6 patients proved the persistence of the beneficial effect of the stimulation by showing a significant reappearance of the subaortic pressure gradient after switching off the PM, from 44 +/- 29 in VDD pacing mode to 77 +/- 44 mm Hg (p less than 0.02). We conclude that atrial synchronized ventricular pacing, together with an optimized AV interval, significantly reduces the outflow gradient and improves symptoms in patients with HOCM. An altered ventricular activation sequence with late septal activation is suspected to be the mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Nowadays patients suffering from supraventricular tachycardia are first treated with antiarrhythmic drugs. In refractory cases alternative treatment is antitachycardia pacemaker implantation or surgery. Recently new percutaneous catheter techniques have been developed to ablate directly the anatomical substrate responsible for the arrhythmia by delivering energy (high or low energy shock or radiofrequency) at the tip of a catheter. This article summarizes the results of clinical application of these different techniques and briefly presents our experience. The very recent studies with RF in patients with drug-refractory av nodal reentry or accessory pathway related tachycardia (WPW syndrome) report a success rate of 92-99% with a very low complication rate. If the long term success of radiofrequency is confirmed this technique will emerge in the near future as the treatment of choice in patients suffering from symptomatic supraventricular tachycardia, since it avoids expensive, longlasting drug treatment with the permanent risk of side effects.

To assess anomalies in these subjects, an ambulatory neurological examination was performed in 12 heart transplant patients and in 1 heart-lung transplant patient. The patients were examined between the 3rd and 51st month following the transplantation. Two had symptoms due to a previous neurological disease. Early postoperative complications were found in 6 patients (seizures in 3 cases, cerebral infarcts in 1 case, anoxia in 1 case and right ulnar nerve damage at the elbow in 1 case). Late postoperative complications included postural tremor (9 cases) or mild polyneuropathy (2 cases). Neurological examination was completely normal in 2 patients. The findings show that the most common late neurological abnormality found in heart transplant patients is postural tremor.

Electrophysiologic studies are used for diagnosis and treatment in patients with sustained ventricular tachycardia. This method can only be employed if high inducibility of the spontaneous tachycardia can be demonstrated. We therefore investigated prospectively the induction yield in 35 patients with a history of documented sustained ventricular tachycardia. The patients' mean age was 58 years. Coronary artery disease was present in 24 patients, cardiomyopathy in 4, other organic heart diseases in 4, and no heart disease in 3. The ventricular tachycardia induction protocol consisted of three extrastimuli delivered during sinus rhythm and at two pacing cycle lengths, followed by intravenous isoproterenol if no tachycardia was induced before. With the method sustained ventricular tachycardia was induced in 100% of patients with coronary artery disease and cardiomyopathy, in 75% of patients with other heart diseases and in 33% of patients without detectable heart disease. We conclude that electrophysiologic studies have a high yield of sustained ventricular tachycardia induction in patients with underlying organic heart disease. The rational basis for use of electropharmacologic testing therefore exists in these patients. However, in patients without heart disease, the low sensitivity of electrophysiologic studies precludes its use for drug efficacy testing.

Numerous highly effective antiarrhythmic agents are now available which have a powerful anti-arrhythmia action but may cause severe side effects in the case of inappropriate use. We report the case of a patient with WPW syndrome in whom inappropriate administration of verapamil during an episode of atrial fibrillation and rapid ventricular response caused ventricular fibrillation.

The case is reported of a young male who presented with massive anterior myocardial infarction after sniffing cocaine. The cardiovascular complications of cocaine abuse are numerous (sudden death, arrhythmia, myocardial infarction, myocarditis) and are being reported more and more frequently in the literature. Thoracic or abdominal pain in any patient known to abuse cocaine should be thoroughly investigated, despite the youth of these patients.

Myocardial infarction is almost always the consequence of a thrombotic obstruction of one or more coronary arteries. We report our experience with the first 24 cases of intracoronary thrombolysis for recanalization of obstructed coronary arteries. 19 cases were successful, 1 case was partially successful and in 4 instances no reopening was observed. The amount of streptokinase used was 206 000 +/- 107 000 units, and reperfusion was achieved after 37 +/- 27.5 minutes. Recanalization of the vessel was accompanied by cessation of precordial pain and partial or complete normalization of the electrocardiogram. In one case bypass surgery was necessary because of reocclusion. Left ventricular function improvement after thrombolysis was dependent on the time-lag between occlusion and recanalization. These observations confirm others' experience that intracoronary thrombolysis appears to have favorable effects in patients with evolving myocardial infarction.

The St. Jude Medical cardiac valve is a low-profile, bileaflet, central-flow prosthesis made of pyrolitic carbon. During a 39-month period (October 1, 1979 to December 31, 1982) a total of 169 St. Jude valves were implanted in 155 patients. While 141 patients received one valve, 95 in the aortic, 45 in the mitral and 1 in the tricuspid position, 14 patients had a double (aortic and mitral) valve replacement. The perioperative mortality rate was 3.2%. All surviving patients had anticoagulation treatment with acenocoumarol and there was a 98% follow-up during a period of 19.5 +/- 4.5 months. The late mortality rate was 4.7%. Substantial clinical improvement resulted with the St. Jude valve: whereas 81.9% of patients were in NYHA functional class III or IV preoperatively, 87.1% were in class I or II after valve replacement. The patients generally had a slight increase in LDH levels but hemolysis was responsible for moderate anemia only in 5 cases. There were 10 nonfatal neurological accidents, probably due to thromboembolic events, resulting in a risk of thromboembolism of 4.04% per patient year; 4 of the 10 patients were incompletely anticoagulated and 3 had cardiac arrhythmia. There were 5 hemorrhagic complications, one of which was fatal (subarachnoidal hemorrhage). Endocarditis occurred in 4 patients and death ensued in one of these. Seven patients developed perivalvular leak which was moderate in 5 cases and severe in 2 cases. In conclusion, these results are promising and the St. Jude Medical cardiac valve appears to be a valid alternative in surgical therapy of valvular heart disease. However, the risk of thromboembolism justifies long-term anticoagulation.

Since July 1982, 12 patients have undergone catheter ablation for refractory arrhythmias. The ablated pathway was the His bundle in 8 patients, an accessory pathway in 3 patients and a ventricular reentrant circuit in 1 patient. The 8 patients in whom the His bundle was ablated comprised 3 cases of atrial flutter, 3 cases of atrial fibrillation, 1 case of atrio-ventricular tachycardia and 1 case of junctional reentrant tachycardia. Results were complete heart block in 6 of these cases, right bundle branch block and first degree a-v block in 1 case and first degree a-v block in the last case. A pacemaker was implanted in 7 patients. The total amount of energy used varied from 50 to 400 joules. In none of these 3 patients did tachyarrhythmia recur. The 3 cases with ablation of the accessory pathway comprised one success, one partial success and one failure. The energy used was 60 to 100 joules. The patient treated for ventricular tachycardia has had no new episodes of tachycardia 4 months after the procedure. The energy used was 200 joules. The mean follow-up for the 12 patients is 12 +/- 7 months. Apart from 2 episodes of thrombophlebitis, no serious complication was noted. Catheter ablation technique is a new and effective treatment for refractory supraventricular tachyarrhythmias. Concerning ventricular arrhythmias, our experience is not sufficient to allow conclusions to be drawn.

A report is presented on 20 patients with cryptogenetic hemoptysis. The following investigations are necessary and sufficient for diagnosis: history, physical examination, chest roentgenogram in posteroanterior and lateral projection, fiberoptic bronchoscopy with bacterial and cytologic analysis of bronchial brushing material, and determination of coagulation factors. Further explorations can be regarded as unnecessary since the above program discloses the cause of hemoptysis in more than 90% of cases. The prognosis of cryptogenetic hemoptysis was good in the 20 cases studied, which were followed up for 1 to 12 (mean 5.5) years.

Although thrombosis of St. Jude valve prosthesis is rare, we report a case of multiple thromboembolism in a patient who had stopped anticoagulant therapy. The consequences were very severe since two abdominal operations (colonic resection) were necessary. Since the patient was not compliant with anticoagulant therapy, aortic valve replacement was performed and a biologic valve implanted. The postoperative phase was long but the patient left the hospital after two months' treatment. This case again demonstrates the importance of anticoagulant therapy in patients with a prosthetic heart valve. Addition of dipyridamole diminished the risk of thromboembolic accident and should be added to the anticoagulant regimen.

The time between coronary artery occlusion and reperfusion remains the decisive factor for myocardial function in acute myocardial infarction. Of 110 patients admitted to hospital less than 3 hours after the onset of chest pain, 83 underwent intracoronary thrombolysis with streptokinase or urokinase. 27 patients underwent mechanical recanalization with the aid of a steerable guide wire (Schneider 0.014") followed by transluminal angioplasty of the residual stenosis. 70 of 83 patients (84%) were recanalized by intracoronary streptokinase perfusion within 45 +/- 10 minutes. By mechanical recanalization the occluded artery could be recanalized in 27 patients within 6 +/- 1 minutes. During the same session transluminal angioplasty was performed while the affected coronary artery was perfused for 20 minutes with 20,000-50,000 U streptokinase. 2 patients died after intracoronary thrombolysis (2.4%) and 1 patient died after mechanical recanalization (3.7%). 25 of 26 survivors of the mechanical recanalization group were discharged after bicycle stress testing, and 1 patient underwent a coronary bypass operation. In the intracoronary thrombolysis group, 4 patients presented with reobstruction of the affected vessel within 24 hours of the intervention (4.8%). Of the remaining 66 patients. 20 underwent transluminal coronary angioplasty (285), 16 coronary bypass (22%) and 30 received drug therapy (43%). Left ventricular injection fraction, measured 24 hours after treatment, was 63 +/- 10% in the mechanical recanalization group and 53 +/- 9% in the intracoronary thrombolysis group.

The time-lag between coronary occlusion and irreversible damage to the myocardium is ill-defined in man. In 10 patients the changes in left ventricular function have been studied after coronary occlusion during diagnostic or therapeutic cardiac catheterization of 1-2 hours' duration. Revascularization was achieved either surgically or through intracoronary streptokinase infusion. The interval between occlusion and onset of extracorporal circulation or reopening was 61 to 119 minutes. Despite enzyme elevation (CPK, CK-MB, SGOT) and appearance of Q-waves in 5 patients, no significant alteration of left ventricular function was noted on repeat cardiac catheterization 10 to 230 days after the accident. These observations, suggest that coronary occlusion of 1-2 hours' duration fails to produce significant irreversible damage to the myocardium despite electrocardiographic and enzymatic signs of myocardial infarction.

Coronary occlusion is the most serious complication of percutaneous transluminal angioplasty. In 440 cases coronary occlusion occurred in 22 patients (5%). Treatment was coronary bypass in 12 cases mechanical recanalization in 7 cases and coronary bypass after unsuccessful mechanical recanalization in 3 cases. One patient died after mechanical recanalization and 9 (41%) had myocardial infarction confirmed by electrocardiography and angiography. The number of coronary occlusions increased initially but decreased with improvements in materials and techniques. It is concluded that coronary occlusion is a severe but rare complication of percutaneous angioplasty. Mechanical recanalization should be attempted, and in case of failure the patient should be referred for surgery. In the large majority of cases the outcome is benign.

We report the case of a patient who developed cardiac tamponade after insertion of a central venous catheter. Often in such situations the first symptoms of this severe complication are late and thus delay correct diagnosis. In our patient the critical situation was recognized only after hemodynamic measurements and echocardiography. Emergency pericardiocentesis was followed by a dramatic improvement. The cardinal features of this serious event and the preventive measures to be taken to avoid this situation after placement of a central venous line are discussed.

The incidence of acute and late complications after coronary stenting has been studied in 95 consecutive patients. A total of 113 stents were implanted: 23 cases for acute occlusion of the dilated vessel and 72 for restenosis. After 16 months of follow-up, minor complications had occurred in 22 patients (23%). They consisted of transient occlusion of the prosthesis in 7 patients (7.3%), non-Q wave infarction in 4 patients (4.2%) and 10 hemorrhages (11%). During the following period major complications were observed in 11 patients (12%) with myocardial infarction in 7 instances and acute occlusion in 7 patients. 5 patients (5.3%) underwent coronary artery bypass graft and 6 (6.3%) died (one in-hospital death). Two deaths were related to the stent, but in the other four no definite correlation between the prosthesis and the death could be demonstrated. Restenosis at 12 months was present in 4 cases: in 3 patients (4.7%) where the stent had been implanted for restenosis and 1 (4.7%) where it had been implanted for acute occlusion. We conclude that for selected patients, coronary stenting is a promising new technique, especially for acute occlusion after PTCA; moreover, at 12 months restenosis is less frequent than after PTCA. However, technical improvement is necessary to diminish the rate of complications, particularly thrombosis and hemorrhage.

A case of variant angina with angiographically "normal" coronary arteries is reported. The clinical picture had been dominated by chronic stable angina for six years, and this symptomatology was complicated by pain at rest and also during the night. Two years later the patient had a myocardial infarction.