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Acute renal failure is a well recognized complication from the use of angiotensin-converting enzyme inhibitors in patients with severe bilateral renovascular disease. A 54-year-old woman presented with acute pulmonary edema with intractable hypertension and a history of lower limb claudication. The addition of lisinopril to her antihypertensive regimen resulted, within 48 h, in the development of acute renal failure that remitted with cessation of the drug. She was found to have a heavily calcified occlusion of her aortic arch and another occlusion of the aorta below the renal arteries. Angiography and Doppler ultrasonography showed normal renal arteries. This is the first reported case of angiotensin-converting enzyme inhibitor-induced renal failure occurring in a patient with atherosclerotic occlusion of the aorta. The literature on suprarenal aortic occlusion is reviewed to determine the manner of presentation, prevalent risk factors and physical findings that typify this unique clinical entity.

To evaluate the physiologic basis for the suboptimal peak oxygen uptake observed after heart transplantation, we calculated the functional aerobic impairment ([(peak predicted oxygen uptake-peak observed oxygen uptake)/peak predicted oxygen uptake] x 100) and related it to donor/recipient, operative, and maximal exercise variables. Fifty-seven heart transplant recipients (mean age 50 +/- 10 years, 1 to 9 years after transplantation) underwent maximal upright cycle exercise testing. Concomitant exercise central hemodynamic measurements were obtained in 36 patients (63%).The mean peak oxygen uptake was 21.7 +/- 6.5 ml/kg/min and functional aerobic impairment was 34% +/- 17%. Functional aerobic impairment correlated positively (p0.01) with peak systemic vascular resistance (r = 0.55) and negatively with peak cardiac index (r = -0.62) and peak systemic arteriovenous oxygen difference (r = -0.66). A weak correlation was found between functional aerobic impairment and the duration of cardiac disease (r = 0.35, p0.01) but not the origin of heart failure. No correlation was seen between functional aerobic impairment and donor age, total ischemic time, time since transplantation, recipient age, and resting and exercise right and left ventricular filling pressures.These results suggest that the decreased exercise capacity observed in heart transplant recipients is in part due to increased peripheral vascular resistance and decreased oxygen extraction possibly due to skeletal muscle atrophy. These factors may be the result of irreversible changes from long-standing heart disease, deconditioning, or the effect of cyclosporine and prednisone.

An international series of pulmonary retransplantation was updated to identify the predictors of survival in the intermediate-term after reoperation for obliterative bronchiolitis. The study cohort included 32 patients with end-stage obliterative bronchiolitis who underwent retransplantation in 15 North American and European centers between 1988 and 1992. Five types of retransplantation procedures were done, including repeat ipsilateral single lung transplantation (7 patients), repeat contralateral single lung transplantation (8 patients), repeat double lung transplantation (3 patients), double lung transplantation after a previous single lung transplantation (3 patients), and single lung transplantation after a previous double lung or heart-lung transplantation (11 patients). The mean interval between transplants was 564 +/- 51 days (range 187 to 1589 days). Postoperative follow-up was 100% complete and the average follow-up in surviving patients was 678 +/- 63 days. Actuarial survival was 72%, 53%, 50%, 41%, and 33% at 1, 3, 6, 12, and 24 months, respectively. Survival did not differ according to the age, preoperative diagnosis, ambulatory or ventilator status, or cytomegalovirus serologic status of the recipient before reoperation. Life-table and Cox proportional hazards analysis identified the type of retransplantation procedure and the year of reoperation as significant (p0.05) predictors of postoperative survival. Actuarial survival was significantly better in patients without an old, retained contralateral graft after retransplantation and in patients who underwent reoperation between 1990 and 1992, as opposed to between 1988 and 1989. Infection was the most common cause of death at all time intervals after retransplantation, although all deaths beyond 2 years resulted from obliterative bronchiolitis of the second graft. Most surviving patients are in a satisfactory clinical condition, with a mean forced expired volume in 1 second of 59% +/- 13% of predicted (repeat double lung transplant recipients) or 41% +/- 6% of predicted (repeat single lung transplant recipients). We conclude that pulmonary retransplantation for obliterative bronchiolitis is associated with significantly worse survival than after primary lung transplantation. The absence of an old contralateral graft after retransplantation and reoperation after 1989 are important predictors of survival. Additional data and follow-up are required to determine the merit of pulmonary retransplantation for obliterative bronchiolitis.

Patients with heart disease are frequently maintained on a regimen of aspirin because of its ability to decrease thrombotic complications and reduce the prevalence of unstable angina and myocardial infarction. Aspirin-induced platelet acetylation also increases bleeding caused by impairment of platelet function during cardiac surgery.Between October 1990 and November 1991 this double-blind, randomized, placebo-controlled, parallel group interventional study examined the efficacy of high-dose aprotinin administration (up to 7 million KIU) to decrease blood loss and transfusion requirements in patients receiving aspirin within 48 hours of undergoing coronary bypass or valvular heart operations. Primary outcome measures in this study were total volume of blood loss (intraoperative blood loss plus postoperative chest tube drainage) and volume of transfusion during hospitalization.Patients treated with aprotinin (n = 29) had significantly lower total blood loss (1409 +/- 232 ml versus 2765 +/- 248 ml; p = 0.0002), intraoperative blood loss (503 +/- 53 ml versus 1055 +/- 199 ml; p = 0.0001), postoperative blood loss (906 +/- 204 ml versus 1710 +/- 202 ml; p = 0.0074), and prevalence of transfusion (59% versus 88% of patients; p = 0.016) than the placebo group (n = 25). The prevalence of complications including myocardial infarction was similar in the two groups.High-dose aprotinin significantly reduces blood loss and red blood cell transfusions in patients receiving aspirin who undergo cardiac operations.

A case control study was performed to determine whether previous implantable cardioverter-defibrillator (ICD) insertion adversely affects outcome after heart transplantation. Six male heart transplant recipients who had undergone ICD insertion 12 +/- 5 months before heart transplantation were compared to a cohort of six heart transplant recipients who were matched according to age, preoperative status and hemodynamics, date of transplantation, graft ischemic time, history of a previous cardiac operation, and duration of follow-up. There were no significant differences in operating room time, chest tube drainage, time to extubation, and the duration of intensive care unit or hospital stay between the two groups. Furthermore, there were no significant differences in the number of units of packed cells, fresh frozen plasma, platelets and cryoprecipitate transfused. The number of treated rejection episodes and the number of patients requiring intravenous antibiotics for infection in the first 90 days was identical between groups. It was concluded that heart transplantation after ICD implantation did not appear to carry more risk than heart transplantation after a previous cardiac operation. Our limited experience supports the potential use of the ICD in patients with life-threatening ventricular dysrhythmias who are awaiting transplantation.

An international survey of redo lung transplantation was performed to identify the morbidity and mortality rates and factors correlating with increased or decreased survival after this procedure. Twenty institutions in North America and Europe participated, and the study cohort included 61 patients who underwent 63 redo lung transplantation operations. Patients undergoing a redo heart-lung transplantation were excluded. The indications for reoperation included obliterative bronchiolitis (32 patients), graft failure (14 patients), intractable airway problems (8 patients), severe acute lung rejection (5 patients), and miscellaneous complications (4 patients). Five types of retransplantation procedures were performed, including redo ipsilateral single lung transplantation (24 patients), redo contralateral single lung transplantation (11 patients), single lung transplantation after double lung or heart-lung transplantation (13 patients), redo double lung transplantation (8 patients), and double lung transplantation after a previous single lung transplantation (7 patients). Actuarial survival was 65%, 49%, 42%, 35%, and 32% at 1, 3, 6, 12, and 24 months, respectively; survival was significantly (p0.05) worse than that of first-time lung transplant recipients recorded in the International Society for Heart and Lung Transplantation Registry. Actuarial survival did not differ according to the original diagnosis of the recipients, the indication for reoperation, or the type of retransplantation procedure performed. Similarly, recipient cytomegalovirus status and ventilator status before reoperation did not affect postoperative survival. Trends toward an improved outcome were noted in patients who were ambulatory before reoperation and in those receiving an ABO identical, as opposed to ABO compatible, graft at reoperation. Life table and step-wise logistic regression analysis identified donor cytomegalovirus status at reoperation to be an important determinant of outcome, with significantly (p0.05) improved survival in the donor cytomegalovirus-negative group. Polymicrobial infection was the most common cause of death at all time intervals after reoperation. The presence of disseminated infection and established multiorgan failure was almost uniformly associated with a fatal outcome. We conclude that redo lung transplantation may be indicated only in well-selected patients with obliterative bronchiolitis, severe airway complications, or graft failure. Donor cytomegalovirus status at reoperation is an important predictor of survival. The presence of disseminated infection and established multiorgan failure should be contraindications to lung retransplantation.

Thirty-nine heart transplant recipients were randomized prospectively to receive OKT3 or antilymphoblast globulin (ALG) for 7 days, having otherwise identical protocols (group 1: OKT3, n = 20 patients; group 2: ALG, n = 19 patients). No preoperative immunosuppression was given. The protocol consisted of methylprednisolone, 500 mg intraoperatively, followed by 1 mg/kg/day, intravenously or orally, tapering to 0.2 mg/kg/day at 1 month; oral cyclosporine starting 3 to 5 days after transplantation; selective use of azathioprine, 1 to 4 mg/kg/day; and either OKT3, 5 mg/day for 7 days, or ALG, 15 mg/kg/day for 7 days. Of the 39 patients in the study, 34 are alive 6 months to 2 years after transplantation. The actuarial survival at 2 years for the OKT3 and ALG groups was 92% (+/- 0.07%) and 83% (+/- 0.09%), respectively (not significant [NS]). The time to first rejection for group 1 was 5.6 weeks and for group 2 was 5.3 weeks (NS). The mean number of rejections for group 1 and group 2 was 2.1 episodes per patient and 1.4 per patient, respectively (NS). Three patients in each group were free of rejection at 6 months. The total number of infections at 6 months was 1.05 per patient in group 1, 0.74 per patient in group 2 (NS), with 35% of patients receiving OKT3 and 52% of patients receiving ALG actuarially free of infection by 6 months after surgery (NS). During the first 24 hours after surgery, no significant differences were noted in mean blood pressure, central venous pressure, or Po2 between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The number of heart transplantations performed over the past 3 years has plateaued. However, the number of pediatric transplantations continues to slowly increase. Unlike adult heart transplantation, for which cardiomyopathy remains the most frequent indication, structural congenital heart disease is the primary indication in children. This report reviews our experience with orthotopic heart transplantation in the presence of structural congenital heart disease with and without prior palliative repair. The diagnoses included transposition of the great arteries, common atrium, left superior vena cava with and without a bridging innominate vein, dextrocardia, and univentricular configurations. The palliative repairs included Blalock-Taussig shunt, bilateral Glenn shunt, Fontan repair, and Mustard and Rastelli procedure. There were no early deaths. Two rejection-related late deaths have occurred at 8 months and at 3 years postoperatively. Extended use of donor tissue and modifications to surgical technique allowed for successful orthotopic heart transplantation in these patients who had structural congenital heart disease with and without prior surgical palliation.

Of 219 heart transplant patients with follow up for at least 3 months after transplantation, cardiac allograft ischemic time was more than 4 hours in 28% and more than 5 hours in 10%. In 1988 and 1989 grafts with ischemic times longer than 4 hours were used in 44% and 45% of cases, respectively. Overall, donor age has been 35 or more years in 22% and 45 or more in 9%. In 1989 donor age was 35 or more years in 39% of cases and 45 or more in 18%. Fifteen of 20 grafts from donors 45 years or older were used for patients aged 50 or older. There was no relationship between donor age or ischemic time and 90-day graft loss. At 3 and 12 months, cardiac function, assessed by treadmill exercise duration, radionuclide angiography, and rest and peak supine exercise hemodynamics, was also unrelated to donor age or ischemic time. Therefore by careful selection of appropriate donors, extending both graft ischemic time and donor age has increased the potential donor pool and has not to date been associated with increased graft loss or adverse effects on cardiac function 3 months and 1 year after heart transplantation.

The results of heart-lung transplantation are improving with increasing experience in postoperative management, but obliterative bronchiolitis may still develop late postoperatively. We have performed 19 heart-lung transplants, with 1-month, 1-year, and 2-year actuarial survival rates of 95% +/- 5%, 84% +/- 8%, and 69% +/- 16%, respectively. Three early recipients died of bronchiolitis, and four patients who were operated on more than 2 years ago are currently being followed up with bronchiolitis. Since August 1988, 13 surviving recipients have undergone serial postoperative bronchoscopies and transbronchial biopsies with topical analgesia. Diffuse bronchomalacia, involving the main bronchi down to the fifth-order bronchi bilaterally, has developed in four patients with bronchiolitis 9 +/- 2 months after the diagnosis of bronchiolitis was confirmed. Pulmonary function tests have revealed a lower ratio of forced expiratory volume in 1 second to forced vital capacity, lower specific airway conductance, and higher airway resistance in heart-lung recipients with bronchomalacia than in patients with bronchiolitis alone. We conclude that diffuse bronchomalacia occurs frequently in heart-lung transplant recipients who have obliterative bronchiolitis. Bronchomalacia worsens the functional airflow obstruction caused by bronchiolitis and may play an important role clinically in the declining respiratory status of heart-lung transplant recipients.

Chronic shortage of donor organs has heightened interest in new strategies for increasing donor availability. Unacceptable hearts for transplant have previously been characterized by donor age greater than 40 years, more than 20% donor/recipient weight mismatch, ischemic time more than 4 hours, and the presence of coronary artery disease. A series of 185 consecutive orthotopic heart transplants were retrospectively examined. A significant number of donor hearts used were unacceptable by one or more of the above criteria. Our current approach is to match donors to recipients using a wide range of criteria. Donors are now accepted from any location in North America. We have accepted donors more than 55 years of age and donors weighing less than 50% of the recipient's body weight. Because of the chronic shortage of donor organs, donor criteria have been effectively liberalized, thereby increasing the donor pool without compromising the overall results of heart transplantation.

To reduce perioperative hemorrhage following heart-lung transplantation, several technical modifications were introduced in June 1988 to secure better posterior mediastinal hemostasis. The intraoperative and postoperative use of blood and blood products, as well as the chest tube drainage in the first 24 hours postoperatively, were compared in the seven patients operated on since June 1988 with the nine patients operated on before that date. Significant (p less than 0.05) reductions were demonstrated in the intraoperative and postoperative transfusion of packed cells, in the postoperative administration of fresh frozen plasma, and in the chest tube drainage within the first 24 hours postoperatively. The one-month and total hospital mortality rates were 6 percent and 12.5 percent, respectively. It is concluded that newer techniques to obtain optimal posterior mediastinal hemostasis have significantly reduced blood loss following heart-lung transplantation in our experience and have contributed to our excellent early postoperative results.

Congenital heart disease as an indication for heart transplantation accounts for a small number of the total heart transplant experience--less than 3% in most centers. We have performed heart transplantation in eight such patients, accounting for 4% of our total experience. All these patients had specific anatomic anomalies relevant to transplantation. None had morbidity directly related to their anatomic defect and subsequent transplant. Six of the eight had undergone no prior palliative or corrective repairs. One child had a left Blalock-Taussig shunt, and one had bilateral Glenn shunts and a Fontan repair. Technical considerations for orthotopic heart transplantation are described for transposition of the great arteries, left superior vena cava with and without bridging innominate vein, common atrium, presence of Blalock-Taussig shunt, bilateral Glenn shunts, and Fontan repair. Anatomic congenital heart disease is becoming a more frequent indication in heart transplantation. Heart transplantation in the presence of structural congenital heart disease may be technically challenging. Nevertheless, transplantation offers an effective therapeutic alternative for patients with end-stage congestive heart failure and congenital heart disease.

The contribution of a liaison psychiatrist to a cardiac transplant programme is described. Ninety one patients were referred to the transplant unit for assessment over four years, and of these, 86 were assessed by the psychiatrist. A high prevalence of preoperative anxiety and depression was found. Thirty four transplants were performed on 33 patients during the study and 22 patients survived. Six patients developed transient delirious episodes during the first 10 postoperative days, three showed symptoms of considerable anxiety, and three developed social and behavioural problems during the convalescent period. Subjects with higher scores on the somatic scale of the general health questionnaire showed increased postoperative mortality. In conclusion, the liaison psychiatrist is useful in evaluating and managing heart transplant patients before and after operation.

The successful operative treatment of aortic valve disruption caused by forceful blunt chest trauma in a 30-year-old previously healthy man is reported. The patients' left coronary cusp was completely avulsed at its annular insertion. Aortic valve replacement with a 23-mm Carpentier-Edwards porcine xenograft was performed. The literature on this rare condition is reviewed.

The current organ shortage prompts reassessment of donor selection. This article describes a patient who underwent heart transplantation with an internal mammary artery graft to the left anterior descending artery beyond a single stenotic lesion in the transplanted heart.

High temporal resolution radionuclide angiography was performed in 24 normal volunteers and 31 healthy cardiac transplant recipients two to 43 months (mean 13 +/- 14 months) postoperatively in order to obtain cardiac volumes and parameters of left ventricular ejection and filling at rest and during supine exercise. The peak left ventricular ejection rate was significantly higher in transplant patients at rest (2.73 +/- 0.62 versus 1.98 +/- 0.29, P less than 0.0001). During submaximal exercise, however, in contrast to normal subjects, peak ejection rate increased in transplant recipients only during later exercise, corresponding to an increase in heart rate. Peak left ventricular filling rate was also significantly higher among transplant recipients at rest (3.52 +/- 0.96 versus 2.36 +/- 0.45, P less than 0.0001) and during submaximal exercise. Peak filling rate increased in transplant patients on initiation of exercise, associated with an increase in the end diastolic volume in the absence of an increase in heart rate. In 13 patients studied more than one year post cardiac transplantation, the peak ejection rate and peak filling rates did not differ from those studied less than one year post transplant. Therefore, in transplant patients, no defect of myocardial filling was apparent either at rest or during exercise. Systolic performance improved in later exercise, presumably as levels of circulating catecholamines and heart rate increased.

The chest radiographic findings and pulmonary radionuclide studies of four patients who underwent heart-lung transplantation between May 1983 and June 1986 were reviewed retrospectively. The two long-term survivors both developed bronchiolitis obliterans (presenting at 32 months postoperatively in the first patient and 14.5 months postoperatively in the second). The etiology of this is likely to be multifactorial and includes pulmonary rejection which may develop without concomitant cardiac rejection. The radiologist must be alert to this complication in heart-lung transplantation. The chest radiographs in our two patients showed diminution of peripheral bronchovascular markings and overinflation. The importance of careful screening of the radiographs of potential donors to detect pneumonia is emphasized. In one patient, a unilateral pneumothorax spread contralaterally due to the absence of normal anatomic barriers. The "reimplantation response" was not a prominent feature and was seen in one patient only. This response has been observed in heart-lung transplant recipients during the second postoperative week. The radiologic appearance is that of interstitial edema not explained by any clinical or hemodynamic findings.

The results of surgery for occlusive coronary artery disease were studied in 600 consecutive, unselected patients who underwent aortocoronary bypass grafting between Jan. 1, 1977 and Dec. 31, 1982. Forty (7%) of these patients had diabetes mellitus, requiring medication. Sixteen of the 40 patients were insulin-dependent, the remainder required oral hypoglycemic agents. The frequency of previous myocardial infarction, hypertension and peripheral vascular disease in the groups of nondiabetic and diabetic patients was 38% and 62.5%, 12% and 22.5%, and 10.5% and 25% respectively. There was no significant difference in the rate of unstable angina, triple-vessel disease, emergency surgery, left ventricular dysfunction, myocardial infarction perioperatively and hospital morbidity or mortality in the two groups. On coronary angiography, 82% of coronary arteries in diabetic patients were graded as being small or moderate in size (less than 2 mm in diameter); at operation, 62% of these arteries were found to be 2 mm or more in diameter. At a mean follow-up of 3.9 years and 3.7 years in the nondiabetic and diabetic patients respectively (range from 1 to 6 years), no significant difference was noted with regard to relief of symptoms or survival in the two groups. It is concluded that diabetic patients with coronary artery disease can be offered bypass surgery with good short-term and medium-term results.

The authors describe their technique of embolization, using detachable balloons to produce endovascular occlusion in three patients with multiple pulmonary arteriovenous fistulas and in one patient with a large peripheral aneurysm. The results were satisfactory. The clinical presentation and treatment course in each of the four patients are described and the role of this form of therapy is discussed. This method of endovascular occlusion is particularly appropriate for treating pulmonary arteriovenous fistulas and aneurysms because placement of the balloon is precise, permanent and localized and the flow of the balloon in the fistula or aneurysm can be directed.

An unusual penetrating chest injury was caused by a ball-point pen. Because of apparent penetration of the heart, preparations were made for an emergency open-heart procedure before emergency thoracotomy was undertaken, with the pen still in situ. The pen had bruised the epicardium but had not penetrated the pericardial sac. After removal of the pen, the wound was closed and a chest tube left in place. Recovery, apart from minor degrees of basal atelectasis, pleural effusion and wound infection, was uneventful. The outcome was consistent with that associated with current aggressive management of penetrating chest injuries. Management is based on three approaches. The primary one is intercostal thoracostomy tube drainage and fluid and blood replacement. In cases of massive hemorrhage or air leak, thoracotomy is necessary. The third approach is to prevent post-traumatic pulmonary insufficiency by using fine, high-efficiency filters during blood transfusion, avoiding excessive administration of intravenous fluids, performing tracheostomy after prolonged endotracheal intubation, and using a volume respirator with positive end-expiratory pressure. The average mortality for penetrating wounds of the heart is 25%.

Current immunosuppression protocols in heart transplantation commonly employ an inductive phase preoperatively, which often is followed by triple therapy (azathioprine, cyclosporine, and prednisone). From 1981 to June 1987, 119 heart transplants were performed in 114 patients. Group I (n = 19) received cyclosporine preoperatively and postoperatively, as well as steroid intraoperatively and postoperatively. Group II (n = 100) received antilymphocyte globulin postoperatively and interval cyclosporine orally 5 to 7 days postoperatively when the antilymphoblast globulin was discontinued. Methylprednisolone was given intraoperatively, and 1 mg/kg was given postoperatively. Steroid was tapered to 20 mg/day within 4 weeks. Cyclosporine was removed from the early postoperative regimen to reduce the deleterious renal effects. Steroid was used in low doses and tapered quickly to lessen steroid-related complications. There was one cyclosporine-related kidney failure in group I and none in group II. In no patient was cyclosporine discontinued because of adverse effects. The rate of rejection remains acceptable. There have been eight deaths as a result of rejection (three in group I and five in group II). Three patients have died of infection (one in group I and two in group II). Since January 1987 no postoperative protective isolation has been used. Overall survival is 77%, and no patient has exhibited late coronary atherosclerosis on follow-up coronary angiography. The regimen of immunosuppression that has evolved is safe and effective and has long-term benefits.

Six left atrial myxomas were detected at one hospital in a 15-month period. These tumours are not as rare as was once thought and they frequently cause systemic problems. The diagnosis may easily be missed, but echocardiography is a simple way of establishing the diagnosis. Excision of the tumour usually results in marked symptomatic improvement.

Clinical assessment of the adequacy of arterial embolectomy and reconstruction is often unsatisfactory and inadequate. Objective information on the state of the distal circulation can be readily obtained at the time of surgery by arteriography. Illustrative cases demonstrating the usefulness of control arteriography obtained during the surgical procedure are presented.

Over a 6-year period at the University Hospital in London, Ont., 101 patients underwent heart transplantation and 5 heart-lung transplantation. The authors review the general surgical problems identified from the charts of 13 of these patients. In the early postoperative period (within 30 days), laparotomy was required for pancreatitis (one), perforated peptic ulcer (two), cholecystectomy (one), pancreatic cyst (one) and appendicitis (one). In addition, a spontaneous colocutaneous fistula and spontaneous pneumoperitoneum occurred; both were managed conservatively. Later, three patients required cholecystectomy; one underwent a below-knee and a Symes amputation for dry gangrene and one surgical correction of a lymphocele. The incidence of surgical problems (13%) indicates an increased susceptibility in this group of patients. Four of the 13 patients died. Pancreatitis is a well-recognized complication of cardiac surgery; it is frequently associated with a normal or only slightly elevated serum amylase level, making a definitive diagnosis without laparotomy almost impossible. Persistence of abdominal signs should signal the need for exploratory surgery. During the early postoperative period and in the absence of multiorgan failure, immediate operation for an acute abdomen is usually successful. Despite the additional risk, cardiac transplantation does not preclude later surgery, but immunosuppression must be continued and carefully monitored.