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Objective: "No-touch" (NT) saphenous vein harvesting preserves the adventitial vasa vasorum, prevents medial ischemia, and is associated with an improved short-term and long-term vein graft patency. It may also be associated with a higher rate of harvest site complications. Endovascular vein harvesting (endo-vein) has a low rate of harvest site complications but also a tendency toward a lower patency rate., Methods: During a 2-year period (2011-2012), we compared the vein graft patency at symptom-directed cardiac catheterization as well as wound complication rates in 210 patients who received either NT (87 patients) or endo-vein (123 patients)., Results: The recatheterization rate for the two groups was similar: 9 (10.3%) of 87 of the NT patients versus 11 (9.0%) of 123 of the endo-vein patients. There was a significant difference in vein graft patency between the groups: 15 (94%) of 16 NT vein grafts were patent versus 6 (27%) of 22 of endo-veins (P < 0.02). The endo-vein graft patency during this 2-year period was similar to the total endo-vein patency (37%) during a 4-year period. A comparison between a more experienced and a less experienced harvester revealed no difference in patency rate. Harvest site complications were significantly higher with the NT harvest: 18% of the NT patients requiring vacuum-assisted wound closure or intravenous antibiotics versus 2% of the endo-vein patients (P < 0.0001). The application of platelet-rich plasma did not significantly lower wound complication rates (P = 0.27)., Conclusions: These results suggest that NT vein harvesting may be associated with improved graft patency, but methods should be developed to lower wound complication rates.

Background: Abdominal aortic aneurysms requiring surgical intervention are generally treated by endovascular means. Such procedures are not always offered in rural hospitals, possibly leaving patients underserved. We reviewed our experience initiating an endoaortic surgery program., Methods: A surgeon in a rural centre was credentialed to perform endovascular aortic aneurysm repair through collaboration with a university centre and was proctored locally for the first 5 abdominal aneurysm repairs. Web-based image storage was used to review complex cases as part of an ongoing partnership. Referred patients were screened for multiple aneurysms and underwent long-term monitoring., Results: In all, 160 patients were evaluated for 176 aortic pathologies. Twenty-five patients (17 men) aged 55-89 years underwent 26 endovascular abdominal (n = 23) or thoracic (n = 3) aortic procedures. Emergent endovascular procedures were not performed. There were no operative deaths, requirements for dialysis or conversions to open repair. Two endoleaks required early reintervention. The median length of stay in hospital for endovascular procedures was 2.5 days. Chronic endoleaks were observed in 7 patients. An additional 8 patients underwent open abdominal aneurysm repair locally and 15 patients were referred to the university program., Conclusion: Creation of an endovascular aortic surgery program in a rural hospital is feasible through collaboration with a high-volume centre. Patient safety is enhanced by obtaining second opinions using web-based image review. Most interventions are for abdominal aortic aneurysms, but planning for a comprehensive aortic clinic is preferable.

Background: Mechanical circulatory support is a highly effective technology to maintain organ perfusion in patients with cardiogenic shock as a bridge to transplantation. Although implantation of a left ventricular assist device alone is often the preferred configuration, patients with biventricular failure and significant end-organ dysfunction often require biventricular assistance., Methods: Between January 2000 and September 2008, 80 patients with severe biventricular failure were accepted for heart transplantation and received a pneumatic biventricular assist devices as a bridge to transplant. Patients were retrospectively divided into 2 groups: those successfully bridged to transplant (Group A) and those who died (Group B). Patients were also divided into 2 periods of implantation: Group X (2000-2005) and Group Y (2006-2008, which used a multidiscipline selection process)., Results: Overall success rate to transplantation was 71.3%, with Group Y demonstrating an 82% success to transplant rate vs 63% in Group X. One-year actuarial survival after transplant was 89% compared with 92% in patients without a ventricular assist device. There were no statistically significant laboratory parameters between Groups A and B identifying potential risk factors for poor outcome., Conclusion: Biventricular assist device therapy represents an effective and reliable means of supporting selected Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients as a bridge to transplantation, with excellent success to transplant rates and post-transplant survival., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: Inhaled nitric oxide has been shown to reduce pulmonary vascular resistance in patients undergoing cardiothoracic surgery, but it is limited by toxicity, the need for special monitoring, and cost. Inhaled prostacyclin also decreases pulmonary artery pressure, is relatively free of toxicity, requires no specific monitoring, and is less expensive. The objective of this study was to compare nitric oxide and prostacyclin in the treatment of pulmonary hypertension, refractory hypoxemia, and right ventricular dysfunction in thoracic transplant recipients in a prospective, randomized, crossover pilot trial., Methods: Heart transplant and lung transplant recipients were randomized to nitric oxide or prostacyclin as initial treatment, followed by a crossover to the other agent after 6 hours. Pulmonary vasodilators were initiated in the operating room for pulmonary hypertension, refractory hypoxemia, or right ventricular dysfunction. Nitric oxide was administered at 20 ppm, and prostacyclin was administered at 20,000 ng/mL. Hemodynamic and oxygenation parameters were recorded before and after initiation of pulmonary vasodilator therapy. At 6 hours, the hemodynamic and oxygenation parameters were recorded again, just before discontinuing the initial agent. Crossover baseline parameters were measured 30 minutes after the initial agent had been stopped. The crossover agent was then started, and the hemodynamic and oxygenation parameters were measured again 30 minutes later., Results: Heart transplant and lung transplant recipients (n = 25) were randomized by initial treatment (nitric oxide, n = 14; prostacyclin, n = 11). Nitric oxide and prostacyclin both reduced pulmonary artery pressure and central venous pressure, and improved cardiac index and mixed venous oxygen saturation on initiation of therapy. More importantly, at the 6-hour crossover trial, there were no significant differences between nitric oxide and prostacyclin in the reduction of pulmonary artery pressures or central venous pressure, or in improvement in cardiac index or mixed venous oxygen saturation. Nitric oxide and prostacyclin did not affect the oxygenation index or systemic blood pressure. There were no complications associated with nitric oxide or prostacyclin., Conclusion: In heart transplant and lung transplant recipients, nitric oxide and prostacyclin similarly reduce pulmonary artery pressures and central venous pressure, and improve cardiac index and mixed venous oxygen saturation. Inhaled prostacyclin may offer an alternative to nitric oxide in the treatment of pulmonary hypertension in thoracic transplantation.

Background: The reluctance to use organs from donors who have died from severe infections is based on the potential transmission of an infectious agent to the recipient and on the uncertainty about allograft function in the setting of severe donor sepsis., Methods: From 1999 to 2007, donor hospital records were reviewed which focused on microbiology cultures and sensitivity results; type and duration of antimicrobial therapy; hemodynamic data, results of echocardiogram, and imaging studies. Preliminary positive and negative results from pre-harvest blood, respiratory, urine, and cerebrospinal fluid cultures were verified with the procurement agency. The harvesting surgeon performed gross inspection of donor valvular structures., Results: Nine donor hearts were transplanted from patients who expired from community onset infections with severe septic shock, meningitis, and/or pneumonia caused by Streptococcus pneumoniae (n = 4), Streptococcus milleri (n = 2), Neisseria meningitidis (n = 2), and unidentified gram- positive cocci (n = 1). Four donors had probable infection-induced intracranial hemorrhage, and all donors were vasopressor-dependent before organ procurement. No evidence of donor-transmitted infection, sepsis, or rejection was observed, and long-term function remained excellent; allograft dysfunction in three patients resolved after transplant. Our series of nine donors represents approximately 1.3% of successfully transplanted cardiac allografts during the respective period of review., Conclusions: Patients succumbing to severe infections (meningitis, pneumonia, and septic shock) should not be arbitrarily excluded for possible heart donation. Assessing the suitability of donors with severe infections requires flawless communication between the donor and transplant facility, including a comprehensive evaluation of donor infection and pathogen(s), severity of sepsis, adequacy of antimicrobial treatment, and the degree of sepsis-induced myocardial dysfunction.

We sought to compare outcomes in patients > or = 60 years of age with those of their younger counterparts who underwent ventricular assist device implantation intended as a bridge to cardiac transplantation and also to identify retrospectively additional pre- and postoperative factors that might portend adverse outcomes.The medical records of 88 patients who were treated with bridge-to-transplantation ventricular assist devices from 1996 through 2007 were reviewed. Laboratory values, hemodynamic parameters, and the need for hemodynamic support were evaluated. Postoperative complications and bridge-to-transplantation success rates versus death rates were evaluated. Seventeen patients were > or = 60 years old and 71 patients were < 60 years old. In the older group, 59% of patients underwent successful bridging to transplantation, compared with 69% of the younger patients (P = 0.41). Multivariate analysis distinguished age > or = 60, female sex, earlier time period of operation, higher mean pulmonary arterial and central venous pressures, need for preoperative intra-aortic balloon pumps, and postoperative respiratory failure as independent risk factors for death. After orthotopic heart transplantation, survival to hospital discharge was 100% in the older group and 93.9% in the younger patients. Median lengths of stay were similar in both age categories.Multivariate analysis identified age as 1 of 6 independent risk factors for death in this study. Patients who successfully underwent cardiac transplantation, however, had similar survival statistics regardless of age category. Case-by-case evaluation is warranted when analyzing risk-benefit ratios of bridge-to-transplantation ventricular assist device therapy in the older patient population.

Background: Heart transplantation in the elderly is increasingly common. In the mid-1990s, 25% of recipients in our program were >62 years of age. We evaluated outcomes from one institution with the hypothesis that older recipients may be at higher risk of major complications associated with immunosuppression., Methods: We analyzed results for 182 patients aged 62 to 75 years (mean +/- SD: 66.3 +/- 11.4 years) who underwent heart transplantation between January 1995 and July 2001 at a single institution. They were compared with a control group of 348 contemporaneous adult recipients aged 18 to 62 years (mean +/- SD: 48.2 +/- 11.4 years). All recipients in this consecutive cohort had a follow-up of at least at least 5 years. End-points studied were Kaplan-Meier survival, freedom from dialysis and freedom from malignancy at 100 months. Follow-up was 100% at 100 months., Results: At 100 months, survival for the elderly was 55% (46 remaining at risk) and 63% (102 remaining at risk) for controls (p = 0.051, log-rank test). Re-transplant and dialysis, but not recipient age or malignancy, were predictive of survival by regression analysis (p = 0.003, p < 0.001, p = 0.53 and p = 0.84, respectively). Freedom from malignancy at 100 months was 68% for the elderly and 95% for controls (p < 0.001). Age predicted malignancy by regression analysis (p < 0.001). At 100 months, freedom from dialysis was 81% for the elderly and 87% for controls (p = 0.005). Pre-operative creatinine, but not age, was predictive of need for dialysis (p = 0.003 and p = 0.47, respectively)., Conclusions: Although long-term survival of older heart transplant recipients is acceptable, it is significantly lower than in young recipients. The increased risk of renal failure and malignancy among elderly patients likely influences the difference in survival observed between the two groups. Pre-operative renal function warrants careful consideration. As ventricular assist device technology improves, it may be used to complement heart transplantation to avoid immunosuppression and its side effect of malignancy in older patients with advanced heart failure.

Atherosclerosis is an example of an inflammatory disorder. During the acute phase and under inflammatory conditions, high-density lipoprotein (HDL), which is normally anti-inflammatory, can become proinflammatory. Reactive oxygen species generated by several enzyme systems can modify phospholipids and sterols, producing oxidized phospholipids and oxidized sterols that reduce the capacity of HDL to protect against undesirable oxidative modifications of molecules. In animal models of dyslipidemia, diabetes, vascular inflammation, and chronic rejection, it is observed that reducing oxidative and inflammatory pressure will help HDL regain its protective role. One way to accomplish this is through the use of apolipoprotein A-I mimetic peptides, which remove oxidation products from lipoproteins and cell membranes, returning normal structure and function to low-density lipoprotein and HDL. These mimetic peptides markedly reduce atherosclerosis in animal models. Published studies of apolipoprotein mimetic peptides in models of inflammatory disorders other than atherosclerosis suggest that they have efficacy in a wide range of inflammatory conditions.

Background and Aim of the Study: The use of autologous pericardium for annuloplasty during mitral valve repair is a subject of controversy; hence, the study aim was to evaluate the authors' long-term results using this technique., Methods: A retrospective review was conducted of 173 consecutive patients (mean age 59.6 +/- 16.3 years; range: 19-92 years) who underwent mitral valve repair complemented by annuloplasty between January 1998 and December 2003. The major causes of mitral regurgitation (MR) were annular dilatation and prolapse of the posterior leaflet. Annuloplasty was performed in all patients using a strip of pericardium treated with 0.6% glutaraldehyde for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the mitral annulus. Follow up continued for a mean period of 5.25 +/- 1.62 years (range: 1.97 to 9.43 years), and was complete., Results: Three patients (1.7%) died within 30 days of surgery. Subsequently, five patients (2.9%) with MR (with or without mitral stenosis) underwent reoperation at a mean of 3.0 +/- 2.7 years after the initial surgery. At seven years after surgery the actuarial survival rate was 92.5%, and freedom from reoperation 97.1%. Follow up echocardiography was performed in 160 patients. Among these patients, no MR was detected in 34 (21.2%), while 88 (55%) had grade 1 MR, 35 (21.8%) grade 2, and three (1.8%) had grade 3. None of the patients had grade 4 MR., Conclusion: The study results indicated that autologous pericardium mitral annuloplasty of the mitral valve provides effective, durable and reproducible repair, and avoids the use of foreign materials.

Uncorrected functional tricuspid regurgitation can lead to long-term morbidity and mortality. To evaluate our results using autologous pericardium annuloplasty to treat tricuspid regurgitation, we retrospectively reviewed 59 consecutive adult patients aged 19 years to 83 years (58.7 +/- 15.5 years) who underwent tricuspid valve annuloplasty between 2000 and 2003. Concomitant procedures consisted of mitral valve surgery in 83% of patients, aortic valve surgery in 28%, coronary bypass in 31%, and atrial-septal defect correction in 28%. Annuloplasty was performed using a strip of pericardium treated in glutaraldehyde 0.6% for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the tricuspid annulus. Follow-up was performed in 100% of the patients, and the mean follow-up was 4.4 +/- 1.2 years (range, 2.4 to 7 years). Postoperative death within 30 days occurred in 1 of 59 patients (1.6%). None of the patients required reoperation related to tricuspid regurgitation or stenosis. The actuarial survival rate was 98.4% at 7 years after operation. Echocardiography was performed in 58 of 58 surviving patients (100%). Up to 7 years postoperatively, tricuspid regurgitation was trace in 67.2% of patients, mild in 31%, and moderate in 1.8%; there was no occurrence of severe regurgitation on follow-up. Our results indicate that autologous pericardium tricuspid annuloplasty is a useful procedure in patients with moderate or severe tricuspid regurgitation. This procedure provides a durable, reproducible annuloplasty of the tricuspid valve.

The ability of high-density lipoprotein (HDL) to promote cholesterol efflux is an important component of its ability to protect against cardiovascular disease. In addition, the anti-inflammatory properties of HDL are important as well. As part of the innate immune system, HDL appears to have evolved to increase inflammation in the presence of an acute phase response but to inhibit inflammation in the absence of an acute phase response. In a study of humans with coronary heart disease, it was found that the patients who had proinflammatory HDL prior to statin therapy (and half of them despite a profound decrease in plasma lipids following statin therapy) continued to have proinflammatory HDL. Anti-inflammatory HDL was effective in promoting cholesterol efflux whereas proinflammatory HDL was relatively weak in its ability to promote cholesterol efflux. Oxidative alterations of the main protein of HDL, apolipoprotein A-I, impaired its capacity to promote cholesterol efflux from monocyte macrophages. Therefore, HDL composition, structure, and function appear to be more crucial than HDL cholesterol concentrations in determining risk for cardiovascular disorders.

Postoperative tricuspid valve regurgitation is moderate to severe in 15% to 20% of heart transplant recipients despite use of the bicaval surgical technique. We hypothesized that the regurgitation might be partly due to increased tension on the donor right atrium. To study the right atrial distortion, we modified the standard bicaval anastomosis. Our technique involves augmenting the donor right atrial anterior wall with a flap of the recipient's right atrium, which is left attached in continuity with the anterior aspect of the inferior vena cava along 65% of its circumference. We measured tricuspid regurgitation, right atrial area, and right atrioventricular diameter in 7 consecutive patients who underwent orthotopic heart transplantation with the modified anastomosis. Tricuspid regurgitation was graded as follows: 1 = trace, <10%; 2 = mild, 10%-24%; 3 = moderate, 25%-50%; and 4 = severe, >50%. All patients were weaned from inotropic support within 1 week after transplantation with excellent ventricular function, no heart block, and 100% survival at 30 days. The median follow-up time was 173 days (44-358 days). Other median measurements included tricuspid valve regurgitation jet area, 0.30 cm(2) (0-1.90 cm(2)); right atrial area, 15.90 cm(2) (14.47-18.00 cm(2)); atrioventricular diameter, 2.70 cm (2.63-3.09 cm); and tricuspid regurgitation, 1.67% (0-12.42%). Mild regurgitation occurred in 1 recipient; in all others, it was trace. The modified inferior vena caval anastomosis is simple and safe. It eliminates moderate and severe tricuspid valve regurgitation without routine annuloplasty after orthotopic heart transplantation via the bicaval technique.

Subepicardial aneurysm is a rare, life-threatening complication of acute myocardial infarction. Relatively few cases are diagnosed early enough to allow for surgical intervention. Features of this unique aneurysm include abrupt interruption of the myocardium, a narrow neck, and a propensity for progressing to sudden transmural rupture. Literature review reveals only 20 reported cases, several of which were identified postmortem. Since the myocardial burrow may progress to pseudoaneurysm or frank rupture prior to the diagnosis being made, the true incidence is unknown. Invariably, the condition develops as a result of a myocardial rent occurring during the weeks to months following acute infarction, and it generally occurs within an area of thinned, infarcted myocardium. Successful surgical repair has been reported in several cases and is the only therapy shown to prevent progression to frank rupture. Antemortem diagnosis has been reported with transthoracic echocardiography, transesophageal echocardiography, cardiac catheterization, and magnetic resonance imaging. Unfortunately, each of these imaging techniques appears to be limited by either inadequate sensitivity or slow acquisition. There remains no standard of reference among available diagnostic modalities. Rapidly obtained, contrast-enhanced computed tomography in the proper clinical setting may improve the ability of clinicians to identify this condition during a window of therapeutic opportunity, allowing surgical intervention to prevent fatal cardiorrhexis. Subepicardial aneurysm should be included in the differential diagnosis for patients presenting with chest pain following acute myocardial infarction., (Copyright (c) 2007 Wiley Periodicals, Inc.)

Objective: Expansion of potential donor pool may be facilitated by using cardiac allografts with long ischemic time. Early graft failure and potential relation to transplant coronary artery disease remains a concern. We sought to evaluate outcomes of heart transplantation in recipients of donor allografts with prolonged ischemia time., Methods: The study group consisted of 46 (mean age, 52 years) consecutive patients at UCLA from 1994 to 2002 that underwent heart transplantation with ischemia time > 300 min. This group was compared to a case-matched control group of 46 (mean age, 51 years) patients identified from our database during this time frame for the following factors: UNOS status, congenital heart disease diagnosis, preop inotropes, pretransplantation creatinine > 1.5 and recipient age. Primary endpoint was mortality and secondary were rejection rate and transplant coronary artery disease. Allografts were perfused and stored in cold University of Wisconsin solution., Results: Mean donor ages of the study and case-matched control group were 34+/-15 and 34+/-14 years, respectively. Mean ischemia times were 388 (range, 301-600 min) and 173 (range, 96-236 min), respectively. The death incidence rate per 100 transplants per year was 9% for the study group and 7.4% for the matched group (P = 0.50). Thirty-day mortality for the study and case-matched groups were 4.3 and 2.1%, respectively (P = 0.9). Late mortality was 16.5 and 18.5%, respectively (P = 0.9). The risk of death after 30 days was 7.5 and 5.8%, respectively (P = 0.5, log-rank). One-year incidence of acute cellular rejection in the study and case-matched groups were 2 and 4.5% (P = 0.36), respectively. One-year incidence of transplant coronary artery disease in the study and case-matched groups were 4.3 and 5.4%, respectively (P = 0.68)., Conclusions: Donor hearts with ischemia time greater than 300 min provide comparable early and intermediate outcomes given judicious and careful donor and recipient matching and our current techniques of myocardial preservation and modified reperfusion.

Gratacos et al. [2001: Cell 106:367-379] described an interstitial duplication dup(15)q24q26 (DUP25) in patients with anxiety disorders; this duplication was found in approximately 90% of patients and in 7% of controls. In order to determine if DUP25 is present in additional individuals susceptible to panic attacks, we tested 44 patients with anxiety disorders, using probes 251c23 and 216c14 mapping in the 15q24 and 15q26 region. We have not detected any DUP25. Our results suggest that DUP25 is not common in people with anxiety disorders in the population tested here., (Copyright 2004 Wiley-Liss, Inc.)

Background: Remodeling occurs in both ventricle and atrium in dilated cardiomyopathy and heart failure. However, the alteration of atrial extracellular matrix components during remodeling and its effect on the electrical remodeling and atrial arrhythmia have never been explored., Methods and Results: Atrial tissue samples of 53 explanted hearts from patients with dilated cardiomyopathy and end-stage heart failure who underwent heart transplantation were examined. Nineteen patients had permanent atrial fibrillation (PmAF), 18 had persistent AF (PsAF), and 16 had no documented AF (NAF). Sixteen donor left atria (LA) were used as controls (CNs). Western Blot analysis revealed a selective downregulation of tissue inhibitor of metalloproteinase (TIMP)-2 in PmAF and PsAF groups compared with the NAF and CN groups and an upregulation of atrial metalloproteinase (MMP)-2 that was most pronounced in the PmAF group followed by the PsAF and NAF groups. Immunofluorescent staining revealed that in the LA, type I collagen volume fraction (CVF-I) increased significantly in the PmAF group followed by the PsAF and NAF groups compared with that in CN. LA CVF-I significantly correlated with LA dimension and TIMP-2 to MMP-2 ratio. In the PsAF group, CVF-I/CVF-III ratio was significantly correlated with AF duration and the frequency of AF recurrence., Conclusions: Atrial extracellular matrix remodeling manifested by the selective downregulation of TIMP-2 along with upregulation of MMP-2 and CVF-I in the atrium is associated with the development of sustained atrial fibrillation in patients with cardiomyopathy and heart failure.

Objective: We sought to evaluate the safety and efficacy of the first available totally implantable replacement heart (AbioCor Implantable Replacement Heart System) in the treatment of severe, irreversible biventricular heart failure in human patients., Methods: Seven male adult patients with severe, irreversible biventricular failure (>70% thirty-day predicted mortality) who were not candidates for transplantation met all institutional review board study criteria and had placement of the AbioCor Implantable Replacement Heart. All were in cardiogenic shock despite maximal medical therapy, including inotropes and intra-aortic balloon pumps. Mean age was 66.7 +/- 10.4 years (range, 51-79 years). Four of 7 patients had prior operations. Six had ischemic and one had idiopathic cardiomyopathy. All had 3-dimensional computer-simulated implantation of the thoracic unit that predicted adequate fit. At the time of the operation, the internal transcutaneous energy transfer coil, battery, and controller were placed. Biventriculectomy was then performed, and the thoracic unit was placed in an orthotopic position and attached to the atrial cuffs and outflow conduits with quick-connects. The flow was adjusted to 4 to 8 L/min. Central venous and left atrial pressures were maintained at 5 to 15 mm Hg. The device is powered through transcutaneous energy transfer. An atrial flow-balancing chamber is used to adjust left/right balance. The balance chamber and transcutaneous energy transfer eliminate the need for percutaneous lines., Results: There was one intraoperative death caused by coagulopathic bleeding and one early death caused by an aprotinin reaction. There have been multiple morbidities primarily related to preexisting illness severity: 5 patients had prolonged intubation, 2 had hepatic failure (resolved in 1), 4 had renal failure (resolved in 3), and 1 each had recurrent gastrointestinal bleeding, acute cholecystitis requiring laparotomy, respiratory failure that resolved after 3 days of extracorporeal membrane oxygenation, and malignant hyperthermia (resolved). There were 3 late deaths: one caused by multiple systems organ failure (postoperative day 56), one caused by a cerebrovascular accident (postoperative day 142), and one caused by retroperitoneal bleeding and resultant multiple systems organ failure (postoperative day 151). This latter patient was not able to tolerate anticoagulation (no anticoagulation or antiplatelet therapy alone for 80% of the first 60 days) and had a transient ischemic attack on postoperative day 61 and a cerebrovascular accident on postoperative day 130. At autopsy, blood pumps were clean. The 2 patients who had large cerebrovascular accidents had thrombus on the atrial cage struts. These struts have been removed for future implants. There has been no significant hemolysis or device-related infections. The balance chamber has allowed for left/right balance in all patients (left atrial pressure within 5 mm Hg of right atrial pressure). Three patients have taken multiple (>50) trips out of the hospital, and 2 have been discharged from the hospital. Total days on support with the AbioCor are 759., Conclusion: The initial clinical experience suggests that the AbioCor might be effective therapy in patients with advanced biventricular failure. There have been no significant device malfunctions. Two of these patients have been discharged from the hospital.

Background: In this study, we used a single-institution database to examine the risks of heart transplantation in patients with diabetes mellitus (DM)., Methods: Recipients 18 years and older who underwent cardiac transplantation from July 1994 to December 2000 were reviewed; 101 consecutive patients with insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus were compared with 244 patients who did not have DM and who received standard donor hearts. Survival, renal function (serum creatinine concentration), development of transplant coronary artery disease (TCAD), severe rejection, and infection (requiring hospitalization) were analyzed., Results: Patients with DM were older (mean age, 57.1 years vs 51.4 years), had greater body mass index (mean, 26.7 vs 24.1 kg/m(2), p < 0.02), and more commonly had ischemic cardiomyopathy (58% vs 43%, p = 0.02). We found a trend toward decreased survival for those with DM at 1 year (85.1% vs 90.9%; p = 0.12). Five-year survival was 81.6% for both groups. Mean follow-up time was 4.1 years. Infection rate within 3 months was greater among those with DM (14% vs 3%, odds ration = 5.09; 95% confidence interval, 1.59-16.23). Freedom from infection at 4 years was 71.0% for patients with DM and 85.0% for those without DM (p = 0.02). Freedom from rejection at 4 years was similar (70.6% vs 73.6%, p = 0.69). At 4 years, transplant coronary artery disease (TCAD)-free survival was 69.5% for those with DM and 81.6% for those without (p = 0.23). Mean serum creatinine concentration at 4 years after transplant was 1.5 mg/dl in patients with DM (vs 1.4, p = 0.28). Multivariate analysis showed increased baseline creatinine level as a significant risk factor for survival and showed pre-transplant ischemic cardiomyopathy as a risk factor for TCAD in both groups. Body mass index >30 was a significant risk factor for survival among patients with DM., Conclusion: We found an increased risk of serious infections in patients with DM, particularly in the early post-operative period. Careful consideration of obesity and renal function during evaluation of candidacy is indicated.

Objective: Cardiac allografts with coronary artery disease may permit a selective expansion of the donor pool. Twenty-two recipients who received donor hearts with mild to moderate coronary artery disease on angiography were reviewed. All donor organs had preserved left ventricle function on echocardiogram., Methods: The procedure was explained to the patients in detail. All survivors have at least 1 year of follow-up. If the coronary arteries of the donor heart were significantly occluded, then the implanting surgeon performed coronary revascularization. Donors were allocated to patients facing imminent death (group I, n = 4) or to those who would otherwise not have been transplanted (group II, n = 18). Median recipient age was 57 years old for group I and 68 years old for group II. Median follow-up was 25 months for group I and 44 for group II., Results: Outcome was evaluated using survival and freedom from graft coronary disease as end points. In group I, 3 of the 4 hearts required revascularization. In group II, 10 of the 18 required revascularization. The majority of the revascularizations were recipient saphenous vein grafts (84.6%) to the donor left anterior descending artery (50%). The 1-month and 2-year actual survivals for group I are 75% and 50% and 87.5% and 81.3 for group II. One patient in group I who was in extremis and 3 in group II died at less than 90 days. Group II early deaths had donor risk factor combinations of coronary artery disease, left ventricular hypertrophy, and long distance. Freedom from new graft coronary artery disease was 100% at 2 years in group I and 87.5% in group II., Conclusions: Selective use of donor hearts with coronary artery disease is acceptable. Early deaths are related to recipient factors as well as associated donor risk factors. Donor hearts with mild or moderate coronary artery disease and preserved function on echocardiogram can be used but may require revascularization with recipient conduit and/or percutaneous transluminal coronary artery angioplasty. Coronary disease in donor hearts requires grading and does not categorically preclude use, particularly in risk-matched recipients.

The AbioCor implantable replacement heart (IRH) is the first available totally implantable artificial heart. We recently initiated a multicenter trial of this device in patients with severe, irreversible biventricular failure. Patients who were not candidates for other therapies, including transplantation, were evaluated. All candidates were adults with inotrope-dependent biventricular failure, whose 30-day predicted mortality was higher than 70%. A three-dimensional computerized fit study predicted fit of the AbioCor thoracic unit in all recipients. At operation, the internal battery controller and transcutaneous energy transfer unit were placed. The AbioCor thoracic unit was placed in an orthotopic position after incision of the ventricals. There were 2 intraoperative deaths (due to intraoperative bleeding or aprotinin reaction). Four late deaths were recorded, 1 from multisystem organ failure and 3 cerebrovascular accidents. Autopsy revealed thrombus on the atrial struts of the 3 patients with cerebrovascular accident. Blood pumps and valves were clean on all patients. Significant morbidity was observed, primarily related to preexisting severity of illness. However, 3 patients recovered to the point of being able to take multiple trips outside of the hospital. Two patients were discharged from the hospital, with 1 patient being discharged home for more than 7 months. No significant device malfunctions or multi-system organ failure device-related infections were noted. The AbioCor IRH may be effective therapy for patients with end-stage heart failure. Many milestones have been achieved in the initial trial in humans, including the successful discharge of a patient to home and no significant device malfunctions. The occurrence of stroke is likely related to the presence of thrombus on the atrial struts and may be decreased as these atrial struts have been removed for future clinical implants.

Between November 2000 and January 2002, two patients with aneurysms that involved the distal part of the aortic arch including the left subclavian artery were treated at our institution. Patient 1 had an aneurysm of 5.8 cm extending to the proximal descending aorta. Patient 2 had a 6.8 cm type II thoracoabdominal aneurysm extending proximal to the aortic bifurcation. Both patients had left subclavian-to-carotid transposition in preparation for distal aortic arch replacement. Complete replacement of the descending thoracic and abdominal aorta was carried out in patient 2. Both cases were done with distal aortic perfusion, spinal catheter drainage, and dual lumen endotracheal anesthesia. There was no mortality. There were no cerebrovascular complications in spite of the fact that patient 1 required aortic cross-clamping between the innominate and left carotid artery. There was no paraplegia, renal failure, or mesenteric or lower extremity complications. Patient 1 had postoperative vocal cord palsy, eventually requiring medialization procedure. He recovered normal voice. Both patients remain alive and well at the time of last follow-up (7 to 20 months). Carotid subclavian reconstruction in preparation for distal aortic arch replacement facilitates the performance of the proximal anastomosis and attempts to maintain flow through the left vertebral system during aortic cross-clamping. This may reduce the risk of stroke during distal aortic arch replacement.

Giant-cell myocarditis is a rare and aggressive form of myocarditis with a high mortality rate. Our purpose is to summarize 3 cases of acute giant-cell myocarditis that illustrate possible outcomes with mechanical support. We reviewed the cases of 3 patients, aged 39 to 59 years, who had giant-cell myocarditis (confirmed by myocardial biopsy). The indication for ventricular assist was circulatory failure despite maximal medical treatment with 2 or more inotropic agents and intraaortic balloon pump support. Immunosuppression and a biventricular mechanical assist (BVS 5000) were used to treat all these patients. The mean duration of mechanical support was 15.7 days (range, 10 to 19 days). One patient had recovery of myocardial function and was weaned from mechanical support. This case is, to our knowledge, the first reported of ventricular support leading to cardiac recovery after diagnosis of giant-cell myocarditis. The 2nd patient was not a candidate for further surgery and died of multisystem organ failure. The 3rd patient underwent orthotopic heart transplantation after 18 days of support and was discharged. We conclude that patients with giant-cell myocarditis tend to have biventricular involvement and can recover myocardial function on mechanical support and immunosuppression. If recovery is not observed, transplantation is warranted. By avoiding left ventricular cannulation, the BVS 5000 is well suited for bridging to recovery, transplantation, or long-term support.

Objective: An alternate (second) adult recipient list was used to match excluded potential recipients with nonstandard donor hearts that would otherwise be unused., Methods: The only absolute criterion for entering the alternate recipient list was age: 65 years old before 1998 and 70 years old after that. Group I consisted of alternates who underwent transplantation, and group II consisted of 401 contemporaneous recipients. Hearts were first offered to regularly listed patients. At least one of the following donor risks accounted for allocation to an alternate: coronary artery disease, reused transplanted heart, high-risk behavior, hepatitis seropositivity, decreased left ventricular ejection fraction, high inotropic requirement, left ventricular hypertrophy, age older than 55 years plus another risk, and small donor with no other matches., Results: Of 102 alternates, 82 were listed were because of age. After a median wait of 107 days, 62 alternates underwent transplantation. Median alternate recipient age was 67 years (vs 54 years, P <.001). Median donor age was 45 years (vs 31 years, P <.001). Survival for alternates at 90 days was 82% (vs 91%, P =.04). Significant recipient predictors of early mortality on multivariable analysis (n = 463) were previous cardiac surgery (odds ratio 2.74, 95% confidence interval 1.37-5.48) and renal dysfunction (odds ratio 1.39, 1.10-176). Alternate listing did not independently predict early or late mortality. Late (>90 days) death rates per 1000 person-months were 4.3 and 3.6 for groups I and II (relative risk 1.2, 0.62-2.36)., Conclusions: Use of two adult recipient lists facilitated allocation of unused donor organs. Satisfactory long-term survival supports the use of an alternate recipient list.

Background: Heart transplantation is the most accepted treatment for end-stage heart disease. A review of 1,083 consecutive transplants (1984 to 2001) was undertaken., Methods: Adult recipients were divided into quartiles. The last 540 transplants were combined. Three eras were created from these, 1984 to 1991, 1991 to 1995, and 1995 to 2001, with three age groups: 0 to 18 years, 19 to 61 years, and 62 to 74 years. All patients have at least 1 year of follow-up time. End points were survival, rejection, and graft coronary artery disease., Results: There were 1,012 patients. Donor age, graft ischemic time, and the proportion of elderly recipients and nonstandard donor hearts have increased in the current era. Actuarial 60-month survivals of recipients after 1995 were 80.7% (0 to 18 years); 75.3% (19 to 61 years); and 76.2% (>62 years). The current era children and younger adult groups demonstrated improved results when compared with previous eras (p = 0.003 and p = 0.05). Rejection episodes equal to or greater than ISHLT grade 3A per person per year improved to 0.15 in the current era (p < 0.001). During the three eras, older recipients (>62 years) demonstrated fewer episodes of rejection when compared with other adults (0.13 versus 0.58, p = 0.03). Deaths attributed to graft coronary artery disease decreased from 11% to 5% from era 2 to era 3. Regression analysis revealed a mild effect of donor age on survival and graft coronary artery disease (hazard ratio = 1.02, p = 0.001; hazard ratio = 1.039, p < 0.001, respectively). Recipient predictors of graft coronary artery disease were diagnosis of ischemic cardiomyopathy (hazard ratio = 1.6, p = 0.014) and congenital heart disease (hazard ratio = 3.41, p = 0.02)., Conclusions: Improved survival in the current era may be attributed to better organ preservation, improved immunosuppression and control of infection, and less life-threatening graft coronary artery disease.

The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to approximately 6000 to 8000 per year. Because the number of available donor hearts has not increased beyond approximately 2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on "Maximizing Use of Organs Recovered From the Cadaver Donor" held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recovery and the impact of these data on donor yield. The rationale for and specific details of a donor-management pathway that uses pulmonary artery catheterization and hormonal resuscitation are provided. Administrative recommendations such as enhanced communication strategies among transplant centers and organ-procurement organizations, financial incentives for organ recovery, and expansion of donor database fields for research are also described.

We describe a case of a 40-year-old man who presented with recent-onset, rapidly decompensating heart failure, and who was found to have giant cell myocarditis (GCM) on biopsy. The patient responded to myocardial rest on a biventricular assist device, as well as immunosuppression that included eradication of T cells using OKT3 therapy, coupled with high-dose steroids. The patient was successfully weaned off mechanical support, and ultimately discharged home, where he continues to do well. Based on a review of the clinical and experimental literature, we believe treatment with T-lymphocytic cytolytic therapy may be beneficial. Further studies using this therapy in the treatment of GCM are warranted.

Background: Pulsatile ventricular assist devices (VADs) are used to bridge adults with end-stage heart disease to transplantation. A combination of external implantable pulsatile and continuous-flow external mechanical support now can be used to bridge pediatric patients with end-stage cardiomyopathy to orthotopic heart transplantation (OHT)., Methods: We reviewed consecutive pediatric patients with cardiomyopathy (n = 28) who required mechanical cardiac support from July 1995 to February 2001. All were OHT candidates with severe hemodynamic compromise despite maximal medical support. We excluded from this series patients who had undergone cardiotomy., Results: Nineteen patients received support from external continuous-flow devices, either with extracorporeal membrane oxygenation or with centrifugal VADs, and 9 patients received pulsatile support. Nineteen of 28 (68%) patients were successfully bridged to transplant (17) or weaned (2) from their devices after recovery. Of the patients successfully bridged to transplant or recovery, 89% are alive to date. Univariate analysis revealed that a lower bilirubin concentration after 2 days of support was associated with a favorable outcome (p = 0.006). As expected, the patients with pulsatile VADs had significantly higher rates of extubation and oral feeding., Conclusion: Pulsatile and continuous-flow devices can complement each other to significantly extend the lives of a wide range of pediatric patients with severe cardiomyopathies.

Background: Donor atraumatic intracranial bleed (aICB) is associated with older age and may reflect a history of hypertension. Hearts from donors who died of aICB may be at increased risk for graft failure because of the associated catecholamine surge. We evaluated whether receiving a heart from a donor who had an aICB independently affected the outcome of transplantation., Methods: We reviewed adult patients (>18 years) who underwent heart transplantation between July 1994 and December 1999. We excluded patients who received non-standard hearts (e.g., donor age >55 years). Group 1 received hearts from donors with aICB (n = 80), and Group 2 received hearts from donors who did not have aICB (n = 171)., Results: Recipient age, gender, United Network for Organ Sharing status, and indication for transplantation were similar for both groups. Donors in Group 1 were older (41 vs 26 years, p = 0.001), more commonly women (55% vs 20%, p = 0.001), and more often had history of hypertension (26% vs 2%, p = 0.001). Survival to discharge was 86% in Group 1 and 95% in Group 2. Actuarial 5-year survival was 72% for Group 1 and 81% for Group 2 (p = 0.52). Regression analysis showed that receiving a heart from a donor with aICB was a risk factor for early recipient mortality but not for long-term outcome (odds ratio = 3.25, p = 0.02, and hazard ratio = 1.16, p = 0.69, respectively). Donor aICB, female gender, and abnormal initial echocardiogram (global hypokinesia) were selected as clinically relevant independent risk factors for early mortality of the recipient, using a fitted multifactor logistic regression model (goodness-of-fit chi-square p value = 0.94). Donor age, accident-to-retrieval time interval, and borderline left ventricular hypertrophy did not significantly differ. Five-year freedom from transplant coronary artery disease in Group 1 was 74% (vs 80% in Group 2, p = 0.05)., Conclusions: The trend observed in this series suggests that receiving a heart from a donor with aICB is a potential independent risk factor for early mortality after transplantation independent of age. Caution should be used when evaluating such donors, particularly when other risk factors such as female donor or depressed ejection fraction are present.

Background: Recipient pulmonary hypertension due to chronic congestive heart failure is a major cause of right ventricular (RV) dysfunction after heart transplantation. We hypothesized that inhaled nitric oxide (NO), in the postoperative period, would a) selectively reduce pulmonary vascular resistance and improve RV hemodynamics and b) reduce the incidence of RV dysfunction compared with a matched historical group., Methods: Sixteen consecutive adult heart transplant recipients with lowest mean pulmonary artery (PA) pressures >25 mmHg were prospectively enrolled. Inhaled NO at 20 parts per million (ppm) was initiated before termination of cardiopulmonary bypass (CPB). At 6 and 12 hours after CPB, NO was stopped for 15 minutes and systemic and pulmonary hemodynamics were measured. RV dysfunction was defined as central venous pressure >15 mmHg and consistent echocardiographic findings. The incidence of RV dysfunction and 30-day survival in this group was compared with a historical cohort of 16 patients matched for pulmonary hypertension., Results: Discontinuation of NO for 15 minutes at 6 hours after transplantation resulted in a significant rise in mean PA pressure, pulmonary vascular resistance (PVR), and RV stroke work index. Systemic hemodynamics were not affected by NO therapy. One patient in the NO-treated group, compared with 6 patients in the historical cohort group, developed RV dysfunction (P< .05). The 30-day survival in the NO-treated group and the historical cohort group were 100% and 81%, respectively (P> .05)., Conclusion: In heart transplant recipients with pulmonary hypertension, inhaled NO in the postoperative period selectively reduces PVR and enhances RV stroke work. Furthermore, NO reduces the incidence of RV dysfunction in this group of patients when compared with a historical cohort matched for pulmonary hypertension. Inhaled NO is a useful adjunct to the postoperative treatment protocol of heart transplant patients with pulmonary hypertension.

Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.

1. The consecutive pre- and post-1994 eras have demonstrated improved survival for all age groups. This is linked to improved preservation methods, surgical technique and immunosuppression agents. 2. The use of marginal donor hearts for Status I and alternate elderly patients has followed the model of matching donor and recipient risk without affecting patient outcome and minimized the use of implantable assist devices. 3. A donor history of systemic gram-negative infection, hypertension, or traumatic intracranial bleeds was an important marker for risk. Younger age and shorter ischemia time could compensate for other hazards. 4. Heart transplantation in carefully selected elderly recipients yielded clinical results similar to those of younger patients with less rejection. 5. An adult alternate recipient list proved useful to prevent diversion of standard donors away from younger recipients. 6. Retransplantation for TCAD is acceptable but much less satisfactory for acute graft failure. 7. Trends show an increase in the use of implantable devices; refinement in technology for mechanical assist and replacement is forthcoming.

Background: Mechanical cardiac assist for small children (< 30 kg) requiring bridge strategy to orthotopic heart transplantation often requires sternotomy for cannulation access to ensure perfusion to the aortic arch. Extracorporeal membrane oxygenation (ECMO) through neck cannulation is an option in very small (< 10 kg) patients, but the risk of stroke is increased in larger children. Another disadvantage is poor decompression of the left atrium, which can cause persistent pulmonary edema., Methods: Two cases are used to illustrate two methods of avoiding sternotomy during mechanical assist in children with dilated cardiomyopathy. One of these approaches avoids the need for extracorporeal oxygenation., Results: Decompression of the left-sided chambers with a left atrial cannula decreased pulmonary edema and improved pulmonary function., Conclusions: Pediatric patients with dilated cardiomyopathy may benefit from a left ventricular assist technique using a centrifugal pump, which avoids the neck vessels and sternotomy, as well as ECMO.

Reconstituting the immune response will be critical for the survival of HIV-infected individuals once viral load is brought under control. While the adult thymus was previously thought to be relatively inactive, new data suggest it may play a role in T cell reconstitution. We examined thymopoiesis in adults up to 56 years of age and found active T cell receptor (TCR) rearrangement, generating a diverse TCR Vbeta repertoire. The resulting thymocytes are functional and are capable of responding to costimulatory signals. These data demonstrate that the adult thymus remains active late in life and contributes functional T cells to the peripheral lymphoid pool.

Background: Hypothermia is critical for proper lung preservation. Ideally, the lungs should be maintained at the optimal preservation temperature during the entire ischemic interval. Lung rewarming during implantation is commonly observed. This study was undertaken to investigate the severity of rewarming ischemia on preservation injury and the possibility of minimizing this by use of leukocyte depletion during initial reperfusion., Methods: Four experimental groups were tested as follows: neonatal piglet heart-lung blocks were either (1) placed on an isolated, blood-perfused, working heart-lung circuit without intervening ischemia (control, n = 6), (2) reperfused on the circuit with whole blood (WB, n = 6) after 13 hours of preservation, (3) reperfused with WB after 12 hours of preservation and 1 hour of rewarming (RWB, n = 5), or (4) reperfused with leukocyte-depleted blood for an initial 10 minutes followed by WB, after 12 hours of preservation and 1 hour of rewarming (n = 6). All groups were studied for 4 hours., Results: The partial pressure of arterial oxygen and lung compliance were significantly lower in the RWB group than in controls (113.8+/-33.1 vs 417.3+/-6.2 mm Hg, p < 0.01; and 0.8+/-0.2 vs 2.9+/-0.4 ml/cm H2O, p < 0.05, respectively). Pulmonary vascular resistance and lung wet/dry weight ratios were significantly higher in the RWB group than in controls (15884.1+/-11354.8 vs 6108.3+/-1309.9 dyne x sec x cm[-5], p < 0.05; and 7.13+/-0.24 vs 5.82+/-0.35, p < 0.05, respectively). The WB and leukocyte-depleted groups did not differ significantly from controls for any measured parameter., Conclusions: This model confirms that rewarming ischemia during lung implantation exacerbates reperfusion injury. Leukocyte-depleted reperfusion as tested for a short period of time (10 minutes) ameliorates this injury and therefore should be considered for clinical lung transplantation.

In the last decade, the number of patients undergoing heart transplant has steadily increased as a result of expanding indications for this procedure. The limitation on the number of transplants performed has been the number of donor organs available. At UCLA, 900 heart transplant procedures have been performed from 1984-1998. Since 1991, the percent of patients free from rejection and infection in the first year after transplant was 70% and 73%, respectively. Actuarial one-, 3-, and 5-year survival rates are 84%, 76%, and 72%, respectively. Survival of patients aged 60 years and over (n = 105) was comparable to that of patients under age 60. We have been pursuing corticosteroid-free immunosuppression, which has led to a decrease in infection complications. Our work with pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes, which has translated into improved survival. Pravastatin also appears to decrease the development of transplant coronary artery disease and appears to have an adjunct immunosuppressive effect in our heart transplant patients on CsA-based immunosuppression. We have also demonstrated benefit of cardiac rehabilitation early after transplant which should therefore be considered as standard postoperative care. Finally, we have participated and led the multicenter mycophenolate study in demonstrating this drug's effectiveness in improved outcomes in primary heart transplant recipients. Future studies include the use of Rapamycin and interleukin-2 receptor blockers which have been demonstrated in kidney transplantation to significantly reduce rejection. Our program is committed to seek better ways to improve outcome and the quality of life of our heart transplant patients.

Background: Our institution has adopted a protocol of primary repair for all patients with double-outlet right ventricle., Methods: Since May 1989, 24 consecutive neonates and infants with double-outlet right ventricle and atrioventricular concordance (median age, 4 months) underwent anatomic biventricular repair. One patient (4%) received prior pulmonary artery banding but was still repaired as a neonate at 22 days of age. Twelve patients had a subaortic ventricular septal defect (VSD), 5 patients a subpulmonary VSD, 3 patients doubly committed VSD, and 4 patients a noncommitted VSD. Sixty-nine of 72 associated lesions were repaired simultaneously. Four types of repairs were used: intraventricular rerouting in 16 patients, arterial switch operation with VSD closure into the pulmonary artery in 4 patients, Rastelli-type repair with extracardiac conduit in 3 patients, and the Damus-Kaye-Stansel repair with concomitant repair of aortic arch obstruction in 1 patient. Ventricular septal defect enlargement was necessary in 15 patients. Repair of subpulmonary stenosis and of subaortic stenosis was carried out in 13 and 4 patients, respectively. Three patients underwent simultaneous repair of aortic arch obstruction with no mortality. Two of the patients with noncommitted VSD had simultaneous repair of complete atrioventricular canal and repair of severe pulmonary venous obstruction., Results: The perioperative mortality was 8% (2 patients, and there was one late death (4%). Two patients (9%) underwent early successful reoperations (5 and 8 weeks postoperatively). The two reoperations were for residual VSD (1 patient) and severe mitral regurgitation (1 patient). All 21 survivors are alive at a mean follow-up of 40 months (range, 7 months to 6 years). The estimated 5-year actuarial survival is 88%, with no deaths after 2 months postoperatively. Ninety-five percent of long-term survivors have no restriction of physical activities because of cardiac status and are receiving no cardiac medications., Conclusions: An institutional protocol of early anatomic biventricular repair of double-outlet right ventricle in infants and neonates achieves excellent survival, making palliative operations unnecessary. Associated lesions should be repaired simultaneously. The complexity of these malformations requires a highly individualized and flexible surgical approach.

A case of major blunt hepatic injury requiring liver resection is described. An associated retrohepatic vena cava injury could not be repaired despite the use of an atriocaval shunt. Deep hypothermic circulatory arrest was used as a last resort.

Simple patch closure is a treatment option for perforated duodenal ulcer. A 46-year-old male was admitted with evidence of perforation of a duodenal ulcer. The decision was made to carry out laparoscopy to confirm the diagnosis and to close the perforation. This was accomplished without difficulty by suture closure of an anterior perforation and application of an omental patch. The patient had an uneventful recovery. Laparoscopy can be of value in the diagnosis and treatment of perforated duodenal ulcer. The principles of management should be essentially similar to those adhered to during open surgery.

Myocardium lacks the ability to regenerate following injury. This is in contrast to skeletal muscle (SKM), in which capacity for tissue repair is attributed to the presence of satellite cells. It was hypothesized that SKM satellite cells multiplied in vitro could be used to repair injured heart muscle. Fourteen dogs underwent explantation of the anterior tibialis muscle. Satellite cells were multiplied in vitro and their nuclei were labeled with tritiated thymidine 24 h prior to implantation. The same dogs were then subjected successfully to a myocardial injury by the application of a cryoprobe. The cells were suspended in serum-free growth medium and autotransplanted within the damaged muscle. Medium without cells was injected into an adjacent site to serve as a control. Endpoints comprised histology using standard stains as well as Masson trichrome (specific for connective tissue), and radioautography. In five dogs, satellite cell isolation, culture, and implantation were technically satisfactory. In three implanted dogs, specimens were taken within 6-8 wk. There were persistence of the implantation channels in the experimental sites when compared to the controls. Macroscopically, muscle tissue completely surrounded by scar tissue could be seen. Masson trichrome staining showed homogeneous scar in the control site, but not in the test site where a patch of muscle fibres containing intercalated discs (characteristic of myocardial tissue) was observed. In two other dogs, specimens were taken at 14 wk postimplantation. Muscle tissue could not be found. These preliminary results could be consistent with the hypothesis that SKM satellite cells can form neo-myocardium within an appropriate environment. Our specimens failed to demonstrate the presence of myocyte nuclei.(ABSTRACT TRUNCATED AT 250 WORDS)

Impairment of mucociliary function occurs after lung transplantation and may predispose patients to repeated pulmonary infections. The purpose of this study is to determine whether and how soon such mucociliary function may recover. Ten dogs underwent left lung autotransplantation. Within 3 weeks five of these dogs underwent study for proximal airway clearance by observation through a bronchoscope of the movement of carbon particles placed at different locations on the tracheobronchial mucosa. The mechanical properties of collected mucus from specific sites were determined by magnetic rheometry. The right lung, which was not operated on, served as a paired control. Similar studies were conducted in the remaining five dogs at 12 weeks after autotransplantation. Lung autotransplantation caused significant depression of proximal airway clearance and a 35% increase in mucous rigidity (p = 0.05) soon after operation. At 12 weeks after operation, there was a partial recovery of proximal airway clearance. Mucous changes were no longer consistent. Histologic and electron microscopic examinations initially revealed focal denudation of ciliated cells and loss of the bronchial glands. At 12 weeks there was a regeneration of cilia and a reappearance of the bronchial glands. We conclude that the mucociliary function, observed to be depressed early after lung autotransplantation, recovers partially during the late postoperative period. Thus the mucociliary functional recovery should be attributed to revascularization rather than to reinnervation, since the latter is unlikely to occur during this period.

The psychological and relational problems present in pediatric patients with congenital cardiac anomalies and in their families are reviewed based on an analysis of the current literature and on the personal experience of the authors. The need for all caretakers, especially the cardiologist and the cardiac surgeon, to be aware of these critical aspects is emphasized. The psychological experience of the patient and of his family is thoroughly addressed. Moreover, the complex relationship that developed between the family and the physician as a result of the family's expectations, requests and unconscious projections are discussed.