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Background: Careful donor and recipient selection are important factors for the success of heart transplantation. Currently, donors with a history of alcohol use are routinely accepted despite the potential deleterious effects of alcohol on the heart., Methods: We examined the frequency of chronic alcohol use (> 2 ounces of pure alcohol daily for > or = 3 months) among organ donors and the outcome of the receipients after heart transplantation. Of 99 consecutive patients who underwent transplantation between December 1988 and August 1993 with an adequate donor history, 17 (17%) had a history of chronic alcohol use (alcohol group), and 82 (83%) did not (nonalcohol group). All recipients received triple-drug immunosuppression, and 10 to 14 days of OKT3., Results: Survival rates at 1 and 2 years were significantly lower in the alcohol group (61% +/- 13% and 61$ +/- 13%) than in the nonalcohol group (95% +/- 3% and 91% +/-4%, p = 0.0001). Most deaths in the alcohol group occurred within 3 months after transplantation. The incidence of rejection episodes did not differ significantly. Fatal rejection occurred more frequently in the alcohol group and was associated with severe ventricular dysfunction before death. Cox multiple regression analysis identified donor alcohol use as an independent risk factor for death after heart transplantation., Conclusions: A substantial proportion (17%) of heart donors have a history of chronic alcohol use. The unfavorable early outcome of patients receiving hearts from alcoholic donors suggests the presence of a subclinical alcoholic cardiomyopathy before transplantation and poor tolerance of rejection episodes after transplantation. Larger prospective studies are needed to determine the mechanism of fatal rejection and whether such hearts can be used safely for transplantation.

A 68 year-old man underwent surgical repair of a ventricular septal defect following an acute myocardial infarction. Recurrent interventricular septal rupture with significant left-to-right shunting led to progressive deterioration in cardiac function and intractable heart failure. The patient underwent orthotopic heart transplantation three months after his initial operation, and he is clinically well sixteen months after transplantation.

Background: Endocardial lymphocytic infiltrates, known as Quilty effect, are a common finding of uncertain pathogenesis in cardiac allografts. Quilty effect was not observed before the use of cyclosporine A for immunosuppression and is not generally regarded as a manifestation of rejection. We hypothesized that the endocardial localization of Quilty effect may be related to a relative absence of cyclosporine A in this region., Methods: We used an indirect immunofluorescence staining method with rabbit polyclonal anti-cyclosporine A antibodies to detect cyclosporine A in fresh frozen sections of 27 cardiac allograft endomyocardial biopsies. Staining was graded 0 to +3. Negative controls were from untreated transplant candidates and from biopsies with the primary antibody omitted., Results: On comparison of endocardial and myocardial fluorescence in biopsy specimens from patients treated with cyclosporine A, there was less endocardial (0.7 +/- 1.1, p < 0.0001) than myocardial (2.2 +/- 0.5) staining. However, in biopsy specimens with Quilty effect (n = 12), this difference was significantly greater (endocardial = 0.2 +/- 0.6 versus myocardial = 2.3 +/- 0.5; p = 0.005) than in specimens without Quilty effect (n = 10) (endocardial = 1.4 +/- 1.2 versus myocardial = 2.1 +/- 0.6; p = 0.7). Endocardial thickness as measured by ocular micrometry was significantly greater in regions with (32 +/- 19 microns) than without (7 +/- 4 microns) Quilty effect, with involved regions showing increased connective tissue (p < 0.0001). In patients with and without Quilty effect, no differences in donor or recipient demographics, prevalence of diabetes, or plasma cyclosporine A levels were found., Conclusions: Although it has been postulated that Quilty effect is due to the presence of cyclosporine A in cardiac tissue (toxic effect or immunologic reaction), these data suggest that Quilty effect is related to reduced endocardial presence of cyclosporine A, leading to localized, contained, and usually not clinically significant endocardial rejection.

Background: Cytomegalovirus is a frequent cause of infection and morbidity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%., Methods: To determine the efficacy of combined antiviral and intravenous immune globulin therapy for prevention of cytomegalovirus disease in transplant recipients receiving OKT3 and to compare two different antiviral drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intravenous ganciclovir for 2 weeks followed by oral acyclovir up to 3 months (group G); all received six infusions of 5% intravenous immune globulin over 2 months. All patients had OKT3 for 10 to 14 days and triple-drug immunosuppression., Results: Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patients (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositive recipients, there was a trend to less cytomegalovirus disease in group G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patients) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% (group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus disease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant)., Conclusions: Prophylaxis with combined antiviral and immune globulin therapy produces a low (10%) incidence of cytomegalovirus disease in OKT3-treated heart transplant recipients. In seropositive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive prophylactic strategies are needed in seronegative patients who receive hearts from seropositive donors.

Orthotopic heart transplantation (OHT) with bicaval and pulmonary venous anastomoses avoids the large atrial anastomoses of the standard biatrial technique. To determine whether the bicaval technique improves atrial performance, we used Doppler echocardiography to study 13 patients with bicaval OHT, 15 with biatrial OHT, and 8 normal subjects. All were in sinus rhythm and free of rejection. Left atrial size, transmitral (M) and late diastolic (A) mitral flow velocity integrals were measured. Atrial transport (A/M, %) and atrial ejection force (kilodynes, calculated from peak A-wave velocity and mitral orifice area) were assessed. Left atrial dimensions in the bicaval (4.3 +/- 0.5 cm) and biatrial groups (4.9 +/- 0.9 cm) were larger than in controls (3.3 +/- 0.8 cm, p < 0.05). Left atrial transport (37% +/- 12% and 35% +/- 12%) and ejection force (14.1 +/- 6.9 kdyne and 10.2 +/- 7.8 kdyne) were similar in the bicaval group and controls (p not significant) but were significantly lower in the biatrial group (20% +/- 19% and 3.6 +/- 4.0 kdynes, p < 0.05). The bicaval and pulmonary venous technique of OHT produces more physiologic atrial function compared with the biatrial technique as evidenced by greater atrial ejection force and more normal atrial transport.

Objectives: We hypothesized that orthotopic heart transplantation with bicaval and pulmonary venous anastomoses preserves atrial contractility., Background: The standard biatrial anastomotic technique of orthotopic heart transplantation causes impaired function and enlargement of the atria. Cine magnetic resonance imaging (MRI) allows assessment of atrial size and function., Methods: We studied 16 patients who had undergone bicaval (n = 8) or biatrial (n = 8) orthotopic heart transplantation without evidence of rejection and a control group of 6 healthy volunteers. For all three groups, cine MRI was performed by combining coronal and axial gated spin echo and gradient echo cine sequences. Intracardiac volumes were calculated with the Simpson rule. Atrial emptying fraction was defined as the difference between atrial diastolic and systolic volumes, divided by atrial diastolic volume, expressed in percent. All patients had right heart catheterization., Results: Right atrial emptying fraction was significantly higher in the bicaval (mean [+/- SD] 37 +/- 9%) than in the biatrial group (22 +/- 11%, p < 0.05) and similar to that in the control group (48 +/- 4%). Left atrial emptying fraction was significantly higher in the bicaval (30 +/- 5%) than in the biatrial group (15 +/- 4%, p < 0.05) and significantly lower in both transplant groups than in the control group (47 +/- 5%, p < 0.05). The left atrium was larger in the biatrial than in the control group (p < 0.05). Cardiac index, stroke index, heart rate and blood pressure were similar in the transplant groups., Conclusions: Left and right atrial emptying fractions are significantly depressed with the biatrial technique and markedly improved with the bicaval technique of orthotopic heart transplantation. The beneficial effects of the latter technique on atrial function could improve allograft exercise performance.

Successful thrombolysis alters the pattern of creatine kinase (CK) release to the plasma after acute myocardial infarction (AMI). Among the important differences there are the early peak of the CK activity curve and the higher peak value for a given infarct size. To determine whether the magnitude of peak CK following thrombolysis still reflects the extent of myocardial damage, we correlated the peak CK value with left ventricular ejection fraction (LVEF) in 114 patients with first anterior AMI who had early peak CK ( < or = 12 h) after thrombolysis. There was a significant (p < 0.001) linear relation between the peak CK value and LVEF both at admission and 2 months later. High ( > or = 1,500 IU/1) as compared with low early peak CK was associated with significantly lower LVEF (p < 0.001) and a higher incidence of poor LVEF (p < 0.05).

A 30-year-old man underwent aortic and mitral valve replacement for the treatment of Q fever endocarditis. Postoperatively, paravalvular leak of the mitral prosthesis, progressive deterioration in cardiac function, and intractable heart failure developed. As a result, the patient underwent orthotopic heart transplantation 15 months after his initial valve operation. The patient is clinically well 14 months after transplantation.

The frequency of cocaine use among donors is currently unknown. Cocaine has cardiotoxic effects and could affect the outcome of heart transplantation. To examine the frequency of nonintravenous cocaine use in organ donors and the outcome of heart transplantation with such donors, we retrospectively analyzed the clinical, biopsy, and donor information on 112 consecutive patients who underwent transplantation between December 1988 and August 1993. Ten patients were excluded because of incomplete information regarding the donor's cocaine status. Of the remaining 102 patients, 16 (16%) had a positive donor history for nonintravenous cocaine use (cocaine group) and 86 patients (84%) had a negative history (noncocaine group). Survival, frequency of cellular rejection (grade > or = 1B), and humoral rejection were compared between the two groups. Survival rates at 30 days (100% versus 97% +/- 2%) and at 1 year (93 +/- 7% versus 89 +/- 3%) were similar (p = not significant, cocaine versus noncocaine group). Freedom from rejection was similar at 30 days (81% +/- 10% versus 79% +/- 4% cellular rejection-free, 33% +/- 14% versus 60% +/- 6% humoral-free) and 6 months (34% +/- 12% versus 55% +/- 5% cellular-free, 16% +/- 11% versus 36% +/- 6% humoral-free) (p = not significant). No significant difference was found in donor inotropic support before procurement, ischemic time, length of stay in intensive care unit, or total stay in the hospital. In conclusion, a high incidence of nonintravenous cocaine use exists among donors. The outcome of patients who receive transplanted hearts obtained from nonintravenous cocaine users is favorable, suggesting that the use of such hearts is safe.

We present our experience with an alternative technique for orthotopic heart transplantation. It consists of total excision of the recipient's atria, with the donor's heart implantation performed using bicaval end-to-end anastomoses as well as pulmonary venous anastomoses. Forty consecutive patients receiving transplants in this fashion were compared with 64 patients who underwent orthotopic transplantation with the standard technique. The incidence of postoperative tricuspid regurgitation was reduced in patients receiving transplants with the new surgical approach (p = 0.003). In addition, the need for pacemaker implantation for severe bradyarrhythmia in the early (0 to 6 weeks) posttransplantation period (p = 0.003) was eliminated. Although not statistically significant, there was a trend in the reduction of postoperative mitral regurgitation in patients who received transplants by the modified technique. Based on this experience, we believe this modified technique for orthotopic heart transplantation has an anatomic and physiologic advantage that may improve long-term hemodynamic results.

The efficacy of flosequinan 100 mg once daily was evaluated in 15 patients with severe congestive heart failure (New York Heart Association [NYHA] class II-IV) who had not responded adequately to digoxin and diuretics. Efficacy assessments using non-invasive techniques included exercise capacity, haemodynamics and left ventricular function. Determinations were made after 3 and 21 days' treatment, and compared with baseline. Flosequinan significantly increased exercise capacity by 27% after 3 days (+79 seconds, p = 0.015) and by 43% after 21 days (+123 seconds, p = 0.0007) and was accompanied by an increase in heart rate (+7.2 beats/min, p = 0.03; +9.1 beats/min, p = 0.03, respectively). Cardiac index and cardiac output were also significantly increased but only after 21 days' treatment (+0.3 l/min/m2, +16% and +0.5 l/min, +14%, respectively; both p = 0.008). Flosequinan was well tolerated, with headache being the most frequently reported adverse event and only 1 patient being withdrawn. One patient died but this was not unexpected in a group of patients with severe heart failure. Using non-invasive techniques this study demonstrated that in patients with severe chronic congestive heart failure, flosequinan increased exercise capacity and cardiac output, the latter being achieved mainly by an increase in heart rate.

Spurious hypoglycemia and hyperkalemia were found in a patient with chronic hemolytic anemia due to an unidentified hemoglobinopathy. The patient had massive reticulocytosis, and many nucleated red blood cells were present in his blood smear. Hypoxemia was induced in vitro. No correlation was found between in vitro hypoglycemia and hyperkalemia. Reticulocytosis and the presence of nucleated red blood cells, as occurs in hemolytic anemia, should be added to the list of hematological causes of spurious hypoglycemia, hyperkalemia and hypoxemia.