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Analysis of planned endomyocardial biopsy specimens of heart allotransplants from 22 recipients revealed signs of humoral type rejection (slight, medium, and severe) presenting as fixation of IgG, IgM, and complement components (C3, C4d) in 61 of 63 sections. Permanent presence of rejection signs attests to rheumatoid course of this process.

The authors analyze the pathogenetic significance of hyperhomocysteinemia, antiphospholipid syndrome, the hyperexpression of cell adhesion molecules, inflammation, and oxidative disorders for, as well as the role of viral infections in the development of coronary artery disease of the grafted heart. The paper shows that viral infections in recipients lead to the development of proinflammatory, proatherogenous, and prothrombogenous status, expressing themselves in an increase in the corresponding laboratory markers in recipients' blood plasma, and points out the role of viral infection in the pathogenesis of coronary artery disease of the transplanted heart. Control and treatment of viral infections, as well as pharmacocorrection of proinflammatory, proatherogenous, and prothrombogenous status would made it possible to influence the development of coronary artery disease of the grafted heart.

The study found bone exchange disorder manifested by accelerated bone resorption, retarded bone formation, and the loss of the bone mineral density (BMD) of the axial and peripheral skeleton in 19 men (39 observations) 66 +/- 44 months following orthotopic heart transplantation (OTHT) and in 92 men 45 +/- 28 months after cadaveric kidney transplantation. An accelerated bone resorption, more pronounced in cadaveric kidney (CK) recipients, is associated with hyperparathyroidism (HPT) and renal dysfunction, while bone formation retardation is associated with a decrease in insulin-like growth factor-1 level. An increase in osteoprotegerin level is of compensatory character. The prominence of HPT depends on the degree of renal dysfunction; in CK recipients it also depends on the degree of the reduction in the levels of biologically active testosterone and estradiol. Reduction in BMD of the peripheral skeleton after OTHT are associated with the degree of renal dysfunction and a decrease in free testosterone index; after CK transplantation it is associated with HPT, the cumulative dose of glucocorticoids, reduction in the levels of biologically active testosterone and estradiol, as well as sex-hormone binding globulin (SHBG); reduction in spine BMD is only associated with SHBG.

Relationship between levels of C-reactive protein (CRP) and neopterin and changes of left ventricular function was studied in 23 patients with heart failure (mean age 48.5+/-11.5 years) subjected to transplantation of autologous bone marrow cells (TABMC). Cells were administered intracoronary irrespective of coronary revascularization (in 11 patients) or during angioplasty (in 5 patients), intracoronary or intra-cardially during aorto coronary bypass surgery (in 7 patients). Reverse correlation was observed between left ventricular ejection fraction (EF) and stroke volume (SV) and blood plasma levels of CRP and neopterin. Efficacy of functional regeneration of the myocardium assessed 1 month after TABMC was related to blood plasma levels of CRP and neopterin before treatment. In all patients with normal initial levels of markers of inflammation EF and SV rose. Among patients with initially elevated levels of CRP and neopterin more positive changes of EF and SV occurred in those subjects in whom lowering of inflammation markers took place during 1 month after TABMC.

Endomyocardial diagnostic biopsies, recipient heart removed at operation, endomyocardial biopsies of allotransplants and postmortem material were studied using immunofluorescence to specify immunopathological process and to detect humoral rejection. Altogether 306 samples from 55 patients were studied. In the early postoperative period (one year) 8 out of 18 patients with heart transplants repeatedly showed immunopathologic picture of acute humoral (vascular) rejection which was characterized by a widespread immunoglobulin G and complement fixation in the capillary walls accompanied by enhanced capillary permeability and fibrin deposition in intestitial tissue. Such patients often had graft dysfunction. 1 to 5 years after transplantation in 24 out of 37 patients discrete focal immunoglobulin and complement fixation was observed as one of chronic rejection component.

Exercise tolerance in postcardiac transplantation patients versus healthy controls was studied at different intervals after the surgery using bicycle ergometry. Being low after the transplantation, exercise tolerance in the patients increased throughout the rehabilitation period but still did not reach the values characteristic for healthy subjects. Initial heart rate in the above patients was higher, while chronotropic and inotropic reserves of the transplanted heart appeared lower than in the controls. The data obtained help objectively assess the condition of the patients with transplanted heart.

Compared to healthy controls, patients with transplanted heart have higher baseline heart rate (HR), delayed initial HR reaction, slower changes of HR both during exercise and after it, diminished chronotropic and inotropic reserves. The data obtained contribute to better understanding of physiology of transplanted denervated heart and objective assessment of patients after heart transplantation.

Comparing echocardiographic parameters with endomyocardial biopsy findings in 6 patients with acute crises of mild, moderate, and severe graft rejections and in 2 patients with persistent acute rejection crisis has shown that there are decreases in end-diastolic size and left ventricular end-diastolic ejection fraction volume, an increase in left ventricular myocardial mass, and thickening of the left ventricular posterior wall and ventricular septum, as evidenced by ultrasonic study. Such changes are detected in moderate and severe acute crises of graft rejection. Normalization of ultrasonic parameters of the grafted heart occurs 2-3 weeks after abolition of rejection crisis. A positive dynamics of echocardiographic parameters in persistent acute rejection crises suggests a good prognosis. Echocardiographic monitoring data obtained in the outpatient setting may serve an indication for unplanned endomyocardial biopsy.

Myocardial tissues of patients with dilated cardiomyopathy were studied by immunofluorescence. While immunoglobulin A fixation was observed in myocardial capillary wall and cardiomyocyte sarcolemma in the majority of patients (11 of 12), immunoglobulin G and C3 complement component were a rare finding. In the vessel wall of heart allografts immunoglobulin A fixation occurred 3-6 days after transplantation. As a result of the intensive immunosuppressive therapy which was used after the operation immunoglobulin A disappeared from heart allografts within 4-5 weeks. Immunoglobulin A fixation in the heart of patients with dilated cardiomyopathy is attributed to the anti-tissue or antivirus antibodies and probably is involved in the development of this disease.

The article discusses the results of surgical treatment of patients suffering from ischemic heart disease with extensive cicatricial affections of the myocardium and circulatory insufficiency. Thirteen patients of group I were treated by various reconstructive operations (resection of an aneurysm, formation of an aortocoronary shunt, septoplasty), 10 patients of group 2 underwent orthotopic heart transplantation. Perioperative and long-term (up to 3 years) mortality rates were, respectively, 7.6 and 8% in group I and, respectively, 30% and zero in group 2. The unfavorable prognosis of survival and medicamentous therapy in such patients, the lack of donors, and the acceptable results of reconstructive operations are evidence that they should be undertaken whenever possible. The main criteria of the selection of patients for a reconstructive operation are the values of regional contractility of the left ventricle, the severity of the dystrophic processes in the preserved segments, and the condition of the coronary arteries.

Holter monitoring was performed in 15 patients surviving over 3 months after homotopic cardiac transplantation. The frequency and types of arrhythmias occurring in the grafted innervated heart were studied according to its postoperative period duration. The follow-up lasted 3 to 29 months. Supraventricular arrhythmias were detected in 80%, whereas ventricular ones were found in 86.7%. Ventricular arrhythmias accompanied chronic graft rejection in 2 patients. It was ascertained that Holter monitoring was of greater diagnostic value than routine ECG recording. Innervation is not essential in the occurrence of cardiac arrhythmias.

The work analyses infectious complications after 35 orthotopic transplantations of the heart. The infectious complications are divided into 2 groups. Group 1 consisted of 6 patients with local complications. Group 2 was made up of 8 patients who died from bacterial infectious complications (mediastinitis 3, sepsis 2), from miliary tuberculosis of the lungs 1, cytomegaloviral infection 1, and systemic candidiasis 1.

Three cases of chronic rejection occurring 7.5, 10, and 24 months after transplantation of the heart are analysed. The clinical features of chronic rejection in the late-term periods after transplantation of the heart are discussed. The problems of clinical diagnosis of chronic rejection, the role of endomyocardial biopsy and disorders of lipid metabolism are dealt with. Tactics of saving the patient are recommended. The authors substantiate the necessity for heart retransplantation and, in the absence of a donor's heart, for two-stage transplantation of the heart through an artificial heart or a biventricular approach by means of artificial heart ventricles.

The article discusses the results of applying for the first time Soviet-made "Modul" and "Yasen" artificial ventricles of the heart (AVH) in a left ventricular bypass regimen in patients with refractory cardiac insufficiency. Improvement of AVH design and rational tactics of attendant drug therapy allowed the period of the safe application of the AVH in the organism to be increased to more than 8 days.

An analysis was made of the work carried out by the Department of Coronary Surgery and Heart Transplantation as regards heart transplantations during 1988. As many as 119 patients, hypothetical heart recipients, received medical advice. The Department refused hospitalization to 42 patients because of the nonconformity to the indications and contraindications to heart transplantation. 77 patients were admitted to the Department. During examinations and treatment, 53 persons were discharged from hospital. 8 patients died before donor's hearts were received. Donor's hearts were transplanted to 10 patients. 3 persons died from severe infectious complications on days 12, 15 and 43 after the operation. Following the operation 7 patients have been surviving from 4 to 17 months. The patients' status remains satisfactory. The functional parameters of the donor's heart are within normal. Taking into consideration the lack of the treatment methods for patients with terminal heart lesions, it is necessary that the number of operations be increased. A great importance in this case is attached to the joint efforts of internists and cardiologists, aimed at the screening and examination of potential heart recipients.

The article analyses the first clinical experience in orthotopic allotransplantation of the heart at the Scientific Research Institute of Transplantology and Artificial Organs, USSR Ministry of Health, in the period from October, 1986 to July, 1989 (26 transplantations of the heart and one two-stage transplantation of the heart with the use of "Poisk-10M" artificial heart for 3.5 days in the first stage). Eleven patients are alive. Follow-up periods: maximum over 2.5 years, minimum 3 months. Sixteen patients died in different periods (up to 12 months). Three-component therapy (cyclosporine A, methylprednisolone, azathioprine) was applied for immunosuppression. The authors analyse the problems of the selection of potential recipients (indications and contraindications) and donor, the optimum surgical techniques, complications of immunosuppressive therapy, and infectious complications. The first clinical experience in two-stage transplantation of the heart is analysed. The first experience in transplantation of the heart in patients allows the conclusion that the use of this method for the management of the terminal stage of congestive cardiac insufficiency is a reality.

In 20 acute experiments on 40 mongrel dogs ranging in weight from 15 to 20 kg, a heterotopic heart transplant was implanted into the chest of the recipient with experimentally induced right ventricular failure. A detailed description is presented of the operative technique in acute and chronic experiments. Haemodynamic findings attest to the efficacy of the work of the transplant, the right ventricle of which is able to take over most of the work of the right ventricle of the recipient.

Over 400 operations of an indirect revascularization of the myocardium have been performed at the A.I. Bakulev institute of Cardiovascular Surgery of the USSR Academy of Medical Sciences. Since 1970, the direct method have been developed, predominantly those of aorto-coronary bypass. Careful examination of 709 patients was carried out, 445 of them were subjected to selective coronary angiography, 108 were operated on. In 1974, 56 operations were undertaken, among them 36 aorto-coronary bypasses, in 6 of them with a preliminary endarterectomy from the coronary artery, 8 double bypasses, 6 procedures for acute myocardial infarction, 5 combined operations of aorto-coronary bypass and resections of cardiac aneurysms, and 15 resections of postinfarction aneurysms of the heart. Twelve patients died in the postoperative period, mainly due to acute cardiac insufficiency. The high figures of mortality are caused not only by the faults of the surgical procedures but also by the grave initial state of the patients (multiple coronary lesions large focal cardiosclerosis due to preceeding infarctions, high degree of initial cardiac insufficiency). The improvement of the results of surgery for the ischaemic heart disease will depend on the perfection of the surgical technique, on proper selection of the patients, and on the precise determination of the indications for such treatment.

The purpose of the study was to find out the character of the restructuring of enzymes and isoenzymes of creatine kinase (CK), lactate dehydrogenase (LDH) and glucose-6-phosphate-dehydrogenase (G 6 P-DH) in the myocardium, which occurs in patients with ischaemic heart disease (IHD), and to compare the activity of the aforementioned enzymes in the myocardium of patients with IHD, examined intra vitam, and in patients who died suddenly. An analysis was made of 11 samples obtained by myocardial biopsy from the left ventricle of patients with IHD and of 11 samples obtained at autopsy of patients with IHD who have died a sudden death. Serving as controls was bioptic material from the myocardium of 12 patients without IHD. In the myocardium of patients with IHD, examined intra vitam, a decrease in the activity of the mitochondrial isoenzyme CK (MiMi) and the isoenzyme LDH-1, and a considerable rise in the activity of G 6 P-DH were found. In patients with IHD, who have died suddenly, there was found only a decrease in isoenzyme LDH-1 activity and a reduced concentration of CK B-units. The experiments proved that the differences in the myocardial isoenzyme spectrum between the two groups of patients with IHD are not connected with the process of autolysis.