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Heart transplant rejection is characterized pathologically by myocyte necrosis and apoptosis associated with interstitial mononuclear cell infiltration. Any one of these components can be targeted for noninvasive detection of transplant rejection. During apoptotic cell death, phosphatidylserine, a phospholipid that is normally confined to the inner leaflet of cell membrane bilayer, gets exteriorized. Technetium-99m-labeled annexin-V, an endogenous protein that has high affinity for binding to phosphatidylserine, has been administered intravenously for noninvasive identification of apoptotic cell death. In the present study of 18 cardiac allograft recipients, 13 patients had negative and five had positive myocardial uptake of annexin. These latter five demonstrated at least moderate transplant rejection and caspase-3 staining, suggesting apoptosis in their biopsy specimens. This study reveals the clinical feasibility and safety of annexin-V imaging for noninvasive detection of transplant rejection by targeting cell membrane phospholipid alterations that are commonly associated with the process of apoptosis.

Newer methodologies have increased the incidence of coronary interventions. At the authors' institution, 5,614 coronary interventional procedures (28% of all catheterizations) were performed over a 3-year period, from 1995 to 1997. Eighty-one patients (1.4%) suffered angiographic accidents, including coronary artery dissection, free rupture, tamponade, foreign body embolism, and wire entrapment, and were retrospectively reviewed. All patients were taken for emergency surgery in less than 4 hours. The mean age was 61.2 years, 44 (54%) were men, and 37 (46%) were in cardiogenic shock at the time of surgery. Fifty-seven patients (70%) had intraaortic balloon counterpulsation. The number of previous cardiac interventions ranged from one to four with a mean of 1.9. One to five bypass grafts (mean, 2.2) were performed, and three patients required temporary ventricular assist devices. There were six deaths for a 30-day mortality rate of 7.4%. Thirty-two patients (39.5%) suffered significant morbidity, including cerebrovascular accidents, and renal and respiratory failure. Perioperative myocardial infarctions were diagnosed in 39 (48%) patients. Average length of stay was 12.1 days. One-year survival was satisfactory at 90% (73/81), with 56 survivors (77%) regaining normal everyday activity. Early surgical intervention, rapid revascularization, and temporary mechanical support are keys to low mortality in this high-risk group. Identification of high-risk interventions and significant comorbid conditions, with concomitant surgical consultation, need to be pursued to reduce the high morbidity rate.

The incidence of coronary artery disease in identical twins is unknown. The knowledge of ischemic heart disease in this patient population is represented by case reports. There is considerable controversy regarding the environmental and genetic factors that play a role in the pathogenesis of this disorder. The natural history of coronary artery disease in an asymptomatic twin with a symptomatic counterpart is unclear. We present a case report and literature review of coronary artery disease in identical twins. On the basis of our patient and the information of other patients, asymptomatic twins of symptomatic counterparts require aggressive assessment and management for occult coronary artery disease.

As the number of nonagenarians increases yearly in the United States, surgeons will be asked more often to evaluate the possibility of intervention for coronary artery disease in this age group. The purpose of this study is to document experience with patients 90 years of age or older in order to determine whether coronary artery bypass grafting surgery is justified. Eleven patients aged 90 years or more underwent cardiac surgery for symptomatic coronary artery disease refractory to medical management between January 1, 1987, and December 31, 1996. All patients were in NYHA Class IV preoperatively. In-hospital death occurred in two patients (18%). In-hospital morbidity occurred in all patients (100%) including seven cardiac, four respiratory, two neurologic, and one infectious. All survivors left the hospital symptomatically improved. The mean length of stay was 28 days. Four patients died at a mean of 2 years and 2 months postoperatively. Five patients remain alive at a mean of 1 year and 7 months. Coronary artery bypass grafting in nonagenarians can be performed successfully in selected cases. However, increased mortality and morbidity rates and length of stay are associated with this age group. For survivors, the quality of life is improved and the projected life expectancy restored.

Amiodarone is a benzofuran derivative with a chemical structure similar to thyroxine. Originally introduced to treat angina pectoris, amiodarone was found to have antiarrhythmic properties, and in 1985, was approved in the United States for treatment of life-threatening ventricular arrhythmias. It is now used for various ventricular and supraventricular arrhythmias refractory to conventional first-line medications, and as a result, side effects have been observed with increased frequency. The most severe and potentially life-threatening of these side effects is the development of pulmonary toxicity. Typically, amiodarone pulmonary toxicity (APT) is manifested by acute pneumonitis and chronic fibrosis. Amiodarone-associated hemoptysis (AAH) is a rare occurrence. The authors describe a case of AAH successfully treated with cessation of drug and steroid therapy.

Air bags have been shown to decrease mortality from automobile accidents. Herein is a unique case of bilateral pneumothorax following deployment and rupture of an air bag with no other associated chest trauma. One may posit that rupture of the air bag allowed high-pressure gases to be expelled into the patient's lungs resulting in explosive barotrauma.

Background: Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures., Methods: We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta-descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting., Results: Double arterial cannulation, retrograde cardioplegia, large-bore aorto-aortic bypass grafts, and early use of alpha-agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course., Conclusions: Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta-descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.

Background: To investigate the duration of effectiveness in the postoperative period of temporary epicardial atrial pacing electrodes on the right atrium, based on position., Methods: The function of temporary epicardial atrial pacing electrodes were examined in 55 patients undergoing coronary artery bypass grafting from March 20, 1996, to July 31, 1996, at Allegheny University Hospitals, Hahnemann Division, Philadelphia, PA. There were 41 male and 14 female patients. The mean age was 71 years (range 35 to 86 years). Two atrial and two ventricular temporary epicardial pacing electrodes were placed at the termination of cardiopulmonary bypass. One atrial electrode was placed on the body of the right atrium at the junction of the superior vena cava (body electrode); the other was passed through the pursestring of the atrial cannulation site (appendage electrode)., Results: The mean thresholds for the atrial body electrodes on the operative day and postoperative days 1 and 2 were 4.96, 6.67, and 6.80 mA, respectively. The mean thresholds for the atrial appendage electrodes were 5.98, 7.50, and 8.59 mA, respectively., Conclusions: Temporary epicardial atrial pacing electrodes are more effective when the wires are placed in the atrial body of the right atrium than if they are wrapped within the pursestring of the right atrial appendage. As a result of these findings, the common practice of placing the pacing wire through pursestring tissue should be abandoned.

Objective: To more fully define the influence of COPD in patients undergoing coronary artery bypass grafting (CABG)., Methods: One hundred ninety-one patients with COPD underwent CABG from March 1, 1995, to June 21, 1996. There were 129 male and 62 female patients. The mean age was 69 years (45 to 86 years). Patients with COPD were defined according to the Summit Database definition: requires therapy for the treatment of chronic pulmonary compromise or has an FEV1 <75% of predicted value., Results: Hospital mortality was 7%. Hospital morbidity was 50%. Statistically significant (p<0.05) morbidity included general pulmonary complications (12%) and atrial fibrillation (27%). Hospital mortality for COPD patients with postoperative pneumonia was 11%. Hospital mortality for patients with COPD receiving steroids was 19%. The hospital mortality for patients > or = 75 years of age was 17%. The combined mortality for patients with COPD who are > or = 75 years of age and receiving steroid therapy was 50%. The mean length of stay was 12 days. Late mortality was 1% at a mean of 1.5 years., Conclusions: Hospital mortality in most patients with mild-to-moderate COPD undergoing CABG is similar to those without COPD. In the minority of patients with severe COPD who are receiving steroids and > 75 years, the hospital mortality is exceptionally high. These findings support CABG in patients with mild-to-moderate COPD. Nonsurgical therapy should be considered for elderly COPD patients with severe disease taking steroids.

Acute myocardial infarction during pregnancy and in the puerperium is a rare event: the incidence ranges from 1 per 10,000 to 1 per 30,000 deliveries. Although the etiology is unknown, the pathology may involve thrombosis, spasm, or dissection of the coronary artery. We present the case of a 34-year-old white woman who presented to our institution in cardiogenic shock after an acute myocardial infarction 2 weeks postpartum. This case reinforces the concept that postpartum coronary artery dissection is a fatal disorder. We were able to successfully support the myocardium and the end-organs with a ventricular assist device. We performed concomitant coronary artery bypass grafting in an attempt to salvage the remaining myocardium. Management with emergency coronary revascularization and ventricular assist device support is described.

The importance of recognizing congenitally absent left pericardium in the setting of acquired cardiovascular disease was recently appreciated during a case of coronary artery bypass grafting. An associated defect in the left hemidiaphragm and an abnormal location of the left phrenic nerve were found. Careful dissection of the phrenic nerve from the surface of the heart and closure of the diaphragmatic defect were necessary to avoid injury to the former and prevent hernia through the latter structure. Absent left pericardium discovered during cardiac surgery requires attention to the location of the left phrenic nerve and recognition of associated defects in the diaphragm.

Sternal wound infection with atypical mycobacteria following open heart surgery is a rare occurrence. Previous reports have described infection by Mycobacterium fortuitum, an acid-fast bacillus and member of a larger family of rapidly growing mycobacteria. The source and mode of transmission have not been identified. Surgical debridement and the combination of aminoglycosides and quinolones have been shown to be effective methods of treatment. More recently, clarithromycin has been shown to be the drug of choice against rapidly growing mycobacteria. We describe a 49-year-old woman who underwent infundibular stenosis repair and in whom M fortuitum sternal osteomyelitis developed. Total sternectomy, muscle flap reconstruction, and antibiotic treatment successfully eradicated the infection.

Background: Use of the left internal thoracic artery as a bypass graft has been shown to result in better long-term patency and improved survival. In elderly patients, the internal thoracic artery has been used less often for coronary artery bypass grafts because of the belief that greater morbidity and mortality are associated with this procedure. This study was undertaken to test this premise in the octogenarian population., Methods: Over an 8-year period, 474 consecutive patients 80 years of age and greater had coronary artery bypass grafting. The left internal thoracic artery was used in 188 patients (39.7%) (group 1) and saphenous vein grafts only (group 2), in 286 (60.3%). The mean age was 82.6 years (range, 80 to 95 years). There were 312 men (65.8%) and 162 women (34.2%)., Results: Use of the internal thoracic artery as a graft has risen steadily each year, as has the number of patients who are octogenarians. The hospital mortality rate was 7.8%. Patients in group 1 had a mortality rate of 9.0% and patients in group 2, a mortality rate of 7.0%. The mortality rate among survivors at 1 year was 6.7%. Long-term survival was significantly greater in group 1., Conclusions: On the basis of this study, we conclude that the internal thoracic artery is the bypass graft of choice, especially in regard to long-term mortality, and should not be denied to this high-risk group.

A 68-year-old white man with lung carcinoma underwent removal of the lower lobe of the left lung. Four months later, the patient developed a hemothorax requiring exploratory thoracotomy, evacuation of hemothorax, and decortication. Postoperatively a persistent airspace with prolonged air leak developed. Bronchoscopic application of fibrin glue failed to seal the leak. Percutaneous transthoracic application of fibrin glue with CT scan guidance partially obliterated the space and completely sealed the leak. We describe this simple and effective technique for management of this special problem.