Chang Vp

Mechanisms of the development and resolution of paradoxical interventricular septal motion after uncomplicated cardiac surgery

Of 16 patients with normal preoperative left ventricular (LV) function studied by simultaneous two-dimensional and M-mode echocardiography before and after uncomplicated cardiac surgery, M-mode interventricular septal motion remained normal in seven (group I) and was paradoxical in nine (group II) 7 to 13 days postoperatively, but was normal in all 12 patients (7 group II) studied 3 to 18 months later. An abnormal systolic increase in normalized septal curvature, the essential feature of truly paradoxical septal motion, was not observed in either group during any study period (mean = 0.92 +/- 0.08), nor were significant differences found in septal thickening, LV fractional shortening, or fractional area change. In contrast, systolic anterior motion of the LV center increased from -0.1 +/- 1.6 mm preoperatively to 4.8 +/- 2.5 mm postoperatively in group II (p less than 0.001), and the LV posterior wall motion:thickening ratio increased from 1.10 +/- 0.33 to 2.16 +/- 0.45 (p less than 0.01), but both parameters had returned to preoperative levels at the follow-up study. Both parameters remained stable in group I during all study periods. In addition, direct intraoperative M-mode recordings (n = 14) demonstrated normal septal motion in both groups before chest closure, but esophageal echocardiograms (n = 10) demonstrated exaggerated anterior systolic LV motion within 2 hours of surgery in those from group II. Thus, early after uncomplicated cardiac surgery, apparently paradoxical septal motion relative to a fixed reference point is an artifact due to exaggerated cardiac mobility that resolves with the progressive restraining effect of postoperative adhesions.

A prospective randomized study of prophylactic OKT3 versus equine antithymocyte globulin after heart transplantation--increased morbidity with OKT3.

The aim of this study was to compare the efficacy and toxicity of prophylactic OKT3 and equine antithymo-cyte globulin when each drug was administered for a similar duration after heart transplantation. Forty-one patients (35 males, 6 females; mean age 46±2 years) were randomized to receive either OKT3 for 10 days (20 patients) commencing within 24–48 hr of transplantation or ATGAM for 8 days (21 patients) commencing on the day of transplantation. All patients were maintained on triple-agent immunosuppression with prednisolone, azathioprine, and cyclosporine. The two groups were well matched with respect to age, sex distribution, pretransplant cardiac diagnosis, and donor heart ischemic time. Mean duration of follow-up was 14 months (range 9–19 months): Actuarial survival at 12 months was 83±9 in the OKT3 group and 81±9 in the ATG group (P=NS). Mean time to first cardiac rejection was 33±8 days in the OKT3 group compared with 27± 5 days in the ATG group (P=NS). Linearized rejection rate did not differ between the two groups at any time point up to 12 months posttransplant. Viral infections were significantly more common in the OKT3 group: 1.6±0.3 vs. 0.8±0.2 infections per patient (P<0.05). Adverse reactions were more common in patients who received OKT3 prophylaxis and included three patients who developed acute respiratory distress, two of whom required assisted ventilation. In conclusion, prophylactic OKT3 and ATGAM result in comparable rejection rates and survival when administered for a similar duration after cardiac transplantation. OKT3, however, is associated with increased morbidity due to a higher incidence of adverse reactions and of viral infections.

Rationale for Simultaneous Carotid Endarterectomy and Aortocoronary Bypass

Seventy-eight patients were treated for coexistent carotid and coronary stenosis by simultaneous reconstructions. Five patients died (6.4%), one from a stroke contralateral to the carotid reconstruction. Four others suffered a perioperative stroke (total stroke incidence 6.4%). Three myocardial infarctions occurred (3.8%) including one fatal infarct. Analysis of the most recent 36 combined reconstructions indicates that the extramorbidity in this group increased the stroke or death rate for all carotid endarterectomies carried out in the same period by only 1%. Alternatively if these patients had been operated upon by aortocoronary grafting alone the mortality would have increased by 0.1% assuming no neurologic complications. Since these 36 patients had severe carotid stenosis and would have been refused carotid endarterectomy as an isolated procedure the results seem better than would have been achieved by staged operations.

Reproducibility of radionuclide left ventricular ejection fraction in patients awaiting cardiac transplantation

Radionuclide-derived left ventricular ejection fraction (LVEF) is used to assess LV systolic function, to follow trends in the natural history of dilated cardiomyopathy, and to prioritize patients waiting for cardiac transplantation. Reproducibility of LVEF at extremely low levels has not, however, been reported. To assess the reproducibility of radionuclide LVEF at levels below 0.30 EF U, 17 highly symptomatic patients (NYHA Class III/IV) with dilated cardiomyopathy were studied on two occasions, 72 hours apart. Sequential scans were analyzed by two independent observers. Mean LVEF was 0.18±0.06 U (scan 1) and 0.17±0.06 U (scan 2). Interoperator reproducibility (SD) was 0.03 U (R=0.76), interscan reproducibility (SD) was 0.03 U (R=0.62), and overall reproducibility (SD) was 0.04 U (R=0.50). The interobserver variation of 0.03 (actually 0.027) was just over one half that seen in normal volunteers (variation 0.05, n=29) studied previously in this department. A change of ≥0.08 U (2SD) in either direction is highly likely to represent a real change in LV function in those with LVEF ≤ 0.30 units, compared with the change of at least 0.10 units required in those with normal LV function. Lower interobserver and interscan reproducibility should be taken into account when interpreting sequential scans in patients with severe LV dysfunction.

Pharmacological Conditioning of Brain Dead Donor Hearts with Erythropoietin and Glyceryl Trinitrate: Clinical Experience

Background: With the increasing success of heart transplantation, older and higher-risk donors and recipients are being accepted for transplantation. The risk of primary graft dysfunction (PGD) is thus increased. We investigated a ‘pharmacological conditioning’ strategy, where Celsior preservation solution supplemented with glyceryl trinitrate (GTN) and erythropoietin (EPO) was used for cardioplegia and hypothermic storage, and determined graft recovery and patient survival after cardiac transplantation.

Cardiac transplantation: Australian results

Between February 1984 and November 1989, 188 orthotopic cardiac transplants were performed at St Vincent’s Hospital, Sydney, in 183 patients. Five patients required retransplantation. All patients were in New York Heart Association Functional Class III to IV before transplantation. Thirty-four of these patients were female and 149 male. Recipient diagnosis in 98 patients was primary cardiomyopathy, while 71 had ischemic heart disease, 13 had valvular heart disease, and 1 patient had congenital heart disease. Three different immunosuppressive protocols have been used: cyclosporin A (CsA) + prednisolone (P), CsA + azathioprine (Aza) + P, and CsA + Aza. Antithymocyte globulin (ATG) was administered for a 7-day period in all groups. Subsequently, there was a prospective trial comparing OKT3 to ATG for prophylactic immunosuppression - there was one death in the OKT3 group due to rejection. There have been 28 deaths overall. From our experience, a combination of CsA and Aza, with or without the addition of prednisolone, has improved our actuarial 5-year survival, which has risen from 68% (CsA + P), to 82.7% (CsA + Aza + P) or 90.48% (CsA + Aza). Our experience demonstrates that with orthotopic heart tranplantation, 1-year survival in excess of 90% and a 5-year survival of 85% can be achieved in patients ranging in age from 9 years to 65 years. The majority of patients return to a productive lifestyle, with 75% returning to employment, home duties, or study.