Enrico Donegani

Successful orthotopic transplantation of a fresh tricuspid valve homograft in a human

We report a successful transplantation of a human tricuspid valve in a human. We used a fresh tricuspid homograft with its chordae tendineae and papillary muscles, harvested 5 days earlier under sterile conditions from a multiorgan donor a few minutes after cardiectomy (the heart was not suitable for cardiac transplantation) and immediately stored at 4 degrees C. We elected to implant the homograft in a young heroin addict. Our experience demonstrates that the implantation of an atrioventricular homograft in the orthotopic position is technically feasible and can achieve good results, at least in the short term.

Detection of human cytomegalovirus myocardial involvement by polymerase chain reaction during systemic infection and correlation with pp65 antigenemia and DNAemia in infected heart recipients.

The presence of human cytomegalovirus DNA was investigated in 103 unfixed endomyocardial biopsies, performed during the first 4 months in 17 heart transplant recipients by polymerase chain reaction. Results were correlated with human cytomegalovirus systemic infection, as detected by the test for the viral lower matrix phosphoprotein pp65 (antigenemia) and by polymerase chain reaction for viral DNA in blood leukocytes (DNAemia). Three patients out of 17 did not develop cytomegalovirus infection and 14 did: 5 had symptomatic disease treated with ganciclovir and 9 developed asymptomatic infection and were not treated. Viral DNA was detected in 24 out of 103 biopsies (23%) from 13 patients: 5 with symptomatic infection during the acute phase of disease (mean levels of pp65: 125+/-232 pp65 positive leukocytes/200,000 examined cells) and 8 patients with asymptomatic infection when the mean antigenemia was 5+/-15/200,000 (4 patients) or when DNAnemia was present in the blood (4 patients). No histological evidence of myocarditis was shown in viral DNA-positive biopsies. No difference in acute rejection was found in viral DNA-positive and DNA-negative biopsy specimens in symptomatic and asymptomatic infected patients. Our experience suggests that during systemic symptomatic and asymptomatic cytomegalovirus infection, polymerase chain reaction can detect a relatively frequent myocardial involvement, but this involvement is not associated with myocarditis or with a higher incidence of acute rejection. THe presence of viral DNA in myocardial biopsies can be a result of high viremia, but it also can be due to low level of viral DNA in circulating infected leukocytes. Polymerase chain reaction is the most sensitive method for cytomegalovirus DNA detection in biopsies, but its results need to be evaluated together with morphology-preserving methods and systemic markers of infection in order to make a correct diagnosis.

Spontaneous dissecting aneurysms of coronary arteries in a cardiac allograft

Abstract Dissecting aneurysms of coronary arteries are a rare finding and have never been reported in a cardiac allograft. We found two spontaneous dissecting aneurysms on the middle third of both the left anterior descending and the right coronary arteries in a female cardiac transplantation recipient. She died 43 days after cardiac transplantation after developing human cytomegalovirus pneumonia and pancreatitis. Dissecting coronary aneurysms, microfoci of subendocardial coagulative necrosis, and area of subepicardial dystrophic calcifications were discovered at necropsy examination.

Comparison between virology and serology for the follow-up of cytomegalovirus infection in heart transplant recipients

Abstract This work aimed to evaluate serology in relation to non-quantitative polymerase chain reaction (PCR) and pp65-antigenemia for the follow-up of cytomegalovirus (CMV) infection in heart transplant recipients. Besides conventional serology, antibodies were also detected by immuno Western blotting (IWB) and by recombinant enzyme immunoassay (EIA). Twenty-five CMV infected patients were evaluated. Twelve of them experienced symptomatic infection and underwent 9-(1,3-dihydroxy-2-propoxymethyl) guanine (DHPG) therapy whereas 13 asymptomatic infections were not treated. Risk factors for developing a symptomatic infection were a high antigenemia level as well as a high and delayed IgM response to ppUL44 (p52) and a low IgG response to the virus. PCR was the most sensitive procedure for detecting CMV infection (24 out of 25 infected patients and a mean time of 40 days after transplant), followed by IWB-IgM (23 patients and 40 days) and antigenemia (22 patients and 41 days). All the 12 symptomatic infections could be detected by one of the three above-mentioned methods, whereas no single test could identify all the 13 asymptomatic infections. The combination of two tests that could detect all the 25 CMV infections was PCR plus a serological procedure (IWB-IgM or recombinant EIA for p52) and pp65-antigenemia associated with IWB-IgM. As PCR results did not correlate with the onset of CMV symptomatic infection, the present data indicate that the most rational follow-up for CMV infection in heart transplant recipients can be obtained by antigenemia and IWB-IgM.

Protection of the heart by nifedipine cardioplegia during coronary artery surgery. A clinical-haemodynamic evaluation.

This study was undertaken to evaluate the myocardial preservation obtained by adding a Ca++ channel blocker, nifedipine, to cold potassium cardioplegia (4 mcg/Kg/L) in 24 patients undergoing coronary artery surgery. They were randomly divided into a treated (N) and a control (C) group. Significant differences between the two groups were noted in the cardiac arrest time (p less than 0.001), in the mechanical recovery mode (p less than 0.01) and in the inotropic support needed (p less than 0.01). Cardiac index increased significantly in group N but decreased in group C (p less than 0.01). Peripheral delta P/delta t and endocardial viability ratio (EVR) decreased in both groups. Coronary sinus and serum CK and CK-MB release were significantly lower in the treated group. ECG ischaemic changes occurred in 8 patients in group C but only in 1 case in group N (p less than 0.001). Arrhythmias occurred in 3 cases in group C (p less than 0.05). The incidence of perioperative myocardial infarction was not significant (2 cases in group C). These data suggest that nifedipine can protect the myocardial cell from ischaemic injury without depressing myocardial contractility or AV conduction.