G.Martin Mullen

Usefulness of Immunosuppression for Giant Cell Myocarditis

Giant cell myocarditis (GCM) is a rare and highly lethal disorder. The only multicenter case series with treatment data lacked cardiac function assessments and had a retrospective design. We conducted a prospective, multicenter study of immunosuppression including cyclosporine and steroids for acute, microscopically-confirmed GCM. From June 1999 to June 2005 in a standard protocol, 11 subjects received high dose steroids and cyclosporine, and 9 subjects received muromonab-CD3. In these, 7 of 11 were women, the mean age was 60 +/- 15 years, and the mean time from symptom onset to presentation was 27 +/- 33 days. During 1 year of treatment, 1 subject died of respiratory complications on day 178, and 2 subjects received heart transplantations on days 2 and 27, respectively. Serial endomyocardial biopsies revealed that after 4 weeks of treatment the degree of necrosis, cellular inflammation, and giant cells decreased (p = 0.001). One patient who completed the trial subsequently died of a fatal GCM recurrence after withdrawal of immunosuppression. Her case demonstrates for the first time that there is a risk of recurrent, sometimes fatal, GCM after cessation of immunosuppression. In conclusion, this prospective study of immunosuppression for GCM confirms retrospective case reports that such therapy improves long-term survival. Additionally, withdrawal of immunosuppression can be associated with fatal GCM recurrence.

Asymmetry of Right Ventricular Enlargement in Response to Tricuspid Regurgitation

BACKGROUND Analysis of right ventricular adaptation to tricuspid regurgitation was studied in 10 heart transplant recipients following inadvertent endomyocardial biopsy disruption of the tricuspid apparatus. METHODS AND RESULTS Echocardiography demonstrated progressive diastolic right ventricular cavity enlargement (19.5+/-5.0 to 30.3+/-5.4 cm(2), P<0.0002), with disproportionate elongation along the midminor axis (3.5+/-0.6 to 5. 0+/-0.5 cm, P<0.001). As the right ventricle remodeled to more spherical (and less elliptical) proportions, the end-diastolic right ventricular midminor axis/long axis ratio increased significantly from 0.52+/-0.10 to 0.68+/-0.07, P<0.005. CONCLUSIONS Ventricular enlargement due to right ventricular volume overload results in disproportionate dilation along the free wall to septum minor axis.

Risk/benefit ratio of perioperative OKT3 in cardiac transplantation

This study shows that perioperative OKT3 provides no benefit in terms of the time of onset or frequency of rejection or patient survival. However, it does result in an increased incidence of infection, particularly CMV infection. Thus, the risk/benefit ratio of perioperative OKT3 does not appear favorable. However, a multicenter, randomized trial including a larger number of patients and longer patient follow-up will be required to definitively answer the question.

Heart transplantation in a patient with chloroquine-induced cardiomyopathy☆

We present the first report of a patient who underwent heart transplantation (HT) after endomyocardial biopsy (EMB) and revealed chloroquine-induced cardiomyopathy (CIC). This patient, who was treated with chloroquine for 6 years, developed a restrictive cardiomyopathy that progressed to congestive heart failure (CHF) resistant to medical management.

Prevention of osteoporosis in cardiac transplant recipients

Osteoporosis is a leading cause of pretransplant and posttransplant morbidity. The need for early detection by measuring bone mineral density, even before transplant, must be emphasized. Preventive measures are not comparable. The use of calcium and vitamin D supplements, although recommended, is inadequate for the prevention of bone loss and complications such as vertebral fractures. Bisphosphonates have been shown to attenuate the bone loss and reduce fractures associated with steroid-induced osteoporosis. Small studies in transplant recipients suggest similar results. Other preventive measures such as hormone replacement therapy are also helpful. There are limited data on the administration of nasal calcitonin in transplant recipients.

Percutaneous transluminal coronary angioplasty in acute myocardial infarction without prior thrombolytic therapy

Abstract In most patients transmural acute myocardial infarction (AMI) is caused by acute coronary artery occlusion consisting of an atherosclerotic plaque with superimposed thrombus. 1 One of the most notable of the recent therapeutic advances for AMI is the use of intracoronary streptokinase, which results in restoration of coronary flow in 64 to 85% of patients. 2,3 Disadvantages of this technique include both subsequent hemostatic problems and frequently severe residual stenosis that may jeopardize any expected wall motion improvement. 4 Percutaneous transluminal coronary angioplasty (PTCA) has recently been used immediately after successful coronary thrombolysis to dilate severe residual stenoses. 5 Some investigators feel that such an approach leads to greater wall motion recovery and lessens the risks of reocclusion. 4,5 Even more recently, PTCA has been proposed as the initial therapy in AMI because it avoids hemostatic problems and long infusion times involved with thrombolytic therapy. 6 We report our experience with PTCA without prior thrombolytic therapy in the management of patients with AMI as an alternative to thrombolytic therapy.