R. Vespignani

Survival and Allograft Rejection Rates after Combined Heart and Kidney Transplantation in Comparison with Heart Transplantation Alone

BACKGROUND The role of solid multiorgan transplantation remains to be determined. We compared our experience with combined heart-kidney transplantation (HKT) and heart transplant alone (HT), and assessed patient survival rates and freedom from allograft rejection in these two patient groups. METHODS We reviewed the clinical outcomes of patients undergoing HKT (n=30) or HT (n=440) between June 1992 and March 2009. Baseline patient characteristics, perioperative factors, incidence of rejection, and survival were examined. RESULTS There were no significant differences between the two groups for age, gender, etiology of heart disease, functional class, preoperative left ventricular ejection fraction, end-diastolic diameter, cardiac output, or transplant waitlist status. Patients with HKT had a higher serum creatinine level (P<.001) and a greater incidence of hypertension (P=.04). No differences were found in cardiac allograft ischemic times, including cardiopulmonary bypass or cross-clamp times. Kidney allograft ischemic time was 14.6±9 hours (mean±SD; range, 4 hours to 49 hours). Kaplan-Meier survival estimates were similar for the HKT and HT groups at 30 days (93%±4.6% versus 98%±0.7%), 1 year (87%±6.2% versus 93%±1.2%), 5 years (68%±9.0% versus 76%±2.1%), and 10 years (51%±11% versus 53%±3.0%; P=.54 for all comparisons). Follow-up serum creatinine levels were similar after HKT and HT at 30 days (1.6±1.8 mg/dL versus 1.1±0.4 mg/dL), 1 year (1.4±0.6 mg/dL versus 1.5±0.6 mg/dL), and 5 years (1.8±1.8 mg/dL versus 1.8±1.2 mg/dL; P>.05 for all comparisons). CONCLUSIONS HKT offers excellent survival and similar renal function when compared with HT alone. Patients with end-stage cardiac and renal failure can be considered for HKT.

Heterotopic Heart Transplantation in Rats: Improved Anesthetic and Surgical Technique

OBJECTIVE An updated anesthetic and surgical technique in a rat model of heterotopic heart transplantation is described. MATERIALS AND METHODS A microsurgical technique via a suprarenal approach was performed, and is described in stepwise fashion, and several technical improvements are compared with previous descriptions. Lewis rats were used as donors and recipients (syngeneic model). RESULTS Factors that affected early surgical outcome included type of anesthetic used; surgeon skill, experience in handling blood vessels, and knowledge of small-animal anatomy; gentle manipulation during the operation; and duration of surgery (<1 hour). Use of isoflurane inhalation anesthesia (10 rats) vs intraperitoneal injection of ketamine, 75 mg/kg, and dexmedetomidine, 0.25 mg/kg (20 rats), was associated with improved early survival (90%) and no occurrence of paralysis, paraparesis, bleeding, or intestinal ischemia. Long-term survival (>11 months) with a functioning graft was achieved in all 9 surviving animals. CONCLUSIONS Survival was substantially improved with administration of isoflurane anesthesia; surgeon microvascular surgical skills and knowledge of small-animal anatomy, and duration of surgery less than 1 hour. These factors collectively contributed to successful early outcomes after heterotopic heart transplantation in rats, with 90% freedom from morbidity and mortality, and resulted in long-term survival (>11 months) with a functioning graft in a syngeneic model. This heterotopic model in rats is suitable for short- and long-term studies of heart transplantation.

Prophylaxis of Cytomegalovirus Disease in Mismatched Patients after Heart Transplantation Using Combined Antiviral and Immunoglobulin Therapy

BACKGROUND Cytomegalovirus (CMV) is a common cause of infection and morbidity after heart transplantation. Seronegative recipients (R-) of seropositive donor hearts (D+) are at high risk for CMV disease. We compared three different CMV prophylaxis regimens using combined antiviral and immunoglobulin therapy. METHODS In 99 patients who survived more than 30 days after heart transplant, all received induction with antilymphocytic therapy and triple-drug therapy. In group A, D+R- patients received one dose of intravenous immunoglobulin (IVIG) followed by one dose of CMV-specific immunoglobulin (CMV-IVIG), and intravenous ganciclovir (GCV) for 4 weeks followed by 11 months of oral acyclovir (ACV). In group B, D+R- patients received one dose IVIG followed by five doses of CMV-IVIG and intravenous GCV for 14 weeks followed by 9 months of oral ACV. In group C, D+R- patients were treated with the same regimen as for group B, except oral ACV was replaced with oral GCV. RESULTS The actuarial freedom from CMV disease for D+R- patients at 1 month, 1 year, and 2 years after transplantation in group A was 100%, 25% ± 15%, and 25% ± 15%, respectively; group B was 100%, 67% ± 27%, and 67% ± 27%; group C was 100%, 83% ± 15%, and 83% ± 15% (P < .01, groups B and C vs group A). By comparison, the actuarial freedom from CMV disease for seropositive recipients (D-R+ or D+R+) at 1 month, 1 year, and 2 years in group A was 100%, 87% ± 7%, and 82% ± 8%, respectively; group B was 100%, 88% ± 8%, and 75% ± 11%; group C was 100%, 72% ± 9%, and 72% ± 9% (P = NS among groups). Rejection rates did not differ among the three groups. CONCLUSIONS A longer course of intravenous GCV with multiple doses of CMV-IVIG was a more effective prophylaxis regimen against CMV disease for the high-risk group of seronegative recipients of seropositive donor hearts.

High Definition Optical System for Microsurgical Heterotopic Heart Transplantation in Rats

BACKGROUND Clinical and experimental cardiovascular surgery as well as other surgical disciplines may require visualization and manipulation of small anatomic structures. A high-definition optical system was developed for magnification and illumination as an alternative to surgical loupes or a traditional operating microscope. MATERIALS AND METHODS A video telescopic optical imaging system that provided a high-definition and magnification of the surgical field was used for visualization of small anatomic structures and as an aid to the performance of small vessel anastomoses in a series of 10 heterotopic heart transplants (HHTx) in rats. RESULTS The video telescopic optical system was easy to manipulate and comfortable to use, and provided high-definition images for magnification of anatomic structures while performing microvascular cardiac surgery in a small animal model of HHTx in rats. Fatigue and neck problems for the surgeon were reduced. CONCLUSIONS The video telescopic imaging system provided high definition and magnification of the surgical field, and was used for visualization of small anatomic structures and as an aid to the performance of small vessel anastomoses. The system is an alternative to surgical loupes or a traditional operating microscope, and was used for the first time in microvascular cardiac surgery in a rat HHTx model.

Concomitant Dual Intravascular and Subcutaneous Microsurgical Implantation of Xenograft Tissue in a Rodent Model for Evaluation of Structural Degeneration

INTRODUCTION An economical animal model to study xenograft tissue degeneration and calcification and the durability of biological vascular patch material and bioprosthetic valve leaflets is desirable. OBJECTIVE A cost-effective model to analyze xenograft degeneration, calcification, immunologic reaction, and anticalcification treatment was developed. Furthermore, a technique for implant into the vascular lumen of the abdominal aorta in rats is presented. METHODS Twelve Lewis rats were used as recipients. The microsurgical procedure was performed using a high-definition optical system. Anesthesia was induced and maintained with isoflurane inhalation. The suprarenal and infrarenal portion of the abdominal aorta was isolated, the abdominal aorta was cross-clamped, and a 4-mm square portion of the abdominal aorta was removed. Subsequently, a complementary-sized piece of porcine or bovine glutaraldehyde-fixed bioprosthetic valve leaflet tissue was sutured as a patch in the abdominal aorta. RESULTS The mean operating time was 45 ± 10 minutes and the mean ischemic time was 25 ± 5 minutes. Early and 3-month survivals were 100%. One rat had intraoperative bleeding. No paralysis or thrombosis was observed. CONCLUSION Feasibility and reproducibility of removing a portion of the abdominal aorta and replacing it with a patch of xenograft tissue was demonstrated in a rodent model with 100% survival at 3 months. Concomitant dual intravascular and subcutaneous microsurgical implantation of xenograft tissue in a small-animal (rat) model is a cost-effective approach for investigation of xenograft tissue degeneration.

Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques

Different surgical techniques, each with its own advantages and disadvantages, have been used to reverse adverse left ventricular remodeling due to postinfarction left ventricular aneurysm. The most appropriate surgical technique depends on the location and size of the aneurysm and the scarred tissue, the patients preoperative characteristics, and surgeon preference. This review covers the reconstructive surgical techniques for postinfarction left ventricular aneurysm.