Timothy C. Wolfgang

Efficacy of percutaneous transluminal coronary angioplasty: Technique, patient selection, salutary results, limitations and complications

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 25 patients and 29 vessels during a 12-month period. In six additional patients scheduled for PTCA, the procedure was cancelled when repeat angiography identified progression to occlusion, coronary spasm, or other adverse factors not previously apparent. PTCA was successful in 14 of 25 patients (56%) and in 18 or 29 vessels (62%); success was associated with clinical improvement in all patients by symptomatology, exercise testing and/or myocardial radionuclide imaging. Beneficial results were particularly achieved with left anterior descending artery lesions and with stenoses showing less than 90% narrowing. One peripheral arterial complication occurred and no patients required emergency surgery. While coronary dissection was detected angiographically in four patients and evidence of coronary spasm was present in three patients post-PTCA, neither was accompanied by untoward early clinical events. Multivessel dilatation in three patients was initially successful but symptoms returned in two during follow-up. Restenosis developed in 3 of 14 patients (21%) after 3 months. Our experience indicates (1) that the specific vessel attempted and lesion severity particularly influence the liklihood of success, (2) the not infrequently induced coronary dissection or spasm does not necessarily represent a serious complication, and (3) angiography repeated in preparation for PTCA identifies a significant minority of patients rwho are no longer candidates.

Effects of percutaneous transluminal coronary angioplasty on lesion-associated branches

To assess the effects of percutaneous transluminal coronary angioplasty (PTCA) on lesion-associated branches, angiograms from 100 consecutive angioplasties involving 109 lesion dilatations were analyzed. Ninety-seven lesion-associated branches occurred in 76 (70%) of the dilated stenoses. Sixty-six (68%) branches were small (less than or equal to 1 mm) and 31 (32%) were moderate (greater than 1 mm) in size. Pre-PTCA branch ostial narrowing was present in 52 (54%), whereas there was no ostial disease in 45 (46%). Decreased ostial lumen occurred in 16 (16%) branches following angioplasty. Decreases in branch ostia were significantly more frequent in branches with preexisting branch disease (14 of 52, 27%) compared to branches with normal pre-PTCA ostia (2 of 45, 4%; p less than or equal to 0.01). However, vessel size, PTCA success, gender, and lesion dissection did not predict likelihood of branch ostial changes. Seven branches became totally or subtotally occluded following PTCA, one after unsuccessful and six following successful dilatation. Of the latter six, three experienced chest discomfort and one had an elevated creatine kinase with myocardial band, but no patient had immediate ECG changes. In summary, although moderate- or small-sized branches frequently accompany PTCA lesions, branch changes following angioplasty are infrequent and occur most often in branches with preexisting ostial disease.

Long-distance transportation of human hearts for transplantation.

Abstract This communication describes the preservation and long-distance (203 to 1,400 km) transportation of 6 human donor hearts with a hemodynamically successful short-term outcome in the recipients, all of whom were critically ill from end-stage cardiac failure. These techniques of long-distance donor heart transportation, not previously described in the human, offer prospects for markedly improving the logistics of heart transplantation in critically ill recipients who require immediate transplantation in face of limited local capability for securing an adequate donor heart. These systems may also prove of value in cardiac transplant protocols, such as rapid retransplantation during rejection and programmed protocols for recipient pre-treatment to promote enhancement of graft survival, that require obtaining a donor heart in an expedient manner.

Acute changes in global and regional rest left ventricular function after successful coronary angioplasty: Comparative results in stable and unstable angina☆

The immediate effects of successful percutaneous transluminal coronary angioplasty on global and regional left ventricular function were assessed by comparing 30 degrees right anterior oblique left ventricular angiograms performed immediately before and after angioplasty on 39 patients undergoing 42 successful procedures. Mean (+/- SD) lesion stenosis decreased from 88 +/- 10% to 35 +/- 11% (p less than or equal to 0.001), whereas left ventricular ejection fraction increased from 57 +/- 11% to 64 +/- 10% (p less than or equal to 0.001) for the entire group. Left ventricular functional changes were further subgrouped according to stability of angina. Eighteen procedures were performed on 17 patients with stable angina: 24 procedures were performed on 22 patients with unstable angina defined as angina at rest or on minimal activity or recently accelerated angina. There were no significant subgroup differences in mean age, gender ratio, vessel anatomy, drug therapy or extent of coronary stenosis before or after angioplasty. Global ejection fraction increased significantly for the unstable group (from 54 +/- 11% to 66 +/- 9%, p less than or equal to 0.001) but was unchanged for the stable group (from 61 +/- 9% to 61 +/- 11%, p = NS). In unstable angina, regional ejection fraction (segmental area method) increased for both jeopardized (from 37 +/- 11% to 52 +/- 9%, p less than or equal to 0.001) and nonjeopardized myocardial segments (from 43 +/- 13% to 51 +/- 13%, p less than or equal to 0.001), but improvement was significantly (p less than or equal to 0.02) greater in jeopardized segments.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporine in Cardiac Transplantation

Cyclosporine is a new immunosuppressive drug that acts early in the exposure of a host to allogeneic stimulation. It is a peptide of fungal origin. It has selective action on T cells, leaving the other cells of the immune system intact. It acts by preventing the function of the early activation signals of T cells, such as the acquisition of receptors for Il 2 and Il 1. It is lipophilic, moderately well absorbed by the gut, and metabolized by the liver. Factors affecting absorption or hepatic metabolism alter the amount of cyclosporine available in the circulation. Circulating levels can be measured by radioimmunoassay or HPLC. Doses should be tailored to trough levels taken approximately 12 hours after an oral or intravenous dose or to individual pharmacokinetic curves. The drug is nephrotoxic, hepatotoxic, and neurotoxic. In addition, cyclosporine has been associated with hypertension, hemolytic-uremic syndrome, increased incidence of intravascular thrombotic events, hypertrichosis, gum hyperplasia, pericardial effusion, and lymphoproliferative disorders. Despite these complications, cyclosporine usage seems to have improved short-term cardiac allograft survival and to have reduced the complications associated with side effects of steroids. As a result, cyclosporine has spawned a resurgence of interest in cardiac transplantation, which will be of great benefit in prolonging the lives of patients with end-stage cardiac disease.

Pull-through esophagectomy without thoracotomy for esophageal carcinoma.

Seventeen consecutive patients underwent pull-through esophagectomy using blunt dissection from laparotomy and cervical incisions for carcinoma of the esophagus. Fifteen patients had a middle-third lesion while 2 patients had a distal-third lesion. The gastrointestinal tract was reconstructed using primary gastroesophagostomy in 15 patients and colon interposition in 2. Both the colon and stomach were placed through the posterior mediastinum. The surgical technique and results are described in detail. There were two major complications. One patient died of massive gastric hemorrhage on the eighth postoperative day in spite of emergency operation. Another patient sustained a tear of the membranous trachea at the time of blunt dissection. This was repaired through a right thoracotomy without difficulty. Esophagectomy using blunt dissection offered excellent palliation and resulted in little morbidity in our series. The shortened operating time, minimal blood loss, total lack of postoperative chest pain, minimal pulmonary complications, and the benefit of a cervical anastomosis are several advantages compared with the present surgical approaches.

Pretransplant transfusions in cardiac allograft recipients.

The role of pretransplant transfusion in cardiac allograft recipients was determined retrospectively in 68 patients. Three groups were studied: group 1 (n=29) received no pretransplant transfusion, group 2 (n=15) received transfusion over one year prior to transplantation, and Group 3 (n=24) received 5 or 10 50–100 ml units of random donor red blood cells or buffy coat 2–4 weeks prior to transplantation. Data were analyzed for survival, number of rejection episodes, and number of infections. Immunosuppression included azathioprine, prednisone, and antithymocyte globulin. Survival in transfused patients (groups 2 and 3) was 68% and 51% at 1 and 5 years, respectively, while in the nontrans-fused population (group 1) it was 35% and 16%. The incidence of rejection episodes per year of survival was similar in the three groups (group 1: 1.3, group 2: 1.1, group 3: 1.3; P<0.05). The number of infections per year of survival were greater in the transfused patients but this did not achieve statistical significance (group 1: 1.0, group 2: 1.2, group 3: 1.7; P<0.05). Thus, we conclude that cardiac transplant recipients who have received blood transfusions prior to transplantation may have enhanced survival over patients who have not received preoperative transfusions.

Improved Immunosuppression for Cardiac Transplantation: Immune Monitoring and Individualized Modulation of Recipient Immunity by In Vitro Testing

These studies demonstrate that immune monitoring and individualized modulation of recipient immune reactivity using a quality-controlled preparation of rabbit antithymocyte globulin can improve results of cardiac transplantation. The most valuable assay in individualizing drug doses was the serial measurement of T-cell levels using a complete lymphocyte profile technique and monitoring with phytohemagglutinin to rule out false low T-cell levels. Using this system, the incidence and severity of early rejections were markedly reduced and no grafts were lost to rejection in the first month. The recent first-year graft survival has been about 60%, an improvement largely related to a reduction in early rejection and infection. This technique of immunosuppression appears quite promising for improving the results of future cardiac transplantations.