Warren D. Widmann

Pretransplantation Patient Characteristics and Survival Following Combined Heart and Kidney Transplantation: An Analysis of the United Network for Organ Sharing Database

HYPOTHESISnPretransplantation patient characteristics determine survival following combined heart and kidney transplantation (HKT).nnnDESIGNnTime-to-event analysis.nnnSETTINGnAcademic research.nnnPATIENTSnThe United Network for Organ Sharing provided deidentified patient-level data. Analysis included 19,373 heart transplant recipients from January 1, 1995, to December 31, 2005.nnnMAIN OUTCOME MEASURESnMultivariate Cox proportional hazards regression analysis was performed to identify pretransplantation recipient characteristics associated with improved long-term survival following HKT. Kaplan-Meier survival functions and Cox proportional hazards regression were used for time-to-event analysis. Using the relative risks calculated in regression analysis, weights were assigned for each risk factor, allowing for the construction of a risk score.nnnRESULTSnAmong heart transplant recipients, 264 (1.4%) underwent HKT. Factors associated with diminished survival included peripheral vascular disease, recipient age older than 65 years, nonischemic etiology of heart failure, dialysis dependence at the time of transplantation, and bridge to transplantation using a ventricular assist device. After stratification by risk score, 1-year survival was 93.2% and 61.9% in the lowest- and highest-risk HKT groups, respectively. Further stratification by estimated glomerular filtration rate (eGFR) was performed based on a previous study showing decreased survival of patients undergoing orthotopic heart transplantation with a preoperative eGFR of less than 33 mL/min. Low-risk patients with an eGFR of less than 33 mL/min undergoing HKT constituted the only group that had significantly better survival compared with isolated patients undergoing orthotopic heart transplantation with eGFRs and risk scores in the same range (P = .006).nnnCONCLUSIONSnWhen patients were stratified by risk score and by diminished eGFR (<33 mL/min), low-risk HKT recipients with a diminished eGFR had improved survival following HKT over isolated heart transplant recipients. Only low-risk patients with combined kidney failure (eGFR, <33 mL/min) and heart failure seem to gain a survival benefit from HKT.

Failure of conservative management of splenic rupture in a patient with mononucleosis

Conservative management of splenic rupture in patients with mononucleosis has not been adequately evaluated because of its infrequent occurrence. Splenic rupture can be lethal in this setting and is the most common cause of death from mononucleosis. We report a case of spontaneous splenic rupture in a young girl with mononucleosis. The initial management was nonoperative but because of recurrent pain and rebleeding, a splenectomy was later performed. We do not recommend observation of splenic rupture in patients with mononucleosis because of the danger of delayed hemorrhage.

C. Walton Lillehei, MD, PhD: a father of open-heart surgery

The challenge of performing heart surgery has both fascinated and intimidated surgeons. At the end of the 19th century, leaders in surgery and medicine pronounced that surgeons who tried to suture the heart would lose the respect of their colleagues and that no method or discovery could alter the problems associated with repair of the heart (Theodor Bilroth, 1883, and Stephen Paget, 1896). With the gauntlet laid down, the combined dictums fell to the successful repair of a cardiac injury in 1896 by Ludwig Rehn. However, the problems of elective operations within the heart remained a challenge for another half a century. The ultimate successes of a number of pioneers opened wide a new era in open-heart surgery, enabling corrections of both congenital and acquired heart defects. A giant among those giants was C. Walton Lillehei. Clarence Walton Lillehei was born in Edina, Minnesota, on October 23, 1918. His father was a dentist, and his mother was a professional pianist. C. Walton was the eldest of 3 sons. He had such dexterous skill that he reportedly built a motorcycle from spare parts and took apart and reassembled the engine of a Model T Ford without the assistance of an instruction manual. Despite skipping 2 years of elementary school, Lillehei was, at best, a mediocre student in high school. He nearly failed chemistry. Some of his instructors predicted poor college performance. Yet, after entering the University of Minnesota in the fall of 1935, he graduated in 1939 with distinction and went on to the University of Minnesota Medical School. There, Lillehei excelled academically, with the exception of 3 C’s, including 1, ironically, in his surgery clerkship. Throughout his college and medical school career, Lillehei adopted the motto “Work hard, play hard,” a philosophy to which he adhered throughout the rest of his life. Lillehei was a second-year medical student when he met Dr. Owen H. Wangensteen, the young chief of surgery with a passion for research and experimentation. Medical school education was accelerated during World War II, and by 1942, Lillehei graduated with both a medical degree and a master’s degree in physiology. After completing his internship, he began military service as a first lieutenant in the Army Medical Corps and was sent to Europe. By the time he returned in 1945, he was a lieutenant colonel and had received the Bronze Star for “Meritorious Services in Support of Combat Operations” in Anzio, Italy. After making but 1 application to surgical residency—the University of Minnesota, under Wangensteen—Lillehei began his formal surgical training in 1946. During the next few years, Lillehei met and worked with Dr. Richard Varco, the department’s closed-heart specialist (Figure 1). Lillehei recognized the difficulties, limitations, and excitement of operating on the closed, beating heart, but before he was able to pursue his interest, his life and career took an unexpected turn. In late 1949 Lillehei noted a small mass just anterior to his left ear that he presumed to be harmless and benign. He put off its excision until February 1950. Dr. David State removed it along with a portion of the parotid gland. Wangensteen and State were shocked with the final pathology report—lymphosarcoma. Incredulous, Wangensteen had the specimen evaluated at 4 other institutions, but all the “second opinions” concurred. Wangensteen finally disclosed this information to Lillehei after about 4 months’ delay. The prognosis for lymphosarcoma was dismal in those pre-chemotherapy days, and perhaps somewhat in desperation, Lillehei agreed to undergo further resection by Wangensteen. After a radical transmediastinal

An improved double-lumen biliary catheter for cholangiography

A double-lumen biliary catheter was developed to aid in the performance of cholangiography and bile duct stone extraction. A prototype catheter was used in four cadavers. Excellent cholangiograms were obtained and a cryoprecipitate coagulum easily formed in the bile ducts without waste. Extraction of the coagulum from the bile ducts was aided by use of the catheter. The catheter also can aid in routine balloon catheter bile duct stone extraction, and thus is useful for both diagnosis and treatment of bile duct stones.