Immunohistochemical model to predict risk for coronary artery disease and failure in heart transplant patients.

Transplant coronary artery disease is the leading cause of long-term morbidity and mortality in cardiac transplantation. We developed a model for early identification of patients who subsequently develop coronary artery disease and graft failure. Serial biopsies obtained from 141 cardiac allografts (5.

Vascular antithrombin and clinical outcome in heart transplant patients.

A procoagulant microvasculature is associated with accelerated development of coronary artery disease (CAD) and failure in heart transplant patients. This study was performed to evaluate how changes in natural anticoagulation within cardiac allografts affect outcome. We prospectively studied 141 consecutive cardiac allograft recipients who underwent transplantation between 1988 and 1997.

Value of serum-soluble intercellular adhesion molecule-1 for the noninvasive risk assessment of transplant coronary artery disease, posttransplant ischemic events, and cardiac graft failure.

Background: Adhesion molecules on arterial endothelium have been implicated in spontaneous atherosclerosis and transplant coronary artery disease (CAD). We studied whether elevated serum-soluble intercellular adhesion molecule-1 (sICAM-1) during the immediate posttransplant period was a risk factor for CAD, posttransplant ischemic events, or cardiac graft failure.

Methods And Results: We initially studied serum sICAM-1 in a subset of 16 cardiac allograft recipients (5.

Cardiac-specific troponin I levels and risk of coronary artery disease and graft failure following heart transplantation.

Context: Previous studies have yielded conflicting data regarding whether a relationship exists between elevated cardiac troponin levels and acute allograft rejection in patients who have received heart transplants.

Objective: To determine whether cardiac troponin I levels after heart transplantation were associated with a procoagulant microvasculature and long-term allograft outcome.

Design: Prospective cohort study with a mean (SE) follow-up of 45.

Utilization of intravenous immunoglobulin to ameliorate alloantibodies in a highly sensitized patient with a cardiac assist device awaiting heart transplantation. Fluorescence-activated cell sorter analysis.

Surgery surrounding the use of mechanical assistance in cardiac transplant candidates often leads to multiple blood/platelet transfusions and subsequent development of alloantibodies. This is a case report of a 50-year-old male patient who had received blood transfusions during coronary bypass grafting 9 years earlier. He presented in acute and chronic heart failure and, despite therapy, became moribund with multisystem organ failure.

The use of tranexamic acid to reduce postoperative bleeding following cardiac surgery: a double-blind randomized trial.

Bleeding during the first 24 hours following cardiac surgery using cardio-pulmonary bypass (CPB) is a serious complication. Attempts to modify the degree of postoperative bleeding with pharmacologic therapy have met with limited success. Tranexamic acid, a potent inhibitor of plasminogen, may decrease the amount of mediastinal bleeding following surgery utilizing CPB.

Improved results with resection of extensive thoracoabdominal aneurysms.

Thoracoabdominal aneurysms are the most extensive of aortic aneurysms, and their correction is associated with the greatest number of complications. The introduction of new techniques has reduced the morbidity and mortality of surgery for these formidable lesions. A description of some of these techniques, as applied to 33 patients, is summarized, and the results presented.

Tissue plasminogen activator, plasminogen activator inhibitor-1, and fibrin as indexes of clinical course in cardiac allograft recipients. An immunocytochemical study.

Background: Tissue-type plasminogen activator (TPA) is the principal activator of plasminogen. Since hemostasis in the microcirculation of allografts is a well-recognized complication of transplantation, we asked (1) whether the distribution and amount of cellular TPA in biopsies of transplanted human hearts are associated with fibrin deposits in and around the microcirculation, (2) whether such changes involve the physiological inhibitors of TPA and plasmin, and (3) whether the presence of these activators and inhibitors of fibrinolysis in tissue is correlated with clinical outcome.

Methods And Results: We immunocytochemically quantified the presence of fibrin, plasmin, TPA, and the TPA inhibitor PAI-1 in 938 biopsies from 68 consecutive cardiac allografts over a 54-month period.

One-stage segmental resection of extensive thoracoabdominal aneurysms with left-sided heart bypass.

Purpose: The purpose of this study is to describe a technique for resection of extensive thoracoabdominal aneurysms, which the authors believe will lower morbidity and mortality rates.

Methods: In an effort to minimize the risk of spinal cord ischemia, we have used a combination of sided heart bypass (left atrium to left femoral artery) with local cooling of the intercostal and visceral arteries and segmental resection of the aneurysm. Segmental resection of the aneurysm allows perfusion of the spinal cord and abdominal viscera as the proximal anastomosis is completed and as each pair of intercostal arteries is reimplanted.

Tissue plasminogen activator in human cardiac allografts.

The activation of hemostasis and fibrinolysis frequently is observed in allografted organs. Plasminogen is activated by urokinase and tissue plasminogen activator (tPA). We have studied human hearts before and after transplantation to determine if fibrin deposition within the microcirculation is associated with a depletion of myocardial tPA, and if such depletion of tPA is associated with decreased fibrinolysis.

Immunoglobulin M antibodies in transplanted human hearts.

We have studied 56 human hearts before and after transplantation for the presence of immunoglobulin M. None of the 56 time-zero biopsy specimens studied contained immunocytochemically detectable immunoglobulin M, but they all had immunoglobulin M deposits on vascular endothelial cells after transplantation. The vascular location of immunoglobulin M was confirmed in double-antibody experiments with antibodies to von Willebrand factor and immunoglobulin M.

Ruptured abdominal aortic aneurysms in a private hospital: a decade's experience (1980-1989).

Despite refinements in elective resection of abdominal aortic aneurysms, morbidity and mortality rates for ruptured abdominal aortic aneurysms (RAAAs) remain high. Between January 1, 1980 and December 31, 1989, we treated 208 patients with RAAAs whose mean age was 70 years. The overall mortality rate was 49.

Vascular lesions in biopsy specimens devoid of cellular infiltrates: qualitative and quantitative immunocytochemical studies of human cardiac allografts.

Biopsy specimens from 80 cardiac allografts were studied immunocytochemically with nine antibodies selected to identify cellular, immunologic, and vascular aspects of rejection. Results from these experiments were converted to a numeric base and used to calculate rejection indexes for each of these aspects of rejection. Pretransplantation biopsy specimens of donor hearts were studied to determine normal values, and clinical, catheterization, and conventional biopsy findings were used to classify patients as stable or unstable.

Laboratory-clinical correlates of time-associated lesions in the vascular immunopathology of human cardiac allografts.

Ninety cardiac allograft recipients were studied for clinical and functional parameters during a 40-month period. Baseline histologic and immunocytochemical data were obtained from donors' hearts before transplantation, and serial endomyocardial biopsy specimens were studied histologically for cellular infiltrates and immunocytochemically for complement and immunoglobulin deposits and for components of the hemostatic, fibrinolytic, and natural anticoagulant pathways. Results were grouped according to the time from transplantation: the first 3 months, 4 to 21 months, and 22 to 40 months.

The learning curve and the cost of heart transplantation.

The effect of learning on hospital outcomes such as mortality or adverse events (the so-called "practice makes perfect" hypothesis) has been studied by numerous investigators. The effect of learning on hospital cost, however, has received much less attention. This article reports the results of a multiple regression model demonstrating a nonlinear, decreasing trend in operative and postoperative hospital costs over time in a consecutive series of 71 heart transplant patients, all treated in the same institution.

Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches.

Patch angioplasty of the internal carotid artery after endarterectomy has been advocated as a means of decreasing early postoperative carotid artery thrombosis, as well as reducing the incidence of recurrent carotid artery stenosis. Noninfectious rupture of saphenous vein patches in the early postoperative period has been reported by several authors, leading others to advocate the use of prosthetic patches. This report describes three patients in whom delayed bleeding through needle holes along the suture lines in polytetrafluoroethylene cardiovascular patches occurred between 1.

Natural anticoagulant pathways in normal and transplanted human hearts.

We have studied two natural anticoagulant pathways in normal and in transplanted human hearts. The first is the thrombomodulin pathway. Our immunocytochemical results show thrombomodulin localized to endothelium in heart biopsy specimens before transplantation.

Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty.

Septic complications after cardiac catheterization and percutaneous transluminal coronary artery angioplasty are distinctly uncommon. However, we have recently treated nine patients with sepsis and life-threatening complications after cardiac catheterization alone or after catheterization and subsequent percutaneous transluminal coronary angioplasty. The common denominator in all patients was either repeat puncturing of the ipsilateral femoral artery or leaving the femoral artery sheath in for 1 to 5 days after the procedure.

Death occurring within one week of cardiac transplantation: findings in eight patients.

Between October 1982 and July 1988, 85 patients underwent orthotopic heart transplantation at Methodist Hospital of Indiana. Excluding perioperative deaths, survival rates at six months, one year, two years and three years were 94%, 80%, 74% and 61%, respectively. However, eight patients (9.

Major histocompatibility antigens in transplanted human hearts before perfusion.

The expression of major histocompatibility class I and II antigens is described in human normal donor hearts before perfusion with recipients' blood. Class I and II major histocompatibility antigens were found on interstitial but not on myocardial cells. Endothelial cells accounted for most of the generic class I reactions (that is, W6/32 and beta 2 microglobulin), and endothelial cells accounted for most of the HLA-DR and -DP reactivity.

Conversion of IgG-mediated complement-dependent cytotoxicity by reducing reagents.

Reducing reagents used in complement-dependent crossmatches reduce IgM but not IgG. A positive IgM crossmatch is not an absolute contraindication to allografting. We have studied an alloantiserum from a patient with 100% panel reactive antibody awaiting heart transplantation whose serum was reduced.

Post inferior myocardial infarction ventricular septal rupture.

Mortality from ventricular septal rupture after myocardial infarction (MI) is high. Ventricular septal rupture after inferior MI is particularly associated with a high risk because of difficulty in diagnosis and surgical approach. These three case reports show how diagnosis and correction can be expedited by emergency transportation and color-flow echo-Doppler cardiography.

Transesophageal echocardiography. A technique for intraoperative monitoring.

Cardiac ischemia and myocardial infarction continue to be major causes of perioperative morbidity and mortality, despite aggressive intraoperative monitoring. Intraoperative TEE is evolving as a helpful noninvasive monitor in patients with coronary artery disease and valvular heart disease. Early detection of ischemia and evaluation of valve function with continuous imaging has allowed the use of TEE as a dynamic tool to optimize therapeutic management of cardiac dysfunction that was not always readily available by conventional invasive techniques.

Cost analysis of heart transplantation from the day of operation to the day of discharge.

Hospital costs from the day of transplantation to the day of discharge were examined in a consecutive series of 53 patients who underwent orthotopic heart transplantation between October 1982 and February 1987. An accounting cost methodology was used to convert billable charges, to costs for 29 separate hospital cost centers. Total cost per case has shown a statistically significant decrease of over $30,000 with no indication of a change in patient selection or a decrease in 3-month survival.