Cardiac surgery and congenital heart disease: reflections on a modern revolution.

The success of cardiac surgery has transformed the prospects of children with congenital heart disease with over 90% now surviving to adulthood. The early pioneering surgeons took on significant risk, whilst current surgical practice emphasises safety and consistency. In this article we review important British contributions to the field and consider challenges for the future, specifically how to better manage and reduce the adverse sequelae of congenital cardiac surgery by continuing to innovate safely.

Combined heart-lung transplantation from a donation after circulatory death donor.

Combined heart-lung transplantation is the optimal treatment option for many patients with end-stage heart failure and fixed severe pulmonary hypertension. It offers the only possibility of long-term survival and a return to a normal quality of life. Unfortunately, it is rarely performed because of donor organ allocation policies.

Surgical technique for heart transplantation: a strategy for congenital heart disease.

The standard techniques for orthotopic heart transplantation often require certain adjustments when the procedure is carried out for complex congenital heart disease. This is because of both the unusual anatomy and possible distortions caused by previous surgery. Such technical adjustments have been described in various published reports over the years.

What are the predictors that affect the excellent long-term benefits of redo coronary artery bypass grafting?

Objective: Recurrent angina refractory to medical therapy in patients having undergone prior coronary artery bypass grafting (CABG) is an indication for repeat surgical revascularisation. The primary aim of this retrospective study was to determine the benefit of redo surgery over the longer term with regards to survival and freedom from cardiac symptoms/events. Our secondary aim was to identify risk factors that compromise surgical efficacy of redo revascularisation.

Deposition of C4d and C3d in cardiac transplants: a factor in the development of coronary artery vasculopathy.

Background: Coronary artery vasculopathy (CAV) is the major life-limiting factor in cardiac transplantation, after 1 year. Antibody-mediated rejection (AMR) has been associated with development of both acute and chronic rejection. We analyzed endomyocardial biopsies for pathologic markers of AMR (C4d and C3d), from the first 2 years post-transplantation, to determine complement deposition in relation to the development of CAV.

Leiomyosarcoma of the retrohepatic vena cava treated by excision and reconstruction with an aortic homograft: a case report and review of literature.

Leiomyosarcoma of the retrohepatic inferior vena cava is a rare entity and presents a number of diagnostic and therapeutic challenges. Here such a case is presented in which the retrohepatic inferior vena cava was excised after full mobilization of the liver under venovenous bypass. The continuity of the vena cava was restored with cryopreserved aortic homograft.

Revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection.

In 1990, an international grading scheme for the grading of pulmonary allograft rejection was adopted by the International Society for Heart and Lung Transplantation (ISHLT) and was modified in 1995 by an expanded group of pathologists. The original and revised classifications have served the lung transplant community well, facilitating communication between transplant centers with regard to both patient management and research. In 2006, under the direction of the ISHLT, a multi-disciplinary review of the biopsy grading system was undertaken to update the scheme, address inconsistencies of use, and consider the current knowledge of antibody-mediated rejection in the lung.

Acute leukaemoid reaction following cardiac surgery.

Chronic myelomonocytic leukaemia is an atypical myeloproliferative disorder with a natural history of progression to acute myeloid leukaemia, a complex and poorly understood response by the bone marrow to stress. Cardiac surgery activates many inflammatory cascades and may precipitate a systemic inflammatory response syndrome. We present a case of undiagnosed chronic myelomonocytic leukaemia who developed rapidly fatal multi-organ dysfunction following cardiac surgery due to an acute leukaemoid reaction.

Is obliterative bronchiolitis in lung transplantation associated with microvascular damage to small airways?

Background: Acute rejection, a vascular-based disorder, has been identified as the major risk factor for obliterative bronchiolitis (OB), an airway-based pathology. This study investigated the hypothesis that changes to the microvascular blood supply of small airways were associated with the development of OB, thus providing a possible link between an acute vascular insult (acute rejection) and chronic airway changes (OB).

Methods: Microvasculature of 695 small airways (99 patients) was assessed in post-mortem lung allograft specimens using monoclonal antibodies for von Willebrand factor and CD31.

APT070 inhibits complement activation during in vitro cardiopulmonary bypass.

Background: The proteins of the complement cascade play an important role in inflammation and the immune response. They have been shown to be activated during cardiopulmonary bypass (CPB), and may be responsible for the inflammatory response to CPB. We looked at the effect of APT070, an anti-complement agent, on human blood during in vitro CPB.

The cumulative effect of acute rejection on development of cardiac allograft vasculopathy.

Background: Acute rejection increases the inflammatory burden of the transplanted organ and predisposes to cardiac allograft vasculopathy (CAV). In this study we aim to determine the magnitude of the association, and to differentiate between the effects of mild vs severe rejection episodes.

Methods: Between 1988 and 2003, 489 1-year survivors of heart transplantation underwent 1,435 angiograms.

The outcomes of lung transplantation in patients with bronchiectasis and antibody deficiency.

Background: Lung transplantation is an established treatment for end-stage bronchiectasis. A proportion of patients with bronchiectasis have an associated antibody deficiency. This group benefits from immunoglobulin replacement therapy, but the outcome of lung transplantation is not known.

Does heart transplantation confer survival benefit in all risk groups?

Background: Over 50,000 heart transplants have been performed in the last 3 decades. The global shortage of donor organs and the relaxation of candidate selection criteria over time has resulted in recent controversy about the benefits of heart transplantation for some risk groups. We assessed the survival benefit acquired in the Papworth Hospital heart transplant population overall, taking into account resuscitated marginal donors and high-risk recipients.

Comparison of survival by allocation to medical therapy, surgery, or heart transplantation for ischemic advanced heart failure.

Background: To ascertain survival of ischemic advanced heart failure patients by treatment allocation, we examined the outcome of transplant assessment patients allocated to medical therapy, high-risk conventional surgery, or transplantation.

Methods: Patients were identified from the Papworth transplant database and excluded if primary etiology was not ischemic. Grouping was undertaken according to treatment allocation at initial assessment, and analysis was performed by intention to treat.

Angiogenesis occurs within the intimal proliferation that characterizes transplant coronary artery vasculopathy.

Background: Vascular remodeling is central to the development of transplant coronary artery vasculopathy (CAV). For remodeling to occur, a sustained blood and nutrient supply is essential. Here we report on the presence of angiogenesis within the neointima of coronary arteries from cardiac transplant recipients.

Short- and long-term outcomes of using pulmonary allograft donors with low Po2.

Background: The establishment of lung transplantation as a treatment modality for end-stage lung disease has led to an imbalance in the demand and supply for such a procedure. Increasingly marginal donors are being accepted for transplantation. We assessed the short- and long-term outcomes with the use of lung donors with low Po(2).

Early mortality after cardiac transplantation: should we do better?

Background: According to International Society for Heart and Lung Transplantation (ISHLT) data, the 30-day survival after heart transplantation has continually improved from 84% (1979-85) to 91% (1996-2001). This has probably been achieved by better donor/recipient selection, along with improved surgical technique and immunosuppressive therapy. On the other hand, the data concerning the early causes of death after cardiac transplantation is incomplete, because in 25% of cases, an unknown cause is listed.

A versatile technique for aortic root replacement without pre-manufactured composite graft: a 12-year experience.

Background And Aim Of The Study: Replacement of the aortic root is the treatment of choice for aneurysmal dilatation. Many modifications of the Bentall technique have been described, as have valve-sparing procedures. The study aim was to determine the outcome of a versatile modification of composite replacement that has been adopted over the past 12 years.

Replacement of a regurgitant pulmonary valve with a stentless bioprosthesis.

Acquired surgical disease of the pulmonary valve is rare. We report a 72-year-old man who presented with subacute endocarditic pulmonary regurgitation. This lesion was surgically corrected with a stentless bioprosthesis.

Microvascular changes in small airways predispose to obliterative bronchiolitis after lung transplantation.

Background: There is strong evidence that obliterative bronchiolitis (OB) in lung transplant recipients is related to acute rejection as graded by parenchymal perivascular infiltrates. OB (chronic rejection) is a small airways, rather than a parenchymal, scarring process. Moreover, there has been no study of the microcirculation in the small airways in lung transplantation.

Neointimal smooth muscle cells in human cardiac allograft coronary artery vasculopathy are of donor origin.

Background: Transplant coronary artery vasculopathy (CAV) is a fibro-proliferative process that leads to lumen occlusion and cardiac failure. Current theories suggest that the process evolves over time in response to inflammation and proliferation of donor derived medial smooth muscle cells (SMC). Animal models of cardiac transplantation have suggested that the neointima is formed by recipient derived circulating progenitor cells.