Biomedical subjects
Publications and source records attributed to H Dalichau.
Massive hemothorax developed in a 58-year-old man 12 hours after a left pneumonectomy. The source of bleeding was a tear in the pulmonary vein stump caused by a titanium clip that had been used during mediastinal lymphadenectomy. Postoperatively, the clip progressively sawed through the vascular wall of the pulmonary vein due to friction during the cardiac cycle.
We describe a patient requiring a HeartMate 1000 IP left-ventricular assist device (LVAD) due to cardiogenic shock. After prolonged gastrointestinal bleeding without identifying the source of bleeding technetium scintigraphy pointed to the right lower abdomen. The patient underwent a laparotomy and inflamed ileum was resected. Pathologic examination revealed cytomegalovirus ileitis. This was treated with ganciclovir and acyclovir. The patient is now (14 months later) awaiting heart transplantation since she could not be weaned from LVAD. The diagnostic and management problems are discussed as well as the relevance for future transplantation.
BACKGROUND: Results in the therapy of locally advanced non-small-cell lung cancer (NSCLC) by operation and/or irradiation only are poor. To improve the long-term prognosis a systemic induction chemotherapy may be successful in reducing local tumor burden and eliminating micrometastases. The efficacy of preoperative docetaxel-carboplatin combination chemotherapy was studied in a phase-II study for NSCLC stage IIIB. METHODS: 15 patients with functionally operable stage IIIB NSCLC (10 squamous-cell, 4 adeno, 1 large-cell) were enrolled to receive 4 cycles of docetaxel (100 mg/m2, day 1) and carboplatin (AUC 7.5, day 2) on an outpatient basis with G-CSF support after cycle 1 and were subsequently evaluated for surgery. Postoperatively the patients were irradiated with 50 Gy (R0-resection) or 60 Gy (R1-resection). RESULTS: Acceptable hematologic and non-hematologic toxicity was observed. On an intent-to-treat basis, 14 patients were evaluable for radiological response after 4 cycles of chemotherapy (1 patient still on therapy): 11/14 patients had radiological response of > or = 50%, 1/14 progressive disease, 2 exclusions because of toxic death (1 patient) and capillary leak (1 patient). Of 11 patients evaluated for surgery, 9 patients were resected, 1 patient is awaiting operation, 1 patient received radiotherapy because of an esophageal fistula. By histological findings a downstaging was achieved in 6/9 resected patients: histological complete response (CR) in 4 patients, partial response (PR) in 2, and no response in 3. With a mean follow-up of 8.1 months (excluding 1 patient in early postop course), 5/5 R0 and histological responders are alive and disease-free. Of the 3 histological non-responders, 1 patient (R1/2 resection) died of respiratory failure, 2 patients (1 R1 and 1 R0) of distant metastases. CONCLUSION: Outpatient therapy with docetaxel/carboplatin chemotherapy is effective in downstaging patients with NSCLC, toxicity is acceptable. Histological response may be the most important prognostic factor. The early results of this phase II study encourage evaluation of the long-term benefit within a prospective randomized phase III study.
In this study we have used monoclonal antibodies directed against antigens of the major histocompatibility complex (MHC) class I and class II to reveal the detailed cellular distribution of swine lymphocyte alloantigens (SLA) in cardiac tissue. By applying a sensitive immunophosphatase staining reaction we detected the ubiquitous expression of SLA class I and class II on the vascular endothelium. Endothelial cells of capillaries and blood vessels were intensely stained structures in the examined swine hearts. Similar staining patterns were observed in control experiments with anti-von Willebrand factor serum and Dolichus biflorus lectin used as immunohistochemical markers for endothelial cells. The luminal layer of studied pulmonary valves exhibited a strong staining reaction with anti-SLA class I and class II antibodies. In contrast, normal cardiac myocytes failed to express immunodetectable amounts of either of the SLA determinants. Intercalated discs in porcine heart tissue did not react with either anti-SLA class I or class II antibodies. Our data showing the abundant expression of SLA molecules on endothelial cells in normal swine heart may have physiological implications in cell-mediated rejection occurring in xenotransplanted hearts.
INTRODUCTION: Anterior ischemic optic neuropathy (AION) describes a defect of the optic nerve leading to irreversible loss of vision in most cases. Pathophysiology of this disease is manifold and has been discussed as a posthemorrhagic complication as well as a neurological complication after operations with cardiopulmonary bypass. METHODS: On the basis of two cases, the clinical picture is described in relation to the available literature. Preoperative risk factors, operative data, cardiopulmonary-bypass, postoperative complications and clinical symptoms are discussed together with ophthalmologic findings in order to elucidate the pathophysiology of this process. RESULTS: There is no reliable and effective treatment of anterior ischemic optic neuropathy. Neither corticosteroids, osmotic diuretics, hemodilution nor surgical decompression of the optic nerve have proved successful. Hence, measures to avoid ischemic optic neuropathy have priority. The following risk factors were determined: History of glaucoma or other ophthalmological problems, prolonged cardiopulmonary bypass-time and myocardial ischemia, general oedema during cardiopulmonary bypass, excessive hemodilution with low hemoglobin and hematocrit, hypo- or hypertension, systemic hypothermia, need for vasoactive medication. CONCLUSIONS: Influenced by a variety of factors, pathophysiological microvascular changes provoke anterior ischemic neuropathy with sudden painless loss of vision, irreversible in most cases. Since therapeutic trials have failed, prevention of possible causes is the only way to avoid this rare but severe complication of cardiac surgery.
Explore the source record for details and available documents.
A 79-year-old woman presented with hypovolaemic shock caused by rupture of a left renal artery aneurysm. She was successfully treated by arterial reconstruction with functional salvage of the kidney. The frequency of renal artery aneurysms, their risk of rupture and the results of urgent surgery are discussed.
A retrospective review was undertaken of 90 patients admitted to the cardiothoracic intensive care unit and who comprised 47% of all transvenous implantable cardioverter defibrillator operations performed between March 1991 and August 1995. The review aimed to evaluate the necessity for routine postoperative intensive care unit (ICU) admission after implantable cardioverter defibrillator operation. Pre-, intra- and postoperative data were analysed. Eight of 90 patients (9%) subsequently required care unique to the ICU. None of the variables examined, including the Acute Physiology Score (APACHE II system), was helpful in identifying patients who required unique ICU services. Patients undergoing transvenous implantable cardioverter defibrillator surgery are identified as a low risk group requiring in over 90% of cases monitoring services rather than active therapy in an ICU. As no reliable predictors seem to exist to identify the necessity for postoperative ICU admission, cardioverter defibrillator implantations should only be performed in hospitals where adequate facilities are readily available.
OBJECTIVE: Pretransplant pulmonary vascular resistance > or = 4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires longer ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemodynamics in pts with high preoperative pulmonary vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart transplantation transplanted between 12/88 and 7/94. Of these, 18 with total and 15 with standard orthotopic heart transplantation had a preoperative pulmonary vascular resistance > or = 4 Wood-units. METHODS: Right heart catheterization data were obtained at each endomyocardial biopsy. All data from biopsies at both 2 weeks and 1 year posttransplant that were free from humoral or greater than 1A cellular rejection (9 versus 13 pts) were included in a two way ANOVA. Pts with postop pacemakers, atrial fib or beta-blocker therapy at the time of biopsy were excluded. RESULTS: Ischemic time was different (172 +/- 44 versus 142 +/- 28 min, P = 0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output and index were higher in the total orthotopic group at 2 weeks (6.5 +/- 1.7 versus 5.1 +/- 1.0 l/min; 3.4 +/- 0.9 versus 2.8 +/- 0.6 l/min per m2) and 1 year (7.1 +/- 2.0 versus 4.9 +/- 1.1 l/min, P = 0.002; 3.6 +/- 1.1 versus 2.6 +/- 0.5 l/min per m2, P = 0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orthotopic heart transplantation at 2 weeks (6 +/- 4 versus 9 +/- 5, P = 0.04; 22 +/- 3 versus 25 +/- 7, P = 0.1) and 1 year (5 +/- 2 versus 7 +/- 3, P = 0.02; 19 +/- 4 versus 25 +/- 7, P = 0.03). Pulmonary capillary wedge pressure (mmHg) was borderline nonsignificant (11 +/- 4 versus 13 +/- 7 at 2 weeks, 8 +/- 3 versus 14 +/- 5 at 1 year, P = 0.055), as well as pulmonary vascular resistance (1.9 +/- 1 versus 2.5 +/- 1 at 2 weeks, 1.5 +/- 0.6 versus 2.7 +/- 1.7 WU at 1 year, P = 0.051). CONCLUSIONS: Total orthotopic heart transplantation improves cardiac output and index in pts with high preoperative pulmonary vacular resistance. There is a lower mean RA and PA pressure perhaps due to less tricuspid and mitral regurgitation. In view of the frequently observed restrictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsided by preserving atrioventricular synchrony and offering better atrial transport.
We have performed a retrospective review of our experience with the intraaortic balloon counterpulsation pump (IABP) during the last decade, to identify aspects of risk factors, complications, and management that affect peripheral vascular morbidity and mortality. Data from 472 patients who had the IABP inserted during the ten-year period from December 1985 to December 1995 were retrospectively reviewed. Risk factors, implantation techniques, complications, and significant variables were evaluated. One hundred forty-five vascular complications needed surgical therapy in 116 patients. Mean age was 62.2 +/- 12.9 years. There were 84 (72.5%) men and 32 (27.5%) women. Mortality rate was 28.3% (n = 181). The mortality for patients with ischemic vascular complications was significantly higher than in patients who did not suffer any vascular complication (59.6% vs 30.1%, p = 0.0001). Complications included acute limb arterial occlusion in 99 cases (68.3%), compartment syndrome in 27 (18.6%), groin hematoma in 15 (10.3%), and persistent lymph fistula in 4 (2.8%). Of these, 97 (76.9%) occurred during IABP therapy and 29 (23.1%) after IABP explantation. Thromboembolectomy was required for 61 (42.2%) of the ischemic limbs. Associated procedures were 24 (16.5%) profundaplasties, 10 (7%) infrainguinal bypasses (5 (3.4%) femoropopliteal supragenicular, 3 (2.2%) femoropopliteal infragenicular, and 2 (1.4%) infrapopliteal), 26 (17.9%) fasciotomies, and 5 (3.4%) amputations. A history of peripheral vascular disease (31 patients [43.6%] with vs 95 [23.6%] without, p < 0.05) and the presence of diabetes mellitus (70 patients [49.2%] with vs 56 [16.9%] without) increased the risk of limb ischemia significantly. Female sex, insertion of IABP by percutaneous technique, and direct removal with groin compression were associated with higher ischemic complication rates, the differences however were not significant. Itis concluded that 1. Limb ischemia remains the primary complication after IABP insertion; 2. Femoral artery thromboembolectomy is usually sufficient for revascularisation; 3. Adequate implantation and surgical explantation techniques are essential to reduce the IABP-related morbidity; 4. Identification of subclinical disease may aid in the management of subsequent acute limb ischemia; 5. The presence of peripheral vascular disease and diabetes mellitus are associated with higher ischemic complication rates.
The effective treatment of refractory allograft rejection with murine antihuman monoclonal antibody muromonab-CD3 (OKT3) and of patients with renal dysfunction has led to its use as induction therapy. The optimal protocol for OKT3 prophylaxis remains to be established. We compared 59 patients consecutively transplanted with the total orthotopic technique between 1/92 and 5/94. The first 21 patients were treated with OKT3 for 14 days, the next 19 for 10 days, and the last 19 for 7 days. Patients operated with different surgical techniques or other induction treatment were excluded. We compared length of stay (total and ICU), time to first rejection, rejection incidence and infection incidence (cytomegalovirus separately), and survival. Preoperative characteristics were similar except for significantly younger age in the 10-day group (p = 0.04). Preoperative hemodynamic parameters were similar except for a significantly higher left-ventricular ejection fraction (21%) in the 7-day group. Length of stays in the ICU and hospital were similar for the three groups (p = NS). Freedom from cellular rejection was lower with the 7 days course (p = 0.02), but freedom from humoral rejection was slightly higher (p = 0.11). However, patients in the 7-day group required treatment for rejection less frequently than patients in the other two groups (95% untreated at 2 months vs. 43% in the 14-day and 53% in the 10-day group; p = 0.002). There were no differences in incidence of infections, including cytomegalovirus. Survival was similar between the groups. There was one death in the 14-day and 1 in the 10-day group, both due to rejection. In conclusion, OKT3 therapy can be reduced safely to 7 days with a higher overall incidence of rejection but no increased necessity to treat for rejection, and no difference in infection incidence.
Acute renal failure (ARF) is a serious complication following cardiac surgery. This first controlled study was undertaken to verify, if Urodilatin (URO) infusion can revert incipient oliguric ARF after cardiac surgery. We conducted a randomized, double blind trial comparing 7 URO (20 ng/kg/min) with 7 placebo patients. Inclusion criterion was oliguria/anuria (< 0.5 ml/kg/hour) refractory to conventional treatment including administration of dopamine and furosemide. No patient in the URO treated group, but 6 patients in the placebo group had to be hemofiltered or hemodialyzed (p < 0.005) during the 7 day treatment period. In the URO group all 7 patients demonstrated a rapid recovery of diuresis after 2 - 8 hours of treatment that persisted throughout the treatment period. In contrast, placebo treated patients remained oliguric. Serum creatinine (SC) decreased in URO treated patients. No adverse effects were observed during URO administration. After termination of URO, 2 patients underwent hemodialysis for elevated blood urea nitrogen (BUN) values. In the postoperative follow-up period of 60 days, 4 out of 7 placebo treated patients died while still on hemodialysis. In contrast, all URO patients survived. URO is an effective drug to reverse oliguric ARF following cardiac surgery. Prolonged renal failure and renal replacement therapy can be avoided.
The Toronto SPV bioprosthesis for aortic valve replacement has been prospectively evaluated in 100 patients, since March 1993. Intraoperative transoesophageal and postoperative transthoracic echocardiography were used to assess valve function. Follow-up was complete in 74 patients at 6 months and in 38 patients at 1 year. The average valve size implanted was 26.5 mm. Some 37 patients had additional coronary artery bypass grafting surgery. The hospital mortality rate was 4%. Non-structural valve dysfunction occurred in one patient and late endocarditis in another patient required operation. There were no other valve complications. None of the patients developed clinically relevant aortic valve incompetence during follow-up and there was a significant decrease in pressure gradients, increase in valve orifice areas and decrease in left ventricular hypertrophy.
The purpose of this study was to determine whether elective abdominal aortic aneurysmectomy in octogenarians is justified or may even be advisable. Between January 1986 and August 1993, 30 octogenarians of mean age 83.1 (range 80-93) years underwent abdominal aortic aneurysmectomy. Patients were divided into two groups: group 1 (n = 9) underwent elective surgical repair; group 2 (n = 21) underwent emergency procedure. In 28 patients location of the abdominal aortic aneurysm was infrarenal; two patients presented with a juxtarenal aneurysm. The average aneurysm diameter was similar in both groups (group 1, 68.8 mm; group 2, 83.5 mm, P = n.s.). In group 2, two patients had free peritoneal rupture, one presented with rupture into the duodenum and one with penetration into the vena cava. Rupture was confined to the retroperitoneum in another 15 patients. Two patients had an expanding aneurysm. Hospital mortality rate was zero in group 1 and 42.8% in group 2 (P = 0.011). Most early deaths were related to cardiac disease. The overall complication rate was 22% in group 1 and 62% in group 2. Mean intensive care unit time was 1.8 (range 1-3) days in group 1 and 3.6 (range 1-8) days in group 2 (P = 0.47). The 5-year survival rate was 67% in the electively managed group and 34% in the emergency group.
A modified monoethylglycinexylidide (MEGX) test was performed in 14 patients undergoing myocardial revascularization to evaluate liver function during cardiopulmonary bypass (CPB). MEGX is the principal metabolite of lidocaine. Different studies have shown a decrease in MEGX formation in patients with impaired liver function. Following a low-dose bolus application of 0.3 mg/kgBW lidocaine MEGX concentrations were measured in five-minute intervals for half an hour. This was done once before and once during CPB. Arterial and hepatic vein blood samples were obtained in order to avoid the effects of hemodilution by CPB priming. Hepatic blood was calculated using the indocyanine green (ICG) infusion extraction technique. MEGX formation during CPB decreased. After the 10 and 15 minutes measurement points the mean arterio-hepatic venous concentrations were 61 +/- 7.2 micrograms/L and 63 +/- 7.3 micrograms/L respectively in comparison to pre-CPB values of 36 +/- 5.8 micrograms/L and 42 +/- 5.1 micrograms/L. Hepatic blood flow increased insignificantly from a mean of 835 +/- 54 ml/min prior to CPB to 913 +/- 83 ml/min during CPB. As a result the MEGX clearance calculated 15 minutes after administration of lidocaine bolus application did not differ significantly before (51.2 +/- 6.4 micrograms/min) and during CPB (40.2 +/- 5.7 micrograms/min). In conclusion, a decrease in MEGX formation was found during CPB. However, due to increased hepatic blood flow there was no significant change in MEGX clearance before and during CPB.
Rejection remains a major problem after cardiac transplantation. One hypothesis is that transfer of recipient HLA genes could lead to expression of the antigens on the surface of donor cells and so facilitate graft acceptance. This paper describes a pilot study for relevant gene-transfer (transfection) experiments on adult cardiac myocytes, investigating the feasibility of transfection using cationic liposomes. The plasmid pcDV1-pL2 vector containing HLA-DR-alpha chain gene was incubated with Lipofectin, a DOTMA and DOPE lipid mixture, for 10 minutes. Embryonic chick cardiac myocytes (ECCM) and COS7 monkey cells were incubated with DNA: Lipofectin ratios of 1:1, 1:2, 1:4, and 1:10 for 16 hours (hrs). Using a fixed ratio of 1:4, incubation periods of 4, 8, and 16 hrs were compared. Finally, cells were incubated for 16 hrs and consecutively cultured for 6 days. Expression of the HLA-DR-alpha chain antigen was detected by indirect immunohistochemical staining. Highest transfection rates were achieved with a DNA: Lipofectin ratio of 1:4 for ECCM and COS7 cells (2.7% +/- 0.6% and 2.4% +/- 0.3% after 16 hrs incubation) and a transfection time of 4 hrs (5.8% +/- 0.6% and 5.3% +/- 1.7%). Immunohistochemically positive cells were present after 6 days (2.0% +/- 1.2% and 2.1% +/- 0.3%). We found a low level of expression of HLA-DR-alpha chain gene, influenced by transfection time and DNA: Lipofectin ratio. To increase the efficiency of liposome-mediated gene transfer and assess potential applications in cardiac transplantation, further investigation of cell properties promoting transfection is necessary.
In follow-up examinations of young patients we often noticed upward displacement of the left shoulder in cases where left-sided posterolateral thoracotomy had been carried out. Finding little discussion of this side-effect in the literature, we undertook the present study. The shoulder girdle of 69 patients who had undergone surgery for coarctation of the aorta between 1964 and 1984 was carefully examined to assess displacements and dysfunctions. In addition, in 24 of the patients electrodiagnostic examination was carried out of the associated muscles and nerves which were affected by the operation. We found disturbances of the muscular apparatus of the shoulder girdle in 80% of the cases: upward displacement of the shoulder (55%), downward displacement of the shoulder (8.7%), deviation of the scapula at rest (72.5%) and maximal elevated arms (40.6%), scapula alata (56.5%), and alterations of the posterior axillary line (39.1%). When considering only the cases of distinct upward or downward displacement of the shoulder, at least 25% of the operated children were affected. Children operated early (surgery during the first year of life) had more distinct alterations (47.6%) than those with later surgery (14.6%). Electromyographic examinations indicate that mainly disorders of the peripheral nerves caused by the operation led to these alterations of the shoulder girdle musculature. Although, except for one patient, no functional disorders were found, there were several cases in which the alteration caused quite severe cosmetic problems. One should pay more attention to positioning for surgery and do careful preparation to reduce these sequelae.
Total orthotopic heart transplantation (TOHT) requires longer surgery than standard orthotopic heart transplantation (SOHT), but offers normal anatomy and synchronous atrial contraction. We endeavored to test whether TOHT improves resting hemodynamics. We analyzed 60 patients with SOHT and 66 with TOHT transplanted between 12/89 and 7/94. Age, preoperative NYHA class, ejection fraction, and donor characteristics were similar. After applying exclusion criteria at 2 weeks postoperatively, 53 SOHT and 58 TOHT patients were accepted for further study. Right-heart hemodynamics were examined at 2 weeks and 6 months posttransplant. Despite a longer ischemic time (161 +/- 36 vs. 142 +/- 37 min, p = 0.004), cardiac output and index were higher in the TOHT group at 2 weeks (6.1 +/- 1.4 vs. 5.4 +/- 1.0 L/min, TOHT vs. SOHT, p = 0.01; and 3.3 +/- 0.7 vs. 2.9 +/- 0.6 L/min/m2, p = 0.005) but similar at 6 months (5.9 +/- 1.2 vs. 5.6 +/- 1.4 L/min; and 3.0 +/- 0.6 vs. 2.9 +/- 0.7 L/min/m2). Right-atrial pressure was lower with TOHT at both time points (7 +/- 4 vs. 9 +/- 4 mmHg, p = 0.02: and 5 +/- 2 vs. 7 +/- 3, p = 0.0006). Wedge pressure was similar at 2 weeks (12 +/- 5 vs. 13 +/- 5, p = 0.045). Heart rate (bpm) was higher at both time points with TOHT (84 +/- 10 vs. 75 +/- 12, p = 0.0003: and 90 +/- 12 vs. 82 +/- 9, p = 0.0006). Pulmonary vascular resistance was similar at both time points. Despite a longer ischemic time, total orthotopic heart transplantation does not impair postoperative cardiac function. There is an early improvement in cardiac output, a sustained higher heart rate reflecting preservation of donor sinus node function, and a lower right-atrial pressure.