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Biomedical subjects

L S Czer

Publications and source records attributed to L S Czer.

At least 91 records · Page 5Linked to original sources
PubMed1984

Mitral valve replacement: impact of coronary artery disease and determinants of prognosis after revascularization.

From 1969 to 1982, 419 patients underwent single mitral valve replacement; of these, 48% had associated coronary artery disease (9% single vessel, 8% double vessel, 28% triple vessel, 3% left main). In 216 patients with no associated coronary disease, in 179 patients with coronary disease that was revascularized, and in 24 patients with coronary disease that was not revascularized, the 30 day mortalities were 4.2%, 13.9%, and 29.2% (p less than .05) after valve replacement. Actuarial survivals at 8 years were 68%, 44%, and 15%, respectively (p less than .01), with 1 to 165 months of follow-up (mean 52). After matching the three cohorts of patients in age, sex, left ventricular ejection fraction, and valve lesion, the presence of associated coronary artery disease decreased long-term survival and revascularization improved survival (p less than .05 for both). Incidental coronary disease in patients with rheumatic mitral valve disease had a significant negative influence on survival if left unbypassed (p less than .05); after revascularization and valve replacement, the 30 day mortality was 7.3% and the 8 year survival was 52%. Coronary disease etiologically related to ischemic mitral regurgitation identified a high-risk group of patients, with a 30 day mortality of 19.6% and an 8 year survival of 37% after the combined procedure. A multivariate logistic regression model was used to determine which preoperative and intraoperative variables predicted early and late outcome after combined mitral valve replacement and coronary revascularization. Predictors of early death were advanced age (greater than 60 years), New York Heart Association functional class (IV), an ischemic etiology of the mitral valve disease, and a depressed left ventricular ejection fraction (less than 55%). Predictors of late death were triple-vessel or left main coronary disease, increased left ventricular end-diastolic volume (greater than 120 ml/m2), and depressed left ventricular ejection fraction (less than 55%). These findings highlight the important etiologic and prognostic role of coronary artery disease in patients requiring mitral valve replacement.

Adolescent↗
PubMed1983

Regional distribution of pulmonary blood volume: an index of pulmonary capillary wedge pressure determined from blood pool scintigraphy.

Progressive redistribution of pulmonary blood flow to the lung apices occurs with increasing degrees of left ventricular failure, and correlates with increasing pulmonary capillary wedge pressure (PCWP). If similar changes in pulmonary blood volume (PBV) occur, then technetium-99m equilibrium blood pool scintigraphy, by assessing relative distribution of PBV, may allow prediction of PCWP. Therefore 30 patients being monitored with pulmonary artery balloon flotation catheters underwent imaging. PCWP was compared with the average radioactive count density arising from apical (A) and basal (B) regions of interest within the right lung, expressed as an A/B ratio. Correlation was strong for patients imaged erect, either posteriorly (r = 0.864, p = 0.001) or in the 45 degrees left anterior oblique position (r = 0.842, p = 0.001), and only slightly less impressive for patients imaged supine (r = 0.678, p = 0.001). Especially when imaging was performed with patients erect, an A/B ratio greater than unity identified with high sensitivity (100%) and specificity (83 to 88%) an abnormally elevated PCWP (greater than 12 mm Hg). Moreover, directional changes in the A/B ratio reflected concomitant changes in PCWP after intervention. Thus, analysis of lung A/B radioactive count ratios obtained by equilibrium blood pool scintigraphy may be used to evaluate PCWP.

Adult↗
PubMed1983

Arrhythmias and conduction disturbances following cardiac operation for the removal of left atrial myxomas.

Between September, 1971, and April, 1982, 11 patients (seven female) with left atrial myxomas underwent surgical resection at Cedars-Sinai Medical Center. The tumors ranged in size from 4 to 9 cm (mean 6.3 cm) and were attached to the interatrial septum (four superiorly, four inferiorly), the free atrial wall (one posteriorly, one at the dome), or both (one). Although all patients were symptomatic preoperatively, arrhythmias were uncommon; only one had chronic atrial fibrillation, and two others had had single episodes of paroxysmal atrial fibrillation in the immediate preoperative period. Early postoperatively, all but one patient had episodes of atrial fibrillation (eight patients), atrial flutter (four patients), junctional rhythm (six patients), sinus arrest (two patients), or complete heart block (three patients). Ten patients required antiarrhythmic therapy, and two required permanent pacemaker implantation. After a mean follow-up of 48 months (range 7 to 124), seven patients continue to have episodic or chronic supraventricular arrhythmias, with only three patients not using antiarrhythmic drugs regularly. The pathophysiological basis for these arrhythmias is unclear, but some patients appear to have sustained injury to the sinus node or atrioventricular node, while others have developed interatrial or intra-atrial conduction delays. Attention should be directed to the basis of these arrhythmias and conduction disturbances, as surgical technique may be the major determinant of this early and late postoperative complication.

Adult↗
PubMed1980

Pathogenesis of respiratory failure (ARDS) after hemorrhage and trauma: I. Cardiorespiratory patterns preceding the development of ARDS.

To evaluate clinical and physiologic determinants of adult respiratory distress syndrome (ARDS), we studied 152 consecutively monitored patients with trauma and hemorrhage: 60 developed ARDS. The cardiorespiratory patterns of hemorrhage and trauma patients who did not develop ARDS were compared to those who subsequently did develop ARDS, but before the time of their ARDS. Comparisons also were made in the patients with trauma and those with hemorrhage, as well as in those who survived and those who did not. Hemorrhage and trauma patients who developed ARDS had greater reductions in blood volume, red cell mass, PaCO2 and O2 delivery throughout all stages, as well as greater pulmonary vascular resistance index (PVRI) and pH in the early and middle stages. Nonsurvivors of ARDS had greater deficits in blood volume and red cell mass, higher PVRI and pH, as well as lower central venous pressure (CVP), hemoglobin (Hgb), and PaCO2 than did ARDS survivors. Hemorrhage patients had lower blood volume, left ventricular function, O2 delivery and VO2, as well as higher systemic vascular resistance index (SVRI), PVRI, and O2 extraction than either the trauma patients or normal subjects. Description of the temporal cardiorespiratory patterns before the clinical appearance of ARDS showed the progressive appearance of these deficits beginning 36 h before the hypoxemia was observed. The data are consistent with the concept that ARDS after hemorrhage and trauma is preceded by hypovolemia, reduced myocardial performance, inadequate O2 delivery, and inadequate O2 extraction needed to maintain VO2 at the elevated levels demanded by the increased metabolic requirements of the injured patients. Thus, the so-called shock lung is a complication of shock associated with hypovolemia, hypoxemia, and inadequate cardiac compensatory responses to increasesd O2 demands.

Female↗
PubMed1980

Pathogenesis of respiratory failure (ARDS) after hemorrhage and trauma: II. Cardiorespiratory patterns after development of ARDS.

Hemodynamic and oxygen transport variables were studied in a series of 60 patients who sustained adult respiratory distress syndrome (ARDS) from hemorrhage and trauma; measurements were made during the period of their ARDS and in survivors after their recovery from ARDS. In general, cardiac index (CI) and myocardial performance were increased over normal values; they were greater in trauma patients than in hemorrhage patients and greater in the survivors than in nonsurvivors. The mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) were high in all groups. Blood volume and hemoglobin (Hgb) concentrations were reduced especially in the nonsurviving hemorrhage patients; hemoglobin saturation (SaO2) and oxygen tension (PaO2) were low initially, but usually responded to therapy; oxygen consumption (VO2) was normal or high in all groups, and was greater in survivors than in nonsurvivors, and greater in trauma than in hemorrhage. Thus, the patient with post-traumatic ARDS has circulatory and metabolic needs which are greater than normal values defined by values from healthy unstressed volunteers and also somewhat greater than hemorrhage and trauma patients without ARDS. Optimal blood volume, hemodynamic and oxygen transport values defined by the survivor's values as well as the standard respiratory care are recommended as goals for preventive or ealy therapy of these patients. Volume therapy should be given provided it does not elevate the pulmonary arterial wedge pressure (WP) above 18 mm Hg to avoid overloading the pulmonary vascular bed and causing pulmonary edema.

Female↗
PubMed1980

Myocardial performance in critically ill patients: response to whole blood transfusion as a prognostic measure.

The standardized stroke work, which is derived from the left ventricular stroke work (LVSW) and the pulmonary capillary wedge pressure (WP), is presented as a convenient index for tracking changes in the overall cardiac function and relating these changes to other cardiorespiratory variables. This index and its response to whole blood transfusion were used to assess cardiac function in 102 critically ill patients with hemorrhagic or traumatic shock. Survivors had greater mean values of the standardized stroke work before, during, and after transfusion than did the nonsurvivors (p < 0.05). Moreover, the maximal change in standardized stroke work in response to transfusion was greater in survivors than in nonsurvivors (p < 0.05): this response was found to be dependent on the stage of shock. The experience of the authors with this index suggests that it is a useful way to follow changes in myocardial performance in critically ill patients over time, and in quantitating changes in myocardial function after whole blood transfusion or other forms of volume therapy.

Adult↗
PubMed1978

Optimal hematocrit value in critically ill postoperative patients.

Failling hematocrit values are traditionally used to observe the course of active bleeding, since hematocrit values usually reflect acute blood losses. However, evidence from the literature suggests that, after volume replacement, some degree of normovolemic hemodilution may be desirable and that return to normal hematocrit values is not necessarily the appropriate goal of transfusion therapy. The optimal hematocrit value was defined empirically by three methods in a series of 94 critically ill postoperative patients. First, the mortality rates of postoperative patients were lowest with hematocrit values between 27 and 33 per cent. Second, mortality rates were examined when both hematocrit values and the important cardiorespiratory variables were reduced; significantly increased mortalties occurred when hematocrit values were less than an average of 32 per cent. Finally, oxygen availability and oxygen consumption increased significantly after whole blood and packed red cell transfusions were given when hematocrit values were less than 32 per cent but not above 33 per cent. When accurate blood volume measurements are not available, hematocrit values of 32 per cent are optimal; when volume therapy is indicated, blood may be given with hematocrit values less than 32 per cent, crystalloids or colloids are preferred with hematocrit values greater than 32 per cent.

Adult↗
PubMedDate not supplied

An update on transplantation in the geriatric heart transplant patient.

Discussions of the ethics involved in allocating scarce resources often proceed without a grounding in factual experience. This study explored whether there was statistical evidence to support the use of set age limits in patient selection criteria for heart transplantation. Many transplant teams have selection criteria that include age limits, excluding patients more than 60 or 65 years of age from being considered as transplant candidates. The hypothesis was made that patients in the age bracket of 60-69 should have a comparable success rate with transplantation to that of younger recipients when selected by using the same medical and psychiatric criteria. Based on their clinical observations, the authors postulated that the elderly would report better quality of life postoperatively than younger control subjects.

Adolescent↗
PubMedDate not supplied

Hemodynamic adaptation to orthostatic stress after orthotopic heart transplantation.

OBJECTIVES: The purpose of this study was to compare the effects of orthostatic stress on cardiovascular stability in heart transplant recipients early and late after transplantation and in healthy controls. BACKGROUND: After transplantation, cardiac reinnervation is heterogeneous, with reports of sympathetic reinnervation after 5 months and parasympathetic reinnervation after 2 to 3 years. METHODS: Sixteen heart transplant recipients early (less than 5 months) after transplantation, 17 recipients late (1 year or more) after transplantation, and 16 matched healthy controls were subjected to 45 minutes of passive upright tilt, with the following variables measured before, during, and after the procedure: cardiac output, heart rate, stroke volume, mean arterial pressure, systemic vascular resistance, and plasma norepinephrine. RESULTS: At rest, heart rate (p < 0.0005) and mean arterial pressure (p = 0.003) were higher, and stroke volume was lower (p < 0.0005), in transplant recipients than they were in controls. With orthostasis, heart rate increased by 30% in controls and by 23% in the late posttransplantation group compared with 13% in the early posttransplantation group (p = 0.028); drop in stroke volume was three times more among controls than among those in either transplantation group (p < 0.001); late transplant recipients had higher norepinephrine increases than did the other two groups (p = 0.012). CONCLUSION: With the exception of heart rate, patterns of hemodynamic response to orthostatic stress after transplantation remain consistent over time and differ from controls. Among transplant recipients, higher mean arterial pressure mitigates the force of gravity and prevents drops in stroke volume. Clinicians may anticipate that transplant recipients will tolerate postural maneuvers well. Later after transplantation, however, orthostatic tolerance is associated with increased norepinephrine release, consistent with enhanced sympathoactivation.

Adaptation, Physiological↗
PubMedDate not supplied

Evidence of time-dependent autonomic reinnervation after heart transplantation.

BACKGROUND: Confirming the clinical significance of reinnervation is important in understanding and anticipating how heart rate (HR) responses of transplant recipients to physiologic stress differs early and late after transplant from that of normal individuals. OBJECTIVES: To evaluate the functional significance of cardiac reinnervation early and late after heart transplantation. METHODS: Handgrip and deep breathing tests, passive 80 degrees head-up tilt, and heart rate (HR) responsiveness of 33 transplant recipients (n = 16 at < 5 months and n = 17 at > 1 year after transplant) were compared with those of 16 age- and sex-matched control participants. RESULTS: HR responses to handgrip and passive tilt were absent early after transplant. HR acceleration normalized but was blunted late after transplant. These findings are consistent with late (>1 year) sympathetic reinnervation in transplant recipients. CONCLUSIONS: When caring for transplant recipients, nurses should consider the time elapsed since transplant in evaluating HR responsiveness to common procedures and interventions.

Analysis of Variance↗
PubMedDate not supplied

Cytokine expression and endothelial cell and lymphocyte activation in human cardiac allograft rejection: an immunohistochemical study of endomyocardial biopsy samples.

We used monoclonal antibodies and immunohistochemical staining of frozen tissue sections to study the expression of cytokines in human cardiac allograft rejection. The 113 endomyocardial biopsy samples were stained for interleukin (IL)-2, IL-6, and interferon-gamma. The findings were compared to expression of the endothelial cell adhesion molecule ICAM-1, and the lymphocyte receptor for the adhesion molecule VCAM-1, VLA-4. Four biopsy samples from patients with idiopathic cardiomyopathy served as controls. IL-2 was not expressed in lymphocytes of controls and only occasionally in mild or moderate cellular rejection, humoral rejection, and Quilty lesions. IL-2 expression was prominent in severe cellular rejection. Interferon-gamma expression increased in proportion to the severity of cellular rejection and was not expressed in other conditions. IL-6 staining, which was only observed in occasional cases, was mild. Cytokine and adhesion molecule expression tended to increase with the severity of cellular rejection. This study shows that cytokine expression can be documented in human allograft endomyocardial biopsy samples with immunohistochemical techniques. The findings support the concept of an important role for cytokines in human cardiac allograft rejection.

Antigens, CD↗
PubMedDate not supplied

Expression of cell adhesion molecules in human cardiac allograft rejection.

Adhesion of leukocytes to vascular endothelial cells is a critical step in a variety of inflammatory conditions. We studied the expression and distribution of intercellular adhesion molecule-1 (ICAM-1) and endothelial leukocyte adhesion molecule-1 (ELAM-1) in frozen sections of 83 endomyocardial biopsy specimens from human allograft hearts using monoclonal antibodies and an avidin-biotin complex-alkaline phosphatase staining technique. Cases with cellular or humoral rejection and Quilty lesions were studied. Staining was graded from 0 to 3+ in lymphocytes and in capillary, arterial, venular, and endocardial endothelial cells. Expression of ICAM-1 in capillaries increased with the severity of cellular rejection and was prominent in humoral rejection. ICAM-1 was also expressed in lymphocytes in proportion to the degree of rejection. Little or no ELAM-1 expression was noted. In Quilty lesions the intensity of ICAM-1 expression was similar to that of mild-to-moderate rejection. Thus adhesion molecule expression can be identified in endomyocardial biopsy specimens of patients with rejection, suggesting a role for adhesion molecules in the process of rejection. These findings may prove useful in monitoring rejection and its response to therapy and in developing specific antisera directed against these molecules.

Capillaries↗
PubMedDate not supplied

Bradyarrhythmias requiring pacemaker implantation after orthotopic heart transplantation: association with rejection.

Patients with severe sinus-node dysfunction that required pacemaker implantation after orthotopic heart transplantation were reviewed. During a 21-month period, 42 transplantations were performed in 41 patients. Five patients (12.2%) required a permanent pacemaker because of severe dysrhythmias. Three patients had moderate-to-severe cellular and/or humoral (vascular) rejection, and two of the five patients (40%) died. In the remaining two patients, bradyarrhythmias were due most likely to trauma to the sinus node during harvesting of the donor heart, and these patients have shown no evidence of significant rejection on repeated biopsies. A strong relationship was found between moderate or severe rejection and the development of significant bradyarrhythmias that required the placement of a permanent pacemaker. The development of severe dysrhythmias during the early or late posttransplantation period should be considered a manifestation of an ongoing rejection episode until proven otherwise. In our experience this evidence of rejection may imply a poor prognostic sign because it is associated with high mortality rates.

Adult↗
PubMedDate not supplied

Combined antiviral and immunoglobulin therapy as prophylaxis against cytomegalovirus infection after heart transplantation.

BACKGROUND: Cytomegalovirus is a frequent cause of infection and morbidity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%. METHODS: To determine the efficacy of combined antiviral and intravenous immune globulin therapy for prevention of cytomegalovirus disease in transplant recipients receiving OKT3 and to compare two different antiviral drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intravenous ganciclovir for 2 weeks followed by oral acyclovir up to 3 months (group G); all received six infusions of 5% intravenous immune globulin over 2 months. All patients had OKT3 for 10 to 14 days and triple-drug immunosuppression. RESULTS: Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patients (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositive recipients, there was a trend to less cytomegalovirus disease in group G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patients) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% (group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus disease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant). CONCLUSIONS: Prophylaxis with combined antiviral and immune globulin therapy produces a low (10%) incidence of cytomegalovirus disease in OKT3-treated heart transplant recipients. In seropositive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive prophylactic strategies are needed in seronegative patients who receive hearts from seropositive donors.

Acyclovir↗
PubMedDate not supplied

Nature and significance of epicardial lymphoid infiltrates in cardiac allografts.

BACKGROUND: Myocardial lymphocytic infiltration after transplantation is usually a manifestation of acute cellular rejection. However, purely endocardial infiltrates are generally not regarded as rejection (so-called "Quilty lesions"). The nature of epicardial lymphoid infiltration in cardiac allografts and its significance when observed in endomyocardial biopsies or autopsies are uncertain. METHODS: Twenty-seven cases of transplant-associated epicardial lymphoid infiltration were identified; 16 cases were identified from 1602 consecutive transplant biopsy specimens from 125 patients, and 11 from 14 autopsies, ranging from 1 to 35 months (mean 7.8 months) after transplantation. RESULTS: The infiltrates were composed of aggregates of lymphocytes and histiocytes distributed throughout the epicardium. Plasma cells were found in 52% of cases, with occasional eosinophils and rare neutrophils. Most were vascular, and four autopsy cases had follicle formation. Twenty-four cases (93%) showed a mixed population of cells in a random distribution consisting of T cells in association with fewer B cells and histiocytes. Fifteen cases (nine autopsies, six biopsies) had acute rejection, and nine autopsies had chronic vascular rejection. Fourteen of twenty-four cases (58%) showed concurrent Quilty lesion (nine autopsies, five biopsies), and the remainder showed at least one Quilty lesion in an earlier biopsy. CONCLUSION: Epicardial lymphoid infiltrates occur with significant frequency after heart transplantation and can be associated with, and mimic, acute cellular rejection. However, they exhibit morphologic and immunophenotypic features which are distinguishable from rejection-associated infiltrates.

B-Lymphocytes↗