Use of long-term preserved organs in heart transplantation : post-operative results and long term follow up.
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Journal Article↗
Biomedical subjects
O Bastien
Publications and source records attributed to O Bastien.
Midazolam disposition in patients undergoing continuous venovenous hemodialysis.
The aim of the study was to investigate the pharmacokinetics and removal of midazolam and unconjugated and glucuronidated 1-hydroxy-midazolam in 4 intensive care patients on continuous venovenous hemodialysis. Plasma midazolam and its metabolites were assessed by HPLC from blood samples collected during continuous infusion and after the end of infusion. Additional samples from the arterial and venous bloodlines and ultrafiltrate were drawn to calculate sieving coefficient and clearance of ultrafiltration. The elimination half-life of midazolam ranged from 7.6 to 22.8 hours. The clearance of ultrafiltration was between 0.13 and 4.7 ml/min and reached approximately 11% of the total clearance. The range of sieving coefficient was from 0.006 to 0.26, with an average fraction removal of 0.2%. 1-Hydroxy-midazolam glucuronide was removed by continuous hemodialysis (sieving 0.36 to 0.63), with a clearance of ultrafiltration ranging from 7.8 to 12.0 ml/min. These preliminary results showed that midazolam is not removed efficiently, and approximately half of the 1-hydroxy-midazolam glucuronide was removed by dialysis.
Aged↗
Prolonged sedation due to an accumulation of midazolam in an intensive care patient with hypothyroidism.
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Aged↗
Relative importance of flow versus pressure in splanchnic perfusion during cardiopulmonary bypass in rabbits.
BACKGROUND: Decreased gastrointestinal perfusion has been reported during cardiopulmonary bypass (CPB). Conflicting results have been published concerning thresholds of pressure and flow to avoid splanchnic ischemia during CPB. This study compared splanchnic perfusion during independent and randomized variations of CPB pump flow or arterial pressure. METHODS: Ten rabbits were studied during mild hypothermic (36 degrees C) nonpulsatile CPB using neonatal oxygenators. Simultaneous measurements of tissue blood flow in four different splanchnic areas (gastric, jejunum, ileum, and liver) were performed by laser Doppler flowmetry (LDF) before CPB (T0) and during a 4-step factorial experimental block design. Pressure and flow were alternatively high or low in random order. RESULTS: Laser Doppler flowmetry was significantly lower than pre-CPB value but was better preserved (analysis of covariance) in all organs, except liver, when CPB flow was high, whatever the pressure. Splanchnic LDF values in the low- versus high-flow groups expressed as perfusion unit were (mean +/- SD): stomach, 94+/-66 versus 137+/-75; jejunum, 118+/-78 versus 172+/-75; ileum, 95+/-72 versus 146+/-83; and liver, 79+/-72 versus 108+/-118. No significant difference of LDF was observed between the high- and low-pressure groups, whatever the flow, except for liver: stomach, 115+/-64 versus 117+/-83; jejunum, 141+/-80 versus 148+/-83; ileum, 127+/-87 versus 114+/-76; liver, 114+/-88 versus 73+/-70. CONCLUSION: Prevention of splanchnic ischemia during CPB should focus on preservation of high CPB blood flow rather than on high pressure.
Animals↗
Prevention of isoflurane-induced preconditioning by 5-hydroxydecanoate and gadolinium: possible involvement of mitochondrial adenosine triphosphate-sensitive potassium and stretch-activated channels.
BACKGROUND: Both mitochondrial adenosine triphosphate-sensitive potassium (MKATP) channels (selectively blocked by 5-hydroxydecanoate) and stretch-activated channels (blocked by gadolinium) have been involved in the mechanism of ischemic preconditioning. Isoflurane can reproduce the protection afforded by ischemic preconditioning. We sought to determine whether isoflurane-induced preconditioning may involve MKATP and stretch-activated channels. METHODS: Anesthetized open-chest rabbits underwent 30 min of coronary occlusion followed by 3 h of reperfusion. Before this, rabbits were randomized into one of six groups and underwent a treatment period consisting of either no intervention for 40 min (control group; n = 9) or 15 min of isoflurane inhalation (1.1% end tidal) followed by a 15-min washout period (isoflurane group; n = 9). The two groups received an intravenous bolus dose of either 5-hydroxydecanoate (5 mg/kg) or gadolinium (40 micromol/kg) before coronary occlusion and reperfusion (5-hydroxydecanoate, n = 9; gadolinium, n = 7). Two additional groups received 5-hydroxydecanoate or gadolinium before isoflurane exposure (isoflurane-5-hydroxydecanoate, n = 10; isoflurane-gadolinium, n = 8). Area at risk and infarct size were assessed by blue dye injection and tetrazolium chloride staining. RESULTS: Area at risk was comparable among the six groups (29 +/- 7, 30 +/- 5, 27 +/- 6, 35 +/- 7, 31 +/- 7, and 27 +/- 4% of the left ventricle in the control, isoflurane, isoflurane-5-hydroxydecanoate, 5-hydroxydecanoate, isoflurane-gadolinium, and gadolinium groups, respectively). Infarct size averaged 60 +/- 20% (SD) in untreated controls versus 54 +/- 27 and 65 +/- 15% of the risk zone in 5-hydroxydecanoate- and gadolinium-treated controls (P = nonsignificant). In contrast, infarct size in the isoflurane group was significantly reduced to 26 +/- 11% of the risk zone (P < 0.05 vs.control). Both 5-hydroxydecanoate and gadolinium prevented this attenuation: infarct size averaged 68 +/- 23 and 56 +/- 21% of risk zone in the isoflurane-5-hydroxydecanoate and isoflurane-gadolinium groups, respectively (P = nonsignificant vs.control). CONCLUSION: 5-Hydroxydecanoate and gadolinium inhibited pharmacologic preconditioning by isoflurane. This result suggests that MKATP channels and mechanogated channels are probably involved in this protective mechanism.
Adenosine Triphosphate↗
Usefulness of procalcitonin for diagnosis of infection in cardiac surgical patients.
OBJECTIVE: To determine the value of procalcitonin (PCT) as a marker of postoperative infection after cardiac surgery. DESIGN: A prospective single institution three phase study. SETTING: University cardiac surgical intensive care unit (31 beds). PATIENTS: Phase 1: To determine the normal perioperative kinetics of PCT, 20 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass were included. Phase 2: To determine whether PCT may be useful for diagnosis of postoperative infection, 97 consecutive patients with suspected infection were included. Phase 3: To determine the ability of PCT to differentiate patients with septic shock from those with cardiogenic shock, 26 patients with postoperative circulatory failure were compared. MEASUREMENTS AND MAIN RESULTS: Phase 1: Serum samples were drawn for PCT determination after induction of anesthesia (baseline), at the end of surgery, and daily until postoperative day (POD) 8. Baseline serum PCT concentration was 0.17 +/- 0.08 ng/mL (mean +/- SD). Serum PCT increased after cardiac surgery with a peak on POD 1 (1.08 +/- 1.36). Serum PCT returned to normal range on POD 3 and remained stable thereafter. Phase 2: In patients with suspected infection, serum PCT was measured at the same time of C-reactive protein (CRP) and bacteriologic samples. Among the 97 included patients, 54 were infected with pneumonia (n = 17), bacteremia (n = 16), mediastinitis (n = 9), or septic shock (n = 12). In the 43 remaining patients, infection was excluded by microbiological examinations. In noninfected patients, serum PCT concentration was 0.41 +/- 0.36 ng/mL (range, 0.08-1.67 ng/mL). Serum PCT concentration was markedly higher in patients with septic shock (96.98 +/- 119.61 ng/mL). Moderate increase in serum PCT concentration occurred during pneumonia (4.85 +/-3.31 ng/mL) and bacteremia (3.57 +/- 2.98 ng/mL). Serum PCT concentration remained low during mediastinitis (0.80 +/- 0.58 ng/mL). Five patients with mediastinitis, two patients with bacteremia, and one patient with pneumonia had serum PCT concentrations of <1 ng/mL. These eight patients were administered antibiotics previously and serum PCT was measured during a therapeutic antibiotic window. For prediction of infection by PCT, the best cutoff value was 1 ng/mL, with sensitivity 85%, specificity 95%, positive predictive value 96%, and negative predictive value 84%. Serum CRP was high in all patients without intergroup difference. For prediction of infection by CRP, a value of 50 mg/L was sensitive (84%) but poorly specific (40%). Comparing the area under the receiver operating characteristic curves, PCT was better than CRP for diagnosis of postoperative sepsis (0.82 for PCT vs. 0.68 for CRP). Phase 3: Serum PCT concentration was significantly higher in patients with septic shock than in those with cardiogenic shock (96.98 +/- 119.61 ng/mL vs. 11.30 +/- 12.3 ng/mL). For discrimination between septic and cardiogenic shock, the best cutoff value was 10 ng/mL, with sensitivity of 100% and specificity of 62%. CONCLUSION: Cardiac surgery with cardiopulmonary bypass influences serum PCT concentration with a peak on POD 1. In the presence of fever, PCT is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics. PCT was more relevant than CRP for diagnosis of postoperative infection. During a postoperative circulatory failure, a serum PCT concentration >10 ng/mL is highly indicative of a septic shock.
Adult↗
[Inhaled nitric oxide: therapeutic applications in cardiac surgery].
The occurrence of right ventricular failure secondary to pulmonary arterial hypertension is a major postoperative complication of cardiac surgery in children and adults. The selective pulmonary vasodilation produced by inhaled nitric oxide (NO) constitutes a fundamental therapeutic advance in the management of this pathology. NO binds immediately with haemoglobin, resulting in its immediate inactivation. This results in perfect maintenance of systemic and coronary blood pressures. A first study performed in 1989 after mitral valve replacement for mitral stenosis with pulmonary hypertension and clinical trials after surgical correction for congenital heart disease and heart transplantation with pulmonary hypertension suggested the efficacy and safety of 20 to 40 ppm NO concentrations in these indications. Potential toxicity of NO (NO2 production by oxidation, methaemoglobin formation) leads to caution with its use. Monitoring of NO concentration and methaemoglobin production is recommended, especially in new-borns.
Administration, Inhalation↗
[Severe digestive complications after heart surgery using extracorporeal circulation].
PURPOSE: To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC). METHODS: Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997. RESULTS: Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9). CONCLUSION: Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.
Adult↗
Parvovirus B19 infection in thoracic organ transplant recipients.
BACKGROUND: Clinical manifestations of parvovirus B19 infection in immunocompromised patients are mostly reported as acute or chronic hematologic disorders. More recently, respiratory or renal involvement has been described. OBJECTIVE: We started in 1994 a prospective study of parvovirus B19 infection in a group of lung (LTP) and heart-lung (HLTP) transplanted patients, including occasionally heart transplanted (HTP) patients. STUDY DESIGN: 62 patients (49 LTP, 11 HLTP, 2 HTP) were included in a serological survey and DNA detection by PCR was performed on each serum sample of the first 29 patients; later we performed it only when serology could suggest an acute episode, or when parvovirus infection could be suspected on clinical or biological observations. A total of 1655 sera were examined by serological tests and DNA detection was done in 500 samples. Specific IgM, seroconversion, significant increase of specific IgG levels, and/or parvovirus B19 DNA detection, were considered as markers of viral infection. RESULTS: We observed the presence of both markers of infection in 24 patients (39%), with an individual combination of positive antibody and PCR results. Acute or chronic anaemia, neutropenia were associated to these laboratory findings in 19 patients, but in five cases, an asymptomatic clinical infection suggested viral persistence. CONCLUSIONS: We report parvovirus associated acute or chronic anaemia and pancytopenia in a group of LTP, HLTP and HTP patients, as well as asymptomatic cases of infection. In the hypothesis of a parvoviral persistent or latent infection, current diagnosis methods may be unreliable to identify any other clinical manifestations.
Adolescent↗
Effects of dopexamine on blood flow in multiple splanchnic sites measured by laser Doppler velocimetry in rabbits undergoing cardiopulmonary bypass.
Decreased gut perfusion has been reported during cardiopulmonary bypass (CPB). Studies of treatments to avoid splanchnic ischaemia during CPB have given conflicting results. We studied 12 rabbits during mild hypothermic non-pulsatile CPB. Tissue blood flow in three different splanchnic areas (gastric, jejunum and ileum) was measured by laser Doppler velocimetry (LDV) before CPB (T0), after steady state (T1), after administration of dopexamine 2 micrograms kg-1 min-1 (T2) and 4 micrograms kg-1 min-1 (T3), and after return to baseline (T4). Splanchnic blood flow decreased during CPB. Dopexamine increased significantly jejunum LDV (100% at T1 to mean 271 (SD 210)% at T2) and ileum LDV (100% at T1 to 187 (112)% at T2). Gastric LDV was not altered by infusion of dopexamine during CPB. This could partly explain the conflicting results on the value of gastric tonometry as an index of splanchnic injury.
Adrenergic beta-Agonists↗
Effect of cardiopulmonary bypass on serum procalcitonin and C-reactive protein concentrations.
We have measured serum procalcitonin (PCT) concentrations after cardiac surgery in 36 patients allocated to one of three groups: group 1, coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) (n = 12); group 2, CABG without CPB (n = 12); and group 3, valvular surgery with CPB (n = 12). Serum PCT and C-reactive protein (CRP) concentrations were measured before operation, at the end of surgery and daily until postoperative day 8. Serum PCT concentrations increased, irrespective of the type of cardiac surgery, with maximum concentrations on day 1: mean 1.3 (SD 1.8), 1.1 (1.2) and 1.4 (1.2) ng ml-1 in groups 1, 2 and 3, respectively (ns). Serum PCT concentrations remained less than 5 ng ml-1 in all patients. Concentrations returned to normal by day 5 in all groups. To determine the effect of the systemic inflammatory response (SIRS) on serum PCT concentrations, patients were divided post hoc, without considering the type of cardiac surgery, into patients with SIRS (n = 19) and those without SIRS (n = 17). The increase in serum PCT was significantly greater in SIRS (peak PCT 1.79 (1.64) ng ml-1 vs 0.34 (0.32) ng ml-1 in patients without SIRS) (P = 0.005). Samples for PCT and CRP measurements were obtained from 10 other patients with postoperative complications (circulatory failure n = 7; active endocarditis n = 2; septic shock n = 1). In these patients, serum PCT concentrations ranged from 6.2 to 230 ng ml-1. Serum CRP concentrations increased in all patients, with no differences between groups. The postoperative increase in CRP lasted longer than that of PCT. We conclude that SIRS induced by cardiac surgery, with and without CPB, influenced serum PCT concentrations with a moderate and transient postoperative peak on the first day after operation. A postoperative serum PCT concentration of more than 5 ng ml-1 is highly suggestive of a postoperative complication.
Aged↗
Cardiovascular effects of concomitant administration of isoflurane and nicorandil in dogs.
Nicorandil, a new KATP channel opener, is used in clinical practice for anti-anginal therapy. It exhibits vasodilator properties as does the halogenated anaesthetic isoflurane. We have examined the cardiovascular effects of increasing concentrations of isoflurane after administration of nicorandil in 10 adult beagle dogs anaesthetized with thiopental and whose lungs were ventilated mechanically. During surgery, anaesthesia was maintained with 1.0-1.5% isoflurane. A left thoracotomy was performed and the heart suspended in a pericardial cradle. Monitoring included: ECG; aortic, left ventricular, arterial, central venous and pulmonary artery pressures; cardiac output; coronary flow; and segmental length in the apical region. After surgery, isoflurane anaesthesia was set at an end-tidal concentration of 1.05% (1 MAC) and measurements obtained; these were repeated with 1.4%, 1.75%, 2.1% and 1.05% isoflurane concentrations after appropriate stabilization periods. Nicorandil (100 micrograms kg-1 bolus, 25 micrograms kg-1 min-1 infusion) was begun and a second dose-response study of isoflurane was obtained as before. Blood samples were obtained for measurement of concentrations of nicorandil. Systolic ventricular function was assessed by systolic shortening (%SS) and preload recruitable stroke work (PRSW). Increasing isoflurane concentration produced decreases in heart rate, systolic pressure, cardiac output, %SS and PRSW. Nicorandil produced a slight decrease in systolic arterial pressure (10 and 15 mm Hg after 1.05% and 2.05% isoflurane) and a slight increase in heart rate (10 and 5 beat min-1 after 1.05% and 2.05% isoflurane). Preload, assessed by end-diastolic length, decreased. Coronary blood flow increased with infusion of nicorandil. Left ventricular function was not affected by infusion of nicorandil. We conclude that nicorandil has only minor vaso/venodilatory effects in the presence of isoflurane. Ventricular function was not altered by infusion of nicorandil.
Anesthetics, Inhalation↗
[Reversible graft dysfunction after cardiac transplantation].
The authors report 3 cases of major graft dysfunction after cardiac transplantation which recovered completely with biventricular mechanical assistance in 4 to 8 days. All three cases were primary biventricular graft failures in patients with normal preoperative pulmonary resistances. These early dysfunctions (with no signs of myocardial infarction on electro- or echocardiography and in the absence of abnormal increased peri-operative enzyme levels) associated with total functional recovery conforming to the definition of the phenomenon of myocardial stunning. These results argue in favour of aggressive management of primary graft dysfunction.
Echocardiography, Transesophageal↗
[Inhaled nitric oxide in anesthesia and intensive care].
The role of endothelium in vascular relaxation is linked to the existence of endothelium derived relaxing factors (EDRF) known since 1980. In 1987, nitric oxide (NO) was identified as one of these factors. NO acts in many physiologic and pathophysiologic events. Atmospheric NO is a pollutant. Inhaled NO allows selective pulmonary vasodilation and is used to treat pulmonary artery hypertension (PAH). As inhaled NO is inactivated immediately in the blood by linking to haemoglobin, systemic vasodilation does not occur and right ventricular coronary perfusion pressure does not decrease. This is particularly important in the treatment of right ventricular failure due to PAH following cardiothoracic surgery. In patients with an acute respiratory distress syndrome (ARDS), inhaled NO improves the perfusion of adequately ventilated pulmonary territories. Very low concentrations of NO, such as two parts per million, decrease intrapulmonary venous admixture and may reverse hypoxaemia. However its long term benefits in ARDS must be assessed more accurately with multicentre controlled studies. Inhaled NO also improves refractory hypoxaemia in neonates. Its bronchodilatory effect, demonstrated experimentally, does not occur in acute obstructive bronchopulmonatory disease. The toxicity of NO, and overall of its oxidated derivative NO2 requires precise conditions of administration and close monitoring of inhaled fractions. In that case, the risk of NO toxicity seems very low when compared to its therapeutic benefits in selected patients.
Administration, Inhalation↗
Predictive factors for usefulness of fiberoptic pulmonary artery catheter for continuous oxygen saturation in mixed venous blood monitoring in cardiac surgery.
The main goal of this prospective study was to identify among cardiac surgery patients, usually monitored through a standard pulmonary artery catheter (PAC), those in whom a fiberoptic catheter oximeter to measure oxygen saturation in mixed venous blood (SVO2 PAC) would be most useful. Data from 286 patients who underwent coronary artery bypass graft (50%) or valvular surgery were recorded, including ASA physical status, New York Heart Association (NYHA) classification, and Parsonnet score (PS). Hemodynamic events and SVO2 changes were collected intra- and postoperatively until weaning from mechanical ventilation. The anesthesiologist in charge graded the usefulness of SVO2 PAC, and another anesthesiologist carried out a blindly controlled overall evaluation. Usefulness was defined as the presence of a change in therapeutic maneuver triggered solely by continuous SVO2 data that would not have occurred based on other routine parameters. SVO2 was also considered useful if earlier recognition of significant adverse events occurred. SVO2 PAC was useful in 57% of the patients. Independent predictive factors (multivariate analysis) for the perioperative usefulness of SVO2 in the whole population consisted of ASA class > or = 4 (P < 10(-5); relative risk [RR] 1.78, 1.51-2.07), mitral surgery (P < 10(-4); RR 1.72, 1.4-2.02), and NYHA score > or = 3 (P < 0.01; RR 1.66, 1.35-2.05). Independent predictive factors for the perioperative usefulness of SVO2 in the coronary artery bypass graft population were NYHA score > or = 3 (P < 10(-5); RR 1.90, 1.42-2.55) and ASA class > or = 4 (P < 0.01; RR 1.99, 1.51-2.63). The presence of three stenosed coronary arteries showed borderline significance (P < 0.06). Independent predictive factors for perioperative usefulness of SVO2 in the valvular population were mitral pathology (P < 10(-5)) and ASA class > or = 4 (P < 0.01). The receiver operator characteristic curve assessed the predictivity of the PS. SVO2 PAC was more useful in the group of patients with the greatest severity of illness (PS in useful group 17.0 +/- 10.3; in nonuseful group 8.7 +/- 6.6; P < 10(-4)). Intensive care unit duration and hospital stay in the useful group was prolonged compared with the nonuseful group. Similarly, morbidity was frequent in the useful group, although it was not always significantly different from the nonuseful group according to the type of complications. Mortality was comparable in the groups despite their different degree of illness and was reduced when taking into account the predictive and observed mortality provided by the PS. This study defined independent preoperative factors associated with SVO2 PAC monitoring and proposed a cutoff point above which SVO2 may be useful.
Aged↗
Pharmacokinetics of acyclovir in patients undergoing continuous venovenous hemodialysis.
The pharmacokinetics of acyclovir in three patients undergoing continuous venovenous hemodialysis was investigated. Acyclovir was administered as an intravenous infusion over 1 hour at a dose of 5 mg/kg daily in one patient and 10 mg/kg every 48 hours in two patients. Samples from the arterial and venous blood lines and from ultrafiltrate were collected to calculate pharmacokinetic parameters, sieving coefficient and clearance of ultrafiltration. Plasma concentrations of acyclovir were assessed by high-performance liquid chromatography. Peak plasma concentrations were 9.3 mg/l for the patient receiving 5 mg/kg daily, 29.6 mg/l and 20.7 mg/l for the two patients with 10 mg/kg every 48 hours. The elimination half-life ranged from 8.8 to 11.2 hours and was approximately half those found in patients with renal impairment. The clearance by ultrafiltration was from 17.4 to 22.3 ml/minute and reached nearly 35% of the total clearance. The sieving coefficient ranged from 0.92 to 0.98 with an average rate of removal over the dosing interval ranging from 6.7 to 13.0 mg/hour. These data should be taken into account to optimize drug therapy in patients on continuous hemodialysis. Until formal guidelines are defined, acyclovir dosage should be adjusted according to monitoring of plasma drug concentrations.
Acyclovir↗
Severe systemic cholesterol embolization after open heart surgery.
Cholesterol crystal embolization (CCE) may be triggered by various factors: intra-arterial angiographic procedures, aortic or vascular surgery, anticoagulant or thrombolytic treatments, or both. There are few previous reports of patients undergoing coronary artery bypass grafting (CABG) experiencing and therefore displaying severe systemic CCE. We describe four patients presenting, shortly after CABG, cutaneous, renal, neurological and hepatic signs related to severe CCE confirmed by skin biopsy. All patients died 11-92 days after surgery. As systemic CCE reveals severe atheromatous disease and is associated with a poor prognosis, it is advisable to avoid CABG in patients who present symptoms of CCE before surgery.
Aged↗
Ganciclovir use during mild renal failure in heart transplantation.
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Antiviral Agents↗