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S A Hunt

Publications and source records attributed to S A Hunt.

100 records · Page 6Linked to original sources
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Accelerated graft coronary artery disease: diagnosis and prevention.

Accelerated graft coronary artery disease (CAD) has become a major factor limiting survival among long-term heart transplant survivors. Currently 14%, 37%, and 50% of patients treated with triple therapy have angiographically apparent accelerated graft CAD at 1, 3, and 5 years after transplantation. Because cardiac allografts are denervated, transplant recipients generally do not experience angina pectoris. Therefore accelerated graft CAD may present as silent myocardial infarction, congestive heart failure, or ventricular arrhythmia leading to syncope or sudden death. Noninvasive tests for CAD have been insensitive for the detection of accelerated graft CAD because of the diffuse nature of the disease. Coronary arteriographic characteristics of accelerated graft CAD are a mixture of typical focal atherosclerotic lesions and unusual diffuse, concentric, and longitudinal narrowing prominent in middle to distal coronary vessels, with distal vessel obliteration and lack of collateral vessel formation. The presence and severity of accelerated graft CAD may be underestimated by routine angiography because of its diffuse and concentric nature. Quantitative arteriography has become an important technique to assess the progression of accelerated graft CAD. Intravascular ultrasound imaging can detect even earlier development of intimal thickening. CAD risk factor modification has had little impact on the overall incidence. We initiated a randomized study of diltiazem versus no calcium blocker to determine if this may prevent accelerated graft CAD. Patients have undergone early postoperative and annual quantitative coronary angiography since inception of the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium Channel Blockers↗
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Increased rejection in gender-mismatched grafts: amelioration by triple therapy.

Increased rejection incidence in female heart transplant recipients receiving immunosuppressive therapy with cyclosporine and azathioprine has been reported and a possible role for gender-mismatched grafting (male donor into female recipient) has been suggested. To test the hypothesis that rejection is more frequent in female patients receiving male hearts, we analyzed the results of heart transplantation in gender-matched and -mismatched grafts in 313 recipients maintained with either double therapy with cyclosporine and prednisone (group 1, n = 104) or triple therapy with cyclosporine, azathioprine, and prednisone (group 2, n = 209). There were 21 female recipients in group 1 and 41 in group 2. The variables studied were 90-day total methylprednisolone sodium succinate requirements, 90-day linearized rejection rate, 90-day event-free actuarial rejection, 6-month actuarial infection-free survival, overall actuarial survival, and median day to first rejection. Statistical analyses included two-tailed t or Cox-Mantel testing as appropriate. In group 1, transplantation of a male heart into a female recipient (M/F grafting) was associated with a 40% higher 90-day cumulative steroid requirement (5008 +/- 3400 mg for M/F vs 3600 +/- 2977 mg for F/F), reflecting a higher rate of rejection in M/F recipients. Linearized rejection rates (90-day) were higher (1.6 +/- 0.4 vs 1.3 +/- 0.5 episodes per patient), and consequent 6-month event-free infection rates were lowest in these patients, although not significantly so. Actuarial survival did not differ significantly between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
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Total lymphoid irradiation for treatment of intractable cardiac allograft rejection.

The ability of postoperative total lymphoid irradiation to reverse otherwise intractable cardiac allograft rejection was examined in a group of 10 patients in whom conventional rejection therapy (including pulsed steroids and monoclonal or polyclonal anti-T-cell antibody therapy) had failed to provide sustained freedom from rejection. Follow-up periods range from 73 to 1119 days since the start of total lymphoid irradiation. No patient died or sustained serious morbidity because of the irradiation. Three patients have had no further rejection (follow-up periods, 105 to 365 days). Two patients died--one in cardiogenic shock during the course of total lymphoid irradiation, the other with recurrent rejection caused by noncompliance with his medical regimen. Total lymphoid irradiation appears to be a safe and a moderately effective immunosuppressive modality for "salvage" therapy of cardiac allograft rejection unresponsive to conventional therapy.

Adult↗
PubMedDate not supplied

Nontuberculous mycobacterial infections in heart transplant recipients: a seventeen-year experience.

A retrospective review was undertaken to determine the clinical features, outcome, and impact on survival of nontuberculous mycobacterial infections in 14 (of 502) heart transplant recipients. The prevalence of these infections was significantly higher (p less than 0.05) during the precyclosporine than during the cyclosporine era. The mean interval from transplantation to diagnosis was 3.5 +/- 0.7 years (+/- SEM). The 14 patients had a higher (p less than 0.05) linearized rejection rate than did other transplant patients during postoperative years 1, 2, and 4 to 6, and had received 7.3 +/- 2 gm of methylprednisolone as bolus treatment of rejection before diagnosis. Eight patients were initially seen with disseminated disease, four had localized pulmonary infection, one had subcutaneous infection in the previous site of a left ventricular assist device, and in one the organism was cultured from a fluid collection adjacent to a hip prosthesis. Twelve patients were first given 3 +/- 1 antimycobacterial drugs; the infections were usually controlled, but in 75% of patients the therapeutic regimen was prematurely stopped or altered because of drug toxicity. Mycobacterial infection was a contributory cause of death in only one patient. Actuarial survival in the 14 patients was not significantly different from the entire transplant population at 4 to 7 years. We conclude that nontuberculous mycobacterial infections occur late after heart transplantation, that drug treatment is usually successful (although difficult), and that long-term survival is not adversely affected if the infection is successfully controlled.

Adult↗
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Dermatologic complications following heart transplantation.

A total of 107 consecutive heart transplant recipients at Stanford University Medical Center were prospectively screened for dermatologic disease as part of their routine postoperative evaluation over a 6-month period. The incidence of nonmelanotic skin tumors and premalignant lesions was approximately 25-fold greater than expected in a normal population. Skin infections were seen in 55% of the patients and dermatologic drug side effects were almost universal including xerosis, hypertrichosis, and steroid acne. Successful excision or cryotherapy of all neoplastic lesions was achieved with no evidence of recurrence to date, a mean of 11 months. The skin infections responded to appropriate antiviral, antibacterial, and antifungal agents and the xerotic and acneiform lesions were successfully treated with emollients and topical retinoic acid, respectively. In addition, patients were instructed in preventive measures including the use of sunscreen agents and protective clothing. We conclude that heart transplant recipients have a significantly increased incidence of neoplastic, infectious, and drug-induced skin diseases. Routine dermatologic screening resulted in early identification and successful treatment of these lesions. We suggest that dermatologic screening is both feasible and valuable in this setting.

Adult↗
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Cardiac sarcoidosis: response to steroids and transplantation.

From 1976 to 1986, six cases of cardiac sarcoidosis have been documented by myocardial biopsy in three of five instances; on examination of the explanted heart after transplantation in two, and at autopsy in one patient. Right ventricular end-diastolic pressure was elevated in all four patients with right ventricular involvement with sarcoidosis. Of three patients treated with steroids, improvement in ventricular function and decrease in arrhythmia occurred in two, whereas failure to respond led to transplantation in the other patient. Two further patients have undergone heart transplantation, one for resistant ventricular arrhythmia and the other for congestive heart failure. No recurrence of sarcoidosis has occurred in the grafts. Because two of five patients had sarcoidosis diagnosed on gross examination, a negative endomyocardial biopsy does not exclude the diagnosis of myocardial sarcoidosis, which should therefore be pursued in the setting of unexplained heart failure, conduction abnormalities, and ventricular arrhythmia, particularly when right ventricular end-diastolic pressure is raised. Steroids may result in improvement in some patients even in the presence of severe morphological damage. Heart transplantation may be performed without increased risk of recurrence of sarcoidosis.

Adult↗
PubMedDate not supplied

Does rapidity of development of transplant coronary artery disease portend a worse prognosis?

We postulated that transplant coronary artery disease with rapid progression to more than 50% stenosis within a 1-year interval may have a different prognosis from transplant coronary artery disease with a more indolent rate of progression. Annual coronary angiograms of 139 consecutive patients who underwent transplantation between January 1968 and February 1990 who survived at least 1 year after transplantation and in whom angiographically apparent transplant coronary artery disease developed were included in the study. Of this group, 45 patients progressed from a normal angiogram to the presence of 50% or greater stenosis in one or more major vessels within 1 year (fulminant group); 94 did not (indolent group). Mean posttransplantation follow-up time was 5.3 +/- 4.1 years for patients with fulminant progression of disease and 6.6 +/- 3.7 years for those with indolent progression. A highly significant difference was found in the time-related incidence of ischemic events (myocardial infarction, congestive heart failure, sudden death, and retransplantation) between the indolent and the fulminant groups after initial detection of transplant coronary artery disease. At 1, 3, and 5 years after initial detection of transplant coronary artery disease, 50%, 33%, and 16% of patients in the fulminant group and 89%, 70%, and 60% of patients in the indolent group were free of ischemic events (p < 0.0001). The fulminant group of patients had a mean of 2.9 +/- 1.5 rejection episodes, and the indolent group a mean of 2.3 +/- 1.4 episodes (p = 0.02) during the first year after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Influence of graft rejection on incidence of accelerated graft coronary artery disease: a new approach to analysis.

Conflicting data exist on the role of graft rejection as a risk factor for later development of accelerated graft coronary artery disease. We analyzed 126 consecutive heart transplant recipients treated with cyclosporine-based immunosuppressive regimens and devised an arbitrary method to incorporate the number, duration, and severity of myocardial rejection episodes during the first postoperative year, resulting in a rejection score for each patient. We then correlated the later incidence (mean follow-up, 4 years) of angiographic accelerated graft coronary artery disease with this rejection score and with its components: number, duration, and severity of rejection; number and duration of untreated rejection; and incidence and duration of delayed rejection therapy. Accelerated graft coronary artery disease developed in 60 patients (48%). The rejection score was 96.7 for patients in the "no accelerated graft coronary artery disease" group and 110.4 for those in the "accelerated graft coronary artery disease" group (p = NS). No significant difference was noted between patients with and without disease in any of the other seven rejection parameters analyzed, and no significant difference in time to occurrence of disease was noted between groups divided at the median rejection score. Donor age was older and fasting triglyceride blood level was higher in patients with accelerated graft coronary artery disease than in those without disease. All other clinical characteristics, including HLA mismatches, ischemic time, blood pressure, lipid profile, and drug therapy, did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
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Heart retransplantation: the 25-year experience at a single institution.

BACKGROUND: The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford. METHODS: There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% +/- 8%, 33% +/- 8%, and 22% +/- 7%, respectively. RESULTS: This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% +/- 2%, 62% +/- 2%, 44% +/- 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% +/- 10% versus 33% +/- 16%), but the 5-year survival was similar in both groups (34% +/- 11% versus 33% +/- 16%). Since 1981, actuarial freedoms from infection and rejection were 22% +/- 8% and 41% +/- 9%, respectively, at 1 year, and 7% +/- 7% and 36% +/- 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I. CONCLUSIONS: We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.

Actuarial Analysis↗