Heart transplantation--state of the art.
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Graft Rejection↗
Biomedical subjects
D Admon
Publications and source records attributed to D Admon.
Absence of a vagina and right sided adnexa uteri in the Waardenburg syndrome: a possible clue to the embryological defect.
An 18 year old single Jewish woman with the Waardenburg syndrome and absence of a vagina and right sided adnexa uteri is reported. Other congenital malformations associated with the Waardenburg syndrome are mentioned and it is postulated that they may be the result of an altered invasion of neurones or altered neurones in certain organ systems early in embryogenesis.
Abnormalities, Multiple↗
Changes in ventricular function and coronary stenosis after successful intravenous thrombolysis in acute myocardial infarction.
Temporal changes in residual stenosis in the infarct-related coronary artery and ventricular function were studied in 30 consecutive patients with an acute myocardial infarction who received rapid, high dose intravenous infusions of streptokinase within 4 h of pain onset. Patients were studied 6 days and 3.9 +/- 1.3 months after the acute episode. Inferior infarction, early thrombolysis (less than 1.5 h after pain onset) and adequate reperfusion (less than 75% residual stenosis in the infarct-related coronary artery) were associated with smaller left ventricular infarcts, smaller ventricular volumes and better ventricular function. Residual stenosis tended to increase with time and in 6 patients the artery closed completely (1 with an overt clinical episode). Ventricular function and volumes improved progressively in patients with good initial function and less residual stenosis in the infarct-related coronary artery.
Aged↗
Colonic ischemia following abdominal aortic reconstruction for ruptured aneurysm in a patient with previous right colectomy. Case report.
Reconstruction of the abdominal aorta after rupture of aneurysm was followed by colonic ischemia in a patient who had undergone right hemicolectomy 6 years previously. The mechanism and management of this rare complication are discussed.
Aged↗
Infection with Streptococcus milleri.
Streptococcus milleri is unique among the viridans streptococci because it produces abscesses. Five serious S. milleri infections were seen in our hospital in 1 year. The English literature dealing with S. milleri was reviewed. An infection caused by S. milleri is often associated with a gastro-intestinal source. Thus, the speciation of viridans streptococci from pus or blood cultures is clinically relevant. The identification of S. milleri from blood cultures suggests the possibility of serious purulent infection, the source of which may lie in the gastro-intestinal tract. The resultant clinical approach to S. milleri infection is discussed.
Abscess↗
Idiopathic thrombocytopenic purpura presenting as iron-responsive thrombocytopenia.
We describe a patient with iron-deficiency anemia, thrombocytopenia and paucity of marrow megakaryocytes, in whom the anemia and the thrombocytopenia responded to the administration of iron. Thrombocytopenia recurred, despite maintenance of normal hemoglobin and iron levels and adequate marrow megakaryocytes. Corticosteroids and splenectomy were required for the control of the thrombocytopenia. In this patient, the initial manifestations of idiopathic thrombocytopenic purpura were modified by the presence of severe iron deficiency. This case strengthens the contention that iron is essential for megakaryopoiesis and thrombopoiesis.
Anemia↗
Is "primary" subphrenic abscess caused by Streptococcus milleri a result of unrecognized gastrointestinal perforation?
An unusual case of subphrenic abscess presenting as empyema of the pleural cavity is described. The abscess developed secondarily to an occult perforation of the gastrointestinal tract, which was, diagnosed indirectly by the discovery of a fishbone within the abscess. Isolation of Streptococcus milleri from the pus was an important clue for the existence of an underlying gastrointestinal pathology.
Empyema↗
Urticarial vasculitis and recurrent pleural effusion: a systemic manifestation of urticarial vasculitis.
A 62-year-old woman with an 8-year history of urticaria, arthralgia and arthritis developed recurrent pleural effusion. A thorough laboratory workup during repeated attacks of concomitant urticaria and pleural effusion disclosed only hypocomplementemia and the histopathological finding of the skin biopsy revealed leukoclastic vasculitis. These findings are compatible with the entity of urticarial vasculitis. It is thus suggested that pleural effusion can form part of the systemic manifestations of urticarial vasculitis.
Complement Pathway, Classical↗
Evaluation of the beta-blocking drug acebutolol in angina pectoris.
The effects of the beta-adernergic blocking drug acebutolol were studied in 23 patients with angina pectoris and angiographically documented coronary artery disease. Patients were evaluated clinically, by graded treadmill testing and by 24-hour Holter monitoring in the control state, after 2 weeks treatment with placebo, and after 2 weeks treatment with 600 mg. and then 1,200 mg. of acebutolol. Acebutolol (in a daily dose of 600 mg.) was an effective antianginal drug: the number of clinical attacks of angina pectoris (p less than 0.001) and the consumption of sublingual nitrate decreased (p less than 0.01), there was a significant increase in the treadmill effort tolerance as measured by the time to appearance of ischemic ECG changes (p less than 0.001) and the total work performed (p less than 0.001), and there was also a significant decrease in ischemic ST segment depression on 24-hour Holter monitoring. Treatment with 1,200 mg. acebutolol was associated with a further decrease in heart rate and a further improvement in effort tolerance on treadmill testing (p less than 0.05). On the large dose of the drug, however, there was no further clinical improvement, and no further improvement on 24-hour ECG monitoring; several patients complained of weakness and fatigue. Graded treadmill testing was an excellent objective method for assessing physical effort tolerance and its improvement after treatment with the beta-blocking drug. Twenty-four-hour Holter monitoring was a useful and complementary test, especially in patients who stopped exercising on the treadmill because of fatigue or weakness, and especially for assessing the efficacy of beta-blockade in controlling emotionally induced tachycardia and ischemia in the patient's own daily environment.
Acebutolol↗
Effect of acebutolol on dynamic ischemic ECG changes: a study using ambulatory twenty-four-hour ECG monitoring.
The clinical effect of the beta-adrenergic blocking drug acebutolol hydrochloride (SECTRAL) was studied in 18 patients with angina pectoris. Ambulatory 24-h ECG monitoring proved to be a useful method for assessing the efficacy of this drug in individual patients in their own daily stresses and environment. Patients were studied in the control state, after two weeks' treatment with placebo, and after two weeks' constant oral dose of the drug. It was found that acebutolol produced a significant decrease in ischemic ST segment depression in patients in whom good beta-blockade was achieved. The drug was less effective in patients in whom the heart rate response to exercise was not suppressed and in those with critical coronary artery obstructions.
Acebutolol↗
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↗
Acute septal myocardial infarction diagnosed by endomyocardial biopsy in a heart transplant recipient.
We describe an unusual case of acute septal myocardial infarction in a heart transplant recipient. The clinical presentation was most suggestive of acute rejection; the correct diagnosis was first made by endomyocardial biopsy and was then verified by coronary angiography. Acute myocardial infarction should be included in the differential diagnosis of acute rejection after heart transplantation and included among the possible diagnoses made by endomyocardial biopsy in these patients.
Biopsy↗
Capillary and myofiber ultrastructure in endomyocardial biopsies from cyclosporine-treated heart transplant patients.
This study focuses on the ultrastructure of microvessels and myofibers in 54 endomyocardial biopsy specimens from 16 patients treated with cyclosporine after heart transplantation. Although the capillary and myofiber pathologic condition was significantly correlated with the degree of rejection, ultrastructural changes sometimes occurred in biopsy specimens with little or no histologic cellular infiltration. Immunocytochemical studies of some biopsy specimens showed that all microvessels were positive for IgM, whereas concentrations of IgG, complement, and fibrin varied. The microvascular and myofiber changes appeared to be reversible and correlated (Pearson's coefficient of correlation of myofiber vacuoles and microangiopathy, R = 0.67, p less than 0.00001). The vacuoles in myofibers resembled those in subendocardial regions of ischemic myocardium. They could, however, be related to cyclosporine toxicity because similar vacuoles have been described in kidneys of transplant patients receiving cyclosporine. We conclude that in cases of unclear graft failure in the absence of classic signs of rejection, electron microscopy could be helpful in detecting microvascular and myofiber pathologic situations that may influence myocardial function.
Adult↗
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↗
Donors with a history of cocaine use: effect on survival and rejection frequency after heart transplantation.
The frequency of cocaine use among donors is currently unknown. Cocaine has cardiotoxic effects and could affect the outcome of heart transplantation. To examine the frequency of nonintravenous cocaine use in organ donors and the outcome of heart transplantation with such donors, we retrospectively analyzed the clinical, biopsy, and donor information on 112 consecutive patients who underwent transplantation between December 1988 and August 1993. Ten patients were excluded because of incomplete information regarding the donor's cocaine status. Of the remaining 102 patients, 16 (16%) had a positive donor history for nonintravenous cocaine use (cocaine group) and 86 patients (84%) had a negative history (noncocaine group). Survival, frequency of cellular rejection (grade > or = 1B), and humoral rejection were compared between the two groups. Survival rates at 30 days (100% versus 97% +/- 2%) and at 1 year (93 +/- 7% versus 89 +/- 3%) were similar (p = not significant, cocaine versus noncocaine group). Freedom from rejection was similar at 30 days (81% +/- 10% versus 79% +/- 4% cellular rejection-free, 33% +/- 14% versus 60% +/- 6% humoral-free) and 6 months (34% +/- 12% versus 55% +/- 5% cellular-free, 16% +/- 11% versus 36% +/- 6% humoral-free) (p = not significant). No significant difference was found in donor inotropic support before procurement, ischemic time, length of stay in intensive care unit, or total stay in the hospital. In conclusion, a high incidence of nonintravenous cocaine use exists among donors. The outcome of patients who receive transplanted hearts obtained from nonintravenous cocaine users is favorable, suggesting that the use of such hearts is safe.
Adult↗
Pathogenesis of Quilty lesion in cardiac allografts: relationship to reduced endocardial cyclosporine A.
BACKGROUND: Endocardial lymphocytic infiltrates, known as Quilty effect, are a common finding of uncertain pathogenesis in cardiac allografts. Quilty effect was not observed before the use of cyclosporine A for immunosuppression and is not generally regarded as a manifestation of rejection. We hypothesized that the endocardial localization of Quilty effect may be related to a relative absence of cyclosporine A in this region. METHODS: We used an indirect immunofluorescence staining method with rabbit polyclonal anti-cyclosporine A antibodies to detect cyclosporine A in fresh frozen sections of 27 cardiac allograft endomyocardial biopsies. Staining was graded 0 to +3. Negative controls were from untreated transplant candidates and from biopsies with the primary antibody omitted. RESULTS: On comparison of endocardial and myocardial fluorescence in biopsy specimens from patients treated with cyclosporine A, there was less endocardial (0.7 +/- 1.1, p < 0.0001) than myocardial (2.2 +/- 0.5) staining. However, in biopsy specimens with Quilty effect (n = 12), this difference was significantly greater (endocardial = 0.2 +/- 0.6 versus myocardial = 2.3 +/- 0.5; p = 0.005) than in specimens without Quilty effect (n = 10) (endocardial = 1.4 +/- 1.2 versus myocardial = 2.1 +/- 0.6; p = 0.7). Endocardial thickness as measured by ocular micrometry was significantly greater in regions with (32 +/- 19 microns) than without (7 +/- 4 microns) Quilty effect, with involved regions showing increased connective tissue (p < 0.0001). In patients with and without Quilty effect, no differences in donor or recipient demographics, prevalence of diabetes, or plasma cyclosporine A levels were found. CONCLUSIONS: Although it has been postulated that Quilty effect is due to the presence of cyclosporine A in cardiac tissue (toxic effect or immunologic reaction), these data suggest that Quilty effect is related to reduced endocardial presence of cyclosporine A, leading to localized, contained, and usually not clinically significant endocardial rejection.
Adult↗