Complex regional pain syndrome and methionine-enkephalin.
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Biomarkers↗
Biomedical subjects
Donald S Esmore
Publications and source records attributed to Donald S Esmore.
Early institution of mechanical support improves outcomes in primary cardiac allograft failure.
BACKGROUND: Primary graft failure (PGF) is the leading cause of early mortality after cardiac transplantation, accounting for 27.1% of deaths within 30 days. PGF is defined as severe dysfunction of the cardiac allograft without any obvious anatomic or immunological cause. The purpose of this study was to analyze our last 9 years of experience with cardiac transplantation to determine predictors of PGF and the influence on survival of our policy of early institution of mechanical circulatory support (MCS) in these patients. METHODS: Data on 214 consecutive cardiac transplants performed at The Alfred Hospital between January 1996 and August 2004 were reviewed. PGF was defined as right or left or biventricular failure manifesting as hypotension (systolic blood pressure <90 mm Hg), low cardiac output (cardiac index <2.0 liter/min/m2 and pulmonary capillary wedge pressure >20 mm Hg after coming off cardiopulmonary bypass despite inotropic support of up to 5 mug/min adrenaline and without any other obvious cause for the graft dysfunction. RESULTS: PGF developed in 51 patients (24%). Significant factors in the development of PGF were long ischemic time, which became significant over 4 hours (odds ratio, 1.43; p = 0.01) and increased donor age (odds ratio, 1.027; p = 0.045). Fifteen patients required mechanical support, and of these, 10 survived to leave hospital. CONCLUSIONS: PGF is the major cause of early mortality after cardiac transplantation. Significant risks for PGF are long allograft ischemic time and increased donor age. Once the patient has survived 30 days, however, the longer-term survival is not influenced by PGF. Our management strategy of early mechanical support has yielded good outcomes in this population with a high risk of early death.
Age Factors↗
First clinical implant of the VentrAssist left ventricular assist system as destination therapy for end-stage heart failure.
The VentrAssist device left ventricular assist system, designed for permanent implantation, is a novel centrifugal pump with a hydrodynamically suspended rotor. The first human implant was into a 72-year-old man with New York Heart Association (NYHA) class IV heart failure due to idiopathic dilated cardiomyopathy. The implant and recovery were uneventful, and the patient survives at 17 months, is NYHA class II, and lives at home. This device shows promise in end-stage heart failure for permanent implantation and bridge to transplantation.
Aged↗
The split radial technique: an alternative to the Y-graft for total arterial myocardial revascularisation.
There is evidence that the use of Y-grafts attached to the left internal mammary artery - to - left anterior descending artery graft may compromise the patency of the distal limb of the left internal mammary artery. We describe a technique (split radial technique) that avoids the use of Y-grafts by constructing two aorto-coronary grafts from a single radial artery. The split radial technique requires the harvesting of the radial artery in its entirety from the brachial bifurcation to the radial styloid. The first radial artery distal anastomosis is performed and the required length of conduit is determined. The conduit is transected, leaving a sufficiently long radial segment for a second aorto-coronary graft. A clinical follow-up 41 weeks after surgery of the first 37 patients in whom the split radial technique was used showed no deaths or major complications. This suggests that the split radial technique is a useful and safe way to maximise the use of radial artery conduit and to avoid the potential risk of compromising internal mammary artery patency with Y-grafts. There is evidence that the use of Y-grafts attached to the left internal mammary artery may compromise the patency of the distal limb of the left internal mammary artery. We describe the split radial technique of constructing two aorto-coronary graft segments from a single radial artery that can be used to avoid the use of Y-grafts.
Aged↗
Extended pericardiotomy avoids cardiopulmonary bypass during bilateral sequential lung transplantation.
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Adult↗
Unexpected donor pulmonary embolism affects early outcomes after lung transplantation: a major mechanism of primary graft failure?
OBJECTIVE: Primary graft failure remains a significant cause of morbidity and mortality after lung transplantation, and its mechanism is not understood. Previously 2 case reports described fatal primary graft failure due to donor-related unexpected pulmonary embolism. This study investigated the incidence, early outcome, and risk factors of unexpected pulmonary embolism in lung transplantation. METHODS: An exploratory retrograde donor lung flush before implantation to diagnose pulmonary embolism (emboli group) or no pulmonary embolism (no-emboli group) was performed in 74 of 122 consecutive lung transplantations. RESULTS: The incidence of macroscopic unexpected pulmonary embolism was 38% (28% clot and 9% fat). In the emboli group, significantly decreased oxygenation (P < .05), increased pulmonary vascular resistance (P < .001), an increased proportion of opacity on chest radiograph (P = .03), prolonged intubation (P < .001) and intensive care unit stay (P < .01), and decreased 1-year survival (P = .03) were seen after transplantation. In multivariate analysis, pulmonary embolism was an independent risk factor for prolonged intubation (hazard ratio, 2.42; P < .01). In logistic regression, death due to trauma with fracture and a smoking history of more than 20 pack-years were significant donor risk factors for pulmonary embolism (adjusted odds ratio, 8.77 and 5.64; P = .02 and .04, respectively). No deleterious effects of the exploratory flush were seen. CONCLUSIONS: Unexpected pulmonary embolism is relatively common, is potentially predicted by donor history (but not by arterial blood gas analysis or chest radiograph), and is associated with primary graft failure. Donor lungs with risk factors of pulmonary embolism should undergo an exploratory flush. When pulmonary embolism is diagnosed, further therapeutic strategies must be considered.
Adult↗
A donor history of smoking affects early but not late outcome in lung transplantation.
BACKGROUND: Liberalization of tobacco exposure history as an exclusion to lung donation has recently occurred to increase donor organ availability. This study investigated the effect of donor smoking status and current and cumulative cigarette dose on early and late outcomes in lung transplantation. METHODS: From 1995 to 2002, 173 heart-lung and bilateral single-lung transplant recipients were retrospectively reviewed. Seventy-seven (45%) of 173 donors were ever-smokers and 64 of those 77 were current smokers. These were divided into subgroups by current number of cigarettes smoked to investigate acute dose effects and by pack-year to investigate cumulative dose effects. Risks of smoking were assessed by univariate and multivariate hazard regression models. RESULTS: Univariate analysis revealed that there were significant differences between current and cumulative dose subgroups in early postoperative variables, including Pao2/Fio2 ratio, ventilation time, and intensive care unit stay. Additionally, these variables were dose dependent. There was no significant difference in 3-year survival between never-smokers and ever-smokers (73% versus 64%, P = 0.27), and a rate of decline of survival was similar. There was a trend for the percentage of patients dying of bronchiolitis obliterans syndrome to be lower in the ever-smokers group compared with the never-smokers group (6% versus 11%, respectively). Multivariate analysis revealed current and cumulative smoking as a risk factor for early but not late outcomes. CONCLUSIONS: Donor smoking history had a significant effect on early outcomes in lung transplantation in a current and cumulative dose-dependent fashion. However, no significant effect on late outcomes, including bronchiolitis obliterans syndrome, was seen.
Adult↗
Epstein-Barr virus primary mismatching and HLA matching: key risk factors for post lung transplant lymphoproliferative disease.
BACKGROUND: Posttransplant lymphoproliferative disease (PTLD) in lung transplant recipients (LTRs) is potentially lethal with considerable morbidity. The role of donor (D)/recipient (R) HLA matching is unknown. METHOD: We reviewed our LTRs from January 1994, when routine D/R Epstein-Barr virus (EBV) serologic screening was begun, through to January 2000. We examined whether D/R HLA match status influenced the risk of PTLD in EBV D+/R- mismatched LTRs. RESULTS: There were 16 D+/R- EBV-mismatched LTRs, 5 (31%) of whom developed PTLD (from a total of 237 LTRs; 218 survived >30 days). There were only two other cases of PTLD among the non-EBV primary mismatched patients. All patients received baseline immunosuppression of cyclosporine, azathioprine, and prednisolone without cytolytics and ganciclovir prophylaxis if "at risk" from cytomegalovirus. The five PTLD cases were diagnosed 81 to 734 (median 116) days from transplantation; three involved the lung allograft and two others involved lymph nodes. All PTLD patients seroconverted for EBV, whereas 7 of the 11 remaining EBV-mismatched patients who did not develop PTLD did not seroconvert. In the 16 EBV primary mismatched patients, there were 4 of 66 HLA allele matches in the 11 PTLD-free patients versus 15 of 30 matches in the 5 PTLD patients (P<0.001). This resulted in 2 or more HLA (A/B/DR) matches in 4 of 5 patients with PTLD versus 0 of 11 in the PTLD-free group (P=0.003). All PTLD patients were treated with reduced immunosuppression and antiviral therapy. Only two of the five LTRs who developed PTLD died, one with progressive disease despite chemotherapy and the other from chronic allograft rejection. CONCLUSION: A high degree of HLA matching in D/R EBV-mismatched LTRs significantly increases the risk of PTLD.
Graft Rejection↗
Heterotopic heart transplantation: an expanding role in the twenty-first century?
BACKGROUND: Heterotopic heart transplantation was first performed in humans in 1974, the main advantage being the continuing function of the patient's native heart, in the event of life-threatening acute rejection. The effect of cyclosporine on acute rejection saw the heterotopic transplantation technique wane. Our unit revisited heterotopic transplantation in response to a growing number of waiting list patients with high pulmonary artery pressures. We also anticipated an increased cardiac allograft utilization, and improvement of our waiting list times. METHODS: We retrospectively analyzed 151 patients undergoing heart transplantation by our unit between August 1997 and September 2003. Twenty received allografts in the heterotopic position. This cohort was compared with the 131 contemporary orthotopic heart transplant recipients with respect to their outcomes. RESULTS: The indication for transplantation was ischemic cardiomyopathy in 14 (70%) of the heterotopic cohort and 47 (36%) of the orthotopic cohort (p = 0.004), and dilated cardiomyopathy in 3 (15%) and 48 (37%) in the heterotopic and orthotopic groups, respectively (p = 0.06). Heterotopic recipients were significantly older than orthotopic recipients, and they had higher pulmonary artery pressures. The heterotopic donors were also older and the ischemic times were longer. A subgroup analysis was made among those patients who had high pulmonary artery pressures as these groups were better matched. Major morbidity in the heterotopic heart transplantation group consisted of reversible allograft dysfunction in 4 patients, renal dysfunction requiring hemofiltration in 3 patients, profound myopathy in 4 patients, and cerebrovascular events in 2 patients. There were two early deaths in the heterotopic transplant group and eight in the orthotopic group (p = 0.87). Kaplan-Meier survival analysis of survival was performed. CONCLUSIONS: Heterotopic heart transplantation is a viable transplant option for selected high-risk heart transplant recipients in spite of somewhat poorer outcomes.
Acute Kidney Injury↗
The challenge of improving donor heart preservation.
Heart transplantation has in recent years become the treatment of choice for end stage heart failure. However while the waiting list for transplantation is growing steadily, the donor pool is not increasing. Therefore, in order to meet demand, transplant programs are using older, "marginal donors" and accepting longer ischaemic times for their donor hearts. As donor organs are injured as a consequence of brain death, during the period of donor management, at organ harvest, preservation, implantation and reperfusion, expansion of acceptance criteria places a great burden on achieving optimal long-term outcomes. However, at each step in the process of transplantation strategies can be employed to reduce the injury suffered by the donor organs. In this review, we set out what steps can be taken to improve the quality of donor organs.
Journal Article↗
Donor history of asthma is not a contraindication to lung transplantation: 12-year single-center experience.
BACKGROUND: Donor asthma has been regarded as a contraindication to lung transplantation (LTx) because of concerns that pre-existing airway inflammation will predispose to early and late graft dysfunction. The aim of this study was to describe LTx outcomes in which lungs had been transplanted from donors with a history of asthma. METHODS: A retrospective chart review was undertaken of 743 consecutive donor lung referrals to the Alfred Hospital between 1990 and September 2002. Seventy-four were noted to have a history of asthma, including 18 in whom asthma was the cause of death. Twenty-seven patients became lung donors, of whom 16 were on asthma treatment (on-treatment group) and 11 were not (no-treatment group). RESULTS: From 27 lung donors, 35 LTx procedures were performed (16 double LTx [DLTx], 19 single LTx [SLTx]). Five recipients died at <30 days (including 3 of early graft failure in the no-treatment group), and 7 died at >30 days (only 1 due to BOS). The 30-day, 1-year and 5-year survival rates in the on- and no-treatment donor groups were 90% vs 76%, 74% vs 69% and 74% vs 60%, respectively, and were not significantly different from our overall LTx survival rates. There were no significant differences in percent predicted forced expiratory volume in 1 second, ICU stay or hospital stay overall, or when analyzed according to on treatment vs no treatment and SLTx vs DLTx. Only 2 procedures LTx were performed from fatal asthma donors, both of whom had subsequent graft dysfunction and died on Days 73 and 484, respectively. CONCLUSIONS: The use of lungs from carefully selected lung donors with a history of asthma may increase the donor pool with acceptable long-term outcomes. The use of fatal asthma donors remains problematic.
Adult↗
Occlusive wrap dressing reduces infection rate in saphenous vein harvest site.
BACKGROUND: Infection in the saphenous vein harvest site is a common problem. We developed an occlusive circumferential wrap dressing technique that reduces skin edge tension, eliminates dead space, and prevents external contamination. We compared the surgical site infection rate using the wrap dressing technique with that of standard longitudinal dressings. METHODS. One hundred fifty-two consecutive patients were randomly assigned to receive either standard dressings or the wrap dressing. Data were collected in the hospital and then 4 to 6 weeks postoperatively. Superficial and deep wound infections were defined by the standard criteria from the Centers for Disease Control and Prevention. RESULTS: The infection rate in the wrap group was 14% compared with 35%, for the standard group (p = 0.006). Multivariate analysis showed that wrap technique was the only significant predictor (negative) of infection (odds ratio, 0.19; p = 0.001). CONCLUSIONS: In saphenous vein harvest wounds, the occlusive wrap dressing technique has the potential to reduce the rate of infection by 50%. This simple and inexpensive technique is also readily applicable to the radial artery harvest site in the arm and may provide similar benefit.
Aged↗
Endogenous cardiac opioids: enkephalins in adaptation and protection of the heart.
Opiates have been used for thousands of years in the form of opium for relief of pain or fever and to induce sleep. However, it was only in the 1970s that the endogenous ligands for the opiate receptors were identified and termed opioid peptides. Opioid peptides activate G protein-coupled receptors in the central and autonomic nervous system, with marked effects on the regulation of pain perception, body temperature, respiration, heart rate and blood pressure. Cardiovascular regulatory effects of endogenous opioids were initially considered to originate from neural centres in the central nervous system, facilitating a regulatory role in neuro-transmission, as demonstrated by the presynaptic co-release from sympathetic neurones of norepinephrine with enkephalin or acetylcholine with enkephalin. However, opioid peptides of myocardial origin have also recently been shown to play a key role in local regulation of the heart. This brief review highlights the key features of the enkephalin opioids in the heart and the current understanding of their role in development, ageing, cardioprotection, hypertension, hypertrophy, and heart failure.
Journal Article↗
Initial in vivo experience of the VentrAssist implantable rotary blood pump in sheep.
VentrAssist (VentrAssist Division, Ventracor Ltd., Chatswood, NSW, Australia) has developed an implantable centrifugal blood pump with an integrated rotor and impeller that is hydrodynamically suspended. Bench testing has been used to assess the performance of the pump under a broad range of operating conditions. This study examined the performance of the pump in vivo up to 90 days implantation. Pumps were implanted via a left lateral thoracotomy. The inflow cannula was inserted at the apex of the left ventricle. The outflow cannula was anastomosed to the descending thoracic aorta. Eighteen implants were performed. Poor recovery from surgery was the main cause of early study termination. These studies demonstrate the suitability of the animal model for evaluation of the VentrAssist rotary blood pump. Further in vivo studies prior to preclinical trials are in progress.
Animals↗
Preventing radial artery spasm.
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Amlodipine↗
Implantation of the VentrAssist Implantable Rotary Blood Pump in sheep.
The VentrAssist Implantable Rotary Blood Pump (IRBP) is a hydrodynamically suspended, electromagnetically driven, centrifugal blood pump that provides continuous flow of up to 10 L/min at 3,000 rpm. In vivo studies in sheep were conducted to assess system design and performance. Surgery involved thoracotomy with subdiaphragmatic pump placement. Cannulae were transdiaphragmatic, with inflow in the left ventricular apex and outflow anastomosed to the descending aorta. Animals had no anticoagulation or antiplatelet therapy after surgery and no prophylactic antibiotics after recovery. Twelve sheep were supported for 622 pump days. Estimated pump flow ranged from 1 to 5.5 L/min at 1,800 to 2,000 rpm using 2.5 to 4.5 W. There was no clinical evidence of hemolysis or cardiovascular, renal, or hepatic dysfunction. Adverse outcomes included kinking/disconnection of the outflow cannula caused by the graft bend relief (n = 4), which was addressed through cannula redesign. Pump electrical malfunction (n = 4), caused by a silicone potting compound, was corrected using a neutral curing potting material. Surgical/husbandry issues (n = 2) also were addressed. The VentrAssist IRBP provides high flow at low rotational speed and power consumption. Further trials are in progress in advance of in vivo studies of the safety and efficacy of the final system.
Animals↗