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Biomedical subjects

O H Frazier

Publications and source records attributed to O H Frazier.

At least 271 records · Page 15Linked to original sources
PubMed1989

Effect of prior cardiac surgery on survival after heart transplantation.

We conducted a retrospective analysis of 182 adult orthotopic heart transplant patients who underwent operations at our institution between July 1982 and October 1987 to determine whether prior cardiac operation affects survival. Group I included the 72 patients (39.6%) who had undergone a previous cardiac operation or operations and group II, the 110 (60.4%) who had not. The mean age of the patients in group I was 52.1 +/- 8.1 years and in group II, 46.1 +/- 10.2 years (p less than 0.01). The incidence of ischemic heart disease was 86.1% in group I and 29.1% in group II (p less than 0.01). All patients received cyclosporine-based immunosuppression. More patients in group I than in group II required reoperation for bleeding after transplantation: 18 (25.0%) versus 9 (8.2%) (p less than 0.01). The actuarial 1-year and 3-year survival rates were 77.6% and 66.5%, respectively, for group I and 77.1% and 66.3%, respectively, for group II. Because both groups had similar survival rates, we believe that prior cardiac operation in heart transplant recipients does not compromise long-term survival.

Adult↗
PubMed1989

Implantation techniques for the Hemopump.

Techniques for implantation of the Hemopump, an intraarterial, axial-flow circulatory assist device, are described. The Hemopump, which is currently undergoing clinical investigation, has been used successfully to treat patients experiencing profound left ventricular failure in a variety of clinical situations, including postcardiotomy shock, acute myocardial infarction, cardiac allograft rejection, and cardiac allograft failure.

Cardiopulmonary Bypass↗
PubMed1989

Improved cardiac function with glucose-insulin-potassium after aortocoronary bypass grafting.

To assess the effectiveness of metabolic support for the heart in patients with refractory heart failure after hypothermic ischemic arrest for aortocoronary bypass grafting we assigned 22 patients to receive either intravenous glucose (50%), insulin (80 IU/L), and potassium (100 mEq/L) at a rate of 1 mL/kg/h for up to 48 hours (GIK) or glucose (5%) and NaCl (0.225%) at the same rate (control). All patients started out with a mean cardiac index of less than 3.0 L/min/m2, were on intraaortic balloon pump assistance, and required inotropic drugs. At 12 and 24 hours cardiac index had increased significantly in the GIK group when compared with the control group (3.6 and 3.4 versus 2.5 and 2.7 L/min/m2, respectively). Time on the intraaortic balloon pump (39 versus 61 hours) and requirements for inotropic drug support were significantly less in GIK group than in the control group. All 11 GIK patients could be weaned from intraaortic balloon pump assistance. At 30 days after operation survival was 10/11 in the GIK group, compared with 7/11 in the control group. We conclude that GIK is both safe and effective in the treatment of refractory left ventricular failure after aortocoronary bypass grafting. The exact mechanism for the beneficial effect of GIK on myocardial contractility remains to be elucidated.

Aged↗
PubMed1989

Improved immunosuppression for heart transplant patients using intravenous doses of cyclosporine.

Inducing immunosuppression in heart transplant patients with intravenous doses of CsA may decrease the incidence of severe rejection in the 1st month after operation. In our initial series, 16 consecutive patients (group A) who had no contraindications to this type of therapy received an i.v. dose of CsA, 1 mg/kg/day, postoperatively, which was then increased by 1 mg/kg every 24 hr until a full maintenance dose of 4 mg/kg/day was achieved (total time, 72 hr). The gradual increase in dosage was designed to prevent nephrotoxicity associated with higher doses of CsA. Intravenous administration was continued for 2 weeks, at which time oral administration of CsA, 14 mg/kg/day, was begun. In a subsequent series, 21 similar patients (group B) received the same amount of CsA, except that doses were increased every 12 hr, so that the full maintenance dose was achieved 36 hr postoperatively. In group B, the i.v. dose of CsA was continued for only 1 week, at which time oral administration of CsA, 14 mg/kg/day, was begun. All patients received the same standard steroid taper (30 mg/day by day 10). Patients from both groups who were greater than or equal to 55 years old and had serum creatinine greater than or equal to 1.5 mg/dl and patients from group B who had creatinine clearance less than or equal to 55 ml/min also received azathioprine, 2 mg/day, which was adjusted to maintain the white blood cell count at a level greater than or equal to 5000/cc. There was a similar number of such patients in both groups. Severe rejection was defined by endomyocardial biopsy with frequent foci of myocyte degeneration. Three (18.7%) patients in group A experienced severe rejection, and 2 (9.4%) in group B did. No patients developed renal failure. All patients survived the 1st month. The overall survival rate for group A at 12.2 +/- 1.5 months was 94%, and for group B it was 86% at 7.5 +/- 1.4 months. Both these groups compared favorably with our historical control group of patients who received oral doses of CsA to induce immunosuppression, in which 59 of 165 (35.8%) had severe rejection in the 1st month, with a 1-year actuarial survival rate of 76%. Based on this experience, we believe that i.v. administration of CsA enhances the induction of immunosuppression, thereby reducing the incidence of severe rejection. This protocol is likely to be effective because it minimizes the problems of oral absorption in the perioperative period.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1989

Comparative evaluation of urographic contrast media, inulin, and 99mTc-DTPA clearance methods for determination of glomerular filtration rate in clinical transplantation.

Plasma clearance of inulin (Cin), 99mTc-DTPA (CDTPA), and urographic contrast media (CCM) were determined simultaneously in 31 patients with varying levels of renal function evaluated in the setting of affiliated cardiac and renal transplantation programs. Cin and CDTPA were calculated from the ratio of simultaneously measured plasma concentration and urine excretion rate of these test agents (UxV/P). CCM was derived from x-ray fluorescence measurement of plasma iodine (PI) content following intravenous injection of 50 ml of nonionic, low-osmolar contrast media (180 mg I/ml). Urine collections were not required for CCM determinations. No adverse reactions attributable to CM occurred in any patient, and follow-up serum-creatinine values did not differ significantly from prestudy levels. CCM determined from the rate of decline in PI between 3 hr and 4 hr following administration of contrast media ("slope-intercept" technique) [Ccm-SI] correlated closely with corresponding levels of Cin (r = .86, P less than 0.0001). and CDTPA (r = 0.89, P less than 0.0001). Mean CCM-SI/Cin and CCM-SI/CDTPA ratios for the entire study cohort were 1.09 +/- 0.06 and 1.08 +/- 0.06, respectively. CCM-SI determinations also correlated well with CCM levels derived from a single measurement of PI ("single sample" technique) made at 3 hr following injection of contrast media (r = 0.94, P less than 0.0001). Both CCM-SI and CCM determined by the "single sample" method (CCM-3 degrees SS) tended to overestimate Cin and CDTPA, however, when the latter were less than 20 ml/min/1.73 m2 (mean CCM-SI/Cin and Ccm-3 degrees SS/Cin ratios 1.36 +/- 0.14 and 1.95 +/- 1.0, respectively. Reproducibility was evaluated by paired comparison of 3-hr vs. 4-hr "single sample" CCM determinations (r = 0.99, P less than 0.0001). In addition, analysis of the variation in iodine content between duplicate specimens obtained at each of these time intervals revealed a mean ratio of 1.0 +/- 0.01 (P = NS vs. identity). Contrast clearance determination utilizing the slope-intercept method is accurate, safe, pragmatic, and more precise than serum-creatinine and endogenous-creatinine clearance for measurement of renal function in clinical transplantation.

Contrast Media↗
PubMed1989

Use of a left ventricular assist device as a bridge to transplantation in a pediatric patient.

Despite many advances in heart transplantation and in mechanical circulatory support, the benefits of staged cardiac transplantation have not been extended to the pediatric transplant recipient, chiefly because implantable circulatory assist devices are still too large. Extracorporeal devices, however, can overcome this impediment. Here we report the 1st case, to our knowledge, in which an extracorporeal left ventricular assist device has been used in a child to support circulation prior to cardiac transplantation. The patient was a 9-year-old boy in New York Heart Association functional class IV, with congestive heart failure as a result of idiopathic biventricular cardiomegaly. In mid-May of 1987, while awaiting a suitable donor, he suffered severe oliguria after an episode of circulatory arrest. Therefore we decided to maintain his circulation-and consequently his peripheral organ function-with an extracorporeal left ventricular assist device. After establishing cardiopulmonary bypass under normothermia and without cardiac arrest, we established flow from the left ventricle through a 36-Fr wire-reinforced straight cannula to a Biomedicus BP-80 centrifugal force pump, with return to the proximal ascending aorta through a 28-Fr wire-reinforced straight cannula. The patient's hemodynamic course under subsequent mechanical circulatory support was remarkably stable, with controllable systemic hypertension and no evidence of hemolysis. Although cardiac activity was minimal and systemic blood flow nonpulsatile, the patient's renal, pulmonary, and hepatic functions improved, and his peripheral circulation was well preserved. After 12 hours of support, a donor heart became available, and a routine orthotopic cardiac transplant was performed. Upon removal, the left ventricular assist device showed a small amount of thrombus formation. The patient's postoperative recovery has been easily manageable, and 20 months after transplant he enjoys unrestricted physical activity. We conclude that an extracorporeal left ventricular assist device can be used as a bridge to cardiac transplantation in children. Moreover, this application of a continuous force centrifugal pump without adverse effect encourages the conclusion that long-term maintenance of terminal heart disease patients might be possible through development of small, implantable pumps with the potential of lower power requirements and reduced thrombogenesis.

Journal Article↗
PubMed1989

Percutaneous transluminal coronary angioplasty after cardiac transplantation.

This report describes the 1st use of percutaneous transluminal coronary angioplasty in a posttransplant patient at the Texas Heart Institute. The patient, a 44-year-old man, experienced 3 episodes of moderate allograft rejection, hypercholesterolemia, transient severe hyperglycemia, and transient severe renal insufficiency in the posttransplant period. His cholesterol levels became elevated immediately and remained between 200 and 250 mg/dL, despite treatment with gemfibrozil. He had increasing lower-extremity claudication that was treated with bilateral femoral-popliteal bypass grafting. At 5-year follow-up, a discrete 75% stenosis was found in the right coronary artery. He was treated successfully with percutaneous transluminal coronary angioplasty on 20 February 1989 and was able to return to work thereafter.

Journal Article↗
PubMed1989

Cardiac transplantation and mechanical circulatory assistance: the Texas Heart Institute experience.

From January 1984 to September 1988, 245 heart transplants were performed at our institution. During this period, 53 staged cardiac transplant procedures were performed using an intraaortic balloon pump (IABP), an extracorporeal centrifugal blood pump (ECBP), an intracorporal left ventricular assist device, and a total artificial heart. Thirty-four (64%) patients underwent subsequent cardiac transplantation and 28 (53%) were discharged. Our data indicate that patients who suffer rapid onset of heart failure and undergo early circulatory support are suitable candidates for successful staged cardiac transplantation. We have also used mechanical support to treat severe heart failure after transplantation, using IABP and ECBP support, as well as an intraarterial axial flow pump. In immunosuppressed patients, infection is the critical issue affecting outcome. There is a need for development of smaller, simpler, less invasive devices with the capacity to provide both systemic and pulmonary circulatory support.

Adolescent↗
PubMed1989

Cardiac surgical emergencies.

Cardiac surgical emergencies are broken down into three categories: cardiac trauma, aortic dissection, and surgery for acute myocardial infarctions. Emphasis is given to describing the presentation of patients with such problems, and to the salient aspects of the clinical strategies for managing each problem. An important goal of each section is focusing the critical care physician on the early recognition of cardiac surgical emergencies and providing him with some rationale for instituting an expeditious plan of therapy.

Aged↗
PubMed1989

Efficacy of metabolic support with glucose-insulin-potassium for left ventricular pump failure after aortocoronary bypass surgery.

Refractory pump failure after cardiopulmonary bypass carries a high mortality. To assess the effectiveness of metabolic support for the heart in patients with refractory heart failure after hypothermic ischemic arrest for aortocoronary bypass surgery, we randomly assigned 22 patients to receive either intravenous glucose (50%), insulin (80 units/I), and potassium (100 meq/l) (GIK) infused at a rate of 1 ml/kg/hr for up to 48 hours or glucose (5%) and NaCl (0.225%) infused at the same rate (control). All patients required inotropic drug support, received intra-aortic balloon pump assistance, and had an initial mean cardiac index (CI) of 2.5 l/min/m2. At 12 and 24 hours, CI had risen significantly in the GIK but not in the control group (3.6 and 3.4 l/min/m2 vs. 2.5 and 2.7 l/min/m2, p less than 0.005). Time on the intra-aortic balloon pump (39 vs. 61 hours) and requirements for inotropic drug support were also significantly less in the GIK compared with the control group. Although the number of patients was relatively small, the GIK group also showed a trend for improved long-term survival: at 60 days after surgery, there were 10 of 11 survivors in the GIK-treated group compared with seven of 11 survivors in the control group. Although the exact mechanism for the beneficial effects of GIK on myocardial contractility remains to be elucidated, we conclude that GIK is safe and effective in the treatment of refractory left ventricular failure after aortocoronary bypass surgery.

Aged↗
PubMed1989

The older cardiac transplant donor. Relation to graft function and recipient survival longer than 6 years.

A donor age of less than 35 years has long been considered crucial for heart transplantation. Because of limited donor heart supply and increasing demand for cardiac transplants, we attempted to expand the donor pool by using hearts from older individuals. This study was designed to determine if older donor hearts adversely affected cardiac transplant patient prognosis by predisposing them to graft failure from coronary artery disease, ventricular dysfunction, or death. Since 1982, 314 heart transplants have been performed at our institutions. Potential donors were deemed fit if there was no history of heart disease, the chest x-ray film was normal, the electrocardiogram showed nonspecific changes only, and blood pressure was maintained without major pharmacological support. In 47 (15%), donor age was 35 years or greater (group 1: mean age, 39 years; range, 35-49 years). In 267 (85%), donor age was less than 35 years (group 2: mean age, 23 years; range, 2-34 years). Mean group 1 recipient age was 55 years (range, 39-68 years) compared with 46 years (range, 0.7-66 years) in group 2 (p less than 0.01). Pretransplant inotropic support, mechanical support, or both were required in 15 (33%) group 1 patients and in 41 (16%) group 2 patients (p less than 0.01). Group 1 and 2 follow-up intervals were 1.1 +/- 1.0 and 1.8 +/- 1.4 years (mean +/- SD), respectively (p less than 0.0001). Overall survival was 64% versus 65%, group 1 versus group 2, and life table analysis showed no significant difference between the groups. There were three of 17 (18%) deaths due to coronary artery disease in group 1 and 20 of 87 (23%) in group 2 (p = NS). Seven patients in group 2 and none in group 1 required retransplant because of coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Cardiac transplantation in patients over 60 years of age.

Cardiac transplant programs have routinely excluded patients over 55 years of age from consideration as transplant candidates. The Texas Heart Institute modified this policy of using age as a contraindication to transplantation. Between July, 1982, and August, 1987, a total of 200 cardiac transplants were performed, 28 (14%) of which were in patients over 60 years of age, the eldest being 66 years old at the time of transplant. Our immunosuppressive regimen consisted primarily of cyclosporine and prednisone. In 1985, azathioprine was added in an effort to decrease dosages of cyclosporine, thereby decreasing its associated nephrotoxicity. The incidences of rejection and infection were 1.2 and 1.4 episodes/patient, respectively, for those over 60 years of age versus 1.7 and 1.3 episodes/patient, respectively, for those less than 60 years of age. Of the 28 patients, 23 are alive and well. Four deaths were caused by infection, and the other by diffuse coronary arteritis. The one-year actuarial survival for patients over 60 years of age was 83%, compared with 75% for the other transplant patients. We conclude that persons over 60 years of age can undergo cardiac transplantation with results equal to or perhaps better than those of other heart transplant patients. Our experience suggests that advanced age should not be considered a major contraindication to cardiac transplantation.

Actuarial Analysis↗