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Biomedical subjects

R M Bolman

Publications and source records attributed to R M Bolman.

At least 109 records · Page 6Linked to original sources
PubMed1990

Rejection and infection after pediatric cardiac transplantation.

Cardiac transplantation has only recently become an accepted therapeutic modality for children and adolescents with end-stage cardiomyopathy. Long-term survival, the incidence of rejection, and the incidence of infection are still being defined. From 1985 to 1989, 21 children aged 6 months to 19 years (average age, 11.2 years) underwent cardiac transplantation at our institutions. Eighteen survived the operative period and have been followed for 5 to 49 months (average follow-up, 24 months). All operative survivors have received triple-drug immunosuppression consisting of cyclosporine, azathioprine, and prednisone. During follow-up, 7 patients have been treated on 12 occasions for rejection as documented by endomyocardial biopsy. Eight (67%) of the 12 episodes of rejection occurred in the presence of subtherapeutic cyclosporine levels. Two of the 7 patients treated for rejection have subsequently died of ongoing cardiac rejection and arrhythmia. There have been no perioperative or late deaths from infection. Bacterial sepsis was identified and treated twice during follow-up, viral infections on five occasions, and fungal infection once. Actuarial 1-year survival and 3-year survival of the 18 operative survivors are 94% and 78%, respectively. In the first 7 months after cardiac transplantation, 73% of patients were free from rejection and 83% were free from serious bloodborne infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

Transplantation of discordant xenografts: a review of progress.

Hyperacute rejection, apparently initiated by natural antibodies and complement, has been viewed as an absolute barrier to the xenotransplantation of vascularized grafts between different species. Until recently, little was known about the molecular and physiological basis for this barrier nor was there evidence that the barrier might be more than transiently breached. In this paper Jeffrey Platt, Fritz Bach and colleagues describe a model of hyperacute rejection and propose that, if hyperacute rejection can be averted for a period after transplantation, prolonged xenograft survival will be possible.

Animals↗
PubMed1990

Pseudo-intracardiac air in a heart-lung transplant patient.

Air in the heart is a serious condition and may be life-threatening. It is usually of iatrogenic origin or the result of trauma. Computed tomography of a heart-lung transplant recipient who had unilateral hydropneumothorax revealed a mediastinal gas collection that appeared to be intracardiac. A follow-up study with intrapleural contrast medium revealed that the gas was not within but was actually between cardiac chambers. Consequently the gas collection mimicking intracardiac air was of no clinical importance.

Adult↗
PubMed1990

Five-year experience with triple-drug immunosuppressive therapy in cardiac transplantation.

Although triple-drug immunosuppression with a combination of cyclosporine, prednisone, and azathioprine has been shown to improve short-term survival after cardiac transplantation, its long-term effects still are unknown. From December 1983 through December 1988, all patients (N = 139) who underwent orthotopic cardiac transplant at our institution received triple-drug immunosuppressant therapy. Follow-up averaged 32.2 +/- 15.8 months. Twenty-one patients died; 134 survived more than 30 days. Actuarial survival was 92% at 1 year, 85% at 3 years, and 78% at 5 years. Twenty-five episodes of acute graft rejection were diagnosed in 21 of the 139 recipients (0.18 episode per patient). In patients, the incidence of infection was 0.82 episode; 72% of infections were viral, with 10% due to cytomegalovirus. The incidence of coronary artery disease was 10% at 1 year, 25% at 3 years, and 36% at 5 years. Coronary artery disease was responsible for 60% of late deaths. Arterial hypertension developed in 81% of patients, despite relatively well-maintained renal function (serum creatinine, 1.7 +/- 0.3 mg/dl). Skeletal complications occurred in 15.8% and lymphoma in 1.4% of recipients. Complete long-term rehabilitation was achieved in all but two of the surviving patients. These data support the short- and long-term effectiveness of triple-drug therapy. This regimen reduces the incidence of rejection, infection, and lymphoma, as well as the degree of renal failure. However, the incidence of posttransplant coronary artery disease has not been reduced, and graft atherosclerosis represents the major cause of late graft failure and death.

Actuarial Analysis↗
PubMed1990

Cardiac transplantation.

With the advent of cyclosporine and triple-drug therapy, cardiac transplantation has developed from a curiosity into an effective therapy. Optimal results require proper recipient selection, careful donor identification and preparation, and skillful surgical and postoperative care. Recent trends to expand the donor and recipient pools will result in an amplification of the problems encountered to date. Causes of significant perioperative morbidity and mortality continue to be graft failure, infection, and rejection. Careful attention to elevated recipient pulmonary vascular resistance and donor heart preservation are essential to prevent graft failure. Diagnosis and treatment of infection and rejection depend on anticipation and vigilance by the cardiac transplant team. Knowledge of and familiarity with immunosuppressive regimens and the inherent side effects, both unique to each drug and common to the group, should enable minimization of the drugs' toxicities. Long-term sequelae of cardiac transplantation are now being defined and our ability to affect them is a continuing challenge. Cardiac transplantation has become a safe and effective treatment for end-stage cardiovascular disease. Success is now measured, not by patient survival, but by the quality of life achieved by those who receive this treatment modality.

Critical Care↗
PubMed1990

The clinical utility of radionuclide ventriculography in cardiac transplantation.

To assess ventricular function in patients who have undergone cardiac transplantation, 247 radionuclide ventriculograms were performed on 94 patients. During the first three days after transplantation, 19% demonstrated left ventricular dysfunction and 41% showed isolated right ventricular dysfunction. In 95 cases, radionuclide ventriculography was performed within 24 hr of myocardial biopsy. A reduction in left ventricular ejection fraction to less than 50% was significantly more common with moderate-severe rejection than with mild rejection. In six instances in which there was discordance between ventriculography and biopsy, radionuclide ventriculography proved particularly useful: three cases showed severe left ventricular dysfunction despite only mild rejection by biopsy, and three cases with ventricular dysfunction from rejection were missed by the initial biopsy. Thus, radionuclide ventriculography can provide functional data in transplant patients that is complementary to myocardial biopsies since biopsy grade is a poor predictor of left ventricular function and biopsy can miss significant rejection.

Biopsy↗
PubMed1990

Cardiac transplantation: the operative technique.

The operative procedure of cardiac transplantation, whether orthotopic or heterotopic, must be performed with meticulous attention to technical detail and hemostasis. The price for technical misadventures and bleeding complications is high in terms of patient morbidity and mortality. Few cardiac surgical procedures are more straightforward than a heart transplant performed in a young individual who has not undergone previous cardiac surgery. Few greater technical challenges exist, however, than the patient in a state of precarious hemodynamic balance undergoing heart transplantation in the wake of one, two, or more previous cardiac surgical procedures. The principles outlined herein will serve as a foundation for the safe performance of cardiac transplantation regardless of the situation.

Anastomosis, Surgical↗
PubMed1989

Circulatory support with a centrifugal pump as a bridge to cardiac transplantation.

Since January 1985, the Heart Transplant Program at Washington University Medical Center, St. Louis, has performed 89 heart transplantations in 86 patients. Twenty patients (23%) have required preoperative mechanical support of circulation or respiration prior to transplantation. The Bio-Medicus centrifugal pump (Bio-Pump) formed the basis of our circulatory support system during the period of this report. Nine patients were placed on the Bio-Pump with the intention of bridging them to transplantation. Six patients required left ventricular assistance; in 2, the device was inserted because they could not be weaned from cardiopulmonary bypass. Two patients required biventricular assistance, 1 because she could not be weaned from cardiopulmonary bypass at the end of a cardiac operation. Extracorporeal membrane oxygenation was necessary in 1 patient for right ventricular decompensation and cardiac arrest four hours after orthotopic cardiac transplantation. One of these 9 patients died on circulatory support, and in another, a complication developed that precluded transplantation. The remaining 7 patients (78%) underwent a successful transplant procedure after an average of 1.6 days of circulatory support (range, 0.5 to three days), and all are long-term survivors of transplantation. There has been 1 late death at 17 months from a cerebrovascular hemorrhage. In summary, the centrifugal pump provides excellent short-term circulatory support for individuals who would otherwise die before cardiac transplantation.

Adolescent↗
PubMed1989

Noninvasive detection of cardiac allograft rejection by analysis of the unipolar peak-to-peak amplitude of intramyocardial electrograms.

The use of standard electrocardiographic monitoring to detect cardiac allograft rejection has become unreliable since the advent of cyclosporine immunosuppression. Unipolar peak-to-peak amplitude analysis has been shown to be a quantitative measure of ischemic myocardial injury. This study was performed to determine if unipolar peak-to-peak amplitude analysis could accurately detect cardiac allograft rejection as determined by blinded endomyocardial biopsies. Ten adult mongrel dogs underwent heterotopic (n = 7) or orthotopic (n = 3) cardiac transplantation with placement of sutureless screw-in electrodes (Medtronic, Inc, Minneapolis, MN) on the anterior and posterior aspect of each ventricle. Postoperatively, animals were immunosuppressed for seven to ten days with cyclosporine and prednisone and then allowed to reject the transplant. Digitally processed intramyocardial electrograms were obtained daily. Endomyocardial biopsy was performed 1 week postoperatively and then at three to five day intervals for histological correlation. A unipolar peak-to-peak amplitude decline of 15% or greater occurred one to three days before the biopsy detection in 10 of 10 episodes of rejection. There were no false negatives and one false positive (although a small focal lymphocytic infiltrate was present). Thus, noninvasive unipolar peak-to-peak amplitude analysis was 100% sensitive and 90% specific in predicting and detecting cardiac allograft rejection.

Animals↗
PubMed1989

Pulmonary disease caused by Mycobacterium chelonae in a heart-lung transplant recipient with obliterative bronchiolitis.

A heart-lung transplant recipient with pulmonary disease caused by the rapidly growing nontuberculous Mycobacterium chelonae and obliterative bronchiolitis is presented. The clinical features, course, and management of the mycobacterial disease and the obliterative bronchiolitis are discussed. The role of transbronchial lung biopsy in determining the significance of rapidly growing mycobacteria in pulmonary specimens and in diagnosing infection and rejection is emphasized.

Adult↗
PubMed1988

Sensitivity of scintigraphy with 111In-lymphocytes for detection of cardiac allograft rejection.

We recently demonstrated the feasibility of noninvasive detection of cardiac allograft rejection after administration of indium-111-labeled lymphocytes. To determine the sensitivity and specificity of the technique, as well as its value for delineating the severity of rejection, we studied 16 dogs with heterotopic thoracic cardiac allografts. Five animals were evaluated while exposed to immunosuppressive agents. Animals were scanned sequentially after administration of 100-400 microCi of indium-111-labeled autologous lymphocytes. Myocardial lymphocyte infiltration was expressed as the indium excess (IE), defined as the ratio of indium activity of the transplant or native heart compared with that in blood. Scintigraphic results were compared with characteristics of simultaneously obtained endomyocardial biopsies. Among 17 biopsy documented episodes of rejection, 16 were detected scintigraphically. Among 18 biopsies with no evidence of rejection, scintigraphy was uniformly negative. Thus, the sensitivity and specificity of scintigraphy were 94 and 100%, respectively. Biopsies graded as showing no rejection were associated with an IE of 0.3 +/- 0.5 (+/- SD); those graded as mild, 2.8 +/- 1.7; those as moderate, 10.7 +/- 7.2; and those graded as indicative of severe rejection, 14.2 +/- 4.5. Thus, scintigraphy with indium-111-labeled lymphocytes sensitively and specifically detects cardiac allograft rejection and delineates the intensity of the rejection process. It should be useful clinically for assessing potential allograft rejection noninvasively.

Animals↗
PubMed1988

Dilated cardiomyopathy in infants and children.

The outcome of medical treatment of dilated cardiomyopathy in infants and children was reviewed to develop a predictive index for selection of patients likely to benefit from cardiac transplantation. The clinical findings, laboratory investigations, treatment and outcome of 20 patients (Group 1) less than 2 years of age at presentation and 12 patients (Group 2) greater than 2 years of age at onset were compared. Of 20 Group 1 patients, 5 (25%) died. Available autopsies (four patients) showed endocardial fibroelastosis. Of 15 survivors, 10 showed improvement in cardiac status and 5 remained unchanged. Ninety-three percent of survivors had dilated cardiomyopathy consistent with endocardial fibroelastosis by angiocardiography. All 12 Group 2 patients died. In addition to age at presentation and poor outcome, Group 2 differed from Group 1 in having a higher incidence of other family members with cardiomyopathy, more significant rhythm disturbances at presentation and a more rapid course to death. Risk factors of poor outcome in both groups included persistent cardiomegaly and the development of significant arrhythmias by Holter electrocardiographic monitoring. Cardiac transplantation is recommended for children with dilated cardiomyopathy presenting after age 2 years who survive 1 month. Those patients less than 2 years old at presentation whose condition has not improved after 1 year and who have persistent cardiomegaly or complex ventricular arrhythmias may also benefit from transplantation.

Actuarial Analysis↗
PubMed1988

The changing face of cardiac transplantation: the Washington University Program, 1985-1987.

Since January, 1985, 59 patients have undergone 62 heart transplantations at Washington University School of Medicine. The experience in this program serves as a useful microcosm of the field of cardiac transplantation as a whole to demonstrate certain trends that are becoming evident. Of the patients, 47% had coronary artery disease compared with 40% with cardiomyopathy. Fourteen patients (24%) were 55 years old or older at the time of transplantation. Sixteen patients (27%) required mechanical support of respiration or circulation or both prior to transplantation. Six patients were maintained with a left ventricular or biventricular assist device, and all survived; 1 patient received extracorporeal membrane oxygenation and lived; 7 patients were maintained with an intraaortic balloon pump, 6 of whom survived; and 2 were maintained with a mechanical ventilator and survived. The preoperative waiting period averaged 51 days for the group as a whole. Status-3 patients experienced an average 81-day waiting period, and those in blood group O waited 155 days. In contrast, critically ill patients (status 0) underwent transplantation within an average of 9 days. Actuarial survival at 12 months for all patients, operative survivors, patients age 55 years old or more, and patients bridged to transplantation was 87%, 92%, 84%, and 87%, respectively. Utilizing the combination therapy of cyclosporine, azathioprine, and prednisone introduced by one of us in 1983 and administered to all patients in this series, 50% of patients were rejection free and 56% were infection free at 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗