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Biomedical subjects

T E Oaks

Publications and source records attributed to T E Oaks.

17 recordsLinked to original sources
PubMed2001

Steroid-free maintenance immunosuppression after heart transplantation.

BACKGROUND: Steroids are routinely used in almost all immunosuppressive protocols after cardiac transplantation. The metabolic side effects of steroids are well known and could lead to significant morbidity and mortality in the posttransplant period. There is growing evidence to suggest that steroids may not be a requirement for adequate immunosuppression and that morbidity may be reduced by withdrawing steroids in select patients. We have reviewed our series of patients undergoing heart transplantation in whom steroids were weaned postoperatively. METHODS: We retrospectively reviewed all adult patients undergoing heart transplantation at our institution between November 1993 and April 2000 treated with a-triple-drug immunosuppressive regimen. Medications were recorded at discharge and at 6, 12, and 24 months posttransplant to determine the success of steroid weaning. Freedom from infection and rejection as well as overall survival was calculated using Kaplan-Meier methods. RESULTS: By 24 months posttransplant, almost 70% of patients were receiving double-drug therapy. Survival for the entire group was excellent with 1-, 3-, and 5-year survival of 98%+/-2.0%, 93.2%+/-3.8%, and 88.3%+/-6.0%, respectively. Freedom from rejection at 6 months was 60.7%+/-6.5%, at 1 year was 60.7%+/-6.5%, and at 2 years was 58.5%+/-6.7%. Infectious complications were low with freedom from infection at 6 months of 78.5+/-5.5%, at 1 year of 76.5%+/-5.7%, and at 2 years of 72.0%+/-6.2%. CONCLUSIONS: Our data suggest that an immunosuppressive regimen without long-term steroid administration results in excellent survival rates without an apparent increase in rejection or infectious complications.

Adolescent↗
PubMed2001

Mediastinal impalement with survival: a case report.

Mediastinal impalement injuries are rare and often fatal. Very few instances of survival after mediastinal impalement have been reported. We present the unusual case of an 18-year-old man who was involved in a motor vehicle crash in which a wooden fencepost intruded through the windshield and impaled him through the superior mediastinum. The patient remained hemodynamically stable and had no other significant injuries except a left pneumothorax. Arteriogram revealed a bovine aortic arch with the wooden piece passing over the aortic arch between the two brachiocephalic arteries at the precise point that a normal left common carotid artery would have been located. No other injuries were seen on arteriogram, venogram, or esophagram. The foreign body was extracted via thoracotomy along with resection of the apex of the left lung and ligation of the thoracic duct. The patient was discharged on hospital day eight and was doing quite well at one-year follow-up with no residual effects of his accident.

Accidents, Traffic↗
PubMed1999

Permanent ventricular assist device support versus cardiac transplantation.

BACKGROUND: Although cardiac transplantation provides excellent therapy for some patients with terminal heart failure, the results are limited by the scarcity of donor organs, reduced long-term survival, and comorbid conditions. Current experience with temporary left ventricular assist devices suggest that a permanent, totally, or near totally implantable device may be a viable alternative. METHODS: We analyzed data from the 1997 International Society for Heart and Lung Transplantation (ISHLT) Registry and other literature on heart transplantation and compared survival and complication rates with our experience and that of others with temporary ventricular assist devices. From these data, we attempted to identify those patients who would benefit most from permanent left ventricular assist systems (LVASs). RESULTS: Among heart transplant candidates, United Network for Organ Sharing (UNOS) status II, O blood type, weight >180 lb, older age, and preformed antibodies are negative factors for receipt of donor hearts. Of patients transplanted, women and nonwhites have poorer outcomes. Success with wearable LVAS's suggest some of these patients might be better served with an LVAS than with cardiac transplantation. CONCLUSIONS: Because LVAS's could be made readily available without the need for a waiting list, they might compete well with the strategy of cardiac transplantation.

Adult↗
PubMed1998

Are efforts at expanding the donor pool misdirected?

BACKGROUND: The number of patients potentially benefiting from heart transplantation far exceeds the number of hearts available. This has led to an increasing interest in use of hearts from previously unacceptable donors. However, the long-term outcome of such hearts is largely unknown. Research on other parts of the donor process may provide a greater number of additional hearts of high quality. METHODS: Journal reviews were conducted to identify proposed methods for use of previously unacceptable donor hearts, as well as research regarding the consent process. Data from the United Network for Organ Sharing were obtained to identify the reason consented heart referrals were not recovered. Data from the Association of Organ Procurement Organizations were obtained for consent rates in the United States. Calculated estimates were made for the number of excess hearts potentially available by use of extended donor criteria versus increasing the consent rate. RESULTS: More than 40 articles proposing extended donor criteria were identified versus only 12 articles about consent. Of the 2199 consented heart referrals not recovered in 1995, more than 1300 fit into a category amenable to a proposed strategy for use of extended donors. If these strategies were used aggressively (50% of the time), 701 additional hearts would have been available. Alternatively, if the consent rate were increased a comparable amount, 1260 excess hearts of high quality would have been available. CONCLUSION: Although research into extended donor criteria is probably justified, transplantation programs should direct research efforts into the consent process as a potential source of additional hearts.

Heart Transplantation↗
PubMed1997

Risk factors and solutions for the development of neurobehavioral changes after coronary artery bypass grafting.

BACKGROUND: As operative mortality for coronary artery bypass grafting has decreased, greater attention has focused on neurobehavioral complications of coronary artery bypass grafting and cardiopulmonary bypass. METHODS: To assess risk factors and to evaluate changes in surgical technique, between 1991 and 1994 we evaluated 395 patients undergoing coronary artery bypass grafting with an 11-part neurobehavioral battery administered preoperatively and at 1 and 6 weeks postoperatively. Patients were instrumented with 5-MHz focused continuous-wave carotid Doppler transducers intraoperatively to estimate cerebral microembolism as an instantaneous perturbation of the velocity signal. Microembolism data were quantitated and compared with surgical technical maneuvers during operation and with neurobehavioral deficit (> or = 20% decline from preoperative performance on two or more neurobehavioral tests) postoperatively. These data and patient demographics were statistically analyzed (chi2, t test) and the results at 2 years (1991 and 1992; group A) were used to influence surgical technique in 1993 and 1994 (group B). RESULTS: Significantly associated with new neurobehavioral deficits were increasing patient age (p < 0.05), more than 100 emboli per case (p < 0.04), and palpable aortic plaque (p < 0.02). Group B patients had a significant decline in the neurobehavioral event rate (group A, 69%, 140/203; versus group B, 60%, 115/192; p < 0.05) of postoperative neurobehavioral deficits at 1 week and at 1 month (group A, 29%, 52/180; versus group B, 18%, 35/198; p < 0.01). The stroke rate was less than 2% in both groups (p = not significant). Modifications of surgical technique used in group B patients included increased use of single cross-clamp technique, increased venting of the left ventricle, and application of transesophageal and epiaortic ultrasound scanning to locate and avoid trauma to aortic atherosclerotic plaques. CONCLUSIONS: Neurobehavioral changes after coronary artery bypass grafting are common and associated with cerebral microembolization. Surgical technical maneuvers designed to reduce emboli production may improve neurobehavioral outcome.

Aged↗
PubMed1995

Acquired cor triatriatum after orthotopic cardiac transplantation.

Orthotopic cardiac transplantation was performed in a 42-year-old woman with idiopathic cardiomyopathy. Postoperative right ventricular failure developed and a transesophageal echocardiogram demonstrated acquired cor triatriatum with marked obstruction to mitral valve inflow and severe right ventricular dilatation. At reexploration, redundant donor atrial tissue was excised correcting the cor triatriatum. She was alive and well with normal hemodynamic parameters 12 months after transplantation.

Adult↗
PubMed1993

Cardiac transplantation: a review.

Cardiac transplantation is no longer an experimental procedure, but rather a definitive therapeutic option for patients with end-stage cardiac failure. The current 5-year and 10-year survival rates following cardiac transplantation are 67% and 52%, respectively. Rejection and infection still result in significant morbidity and mortality, and the development of graft coronary occlusive disease limits even longer-term survival. This review summarises donor and recipient selection criteria, the operative procedure, the current immunosuppressive protocols, as well as newer immunosuppressive agents and the complications of cardiac transplantation, namely infection, rejection, nephrotoxicity and graft coronary occlusive disease.

Graft Rejection↗
PubMed1988

Soft-tissue expansion in the lower extremities.

Soft-tissue expansion enjoys ever-wider use, but to date an experience using this technique in the lower extremity has never been presented. We reviewed our first 16 patients to describe the indications and contraindications for the use of tissue expansion in the lower extremity. Guidelines evolved from study of the data. Soft-tissue expansion merits consideration for coverage of problem wounds, in preparation for removal of large benign lesions, and for the repair of contour defects. The operator should know that an open wound below the knee predicts a complication if soft-tissue expansion is attempted in that location. In the thigh, incisions can be confidently placed at the edge of the defect. In every location, large expanders should be chosen so that they are as long as or longer than the adjacent defect. The increase in circumference of the limb should be followed. Simple designs for advancement flaps usually work well. As our experience has grown, reconstruction using soft-tissue expansion in the lower extremity has become safer and the results more predictable through better patient selection and diligent monitoring of intraluminal pressures, even if only by ensuring that the patient is always comfortable. Soft-tissue expansion has a role in reconstruction of the lower extremity.

Adolescent↗
PubMedDate not supplied

Results of mechanical circulatory assistance before heart transplantation.

Between February 1984 and December 1987, 63 patients were accepted as candidates for heart transplantation. Eighteen patients (29%) required some form of mechanical circulatory support before transplantation; eight patients received an intraaortic balloon pump, five patients had left ventricular assist devices, two patients received biventricular assist devices, and in three patients the total artificial heart was implanted. Fourteen of the 18 patients underwent transplantation with seven longterm survivors.

Assisted Circulation↗
PubMedDate not supplied

Atrial natriuretic peptide in recipients of human orthotopic heart transplants.

Atrial natriuretic peptide (ANP) has been proposed to play a role in the maintenance of fluid and electrolyte homeostasis. ANP can be secreted in response to atrial stretch, and right atrial pressure has been proposed to control its secretion in vivo. This study was designed to characterize plasma immunoreactive (IR)-ANP in heart transplant recipients and to determine if IR-ANP levels in these patients correlate with cardiac filling pressures. Nineteen heart transplant recipients were studied during endomyocardial biopsy (group 1), and 20 patients with symptoms of coronary artery disease were studied during cardiac catheterization (group 2). Central venous blood samples and right heart catheterization data were obtained in each patient. IR-ANP levels were measured with a radioimmunoassay for alpha human ANP in extracted plasma samples. There were no differences between groups 1 and 2 in right atrial pressure (6.5 +/- 0.8 versus 6.1 +/- 0.6), pulmonary capillary wedge pressure (13.3 +/- 1.2 versus 11.2 +/- 1.3), mean pulmonary artery pressure (18.0 +/- 1.2 versus 18.2 +/- 1.3), or cardiac index (2.8 +/- 0.0 versus 2.8 +/- 0.1), but patients in group 1 had a higher mean blood pressure (110.6 +/- 2.4 versus 98.3 +/- 3.1, p less than 0.001). Plasma IR-ANP levels in heart transplant recipients were higher than normal (217.0 +/- 28.1 versus 19.2 +/- 2.1 pg/ml, p less than 0.001) and higher than in cardiac catheterization patients (217.0 +/- 28.1 verus 71.1 +/- 11.5 pg/ml, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Survival following rupture of a pancreatic abscess in a heart transplant recipient.

A 43-year-old man underwent orthotopic heart transplantation for end-stage ischemic cardiomyopathy. Immunosuppressive therapy consisted of cyclosporine and corticosteroids. The diagnosis of acute pancreatitis was made on the ninth postoperative day and was based on clinical symptoms and an upper gastrointestinal barium study. Both serum and urine amylase values were normal. Abdominal ultrasound examination was nondiagnostic. Two weeks postoperatively, the patient's clinical condition deteriorated sharply. Chest and abdominal roentgenograms revealed free intraperitoneal air, as well as air in the lesser sac. Diagnosis of a ruptured pancreatic abscess was made, and he underwent immediate exploratory laparotomy. Four liters of purulent fluid were present in the peritoneal cavity. A ruptured pancreatic abscess was found, and it had dissected above the superior mesenteric vessels and down the right gutter over the inferior vena cava. After extensive retroperitoneal debridement and copious irrigation, multiple surgical drains were placed. The patient is now well and is performing normal daily activities 16 months after the transplantation procedure. The incidence and proposed causes of pancreatitis occurring after heart transplant are reviewed, and we discuss our management of this complication.

Abscess↗
PubMedDate not supplied

Aortic rupture caused by fungal aortitis: successful management after heart transplantation.

A 26-year-old man with end-stage idiopathic cardiomyopathy was supported with a Pierce-Donachy left ventricular assist device for 31 days before orthotopic heart transplantation. Fungal endocarditis was discovered at the time of recipient cardiectomy, and antifungal therapy was begun. Fungal mediastinitis developed 4 days after transplantation and was treated with mediastinal irrigation. Massive mediastinal hemorrhage caused by fungal aortitis occurred on two occasions and was successfully treated with a bovine pericardial patch. The patient is well 9 months after transplantation.

Adult↗
PubMedDate not supplied

Domino heart transplantation: the Papworth experience.

The use of donor hearts from heart-lung recipients, the so-called domino procedure, began at Papworth Hospital in November 1988. Between then and September 1992, 198 heart transplantations and 86 heart-lung transplantations were performed. Fifty-three heart-lung recipients donated their hearts for use in the domino procedure. Thirty-two domino hearts were transplanted at Papworth and 21 were exported to other centers. Institution of the domino procedure allowed us to perform 19% more heart transplantations (166 to 198) than would have been done had the procedure not been used. The ischemic time was significantly shorter for the domino hearts compared with organs from brain dead donors (134 minutes versus 191 minutes; p < 0.001). No difference was found in the 3-month (84% versus 83%) or 1-year (74% versus 76%) survival between domino and nondomino recipients. Other potential advantages of the domino procedure include detailed pretransplantation evaluation of the heart in live donors and the potential for human leukocyte antigen matching. Additionally many heart-lung recipients have elevated pulmonary artery pressures and a "conditioned", hypertrophied right ventricle. The use of such hearts for heart transplantation has theoretic appeal for patients with elevated pulmonary vascular resistance.

Actuarial Analysis↗