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Biomedical subjects

V A Starnes

Publications and source records attributed to V A Starnes.

At least 127 records · Page 7Linked to original sources
PubMed1990

Fatal postoperative Legionella pneumonia in a newborn.

This is a case of postoperative Legionella pneumonia in a full-term infant with hypoplastic left heart syndrome. The infant had an uncomplicated prenatal history, normal vaginal delivery, Apgars of 8 at 1 and 5 minutes, but was cyanotic at birth. At 3 days of age she had a stage 1 Norwood surgical procedure to palliate her congenital heart disease. A synthetic patch was placed over the thoracic midline because of difficulty in reapposing the sternum. Peritoneal dialysis was used to manage renal failure. At 20 days of age she had disseminated intravascular coagulopathy and pneumonia associated with sepsis. Four days later she died. Legionella pneumophila serogroup 1 was isolated from a lung culture taken at autopsy.

Adult↗
PubMed1990

Heart-lung transplantation: an overview.

Heart-lung transplantation is in a state of evolution, but for selected patients with end-stage cardiopulmonary and pulmonary disease, it can offer long-term rehabilitation. In the 8 years since heart-lung transplantation was begun at Stanford, much experience has accrued and significant improvements have been made. Advances that have made heart-lung transplantation feasible include better immunosuppression, particularly the triple-drug protocol of cyclosporine, azathioprine, and corticosteroids which decreases the incidence of obliterative bronchiolitis. Techniques of improved lung preservation have made distal donor procurement a reality, and increasing numbers of lung and heart-lung transplantations are now being performed. More importantly, better recipient and donor selection has occurred such that the perioperative mortality has been reduced from 35 to 16 per cent. Currently, the major threat facing survivors of heart-lung transplantation is the insidious development of restrictive airway disease. Our impression is that the development of obliterative bronchiolitis results from repeated rejection episodes or possibly an injury mechanism following severe viral pneumonia. The common pathway seems to be repeated injury and repair mechanism, with the end-stage being obliterative bronchiolitis by scar formation. As suggested, the injury mechanism is probably that of repeated or chronic rejection. To further support the hypothesis of an immunerelated etiology, obliterative bronchiolitis has occurred in recipients of bone marrow transplants if they develop graft-versus-host disease. In an attempt to ameliorate the effects of rejection on airway function, we have increased our maintenance immunosuppression by adding azathioprine. Consequently, patients with early obliterative bronchiolitis on enhanced immunosuppression have had stabilization of the airway disease, and we have noted a significant reduction in the occurrence of obliterative bronchiolitis from 62 per cent in Group 1 patients to 20 per cent in Group 2 patients. Since obliterative bronchiolitis may be reversed by early recognition and treatment of rejection, we have aggressively used bronchoscopy with transbronchial lung biopsy and bronchoalveolar lavage for surveillance of both rejection and infection in our recent patients. Open lung biopsy has not been used since 1986 to diagnose rejection, and we are encouraged that bronchoscopic surveillance is sensitive and effective. The primary goal of the bronchoscopic evaluation protocol was to monitor the patients closely and to treat both rejection and infection early and effectively. Concurrently, we are also measuring pulmonary function parameters, which includes FEV1, FEF 25-75, PaO2, total lung capacities, and profusion gradients. The desired outcome was the maintenance of normal airway dynamics by reversing airway disease at a reversible stage.(ABSTRACT TRUNCATED AT 400 WORDS)

Age Factors↗
PubMed1989

Cardiac retransplantation in the cyclosporine era.

Between December 1980, when immunosuppression with cyclosporine was introduced, and May 1988, 288 patients underwent primary transplantation for end-stage cardiac disease (group TX). Fourteen patients underwent retransplantation for accelerated graft atherosclerosis (group RTXAGA), and 9 underwent retransplantation for intractable acute allograft rejection (group RTXREJ). Cumulative patient follow-up was 724 patient-years (range, 1 month to 7.5 years; mean, 2.3 years). Within the first 3 postoperative months, no differences were noted between groups for linearized rates of infection or rejection except between the rate of rejection for group TX (1.69 +/- 0.09 events/100 patient-days) and group RTXAGA (0.94 +/- 0.3 events/100 patient-days) (p less than 0.02). No significant differences existed between groups for actuarial rates of remaining rejection-free or infection-free for more than 7.5 years. No significant differences in actuarial survival existed except between group TX (81% +/- 2% at 1 year and 58% +/- 4% at 5 years) and group RTXREJ (44% +/- 17% at 1 year and 44% +/- 0% at 5 years) (p less than 0.05). We conclude that patients who undergo retransplantation for accelerated graft atherosclerosis experience a lower rate of early rejection and similar rates of infection and survival compared with patients who receive primary transplants. Cardiac retransplantation for rejection incurs rejection and infection at rates similar to those of primary procedures. However, patients who undergo retransplantation for rejection survive these complications significantly less often than do patients who receive primary transplants. This information should be considered when scarce donor hearts become available and retransplantation is contemplated.

Adult↗
PubMed1989

Heart and heart-lung transplantation: the Stanford experience.

As of October 1989, over 560 patients with end-stage heart disease have received heart transplants at Stanford. In addition, 70 patients have received heart-lung transplants (H-L Tx) and 5 patients received single-lung transplants for end-stage pulmonary disease. Cyclosporine A (CsA) significantly improved survival, especially during the first posttransplant year. All patients now receive maintenance CsA, prednisone (P), and azathioprine (AZA). Fourteen-day prophylactic OKT3 significantly reduces early rejection after heart transplantation. One-year survival for cardiac transplants is 82% using CsA and 73% for our recent H-L Tx group. All 5 patients are alive after single-lung transplantation. Children with heart transplants and patients bridged to transplant with a Novacor ventricular assist system have a 1-year survival rate similar to routine heart transplant patients. Beyond the first year, heart transplant mortality continues at 5% per year. Transplant coronary artery disease (Tx CAD) accounts for 33% of the mortality, and other patients require retransplantation for Tx CAD. Cytomegalovirus contributes to the development of TX CAD and antiviral agents are being used for the early treatment of CMV infections. Cytomegalovirus is also thought to contribute to obliterative bronchiolitis (OB), the late complication that threatens H-L Tx patients. Surveillance bronchoscopy and pulmonary function tests can be used to detect early lung infection and rejection. Hopefully this will lead to improved late graft function. Future immunosuppressive efforts will be directed toward decreasing the morbidity and mortality after the first year in both heart and lung transplant patients.

Adult↗
PubMed1989

Prophylactic OKT3 used as induction therapy for heart transplantation.

The benefit of an immunosuppressive agent should be demonstrated by less rejection, less toxicity, decreased hospital stay, and equal or superior patient survival. Since June 1987, a total of 61 patients have received prophylactic OKT3 for 14 days, beginning on postoperative day 1, in addition to cyclosporine, azathioprine, and prednisone (group 1). Group 1 was compared with our conventional-therapy group (group 2, n = 116) treated with cyclosporine, azathioprine, prednisone, and antithymocyte globulin. The hospital stay was reduced from 36 to 22 days (p less than 0.0001). The linearized rejection rate was reduced with OKT3 from 2.82 to 1.09 (p less than 0.0002), from 1.82 to 1.45 (p less than 0.02), and from 1.22 to 0.56 (p less than 0.04) during the first 3 months, respectively. Actuarial freedom from rejection at 12 months was 32% versus 12% (p less than 0.005). Antimurine antibodies developed in 12.7% of OKT3-treated patients.

Adult↗
PubMed1989

Evaluation of heart-lung transplant recipients with prospective, serial transbronchial biopsies and pulmonary function studies.

The insidious development of obliterative bronchiolitis after heart-lung transplantation is thought to be due to rejection and possibly infection (cytomegalovirus). To evaluate further, we prospectively managed the last 16 consecutive heart-lung transplant recipients with serial transbronchial biopsies with lavage and pulmonary function studies as part of a surveillance protocol or as dictated by clinical presentation. A total of 123 transbronchial biopsies with lavage were performed, 77 for clinical indications (group I) and 46 for routine surveillance (group II). Results of 64 (83.1%) group I biopsies were positive for rejection or infection. Thirty-one of these biopsy specimens showed signs of rejection (29 in group I and two in group II), characterized by a perivascular mononuclear infiltrate, lymphocytic bronchiolitis, and occasionally alveolar septal mononuclear infiltrate. Forty-six serial pulmonary function tests were performed. The forced expiratory volume in 1 second (percent predicted), forced expiratory flow rate between 25% and 75% of the forced vital capacity (percent predicted), and arterial oxygen tension (millimeters of mercury) were significantly reduced from baseline values during rejection episodes: forced expiratory volume in 1 second, 75.7% +/- 20.1% versus 52.7% +/- 18.3% (p less than or equal to 0.05); forced expiratory flow rate between 25% and 75% of the forced vital capacity, 97.6% +/- 30.5% versus 49.8% +/- 22.3% (p less than or equal to 0.05); and arterial oxygen tension, 92.1 +/- 8.8 mm Hg versus 71.4 +/- 18.8 mm Hg (p less than or equal to 0.05). The fall in pulmonary function was reversible with pulse methylprednisolone. Asynchronous heart and lung rejection was documented. Of the 29 episodes of pulmonary rejection, 18 (62%) occurred asynchronously. Ten of the 16 (62%) heart-lung recipients had at least one episode of cardiac rejection. Thirteen of 16 (81%) had at least one episode of lung rejection. Serial transbronchial biopsies with lavage, as dictated by pulmonary function tests and clinical status, have guided early and more specific therapy directed against rejection and infection. With early detection, small airway dysfunction has been reversible.

Adult↗
PubMed1989

Pulmonary infiltrates after heart-lung transplantation: evaluation by serial transbronchial biopsies.

Since January 1988, prospective serial transbronchial lung biopsies have been performed as a diagnostic procedure to facilitate the care of recipients of heart-lung transplants. Eighty-five cardiac and 70 transbronchial lung biopsies have been prospectively performed in 10 patients beginning within the first week of transplantation. Forty-eight percent (34/70) of the transbronchial lung biopsies and 16.5% (14/85) of the heart biopsies were positive for either rejection or infection. Pulmonary rejection was evident by a perivascular lymphocytic infiltrate that cleared with pulse steroid therapy. Pulmonary and cardiac rejection were present synchronously on six occasions and asynchronously on 16 occasions (nine pulmonary and seven cardiac). Four patients had early cytomegalovirus pneumonitis on biopsy specimen and were successfully treated with ganciclovir. Of the 40 clinically indicated biopsies, 29 (72.5%) were positive for rejection or infection and guided subsequent therapy. In summary, transbronchial lung biopsies have provided prompt (within 24 hours) serial diagnostic information that has guided successful treatment of infection (cytomegalovirus, aspergillosis, and Pneumocystis) and rejection. Asynchronous rejection of the heart and lungs has been conclusively demonstrated. With the early detection of rejection and infection, we are optimistic that chronic airway disease in patients with a heart-lung transplant may be reduced.

Adolescent↗
PubMed1988

The effect of verapamil cardioplegia on myocardial ultrastructure.

The calcium channel blocker, verapamil, was evaluated as an adjunct to cold cardioplegia in 16 randomized patients with unstable angina pectoris who received saphenous vein bypass grafts. Myocardial biopsies taken before cardioplegia showed various degrees of ischemic change as assessed by ultrastructural parameters (mitochondrial swelling, matrix clearance, and sarcotubular dilatation). After reperfusion, the majority of the patients had progressive changes of ischemia, with marked mitochondrial and sarcotubular swelling, depletion of glycogen, chromatin clumping, and myofibrillar disruption; amorphous mitochondrial densities were occasionally seen. The ultrastructural changes after cardioplegia were dependent primarily on the extent of preexisting ischemic damage and did not correlate with the use of verapamil. Verapamil did not protect the ischemic myocardium during cold cardioplegia as assessed ultrastructurally.

Biopsy↗
PubMed1988

Isolated left ventricular assist as bridge to cardiac transplantation.

The electrically driven Novacor implantable left ventricular assist device has been implanted in six patients (four men and two women) since Sept. 7, 1984. In four of the six patients (67%) the device was a successful bridge to cardiac transplantation. One patient died of multiple organ failure and Candida sepsis after 16 days of support with the device. One patient died in the operating room of uncontrollable hemorrhage and biventricular failure caused by severe cardiac rejection. Three patients are alive with cardiac transplants 38, 17, and 10 months after transplantation. One patient died after cardiac transplantation of presumed sepsis. The Novacor left ventricular assist device performed in all cases without mechanical or electrical failure. Excluding the intraoperative death, assist duration ranged from 2 to 16 days. The cardiac index (synonymous with device output) ranged from 2.4 to 3.4 L/min/m2. No embolic events (cerebrovascular or systemic) occurred during assistance with the device. Minimal red cell hemolysis was documented during the period of support. The Novacor left ventricular assist device is a safe and effective bridge to cardiac transplantation in patients with refractory cardiogenic shock.

Adult↗
PubMed1987

Distant graft procurement for combined heart and lung transplantation using pulmonary artery flush and simple topical hypothermia for graft preservation.

Although combined heart and lung transplantation has great potential for improving survival and rehabilitation in selected patients with pulmonary vascular disease, the lack of suitable donor organs has restricted the number of operations performed. We report a heart and lung transplantation operation for Eisenmenger's syndrome in which distant donor graft procurement was used with a simple system for preservation.

Adult↗
PubMed1987

Proper donor selection for heart-lung transplantation. The Stanford experience.

Clinical cardiopulmonary transplantation is currently limited by the availability of suitable heart-lung donors. Distant graft procurement, with pretreatment, of the donor by intravenous prostaglandin E1 and cooling of the graft with pulmonary artery perfusion, is now clinically established and should increase the number of available donors. Between March 1981 and September 1986, 40 heart-lung transplantations were performed. The characteristics of the donor pool were analyzed. Gram stain of the donor tracheal aspirate revealed gram-positive bacteria in 80% and gram-negative organisms in 35%. Yeast was present on stain in 25% of the patients. Donor arterial oxygen tension was less than 100 torr inspired oxygen concentration 40%) repeatedly in one patient; this recipient died of lung failure at operation. Severe deterioration of allograft lung function was seen in 11 (27.5%) recipients. The causes of deterioration were substantial postoperative bleeding in six patients, sepsis in two, and acute rejection, poor lung function, and allograft heart failure in one patient each. HLA-A locus mismatch, poor donor alveolar-capillary gas exchange, tracheal colonization with heavy polymorphonuclear cells, and heavy bacteria and fungus resulted in increased operative mortality. Donor pretreatment with prostaglandin E1 was associated with improved survival. Recipient selection, emphasizing adequate liver function and absence of previous thoracic operation, careful surgical technique with minimal bleeding, and brief perfusion time were factors associated with improved survival. Early morbidity and mortality were principally related to recipient risk factors, and the strict criteria observed for selection of heart-lung donors were valid. The importance of appropriate recipient selection is underscored.

Adolescent↗
PubMed1987

Heart transplantation--Stanford experience.

Heart transplantation has evolved from an experimental procedure with minimally acceptable results to a therapeutic option for patients with end-stage heart disease. Since 1968, 429 patients have undergone cardiac transplantation at Stanford. The recipient diagnosis was cardiomyopathy in 205 patients, coronary artery disease in 188, and valvular heart disease in 20 patients. The age range was 5 months to 60 years with equal survival among children and adults. Immunosuppression included a 3-drug protocol of CsA, azathioprine, and prednisone. The current one- and 5-year survival is 83% and 55%, respectively. A totally implantable electrically driven left ventricular assist device (Novacor) has been implanted in 6 patients as a "bridge-to-transplantation." Four patients received cardiac transplants after a mean support period of 7 days (range 2.0-16.5 days). Of the four transplanted patients, 3 (75%) are alive at 32, 11, and 4 months. With improved immunosuppression and standardized protocols, heart transplantation has been successfully employed by many centers. The number of heart transplants has risen from 103 in 1982 to 719 in 1985. Undoubtedly, due to the expanding number of centers, future issues will include distribution of donors and minimal acceptable standards for heart transplantation centers.

Adolescent↗
PubMed1987

Cardiac transplantation in children and adolescents.

Cardiac transplantation represents an expanding therapeutic modality for end-stage heart disease in children and adolescents. During the past 5 years, 27 patients (15 boys; 12 girls) between the ages of 2 and 18 have undergone cardiac transplantation. The preoperative diagnosis was cardiomyopathy in 24 (six familial), congenital heart disease in two, and endocardial fibroelastosis in one. Immunosuppression included cyclosporine, azathioprine, and prednisone. There were 22 survivors, with four hospital deaths (three infection, one pulmonary hypertension), and one death at 4.5 years from graft atherosclerosis. The actuarial survival at 4 years was 83 +/- 7.4% and that at 5 years was 69 +/- 14.2%. Renal function was stable at 4 years, with an average creatinine clearance of 69.75 +/- 27.0 ml/min/m2. Hypertension was present in 21 of 22 patients, who require multiple drug therapy. Rehabilitation is 100% among discharged patients, with 14 in school, six employed, and two toddlers.

Adolescent↗
PubMed1986

Prostacyclin reduction of regional ischemic injury in the canine myocardium.

The effect of prostacyclin (PGI2) on the myocardium of the awake dog subjected to coronary artery occlusion was examined. Animals were randomly administered PGI2 200 ng/kg/min (n = 6), PGI2 100 ng/kg/min (n = 6), or the vehicle control (n = 6), beginning 30 min prior to coronary artery occlusion. Radiolabeled microspheres (15 microns) were used to measure myocardial blood flow. The myocardial region at risk was determined by fluorescein injection, and infarct size was assessed by triphenyl tetrazolium staining. Segmental myocardial function was evaluated from the systolic ejection shortening (SES) by subendocardial ultrasonic dimension crystals in normal, ischemic, and border zones. PGI2 200 ng/kg/min produced significant decreases in aortic pressure and systemic vascular resistance. PGI2 100 ng/kg/min, which achieves 95% platelet inhibition, had no significant hemodynamic effects. Animals receiving PGI2 200 ng/kg/min had significantly higher blood flow to the ischemic region, better border zones SES, and a smaller infarct. PGI2 ameliorates myocardial injury and reduces functional impairment produced by ischemia in doses that elicit vasodilation. This beneficial effect of PGI2 does not appear to be mediated solely by an antiplatelet mechanism.

Animals↗
PubMed1986

A reconsideration of cerebral perfusion in aortic arch replacement.

Ten patients underwent aortic arch replacement for aneurysmal disease from 1970 to 1985 using a simplified cardiopulmonary bypass (CPB) technique with partial brachiocephalic perfusion, low CPB flow (30 to 50 ml/kg/min), moderate systemic cooling (26 degrees to 28 degrees C), and topical hypothermic myocardial protection. The arterial line from a single pump head has a Y shape to perfuse the femoral artery (20F cannula) and either the innominate or left carotid artery (14F). Of the 10 patients (mean age, 58 years) with arch aneurysm (6 atherosclerotic, 2 dissections, and 2 degenerative), 3 had previously undergone major cardiovascular operations. Concomitant procedures included aortic valve replacement in 4 and coronary artery bypass grafting in 3. Eight patients survived the procedure, and 1 died three weeks after operation of a ruptured abdominal aneurysm. Among the survivors, CPB time was 119 +/- 36 minutes (+/- standard deviation), myocardial ischemia time was 79 +/- 32 minutes, and intraoperative blood requirement was 5.9 +/- 3.4 units. There were no postoperative strokes. Neurological complications were only minor and included an asymptomatic miosis and ulnar nerve paresthesias in 1 patient and transient vocal cord palsy in another. Applicable in most patients undergoing elective resection of degenerative and atherosclerotic arch aneurysms and in selected patients with arch dissections, this simplified technique of brachiocephalic perfusion without circulatory arrest provides an attractive and safe alternative; the potential advantages are technical simplicity, reduced CPB and operating times, and satisfactory cerebral protection.

Adult↗
PubMed1986

Operative management of the kinked carotid artery.

In instances in which coexistent significant carotid artery disease and internal carotid redundancy coexist, we have found that use of the resected autogenous internal carotid artery to be a convenient and satisfactory way of patching the frequently small distal internal carotid artery following resection of the redundant portion. There has been no morbidity associated with additional suture lines, and in follow-up care extending through 24 months, there have been no recurrent symptoms.

Carotid Artery Diseases↗