We read with attention the article by Russo et al. (1) about predictive factors and outcome of patients with primary graft failure (PGF) after heart transplantation. Their results are interesting, as they provide a thorough statistical analysis including a complete list of pretransplant variables associated with the onset of PGF. However, as the authors state in their article, this analysis reveals some limitations. In our opinion, the main limitation is the definition and the inclusion criteria of the study. “Hard outcomes,” defined as death or retransplantation in the first 90 days after transplantation because of graft failure, not related to rejection or infection, does not represent the clinical reality of PGF. If death is an obligate criterion for the diagnosis of a disease, patients who have been treated successfully will not be diagnosed, and therefore, the analysis of therapeutic approaches is impossible. However, as Russo et al. stated, PGF is a complication associated with high mortality rates, and promising therapeutic strategies are urgently needed. Thus, we agree with the assumption of the authors that their analysis may underestimate the incidence of PGF. Furthermore, the rationale of excluding patients with mechanical sup-port, high-dose inotropes, and death after 90 days is unclear. In a study published by our group, the criteria for PGF were defined much stronger than in the former study by Lima et al. (2) but with a “chance to survive” for the patients who have ejection fraction less than 30%, despite the use of epinephrine (>0.1 μg/kg/min) plus milrinone (3) (>0.3 μg/kg/min). Reasonable approaches to treat patients with PGF will remain inconclusive as long as the International Society for Heart and Lung Transplantation does not provide international valid criteria (as there are for PGF after lung transplantation). These criteria should be carefully chosen to define an entity that is associated with a high early mortality but not obligatory with death. In our study, one main issue attributed to our therapeutic approach (i.e., levosimendan) was the avoidance of mechanical support, which is obviously another criterion to be included in the future definition of PGF. Andres Beiras-Fernandez Ingo Kaczmarek Florian Weis 1 Department of Cardiac Surgery University Hospital Grosshadern Ludwig-Maximilians-University Munich, Germany 2 Department of Anesthesiology University Hospital Grosshadern Ludwig-Maximilians-University Munich, Germany
Left atrial cardiac myxomas are among the most common cardiac masses. However, occurrence of left atrial myxomas in post-transplant patients is very rare and often misdiagnosed as left atrial thrombus formation.We report the case of a 67-year old female, who was referred due to suspected left atrial thrombus but was found to have a pediculated mass at the suture line of the left atrium on cardiac MRI. After resection, the diagnosis myxoma was confirmed histologically and the donor origin of the myxoma was proven by tissue typing.Despite a rare entity, atrial myxomas may occur in post cardiac transplant patients and may therefore support the role of advanced imaging techniques in patients with suspected left atrial masses.
Background: Severe systemic inflammation (systemic inflammatory response syndrome) associated with cardiac surgery often leads to a worse short-term and long-term outcome. Stress doses of hydrocortisone have been successfully used to improve outcome of CS. The interleukin (IL)-6 to IL-10 ratio is associated with outcome after trauma and major surgery. Objective: To evaluate immunologic effects (especially IL-6 to IL-10 ratio) of stress doses of hydrocortisone in a high-risk group of patients after cardiac surgery with cardiopulmonary bypass. Design: Prospective, randomized, double-blinded, placebo-controlled trial. Setting: Cardiovascular intensive care unit of a university hospital. Patients: High-risk patients (n = 36) undergoing CS. Intervention: Stress doses of hydrocortisone or placebo. Main Outcome Measures: IL-6 to IL-10 ratio and other markers of systemic inflammation at predefined time points; short-term clinical outcome. Results: The two study groups did not differ with regard to demographic data. The patients from the hydrocortisone group (n = 19) had significantly lower levels of IL-6 and higher levels of IL-10, resulting in an attenuated change in IL-6/IL-10 ratio (28.7 [6.4/128.7] vs. 292.8 [6.5/534.6] 4 hours after cardiopulmonary bypass; p < 0.001). Patients in the hydrocortisone group had a shorter duration of catecholamine support (1 [1/2] vs. 4 [2/4.5] days; p = 0.02), a shorter length of stay in the intensive care unit (2 [2/3] vs. 6 [4/8] days; p = 0.001), and a lower incidence of postoperative atrial fibrillation (26% vs. 59%; p = 0.04). Conclusions: Stress doses of hydrocortisone attenuate the evolution of IL-6/IL-10 ratio in patients with systemic inflammatory response syndrome after CS, which seems to be associated with an improved outcome. The immunologic effects of hydrocortisone may thus be both, inhibitory (IL-6) and permissive (IL-10), regarding the immune response.
Introduction: Galectins are a family of soluble lectins expressed on a variety of tissues that play many important regulatory roles in inflammation, immunity, and cancer. The up-regulation of galectin-3 in hypertrophied hearts, and the development of fibrosis have been shown in experimental studies. Increased galectin-3 levels are associated with poor long-term survival in chronic heart failure (CHF). We examined the relationship between plasma galectin-3 levels and the myocardial tissue expression of galectin-3 in patients with end-stage CHF. Material and methods: Expression of Galectin-3 was assessed by means of real-time PCR on left ventricle and atrial myocardium of patients (n=12) with CHF undergoing heart transplantation. All patients gave informed consent. A control group consisting of left ventricle (n=5) and right atrium (n=5) muscle biopsies from patients with good ejection fraction (EF > 65%) was designed. Serum expression of Galectin-3 was assessed by means of ELISA in serum from 20 patients in end-stage CHF and in 20 healthy volunteers, who served as control. Results: Expression of Galectin-3 was similar in the myocardium of patients in comparison to the control group independently of the anatomical area (CHF vs. healthy ventricle: 1.73E-02 vs. 1.50 E-02; CHF vs. healthy atrium: 1.32E-02 vs. 1.16E-02). However, serum expression of Galectin-3 was significantly higher in the end-stage CHF patients compared to the healthy controls (13.02 ± 10.6 vs. 3.7 ± 1.3 ng/ml; p< 0.05) Conclusions: Plasma galectin-3 levels correlate with the ejection fraction and are elevated in patients with CHF. However, the myocardial expression of Galectin-3 does not correlate with the ventricular ejection fraction. Our data support the use of Galectin-3 as a marker of heart insufficiency, though the therapeutic potential of Galectin-3 in the treatment of heart failure may be limited.
Aims: Hepatic dysfunction is a rare but serious complication after cardiac surgery. Plasma clearance of indocyanine green has recently been established as an excellent tool to measure even small changes in hepatic function. Reduced indocyanine green clearance has been associated with adverse outcome in cardiac surgery patients, and cardiopulmonary bypass (CPB) has been hypothesized to be one important triggering factor. Thus, we performed a prospective observational study comparing the influence of off-pump and on-pump coronary surgery on perioperative indocyanine green clearance.
We report a 56‐year‐old male patient developing hypoxemia after surgical replacement of infected valves of a left ventricular assist device (LVAD, Novacor TM ) which had supported him during the previous 15 months. Contrast transesophageal echocardiography (TEE) revealed an atrial septal defect with intermittent right‐to‐left shunt across a patent foramen ovale. We postulate that the shunt detected in this patient occurred as a consequence of reduced pulmonary vascular compliance due to positive end‐expiratory pressure (PEEP) and an increase of mean intrathoracic pressure. Furthermore, we hypothesize that synchronized LVAD operation exacerbates any potential right‐to‐left shunt due to the profound left ventricular unloading which occurs during LVAD support. In this first report of a right‐to‐left shunt from a previously unrecognized patent foramen ovale in a Novacor TM patient, the subsequent transient hypoxemia could be managed by avoiding PEEP of more than 3 mmHg, and mean airway pressure of more than 11 mmHg and by careful volume replacement in order to prevent the pump from completely emptying the left ventricle (LV) and the left atrium (LA). Thus, prior to every LVAD implantation a transesophageal contrast echocardiography with Valsalva maneuver should be performed to identify intracardiac right‐to‐left shunt.
