397 Although treatments for cardiac allograft rejection varies among institutions, intravenous steroid therapy is frequently administered for"moderate" 3A rejection. Oral steroid bolus followed by tapering doses has been studied and found to be effective. To determine the efficacy of oral steroid bolus without a taper for the treatment of asymptomatic 3A cardiac allograft rejection, a retrospective analysis was performed on all consecutive cardiac transplant recipients transplanted between Jan 1995 through Dec 1997. Of 230 recipients, 113 were treated for 197 new episodes of 3A rejection. Treatment consisted of 100 mg of prednisone for 3 consecutive days followed by resuming the pre-rejection steroid dose. The treated episodes were analyzed as success (S) if follow up biopsy (at 1-2 weeks) were Grade 0, 1A, 1B, or 2; treatment was counted as failure (F) if follow-up biopsy showed Grade 3A or higher. The 113 patients included 89 (79%) males; mean age was 51.9 ± 11.1 years (range 19-68; median 54). Thirty-one patients (28%) had left ventricular assist device as a bridge to transplant (LVAD BTT). Of the 197 3A rejections treated solely with a three-day bolus of oral steroids, 146 episodes (74%) responded. A comparison of the success rates among those patients who received oral pulse treatment>90 days post transplant versus recipients who required treatments earlier revealed the response rates to be 88% versus 69%, respectively (p=0.007). Comparing response rate for the patients who received treatment >60 days to those who were treated earlier showed a slight decreased in the responder rate to 84% (versus 68%, p=0.02). Among patients treated for moderate rejection before and after 30 days of transplant, there was a significant decrease in the response rate to 69% and 78%, respectively (p=ns). The mean age of the recipients showed a trend to be lower among the failure group (49± 13 years) than the success group (53 ± 10 years) (p=0.07). Having LVAD BTT did not significantly affect the treatment outcome after an oral pulse for a moderate grade rejection. The response rates were 66%, for the patients who received LVAD BTT, versus 77% for those not bridged (p=ns). There was no difference between the two groups in regards to gender, the mean dose of cyclosporine (4.9 (F) vs. 4.5 (S) mg/kg/day), the mean dose of prednisone (19 (F) 18 (S) mg/day) or the mean dose of azathioprine (1.7 (F) vs. 1.9 (S) mg/kg/day). We also compared the difference in the cost between the oral and IV therapies. The total cost of three-day outpatient nursing supervised IV steroid therapy was $861.48; for three-day oral prednisone, it was $6.88. In conclusion, oral steroid bolus therapy is an effective and economical way to treat asymptomatic moderate grade cardiac allograft rejections especially after the immediate post transplant period.Table
The role of thrombolysis in brain ischemia in patients with atrial myxoma is unknown. A patient with acute brain ischemia and previously undiagnosed atrial myxoma recanalized an occluded middle cerebral artery with intra-arterial thrombolysis. Arterial occlusion from presumed myxoma may be amenable to fibrinolysis. Angiography before eurysm and patients with atrial myxoma excludes a myxomatous pseudoaneurysm and permits site-specific thrombolytic instillment.
Thirty-four patients with history of congestive heart failure, dilated cardiomyopathy, and biopsy-proven lymphocytic myocarditis were treated for six months with immunosuppressive agents (prednisone and azathioprine) in addition to standard therapy for congestive heart failure. Seventy-three percent had improvement or resolution of the lymphocytic infiltrate, whereas 27% had persistent infiltrates. Improvement in myocardial histologic findings was unpredictable and did not correlate with age, gender, duration of symptoms, initial functional class, severity of left ventricular dysfunction, intensity of initial inflammatory infiltrate, or degree of myocardial cell injury. Histologic response was associated with significant improvement in left ventricular ejection fraction, but not cardiothoracic ratio, left ventricular dimensions, or survival. Functional class improved equally whether patients' disease did or did not respond to the treatment, and was not necessarily associated with objective improvement in cardiac function. Immunosuppressive therapy resulted in serious or fatal side effects in 24% of patients. Overall long-term survival was 79% at one year and 76% at two years. Poor survival was related to left ventricular ejection fraction less than 20%, male sex, age less than 50 years, and marked left ventricular dilation, but not to myocardial histologic findings. These findings indicate that the potential benefits nu the risks of immunosuppressive therapy must be weighed carefully in the individual patient.
Endomyocardial lymphocytic infiltrates (ELI), or "Quilty" lesions are morphologically and immunohistochemically distinct and are thought to be due in part to Cyclosporine therapy. In order to evaluate the relationship of ELI to CsA therapy, we compared the whole-blood CsA levels (WBCsA) with the frequency of ELI in our cardiac transplant patients. From January 1, 1987 to January 1, 1988, 364 concurrent endomyocardial biopsies and WBCsA were performed on 43 cardiac transplant patients. All biopsies were evaluated for acute rejection. ELI were recognized as well-circumscribed, flat or pedunculated lesions within the endomyocardium composed of mature T lymphocytes with pockets of B lymphocytes and occasional macrophages and plasma cells. All WBCsA were trough levels and were determined by high-pressure liquid chromatography. Results were evaluated using a logistic regression model for clustered data. ELI were observed in 17.9% (65/364) biopsies, and 60.5% (26/43) of patients had at least one ELI during the study period. The mean WBCsA was 155.2 ng/ml (SD = 62.9) in the ELI-positive group, and 190.2 ng/ml (SD = 97.0) in the ELI-negative group. Applying the regression model revealed a statistically significant negative correlation between WBCsA and the presence of ELI (P = 0.033)--that is, a lower WBCsA was associated with an increased probability of ELI. The frequency of clinically significant rejection was lower in the ELI-positive biopsies, and this correlation approached statistical significant (P = 0.053). These data suggest that ELI are unrelated to increased WBCsA and may represent an idiosyncratic reaction to CsA, or be related to factors other than CsA therapy.
