Aims: To report the clinical experience of the first 150 patients undergoing cardiac transplantation at the Alfred Hospital from February 1989 to March 1993. Methods: Major indications were idiopathic dilated cardiomyopathy (47%) and ischaemic heart disease (36%). Results: Of 433 patients referred, 242 (56%) were accepted onto the waiting list, of whom 150 (62%) received cardiac transplants. Median time on the waiting list was 42 days. Acute rejection was seen in 125 patients (83%). Transplant coronary disease was diagnosed in 16 patients (14%) who underwent coronary angiography. Infection was a major contributor to morbidity. During the follow-up period, 23 patients (15%) died. Eight patients (5%) died within 30 days of the surgery. Actuarial survival was 88% at 1 year and 82% at 4 years. Conclusion: Cardiac transplantation continues to evolve as an increasingly successful option for patients with end-stage cardiac disease.
The pyrimidine base, orotic acid (OA), markedly improves the function of recently infarcted hearts subjected to global ischemia. The mechanism of cardiac action of OA is unclear, but it has been proposed that OA acts by correcting a relative deficiency of nucleotide precursors required for RNA synthesis in the stressed myocardium or by improving myocardial energy supply. The aim of this study was to investigate the mechanism of action of OA by (1) determining whether a high dose of OA can raise the concentration of pyrimidine metabolites in plasma, liver, and heart; (2) examining the effects of OA on adenine nucleotide (AN) concentrations in normal and infarcted hearts, before and after global ischemia; and (3) determining the effect of uridine, an important metabolite of OA, on myocardial energy metabolism. Three studies were performed: (1) The time course of changes in tissue and plasma concentrations of pyrimidine compounds was examined in unoperated rats after the administration of 100 mg/kg OA. (2) Rats were given OA (30 mg/kg/d) for 2 days after experimental infarction, and tissue and plasma pyrimidine concentrations were examined; the hearts were removed for perfusion in the isolated working rat heart model (37°C), subjected to 30 minutes of global ischemia, and recovery of function was assessed. AN content was assessed in the noninfarcted myocardium before and after ischemia. Isolated hearts were subjected to 30 minutes of hypoxic perfusion and the effect of adding 17 μM uridine to the perfusate was examined.
The adequacy of right ventricular (RV) preservation and cooling with retrograde cardioplegia has been questioned. We compared the effects of retrograde with antegrade cardioplegia on the recovery ventricular function inpatients undergoing coronary artery surgery. Two groups of similar age, left ventricular function and extent of disease received either retrograde (RC) or antegrade (AC) multidose cold-blood cardioplegia. A right ventricular rapid-response catheter measured right ventricular haemodynamics before and after bypass. Needle thermistors recorded intramyocardial temperatures in the right ventricular free wall, the left ventricular free wall and the septum. There were no differences in bypass times, ischaemic times, inotrope requirements or arrhythmia frequency between the 2 groups. RV haemodynamics were similar in both groups before bypass. Immediately after bypass the RV end diastolic volume index was lower in the retrograde group than in the antegrade group, and RV ejection fraction was higher. This indicates better RV preservation with retrograde cardioplegia early after bypass. By 30 min after bypass all haemodynamic variables had returned to baseline values in both groups. Retrograde cardioplegia provided effective cooling in all areas of the heart. The mean time to achieve electromechanical quiescence was longer with retrograde cardioplegia, and a larger total volume of cardioplegia was required. Except for a minor advantage for RC soom after bypass, this study suggests that RV protection during coronary artery surgery is the same whether retrograde or antegrade cardioplegia is used. The time taken o achieve diastolic arrest with retrograde cardioplegia may presuade surgeons that combination of antegrade and retrograde cardioplegia remains the most satisfactory technique.
A patient with primary malignant pericardial mesotheliomar had symptoms, including a family history of tuberculosis, which led to a mistaken diagnosis of tuberculous pericarditis. The true nature of the disease was diagnosed during surgical exploration. The tumour had spread over the surface of the heart, superior vena cava, the root of the aorta and the pulmonary trunk. The patient subsequently died.
Two patients with hepatocellular carcinoma growing into the right atrium had successful surgery. The first patient had an atrial hepatocellular carcinoma which prolapsed through the tricuspid valve and obstructed it. Palliative resection was achieved under deep hypothermia and a brief period of circulatory arrest. In the second patient, the right atrial hepatocellular tumour embolised to the lung. Pulmonary embolectomy was performed under normothermic cardiopulmonary bypass. Both patients survived the hospitalisation period.
A 38-year-old woman with severe rheumatic mitral stenosis associated with a giant left atrium underwent mitral valve replacement and a reduction left atrioplasty. She developed a rare and fatal ventricular rupture in the postoperative period. The management of giant left atrium in the context of mitral valve replacement is controversial.
