BACKGROUND:Bronchioloalveolar carcinoma (BAC) is a well-differentiated lung adenocarcinoma that has a tendency to spread chiefly within the confines of the lung by aerogenous and lymphatic routes and may therefore be amenable to local therapy. However, a high rate of local recurrence after lung transplantation was recently reported. We describe two patients with unresectable and recurrent extensive BAC limited to the lung parenchyma who underwent lung transplantation with curative intent.METHODS:Patients were chosen to receive lung transplants for BAC if they met the following criteria: (1) recurrent or unresectable BAC limited to the lung parenchyma without nodal involvement and (2) suitable candidate for lung transplantation.RESULTS:The first patient relapsed in the lungs at 9 months after transplantation. The pattern of disease suggested contamination of the new lungs at the time of implantation. Repeat lung transplantation was performed, with cardiopulmonary bypass and irrigation of the remaining upper airway. This patient has had no evidence of local or systemic tumor recurrence at more than 4 years since the second transplantation. The second patient underwent transplantation using the modified technique and expired 16 months after transplantation of other causes. An autopsy showed no evidence of recurrent BAC in the lungs or of metastatic lesions at any site.CONCLUSIONS:Lung transplantation may be an option for unresectable or recurrent BAC confined to the lungs. Isolation of the diseased lungs and the use of cardiopulmonary bypass during surgery may be important in this disease and should be studied further.

BACKGROUND:Symptomatic improvement of a patient's hemodynamic condition during intraaortic balloon counterpulsation (IABC) is considered to result largely from a reduction in afterload. Afterload can be accurately quantified by arterial input impedance measurements. Here we report the effect of IABC on arterial impedance in humans.METHODS:To characterize the effects of IABC on arterial input impedance, impedance measurements were obtained using aortic annulus Doppler flow and pressure from the aortic balloon catheter. Impedance spectra were compared between the cardiac cycles preceding and following the cycle with IABC in 25 patients.RESULTS:Intraaortic balloon counterpulsation increased stroke volume (23%; p = 0.001), reduced myocardial oxygen demand (11%; p = 0.02), and decreased the aortic pressure at the onset of systole (16%; p = 0.001). There was also a decrease in systemic vascular resistance (24%; p = 0.001), characteristic arterial impedance (21%; p = 0.002), and pulse wave reflection (20%; p = 0.006). Linear regression analysis showed that an increase in stroke volume was predicted only by the decrease in systemic vascular resistance (r = -0.81; p = 0.001).CONCLUSIONS:The reduction in systemic vascular resistance appeared to be the major mechanism by which IABC improved cardiac pumping efficiency. This effect may result from the passive distention of the peripheral vascular bed due to the propagation of the balloon-augmented diastolic pressure through the arterial system.

The pathophysiology of mitral and valvular heart disease is presented with an emphasis on the relationship of these conditions to pregnancy. Management options are discussed. Special attention is directed to patients who have prosthetic valves in place and who become pregnant. The care of this group of patients may be difficult, and treatment strategies are presented.

Objectives. This study sought to analyze the outcomes of revascularization procedures in the treatment of allograft coronary disease.Background. Allograft vasculopathy is the main factor limiting survival of heart transplant recipients. Because no medical therapy prevents allograft atherosclerosis, and retransplantation is associated with suboptimal allograft survival, palliative coronary revascularization has been attempted.Methods. Thirteen medical centers retrospectively analyzed their complete experience with percutaneous transluminal coronary angioplasty, directional coronary atherectomy and coronary bypass graft surgery in allograft coronary disease.Results. Sixty-six patients underwent coronary angioplasty. Angiographic success (less than or equal to 50% residual stenosis) occurred in 153 (94%) of 162 lesions. Forty patients (61%) are alive without retransplantation at 19 +/- 14 (mean +/- SD) months after angioplasty. The consequences of failed revascularization were severe. Two patients sustained periprocedural myocardial infarction and died. Angiographic restenosis occurred in 42 (55%) of 76 lesions at 8 +/- 5 months after angioplasty. Angiographic distal arteriopathy adversely affected allograft survival. Eleven patients underwent directional coronary atherectomy. Angiographic success occurred in 9 (82%) of 11 lesions. Two periprocedural deaths occurred. Nine patients are alive without transplantation at 7 +/- 4 months after atherectomy. Bypass graft surgery was performed in 12 patients. Four patients died perioperatively. Seven patients are alive without retransplantation at 9 +/- 7 months after operation.Conclusions. Coronary revascularization may be an effective palliative therapy in suitable cardiac transplant recipients. Angioplasty has an acceptable survival in patients without angiographic distal arteriopathy. Because few patients underwent atherectomy and coronary bypass surgery, assessment of these procedures is limited. Angiographic distal arteriopathy is associated with decreased allograft survival in patients requiring revascularization.

Impaired platelet function is considered the main cause of bleeding after patients undergo cardiopulmonary bypass surgery (CPB). The requirement for blood products and other postoperative drugs has not been eliminated even with improvements in technology.l Various studies have shown the activation of platelets when in contact with the extracorporeal unit.2.3 Yet, there are data that demonstrate that this response may be reversible. Aprotinin, a protease inhibitor, has recently been used in the United States on a compassionate-use basis in cardiovascular surgery patients determined to be at high risk for bleeding. Previous studies in Europe have concluded that the use of aprotinin decreases postoperative blood loss by about one-half.,6 In addition to inhibiting trypsin, kallikrein, and plasmin, aprotinin is also thought to preserve the adhesive abilities of platelets via the glycoprotein Ib (GP Ib) receptor.7.8 Although questionable, some studies have demonstrated a correction of the diminished interaction between platelets and the subendothelial layer in the presence of aprotinin.9• Due to the consistent decrease in postoperative blood loss, there has been a growing interest in the monitoring of aprotinin and in more precisely determining its mechanism of action. More importantly, a limited number of postoperative cases of thrombosis have been reported with the clinical use of aprotinin. ll Current studies are thus centering on the effect of aprotinin on heparin moni-

The quantitative measurement of right ventricular (RV) volume has been attempted by a number of methods, including nuclear magnetic resonance imaging, contrast angiography, echocardiography, and radionuclide angiography. All of these methods have limitations. Ultrafast cine computed tomographic (CT) scan is a new technology that may have an important role in on-line ventricular volume measurements. Twelve human explanted hearts, fixed in formalin, were subjected to ultrafast cine CT scans to estimate RV volume. The volumes derived from the CT scans were compared with actual fluid volumes needed to fill the RV volume measurements. All measurements were conducted independently by two observers. Actual RV volumes in the 12 hearts ranged from 29.8 ml to 174.6 ml. A strongly significant correlation between actual volume and CT volume was seen (r = 0.99). Agreement between observers was also seen to be highly significant (r = 0.992). Limitations to accurate in vivo assessment due to bolus injection of contrast medium might include alterations in ventricular pressure change. Similarly, differentiation of the endocardial border with contrast may not be as sharp as that with an air-tissue interface. This study demonstrates that RV volumes can be reliably determined by ultrafast cine CT scans in explanted hearts. On-line systolic and diastolic volumes and thus stroke volume, ejection fraction, etc, can be accurately defined independent of cardiac orientation. This technique offers opportunities to study ventricular function under various conditions.

Over a 3 year period, 140 patients underwent attempted implanation of an automatic cardioverter/defibrillator using the nonthoracotomy lead (NTL) system. Indications included sustained monomorphic ventricular (VT) (84), nonsustained (VT) with poor ventricular function (7), ventricular fibrillation (VF) (31), VT/VF (16), and familial long QT syndrome (2). A total of 115 males and 25 females comprised the group; mean age was 57 +/- 14 years; 59% had previous coronary bypass and/or valve surgery. Mean left ventricular ejection fraction was 31 +/- 14%, cardiac index was 2.4+/-1 L/m2, and systolic pulmonary artery pressure was 42+/-15 mm Hg. Under general anesthesia the NTL was introduced through the left subclavian vein. The subcutaneous patch and generator were placed posteriorly on the serratus muscle and left upper quadrant, respectively. The length of the procedure was 117 +/- 46 minutes, and the mean number of defibrillation shocks for a successful implant was 9 +/- 4. A total of 110 patients (79%) had successful implantations. Failures were caused by a high defibrillation threshold (27) and the inability to place the right ventricular lead (3). Predictors of failure included preoperative antiarrhythmic drugs and cardiac index less-than-or-equal-to 1.8 +/- 4. Only 3 patients (2.0%) died postoperatively, from heart failure (2) and chronic heart transplant rejection (1). migration or dislodgement (8), infection (1), and hematoma (4). In summary, the NTL system provides an alternative to epicardial systems in patients requiring cardioverter/defibrillator implantation.

Over a 2-year period, 110 patients underwent attempted implantation of an automatic cardioverter-defibrillator using the nonthoracotomy lead system. Indications included sustained monomorphic ventricular (n = 62), nonsustained with poor ventricular function (n = 7), ventricular fibrillation (n = 21), ventricular tachycardia/fibrillation (n = 18), and familial long QT syndrome (n = 2). There were 90 male and 20 female patients. Mean age was 57 +/- 15 years. Sixty percent had previous coronary bypass or valve operations, or both. Mean left ventricular ejection fraction was 30% +/- 14%, cardiac index was 2.4 +/- 0.9 L/m2, and systolic pulmonary artery pressure was 41 +/- 14 mm Hg. Under general anesthesia, the nonthoracotomy lead was introduced through the left subclavian vein. The subcutaneous patch and generator were placed posteriorly on the serratus muscle and left upper quadrant, respectively. The length of the procedure was 116 +/- 44 minutes and the mean number of defibrillation shocks for a successful implant was 8 +/- 4. Eighty-five patients (77%) had successful implantations. Failures were due to high defibrillation threshold (n = 23) and inability to place a right ventricular lead (n = 2). Predictors of failure included preoperative antiarrhythmic drugs and cardiac index of 1.8 +/- 4 L/m2 or less (p = 0.004). Three patients (2.7%) died after the operation of heart failure (n = 2) and chronic heart transplant rejection (n = 1). Complications included lead migration or dislodgment (n = 8), infection (n = 1), and hematoma (n = 3). In summary, the nonthoracotomy lead system may provide an alternative in patients undergoing cardioverter-defibrillator implantation.

Five high-risk patients undergoing the Fontan operation required large fenestration (1 cm) because of high central venous pressure and low cardiac output. Because of major arterial desaturation, obligatory Glenn shunts were performed. Three patients had pulmonary atresia, 1 had tricuspid atresia 1-B, and the fifth had single ventricle with subaortic stenosis. The age ranged from 16 to 40 months (mean age, 25 +/- 9 months) and weight from 7.9 to 14.6 kg (mean weight, 11 +/- 2 kg). One patient had single and 3 had bilateral subclavian pulmonary artery shunts. The fifth patient had pulmonary artery banding and coarctation repair followed by an aortopulmonary window and central shunt. The first 2 patients repeatedly had to go back on cardiopulmonary bypass for a larger fenestration and subsequently had an obligatory Glenn shunt because of arterial desaturation. The last 3 patients had planned obligatory Glenn shunt and large fenestration. The first patient died on the second postoperative day of a combination of prolonged operation, repeated cardiopulmonary bypass, and periods of hemodynamic instability. Three patients had closure of the adjustable fenestration under local anesthesia at 4, 5, and 8 weeks postoperatively. The last patient is awaiting closure. We believe that in certain high-risk patients, a large fenestration combined with an obligatory Glenn shunt should be considered to minimize repeated cardiopulmonary bypass and urgent tightening or closure of fenestration in the immediate postoperative period.

To determine the effects of donor/recipient weight mismatch on allograft function and survival after orthotopic heart transplantation, we retrospectively compared the clinical and the hemodynamic characteristics of recipients weighing more than their donor (undersized) with those of recipients weighing less than their donor (oversized). The median follow-up period was 24 months (range, 0 to 67 months). In 88 patients (59%) donor weight was 1% to 46% less than recipient weight (13.5 +/- 8.9 means +/- SD). In 61 patients (41%) donor weight exceeded recipient weight by 0% to 139% (20% +/- 23%). When recipient ideal body weight was used in the analysis, 75 patients (51%) were undersized by 1% to 59% (13% +/- 10%), and 72 patients (49%) were oversized by 0% to 67% (19% +/- 18%). Preoperative transpulmonary gradient, ventricular function, and exercise tolerance were similar in the two groups. The number and severity of episodes of rejection and infection after transplantation were also similar in the two groups 1, 6, and 12 months after transplantation. When recipient ideal weight was used in the analysis, right ventricular (RV) and left ventricular (LV) ejection fractions (EFs) were within normal limits (RVEF greater than 40%; LVEF greater than or equal to 45%) and similar in the two groups. When recipient actual weight was used in the analysis, the LVEF measured at 12 months after heart transplantation was higher in the oversized than in the undersized group (52 +/- 11 vs 46 +/- 10; p less than 0.05). Postoperative hemodynamic values and exercise tolerance were similar in the two groups regardless of whether recipient weight or ideal body weight were used in the analysis. Forty-six recipients died 0 to 46 months (median, 7 months) after orthotopic heart transplantation. In a Cox regression model, recipients with donor weight greater than recipient ideal weight had a significantly greater risk of death within the follow-up period than did recipients with donor weight less than recipient ideal weight (relative risk = 2.19; p less than 0.05). When percent donor weight/recipient ideal weight mismatch was used as a continuous variable, donor heart oversizing was negatively related to survival, independent of preoperative transpulmonary gradient values (p less than 0.05). In contrast to common belief, oversizing of donor hearts does not improve the outcome of orthotopic heart transplant recipients who have reversible preoperative pulmonary hypertension. Acceptance of undersized donor hearts is not detrimental to allograft function and recipient survival. Use of undersized donor hearts may maximize the use of critically scarce donor organs.

Twenty-six patients on long-term renal dialysis underwent coronary artery bypass grafting. The patients were divided into two groups: group 1, (16 patients) saphenous vein bypass grafts, and group 2, (10 patients) internal mammary artery in combination with saphenous vein bypass grafts. Both groups were similar in terms of cardiac hemodynamics and previous number of myocardial infarctions, though more group 1 patients were in New York Heart Association class III or IV. Patients in group 1 received 2.9 bypass grafts per patient; patients in group 2 received 4.0 bypass grafts per patient (4 with bilateral mammary arteries). No wound healing problems occurred in either group. Blood replacement was similar for both groups (group 1, 5.5 units/patient; group 2, 5.3 units/patient). More platelets were given to group 1 patients (16.2 units/patient) than group 2 patients (3.1 units/patient). We conclude that use of the internal mammary artery in patients on long-term renal dialysis does not alter wound healing or increase blood loss in this subset of patients.

The proliferation of transplantation programs has not been paralleled by a similar increase in the availability of organ donors. Between 1984 and 1987, 104 orthotopic heart transplantations were performed at Loyola University Medical Center. During the same period, 25 patients died while awaiting a donor organ. To reduce the mortality, we began using the total artificial heart (TAH) and a ventricular assist device (VAD) as a bridge to transplantation in 1988. Of 29 patients who underwent transplantation, 15 patients required a TAH and three patients required a VAD as a bridge. The underlying heart conditions were ischemic cardiomyopathy (11 patients), dilated cardiomyopathy (5 patients), giant cell myocarditis (1 patient), and allograft failure (1 patient). The average duration of mechanical support was 10 days (range, 1 to 35 days). Of the 17 patients who successfully underwent transplantation, 1 patient died at 17 days because of acute rejection of the transplanted heart, and another patient died at 14 days because of a cerebral vascular event. Fifteen patients (83%) were long-term survivors. Nine patients required reoperation for bleeding. While the mechanical device was in place, the activated clotting time was maintained between 170 and 200 seconds with heparin. Dipyridamole was given. We conclude that the TAH and VAD are excellent mechanical bridges to transplantation.

The number of open heart operations continues to increase all over the world. Concern for the num ber of blood units used and the strain placed on blood bank resources has been voiced by

Twenty-two open-heart operations have been performed on 21 patients receiving chronic renal dialysis. These cases include 16 aortocoronary bypasses and six valve replacements. The average time on dialysis prior to surgery was 26 months; 18 of 21 patients were in NYHA grade 3 or 4. Twenty-seven postoperative complications occurred, with six requiring further surgery and 21 treated nonsurgically. Two perioperative deaths occurred, both due to sepsis. Long-term follow-up was achieved on all hospital survivors. Ten patients remain alive with a mean follow-up of 21 months. At a mean of 16.5 months after surgery, nine deaths occurred, with only two due to known cardiac problems. In summary, indicated cardiac surgery can be performed on chronic renal dialysis patients with a reasonable morbidity and mortality; however, the long-term survival of our patients has not been assured by a successful cardiac operation.

A left ventricular aneurysm developed in 3 patients sustaining blunt chest injury. Evidence of an acute myocardial infarction on the electrocardiogram and enzyme analysis prompted cardiac catheterization, which revealed total occlusion of the left anterior descending coronary artery in 2 of the 3 patients. Ventricular aneurysmectomy was performed in each patient. A review of the literature revealed 32 previously reported patients with left ventricular aneurysm caused by blunt trauma. Clinical features, catheterization or autopsy findings, and outcome are examined.