RESUMEN
Since August 1981, 33 orthotopic heart transplantations were performed in our hospital. Three of these patients (9%) had sinus bradycardias with rates as low as 30 beats/min; they were treated by implantation of a dual chamber pacemaker. These patients had two atria as a result of orthotopic heart transplantation, but only the donor atrium was suitable for positioning the atrial lead. In the postoperative period, some nonsurgical complications were observed in one patient who developed atrial fibrillation which we treated with drugs. A cyclosporin-evoked tremor produced several asystoles due to false inhibition by myopotential interference in the VVI mode. During an episode of acute rejection combined with renal insufficiency, loss of atrial and ventricular sensing occurred. The other patients showed no pacemaker-related complications. Our findings in this unique population of pacemaker patients are discussed.
Asunto(s)
Arritmia Sinusal/terapia , Bradicardia/terapia , Trasplante de Corazón , Marcapaso Artificial , Complicaciones Posoperatorias/terapia , Adulto , Arritmia Sinusal/etiología , Bradicardia/etiología , Electrocardiografía , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
During the past 4 years, 36 orthotopic heart transplantations and two heart-lung transplantations were performed at Munich University Hospital. Immunosuppressive regimen consisted of cyclosporine A and low dose prednisone. The rejection diagnosis was based on daily cyto-immunological monitoring (CIM) and high frequency electrocardiography. In addition, viral, bacterial, and fungal infections were examined by CIM. The CIM is based on an evaluation of activated lymphocytes, lymphoblasts, and lymphocyte subsets in the mononuclear concentrate isolated from the peripheral blood by Ficoll Hypaque separation. Of the 38 patients, 24 are currently alive from 1 month to 4 years later (including one heart-lung recipient 1.5 years postoperatively). Altogether, 40 rejection episodes occurred among the patients. The diagnosis was based on CIM (sensitivity = 95%) and on endomyocardial biopsies (sensitivity = 95%). Control of rejection therapy was also done by using these methods. When the biopsies showed ongoing acute rejection, additional antithymocyte globulin or antilymphocyte globulin therapy was administered, relative to the CIM results. When using the endomyocardial biopsies for rejection control only, results showed a very low rate of two to three biopsies per patient in the first 3 months postoperatively. In addition, 16 infection periods were detected: five viral, six bacterial, four fungal, and one case of toxoplasmosis. The CIM showed typical hints of these inflammations in 12 cases (sensitivity = 75%) before clinical signs were visible. This immediately led to further diagnostic examinations and specific anti-infectious therapies, which were initiated early.
RESUMEN
This study assessed the ability of immunomonitoring to differentiate between acute cardiac rejection and viral, bacterial or fungal infections, using data of thirty-five cyclosporine treated heart and heart-lung transplant recipients. Peripheral blood samples were analyzed daily for 20 days, then three times weekly until the patient's discharge. Later, peripheral blood was examined every fourteen days on an outpatient basis. White blood cells were counted and differentiated. A mononuclear concentrate was obtained by the Ficoll-Hypaque gradient and centrifugation method, and cytocentrifuged onto slides. The cells were stained by a five minute method. Percentages of lymphocytes, prelymphoblasts, lymphoblasts, large granular lymphocytes and monocytes were calculated. When activated cells were detected, aliquots of the mononuclear concentrate were labeled using monoclonal antibodies. In these thirty-five patients, more than 60 acute rejection episodes were diagnosed by the cytoimmunological method. Acute rejection was characterized by a significant rise of the number of leukocytes, lymphocytes, prelymphoblasts and lymphoblasts. The T-lymphocyte population increased while the B-cells remained normal. Ninety-five percent of all acute rejection episodes were diagnosed using cytoimmunological parameters. During viral infection more than 20% of the mononuclear cells were large granular lymphocytes and the OKT4/OKT8 ratio was less than one. During bacterial and fungal infections the B-lymphocytes increased to 40% of the mononuclear cells. In addition, juvenile polymorphs appeared in the mononuclear concentrate and the OKT4/OKT8 ratio was within normal limits (1.5 to 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Infecciones Bacterianas/inmunología , Rechazo de Injerto , Trasplante de Corazón , Micosis/inmunología , Complicaciones Posoperatorias/inmunología , Virosis/inmunología , Anticuerpos Monoclonales , Diagnóstico Diferencial , Humanos , Linfocitos/clasificaciónRESUMEN
Between August 1981 and August 1983 11 heart transplantations were carried out at the Klinikum Grosshadern of the University of Munich. The recipients were 10 men and 1 women. The age of the patients at the time of the operation ranged from 20 to 45 years. The diagnosis was: congestive cardiomyopathy (4 cases), coronary heart disease (5 cases), Uhl's disease (1 case), valvular heart disease (1 case). Cyclosporin A was used as the main immunosuppressive agent in all cases. 3 patients died (1., 10. and 73. postop. day). 8 patients survived now since 2 to 25 months. The survival time exceeds 0.5 years in 5 cases and 1 year in 3 cases.