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Influence of post-surgery time after cardiac transplantation on exercise responses. Med. Sci. Sports Exerc., Vol. 28, No. 2, pp. 171-175, 1996. To test the hypothesis that exercise response changes with time after cardiac transplantation, we investigated the cardiorespiratory responses of nine orthotopic heart transplant patients (52.4 +/- 2 yr) during graded exercise tests (30 W.3 min-1) done at 1, 3, 6, 9 and 12 months post-surgery. At peak exercise, 1) oxygen uptake per kg of body weight (VO2), minute ventilation (VE) and oxygen pulse (O2 pulse) did not change significantly between 1 and 12 months postsurgery; 2) transplanted heart rate (HRt) and delta heart rate (peak exercise heart rate--resting heart rate) increased significantly over time (P < 0.01; P < 0.05) with a marked increase between 1 and 3 months (P < 0.05); and (3) a significant negative correlation existed between O2 pulse and HRt (r = -0.36, P < 0.05), whereas no correlation was found between delta heart rate and delta VO2 (peak exercise VO2- resting VO2, l.min-1). During submaximal exercise, HRt increased significantly over time (P < 0.001); VO2, VE, and O2 pulse showed no significant change; and the VO2-HRt relationship shifted toward higher values of HRt. We conclude that, in the absence of formal physical training, the exercise response of denervated transplanted heart increases in relation to post-surgery time but does not affect oxygen uptake at submaximal and peak levels of exercise.

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Following cardiac transplantation bacterial mediastinitis is a severe early complication. Between March 1986 and September 1993, cardiac transplant operations were performed in 101 patients, of whom six developed purulent mediastinitis. Treatment consisted of surgical débridement, closed local irrigation, drainage and systemic antibiotics. No patient died as a result of bacterial mediastinitis. Low cardiac output and requirements for resternotomy for bleeding and prolonged artificial ventilation were significantly higher in the group with sternal infection. In contrast, since January 1991 the dose of corticosteroid was decreased from 5 mg/kg per day to 1.5 mg/kg per day beginning on the first day after operation. A total of 51 heart transplant operations have been subsequently performed without sign of mediastinal infection.

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Excessive bleeding during and after cardiac surgery with cardiopulmonary bypass is a real problem in this kind of surgery. The use of prophylactic high doses of aprotinin (APROT) reduces blood loss in this context but this treatment is expensive. Some investigators have advocated that epsilon-aminocaproic acid (EACA), a cheaper antifibrinolytic drug, could reduce blood loss in cardiac surgery. The goal of this prospective study was to determine if EACA is as effective as APROT for this clinical condition. Sixty patients undergoing elective surgery for cardiac disease were randomly allocated to one of the two groups. Drugs were administered after induction of anesthesia at a dose of 2.10(6) UIK in the APROT group or 5 g in the EACA group. The same dose was added to the priming of the cardiopulmonary bypass circuit. Until the skin closure the patients received 5.10(5) UIK/h of APROT or 2 g/h of EACA. Bleeding during and after surgery was not different between the two groups. No complication, directly due to the treatment administered, was observed. EACA seems to be as effective as APROT to reduce intra and post cardiac surgery blood loss. EACA has the advantage of being cheaper (treatment is approximately 200 times cheaper), therefore allowing a wider use.

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After cardiac transplantation bacterial mediastinitis is a severe early complication. Between 1986 and 1990, we performed 49 cardiac transplantations. Six patients developed purulent mediastinitis. Treatment consisted in surgical debridement, local irrigation, drainage and systemic antibiotics. No patient died of this bacterial mediastinitis. Low cardiac output, re-sternotomy for bleeding, prolonged artificial ventilation were significantly higher in the group with sternal infection. Closed tube irrigation is a simple and efficient treatment of mediastinitis.

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To maintain good cellular oxygenation during bronchopulmonary lavage for alveolar proteinosis is often a difficult problem to solve. A case is reported of alveolar proteinosis in whom four lavages were performed. Details of the technique are discussed, as are the problems with expedients used to improve PaO2. The use of a 10 cmH2O positive end-expiratory pressure was useful only during the "in-phase"; in the "out-phase", it worsened the PaO2. PaO2 during lavage in patients with alveolar proteinosis can only be improved by three ways: cancellation of the shunt during lung filling and, during the "out-phase", an increase in FIO2 or pulmonary artery occlusion by a balloon.

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In 18 subjects undergoing aorto-bifemoral by-pass, pre-operative isovalaemic hemodilution was carried out (using a dextran of molecular weight 60,000) at the same time as venous section of a mean value of 1087 ml reducing the hematocrit to 0.30. The following were studied before, immediately after and 24 hours after hemodilution: blood viscosity (at variable shearing rates), oncotic pressure, sedimentation rate, clotting factors, plasma electrolytes. These results showed that at the end of hemodilution, oncotic pressure was maintained and even increased despite the fall in blood protein levels, with also a decrease in blood viscosity, a tendency to dynamic hypocoagulability (thrombocytopenia, fall in fibrinogen and increase in cephalin kaolin time and Quinck time) without any increase in lytic activity. 24 hours later, these parameters tended to return to normal. Discussion on the basis of a study carried out in vitro, seeks to demonstrate which of these changes were related to the dextran molecule and which were related to the hemodilution.

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The approach to the sub-clavian venous axis being carried out blindly, the difficulties encountered oblige one: - to avoid the danger (pleural dome in particular); - to guide the catheter along the sub-clavian axis (and not in the jugular vein) and therefore to know the anatomical landmarks and a precise method. A variant of the CARLE technique, that which is proposed is based on no other anatomical argument than the direction of the sub-clavian axis and of its junction. The puncture site is higher and more external, a guiding finger shows the pathway in such a way as to try and leave the dangers behind the pathway of the needle. The obligatory long tunnelization of the catheter, becomes an advantage (fights against the danger of infection) to be added to the already known advantages of this pathway.

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Fifty one patients from different surgical units, hence anesthetized by different anaesthesists, underwent reinterventions in abdominal surgery. The indications for the first intervention essentially involved the supra-mesocolic region of the abdomen (62 out of 100 cases). The operative risk during the first intervention was on the average 18 pour cent. The protocol of the first anaesthesia which was known in 42 cases, was of the narco-ataralgestic type. The date of the return to the operation table varied from 1 to 60 days. The state of the patients was in general catastrophic (organic renal failure, acute respiratory failure). Here again the anaesthesia was of the narco-ataralgesic type but the choice of drugs varied depending on the patients' state. However non significant difference was noted in the average hourly drug consumption between the two interventions. Apart from one circulatory arrest during induction, in one patient with hemorrhagic shock, no death was attributable to the anesthetic technique. The authors, using these findings, attempt to pick out a practical line of behaviour.

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