Cardiopulmonary transplantation

Griffith BP, Hardesty RL, Trento A, Bahnson HT. 1985. Asynchronous rejection of heart and lungs following cardiopulmonary transplantation. Ann Thorac Surg. 40 488-493. 

Brown ME, Sarris GE, Oyer PE (1996) Cardiac donor evaluation, retrieval, and matching to recipient. In Smith JA, MacCarthy PM, Sarris GE, Stinson EB, Reitz BA (eds) The Stanford manual of cardiopulmonary transplantation. Futura, Armonk, pp 15-30... 

A 60-year-old white man was admitted for kidney transplantation. Immediately after reperfusion and intravenous methylprednisolone 500 mg, he developed severe bradycardia with hypotension and then cardiac arrest. After resuscitation, his clinical state improved quickly, but on the morning of the first postoperative day directly after the intravenous administration of methylprednisolone 250 mg, he had another episode of severe bradycardia, hypotension, and successful cardiopulmonary resuscitation. A third episode occurred 24 hours later after intravenous methylprednisolone 100 mg, again followed by rapid recovery after resuscitation. Two weeks later, during a bout of acute rejection, he was given intravenous methylprednisolone 500 mg, after which he collapsed and no heartbeat or breathing was detectable after cardiopulmonary resuscitation he was transferred to the intensive care unit, where he died a few hours later. 

W2. Wan, S., LeClerc, J. L., and Vincent, J. L., Cytokine responses to cardiopulmonary bypass Lessons learned from cardiac transplantation. Ann. Thorac. Surg. 63, 269—276 (1997). 

This concept has enormous implications in the setting of cardiac surgery and heart transplantation [11-13]. Conditions of ischemia and reperfusion are created routinely by the surgeon during open heart procedures, i.e., cardiopulmonary bypass and aortic cross-clamping [11,12], Similar conditions prevail during heart transplantation when the ischemic donor heart is rapidly reoxygenated by the recipient s blood [14]. 

A 30-year-old woman with a history of bronchial asthma and cocaine abuse had a cardiorespiratory arrest preceded by sudden dyspnea 1 hour after cocaine inhalation. Direct laryngoscopy showed edema of the glottis. After extended cardiopulmonary resuscitation, she went into a deep coma with dilated non-reactive pupils. Toxicological analysis showed cocaine and amphetamines in her urine. She was brain dead 11 hours later and her organs were used for transplantation. Her liver was given to a 14-year-... 

The changes of serum CK and its MB isoenzyme following a myocardial infarction are discussed in Chapter 44. Other cardiac conditions have been reported to increase serum CK and CK-MB in serum. These conditions include cardioversion, cardiopulmonary bypass and coronary artery bypass surgery, cardiac transplantation, myocarditis, pericarditis, and pulmonary embolism. Despite improvements, in the diagnostic performance and practicality of CK and CK-MB assays, there is no controlled cUnicai impact trial showing that these tests are effective for decisions to send a patient home or to the appropriate level of care of admission for patients with suspected acute cardiac ischemia, either as one-time or serial tests.For diagnosis of acute myocardial infarction, it is now advantageous to use more cardiac-specific nonenzymatic tests, such as cardiac troponin I orT. 

Discordance between total and free magnesium measurements has been reported in selected patient populations, including those with cardiovascular disorders, diabetes meUitus, alcoholism, migraine headaches, asthma, renal transplants, head trauma, and in pregnant women. Interferences, such as that from thiocyanate, in measurement of fr ee magnesium may explain some of these discrepencies. Free magnesium determinations may be helpfiil in others of these disorders and in critically ill patients and during cardiopulmonary bypass, preeclampsia, neonatal distress, and therapy with a number of... 

Heart transplantation is usually an orthotopic procedure. Leaving most of the atria and septum of the recipient, the patient is placed on cardiopulmonary bypass. The donor heart is implanted by anastamosis of the left atrium to the residual left atrial wall and joining the right atrial wall and septum. The main pulmonary artery is connected to the ascending aorta."... 

Heart Valves. The cardiopulmonary bypass machine, which allows blood flow to bypass the heart and lungs, is also used in other surgical procedures, such as valve repair and replacement, repairs of septal defects and congenital heart defects, and heart transplantation. Surgeons repair or replace heart valves in 99,000 operations per year in the United States. The... 

If the recipient had previous open heart surgery (a situation not uncommon for heart transplant recipients) we usually dissect the common femoral artery and femoral vein for a short distance in one of the groins. Umbilical tapes are placed around the vessels and everything is prepared for emergency femoral cannulation. Cardiopulmonary bypass can be established immediately if there are serious complications during chest reopening or stepwise division of fibrous adhesions. 

There are some complications which can lead to an initial failure of the transplanted heart. Bleeding from the anastomoses, which is sometimes a major concern, requires a careful search for the source especially as many patients take oral anticoagulants up until the transplantation and therefore suffer from coagulopathy. Massive volume substitution (blood or plasma) after separation from cardiopulmonary bypass (CPB) can lead to right heart failure. 

Miniati DN, Robbin RC (2002) Heart transplantation a thirty-year perspective. Annu Rev Med 53 189-205 Mohanty PK, Thomas MD, Arrowood JA et al (1987) Impairment of cardiopulmonary baroreflex after cardiac transplantation in humans. Circulation 75 21 Moreira LFP, Stolf NAG, Braile DM et al (1996) Dynamic cardiomyoplasty in South America. Ann Thorac Surg 61 413-419... 

More specifically in heart transplant recipients, bleeding, leaks, and frank rupture can occur at the anastomosis sites the most critical of which is the aortic anastomosis, particularly if there is a marked difference in diameter between the donor and recipient aorta (Knisely et al. 1999 Reitz et al. 1982) (Fig. 2.2.3). In addition, acute or chronic breakdown at the aortic anastomosis can lead to aortic dehiscence, dissection, and pseudoaneurysm formation (Henry et al. 1989 Knollmann et al. 2000a Knosalla et al. 1996). Pseudoaneurysms can also form at two additional sites in the cardiac transplant patient at the cannulation sites used for cardiopulmonary bypass and at the endomyocardial biopsy sites in the right ventricle, taken to look for rejection (Knisely et al. 1999). Although most of these complications occur in the immediate post-operative period, some can occur months to years later (Knisely et al. 1999). Aortic dissection, when it occurs in the heart transplant patient (l%-2%), usually involves the recipient s native aorta, although rare cases of dissection involving the donor s aorta have been reported (ScHELLEMANS et al. 2004). Dissection can occur in the immediate peri-operative period usually due to mismatches in donor-recipient vessel size or years later when they may he due to infection or accelerated atherosclerosis (Schellemans et al. 2004). 

To illustrate the effects of ROS on microvascular function, ischemia-reperfusion (I/R) will be briefly discussed. A prolonged reduction or absence of blood flow (i.e., ischemia) results in a series of biochemical changes within endothelial cells that will initiate a microvascular inflammatory response upon reintroduction of blood flow to the tissue (i.e., reperfusion).Clinical situations involving I/R-induced microvascular dysfunction include organ transplantation, coronary angioplasty, thrombolytic therapy, and cardiopulmonary bypass. ... 

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