A 45-year-old man received a combined heart and kidney transplant provided by the same donor. The patient was in the terminal stage of renal failure and was submitted to 3 sessions of haemodialysis per week for 2 years before transplantation. A dilated cardiomyopathy with severe impairment of left ventricular (LV) function was discovered, precluding renal transplantation alone. In the postoperative course, a cardiac rejection episode was detected by echocardiography and documented by endomyocardial biopsy; no simultaneous rejection of the kidney could be detected. The patient was discharged after 2 months, and he resumed a normal and active life. The specific problems raised by the management of such multi-organ transplantation are briefly reviewed.
Paroxysmal tachycardias proved fatal in a middle-aged man with type A Wolff-Parkinson-White syndrome. Efforts to control his arrhythmias included a surgical incision into the left atrium, based on discovery of early left ventricular activation during epicardial mapping. The incision did not alter any electrocardiographic or clinical feature; at later necropsy examination it was found that the incision had not cut a nearby left atrioventricular (A-V) connection. Serial section study of the entire A-V rings and septal junction of this heart also demonstrated a second unusual A-V connection, between the atrial septum and the region of the His bundle. This latter connection was anatomically eccentric to the normal organization of this region and may have caused an alteration in the local electrophysiological behavior. The left lateral A-V connection may have been of no electrophysiological significance since it was composed of ordinary working myocardial cells. These and other possible correlations are discussed in the context of the clinical features, numerous electrophysiological observations, and the meticulously determined anatomical findings.
Maintenance of the body's perfusion by a total artificial heart (TAH) may result in physiological alterations to the circulatory system. Little has been said about modifications to systemic vascular resistances (SVR) during TAH assistance. This paper reports on two patients implanted with a Jarvik - 70 cc TAH, who died after 1 and 3 days, both with an irreversible drop of SVR related to a complete loss of vascular tone but not related to sepsis. Activation of multiple cascades of inflammation, triggered by the extracorporeal circulation (ECC), is maintained during TAH support. Desperately sick patients might not be able to face the vaso-active situations created by the inflammatory response.
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