We studied the effects of cytomegalovirus (CMV) infection on 301 cardiac transplant recipients who were treated during the cyclosporine era of immunosuppression (1980 to the present). These patients received varying combinations of cyclosporine, azathioprine, prednisone, rabbit antithymocyte globulin, and OKT3 as their immunosuppressive therapy. Two hundred ten patients were free of CMV infection (non-CMV group). During the same period CMV infection developed in 91 patients, as manifested by a fourfold IgG serologic titer rise, demonstration of CMV inclusion bodies in tissue, or positive cultures for the virus (CMV group). The rate of graft rejection was significantly higher in the CMV group. Graft atherosclerosis was significantly more severe in the CMV group as judged by angiographic criteria or by pathologic study. Patient survival rates were significantly lower in the CMV group. Death caused by graft atherosclerosis was significantly more common among patients in the CMV group. Finally, the graft loss rate (from either death or retransplantation for atherosclerosis) was significantly greater in the CMV group. These data demonstrate that CMV infection in cardiac transplant recipients is associated with more frequent rejection, graft atherosclerosis, and death.
The use of the internal mammary artery (IMA) in coronary artery bypass surgery has increased substantially over the past 20 years, being at present the conduit of choice for most patients. Complications associated with its use occur occasionally and include life-threatening postoperative ischemia or the revascularized myocardium. We reviewed the records of 1,971 consecutive patients who underwent coronary artery bypass grafting over a 5-year period. All operations included an IMA graft to the left anterior descending coronary artery. Twenty-eight of these patients (1.4%) underwent additional placement of a vein graft on the same region as a salvage maneuver for suspected hypoperfusion as a result of IMA failure. All 28 patients showed life-threatening hemodynamic compromise. Twenty-two of the 28 patients (79%) survived. This was the result of immediate surgical correction, which reversed their hemodynamic instability. IMA hypoperfusion was found more frequently in reoperations and in women and diabetic patients. This syndrome is the result of an imbalance between IMA flow and myocardial demand, causing sudden and unexpected myocardial failure. Its detection and expeditious treatment can successfully modify a serious and potentially lethal clinical situation.
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