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Ann Thorac Surg 1995;59:811-812
© 1995 The Society of Thoracic Surgeons
DR JOHN H. CALHOON (San Antonio, TX): Doctor Fullerton, this represents a beautiful series and was a beautifully presented paper with some really awesome results. I have a couple of questions. The first is about the total lymphoid irradiation (TLI). We have not used that in our program. Has it led to any infections or did you obviate that with CSF that you gave to some of those patients, and can TLI be reused? The other question I might ask is your incidence of cytomegalovirus (CMV) conversion. You do not have a very high incidence of coronary artery disease, so are the patients all CMV negative or positive, do you know, and are you using prophylaxis for CMV?
DR FULLERTON: Approximately half of our patients have converted from CMV negative to CMV positive. We do not routinely use ganciclovir as prophylaxis. We reserve its use for those patients who are CMV negative receiving a CMV-positive donor. We have had, I believe, two episodes of CMV disease, which was mild in each case. It did require hospitalization for about 72 hours in both cases-this is 8 months after transplantation-and was successfully treated with ganciclovir.
I do not know if TLI can be reused. Although our standard protocol calls for 800 Gy to be administered, in 4 patients we have actually extended that to 1,400 Gy because the patient still had significant problems with rejection midway through the course of TLI. Our impression is that it is very effective. After about 200 Gy you can see a marked improvement in the echocardiogram. Our patients have not had any serious infections thus far as a consequence of the use of the TLI. We have been pretty vigilant about trying to maintain absolute neutrophil counts greater than 1,500/µL with CSF, and as you have mentioned, perhaps this has contributed to the results. But surprisingly enough, our patients have not had any serious infections.
DR KIRK R. KANTER (Atlanta, GA): I have one question and one comment. First of all, in the current climate with multiple organ retrieval and the need for the lungs, we have found it useful to harvest the descending thoracic aorta from the donor and use that to help reconstruct the pulmonary artery with success rather than using Gore-Tex or Dacron.
Have you had patients with previous cardiac operations who have high levels of preformed antibodies requiring a preoperative cross-match who never came to transplantation because of an unacceptably high PRA level?
DR FULLERTON: Thank you for that suggestion. That is a great idea and we will try that.
We have 1 patient who has been on our list for more than a year now with a very high PRA level. We are fortunate in that we are relatively donor-rich in the Mountain West, so when donors are available there it is easy enough to get a cross-match. We routinely obtain cross-matches if the PRA level is more than 12% to 14%. No patients have died waiting because we were unable to obtain a cross-match. Although I really do not know the average wait for an organ in our series, as I recall, it is about what it is in other series. So I do not think that is holding us back.
DR CLIFFORD H. VAN METER (New Orleans, LA): With regard to humeral as opposed to cellular rejection, do you routinely do immunofluorescence on your endomyocardial biopsy specimens, and how do you treat those findings? Also, in your patients with elevated PRA levels, have you done prospective or prophylactic plasmapheresis?
DR FULLERTON: In our pediatric program we so rarely perform biopsies that I really cannot answer that question. In our adult population, whenever there is any question at all about the possibility of humeral rejection, biopsy specimens are sent to the University of Utah for those studies. But I really cannot address that in the pediatric patients.
DR VAN METER: Have you had the occasion to have patients with elevated PRA levels who on their prospective cross-match have a negative T cell but positive B cell cross-match and prophylactically plasmapherese them and perform transplantation in that setting?
DR FULLERTON: We have not, but we have not faced that situation either.
DR THOMAS L. SPRAY (St. Louis, MO): I congratulate you on an excellent series. I think your results support the concept of being very selective about which patients to give transplants. With such low pulmonary resistance, one would anticipate that the results would be good, but this series is certainly outstanding.
In our own series of more than 60 children we have had a very low incidence of refractory rejection. In fact, only 2 of almost 70 patients have had any kind of refractory rejection, and in 1 case the rejection was manifested by graft atherosclerosis in a child in whom a severe rejection episode developed after weaning from steroid therapy, which responded to increased immunosuppression. Your patients have a significant incidence of refractoryrejection requiring total lymphoid irradiation. Why don't you use steroids in these children?
DR FULLERTON: I think that is a very good question. In long-term follow-up the primary care of the patient falls under the direction of the transplant-cardiology team. They remain convinced that the complication rate is greater with chronic steroid use, and that is the reason that a strong effort is made to avoid chronic steroids. But I would agree that may contribute to the incidence of significant rejection.
DR D. GLENN PENNINGTON (St. Louis, MO): That was a great paper. However, I am a bit concerned that we might go away with the idea that coronary artery disease is not a problem in children. In a couple of surveys of cardiac transplantation in children we did several years ago, the incidence of coronary artery disease was about 8%; in a later survey by a different group it was about 8% also. My concern is that we may not be diagnosing it. In your series, of course, the patients are pretty young and it may take several years to show up. Do you have any studies such as intravascular ultrasound, for example, looking at coronary changes even though they have not become occlusive yet?
DR FULLERTON: Thank you for pointing that out. I certainly would like to understate rather than overstate the low incidence of coronary artery disease. What we have is a protocol calling for the use of intravascular ultrasound in all recipients who are more than 9 years of age. I do not know how many children have had that study in conjunction with their coronary arteriogram on an annual basis, but there has been a strong correlation between the angiographic findings and the ultrasound findings. Even with ultrasound, which, as you know, is much more sensitive than arteriography, we have recognized no abnormalities in the coronary circulation in these children.
Related Article
Ann. Thorac. Surg. 1995 59: 804-811.
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