Bio

Clinical Focus


  • Heart and Lung Transplantation
  • Cardiothoracic Surgery

Academic Appointments


Administrative Appointments


  • Associate Chair, Stanford University School of Medicine - Cardiothoracic Surgery (2003 - Present)

Professional Education


  • Residency:Stanford University School of Medicine (1976) CA
  • Residency:Stanford University School of Medicine (1974) CA
  • Internship:Stanford University School of Medicine (1971) CA
  • Medical Education:University of Chicago School of Medicine (1969) IL
  • Residency, Stanford University Hospital, General Surgery (1976)
  • Residency, Stanford University Hospital, Cardiovascular Surgery (1974)
  • PhD, University of Chicago, Biochemistry (1970)
  • MD, University of Chicago, Medicine (1969)

Research & Scholarship

Current Research and Scholarly Interests


Development of an artificial heart assist device; heart, and heart-lung transplantation.

Clinical Trials


  • Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure Recruiting

    The purpose of this study is to evaluate the safety and effectiveness of the HeartWare® LVAD System in patients listed for cardiac transplantation with refractory, advanced heart failure at risk of death. The primary endpoint is survival at 180 days which is defined as alive on the originally implanted HeartWare® LVAD or transplanted or explanted for recovery. Patient must survive 60 days post-explant for recovery to be considered successful. Secondary endpoints include: - Overall survival - Incidence of all serious adverse events, neurocognitive status and unanticipated adverse device effects. - Incidence of all device failures and device malfunctions - Quality of Life improvement, as measured by Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQoL EQ-5D - Functional status improvement, as measured by the New York Heart Association (NYHA) and 6-minute walk

    View full details

  • A Clinical Trial to Evaluate the HeartWare® Ventricular Assist System (ENDURANCE SUPPLEMENTAL TRIAL) Not Recruiting

    This is a prospective, randomized, controlled, unblinded, multi-center evaluation of the stroke incidence in patients implanted with a HeartWare® HVAD who receive optimal blood pressure management. The study compares results of stroke incidence in a new cohort of subjects receiving optimal blood pressure management to a reference stroke incidence observed in the original IDE clinical trial (HW004) that did not specify optimal blood pressure management. In addition, a secondary endpoint will evaluate non-inferiority of stroke-free success on the originally implanted device to a control group (i.e. any FDA-approved LVAD for destination therapy).

    Stanford is currently not accepting patients for this trial. For more information, please contact Ian Rogers, (650) 723-8138.

    View full details

Teaching

2013-14 Courses


Publications

Journal Articles


  • Combined Heart-Liver Transplantation in the MELD Era: Do Waitlisted Patients Require Exception Status? American journal of transplantation SCHAFFER, J. M., Chiu, P., Singh, S. K., Oyer, P. E., Reitz, B. A., Mallidi, H. R. 2014; 14 (3): 647-659

    Abstract

    Combined heart-liver transplant (HLT) is a viable therapy for patients with concomitant end-stage heart and liver failure. Using data from the United Network for Organ Sharing database, we examined the cumulative incidences of transplant and mortality in waitlisted candidates for HLT, isolated heart transplant (HRT) and isolated liver transplant (LIV) in the Model for End-Stage Liver Disease era. The incidence of waitlist mortality was higher in HLT candidates than in HRT candidates (p = 0.001, 26% vs. 12% at 1 year) or LIV candidates (p = 0.005, 26% vs. 14% at 1 year). These differences persisted after stratifying by disease severity. Posttransplant survival was not significantly different between HLT and HRT recipients or between HLT and LIV recipients. In a multivariable model, undergoing HLT was associated with enhanced survival for HLT candidates (hazard ratio, 0.41; confidence interval, 0.21-0.79; p = 0.008), but undergoing HRT alone was not. Interestingly, 90% of HLT recipients were allocated an organ locally, compared to 60% of HRT candidates and 73% of LIV candidates (both p < 0.001). These data suggest that the current cardiac and liver allocation systems may underestimate the risk of death for patients with concomitant end-stage heart and liver failure on the HLT waitlist.

    View details for DOI 10.1111/ajt.12595

    View details for PubMedID 24517245

  • Heart and combined heart-kidney transplantation in patients with concomitant renal insufficiency and end-stage heart failure. American journal of transplantation SCHAFFER, J. M., Chiu, P., Singh, S. K., Oyer, P. E., Reitz, B. A., Mallidi, H. R. 2014; 14 (2): 384-396

    Abstract

    In patients with end-stage heart failure (ESHF) who are candidates for isolated heart transplant (HRT), dialysis dependence (DD) is considered an indication for combined heart-kidney transplantation (HKT). HKT remains controversial in ESHF transplant candidates with nondialysis-dependent renal insufficiency (NDDRI). Using United Network for Organ Sharing data, we examined the cumulative incidences of transplant and mortality in patients with DD and NDDRI waitlisted for HKT or HRT. In all groups, 3-month waitlist mortality was dismal: 31% and 21% for HRT- and HKT-listed patients with DD and 12% and 7% for HRT- and HKT-listed patients with NDDRI. Five-year posttransplant survival was improved in HKT recipients compared with HRT recipients for both patients with DD (73% vs. 51%, p < 0.001) and NDDRI (80% vs. 69%, p < 0.001). Likewise, multivariable analysis associated HKT with better outcomes than HRT in HKT-listed patients, although both improved survival. These data argue strongly for HKT in ESHF transplant candidates with DD. However, in patients with NDDRI, HKT must be weighed against the possibility of renal recovery with isolated HRT. Whether HRT (followed by a staged kidney transplant in patients who do not recover renal function after HRT), as opposed to HKT, maximizes organ benefit for patients with NDDRI and ESHF requires assessment. Nevertheless, given their dismal waitlist outcomes and excellent posttransplant results, we suggest that patients with DD and NDDRI with ESHF be considered for early listing and transplant.

    View details for DOI 10.1111/ajt.12522

    View details for PubMedID 24279876

  • Heart transplant graft survival is improved after a reduction in panel reactive antibody activity. journal of thoracic and cardiovascular surgery Schaffer, J. M., Singh, S. K., Reitz, B. A., Oyer, P. E., Robbins, R. C., Mallidi, H. R. 2013; 145 (2): 555-564

    Abstract

    Allosensitization in potential orthotopic heart transplant recipients is evaluated with the panel reactive antibody assay. Sensitized patients have prolonged wait times and increased waitlist and post-transplant mortality. Although low panel reactive antibody activity at the time of orthotopic heart transplantation is associated with improved outcomes, literature regarding the survival benefit of a panel reactive antibody reduction in the sensitized orthotopic heart transplant recipient remains limited.Adult orthotopic heart transplant recipients listed in the United Network for Organ Sharing database (October 1, 1987, to June 29, 2004) were stratified by peak panel reactive antibody activity and whether a substantial decline from peak to most recent panel reactive antibody activity occurred before transplant. Propensity matching adjusted for differences in recipient and donor characteristics. Graft survival was assessed with Kaplan-Meier analysis. Cox proportional hazards regression determined predictors of graft survival.Pretransplant characteristics differed between sensitized patients who had a substantial decline in panel reactive antibody activity and those who did not. Propensity matching compensated for these differences. Kaplan-Meier survival analysis of matched groups showed that the median graft survival was 120 months in patients with a significant panel reactive antibody reduction and 103 months in patients with a trivial reduction (P = .007, log-rank). In Cox proportional hazards modeling, a significant reduction in panel reactive antibody activity had an independent protective effect on graft survival (hazard ratio, 0.88; confidence interval, 0.80-0.96; P = .006).Sensitized patients who had a substantial reduction in panel reactive antibody activity had an associated decline in the incidence of graft failure compared with those without a panel reactive antibody activity reduction. These results support efforts to reduce panel reactive antibody activity before orthotopic heart transplantation in patients with high panel reactive antibody activity.

    View details for DOI 10.1016/j.jtcvs.2012.10.025

    View details for PubMedID 23246047

  • Late profound muscle weakness following heart transplantation due to danon disease MUSCLE & NERVE van der Starre, P., Deuse, T., Pritts, C., Brun, C., Vogel, H., Oyer, P. 2013; 47 (1): 135-137

    Abstract

    Postoperative muscle weakness is a serious complication in surgical intensive care patients. It is mostly described as critical illness polyneuromyopathy. Risk factors include intensive care length of stay, sepsis, poor glycemic control, and combined use of corticosteroids and neuromuscular blocking agents, malnutrition, and electrolyte imbalance.We report a case of late-progressive, profound weakness after heart transplantation for noncompaction cardiomyopathy which required prolonged mechanical ventilation. The patient's muscle strength recovered completely after prolonged rehabilitation.Electromyographic assessment showed myopathy. Muscle biopsy revealed Danon disease, a genetic disorder affecting the lysosomal-associated membrane protein 2 gene (LAMP2).The finding of this genetic disorder was unexpected, because the preoperative echocardiographic diagnosis of noncompaction cardiomyopathy has not been reported in Danon disease. This report underlines the need for early availability of pathology results from the explanted heart, which showed the same disorder.

    View details for DOI 10.1002/mus.23517

    View details for Web of Science ID 000312657200022

    View details for PubMedID 23168931

  • Changing trends in infectious disease in heart transplantation JOURNAL OF HEART AND LUNG TRANSPLANTATION Haddad, F., Deuse, T., Pham, M., Khazanie, P., Rosso, F., Luikart, H., Valantine, H., Leon, S., Vu, T. A., Hunt, S. A., Oyer, P., Montoya, J. G. 2010; 29 (3): 306-315

    Abstract

    During the past 25 years, advances in immunosuppression and the use of selective anti-microbial prophylaxis have progressively reduced the risk of infection after heart transplantation. This study presents a historical perspective of the changing trends of infectious disease after heart transplantation.Infectious complications in 4 representative eras of immunosuppression and anti-microbial prophylaxis were analyzed: (1) 38 in the pre-cyclosporine era (1978-1980), (2) 72 in the early cyclosporine era (1982-1984), where maintenance immunosuppression included high-dose cyclosporine and corticosteroid therapy; (3) 395 in the cyclosporine era (1988-1997), where maintenance immunosuppression included cyclosporine, azathioprine, and lower corticosteroid doses; and (4) 167 in the more recent era (2002-2005), where maintenance immunosuppression included cyclosporine and mycophenolate mofetil.The overall incidence of infections decreased in the 4 cohorts from 3.35 episodes/patient to 2.03, 1.35, and 0.60 in the more recent cohorts (p < 0.001). Gram-positive bacteria are emerging as the predominant cause of bacterial infections (28.6%, 31.4%, 51.0%, 67.6%, p = 0.001). Cytomegalovirus infections have significantly decreased in incidence and occur later after transplantation (88 +/- 77 days, pre-cyclosporine era; 304 +/- 238 days, recent cohort; p < 0.001). Fungal infections also decreased, from an incidence of 0.29/patient in the pre-cyclosporine era to 0.08 in the most recent era. A major decrease in Pneumocystis jiroveci and Nocardia infections has also occurred.The overall incidence and mortality associated with infections continues to decrease in heart transplantation and coincides with advances in immunosuppression, the use of selective anti-microbial prophylaxis, and more effective treatment regimens.

    View details for DOI 10.1016/j.healun.2009.08.018

    View details for Web of Science ID 000276005200013

    View details for PubMedID 19853478

  • Ventricular Assist Devices: History, Patient Selection, and Timing of Therapy JOURNAL OF CARDIOVASCULAR TRANSLATIONAL RESEARCH Tang, D. G., Oyer, P. E., Mallidi, H. R. 2009; 2 (2): 159-167

    Abstract

    Timing of therapy and selection of patients in the use of ventricular assist devices (VADs) can be difficult. In general, consideration for VAD implantation is appropriate in patients with endstage heart failure who are failing optimal medical therapy and in whom no alternative traditional surgical treatment options are available. However, identifying when a particular patient has reached this point is not always straightforward. There are a broad range of medical and surgical therapies for patients with overt heart failure, and this armamentarium is constantly expanding. The risks, benefits, and expected outcomes with VAD therapy have also undergone dramatic changes over the last decade. Advances in technology have led to a proliferation of newer generation devices that are smaller, lighter, easier to implant, and more reliable than previous generation devices. This, in turn, has led to a markedly improved risk-benefit ratio, with increased durability and reduced morbidity. The indications for the implantation of ventricular assist devices have also evolved over the last several years, and specific patient presentations and goals of therapy have led to specific indications. Device therapy has traditionally been classified as bridge to recovery, bridge to transplantation, and destination therapy. However, such designations may not be well defined at the time of implantation, and recovery and response following initiation of VAD support may allow patients to change from one classification to another. The current data regarding indications and timing of device implantation are reviewed.

    View details for DOI 10.1007/s12265-009-9098-5

    View details for Web of Science ID 000284690100005

    View details for PubMedID 20559983

  • Trends in invasive disease due to Candida species following heart and lung transplantation TRANSPLANT INFECTIOUS DISEASE Schaenman, J. M., Rosso, F., Austin, J. M., Baron, E. J., Gamberg, P., Miller, J., Oyer, P. E., Robbins, R. C., Montoya, J. G. 2009; 11 (2): 112-121

    Abstract

    Although invasive candidiasis (IC) causes significant morbidity and mortality in patients who undergo heart, lung, or heart-lung transplantation, a systematic study in a large cohort of thoracic organ transplant recipients has not been reported to date. Clinical and microbiological data were reviewed for 1305 patients who underwent thoracic organ transplantation at Stanford University Medical Center between 1980 and 2004. We identified and analyzed 76 episodes of IC in 68 patients (overall incidence 5.2% per patient).The incidence of IC was higher in lung (LTx) and heart-lung transplant (HLTx) recipients as compared with heart transplant (HTx) recipients (risk ratio [RR] 1.7, 95% confidence interval [CI] 1.1-2.7).The incidence of IC decreased over time in all thoracic organ transplant recipients, decreasing from 6.1% in the 1980-1986 time period to 2.1% in the 2001-2004 era in the HTx recipients, and from 20% in the 1980-1986 period to 1.8% in the 2001-2004 period in the LTx and HLTx recipients.The most common site of infection differed between the HTx and LTx cohorts, with bloodstream or disseminated disease in the former and tracheobronchitis in the latter. IC in the first year after transplant was significantly associated with death in both HTx (RR 2.9, 95% CI 1.8-4.6, P=0.001) and LTx and HLTx patients (RR 3.0, 95% CI 1.9-4.6, P<0.001). The attributable mortality from IC decreased during the 25-year period of observation, from 36% to 20% in the HTx recipients and from 39% to 15% in the LTx and HLTx recipients. There were a significant number of cases caused by non-albicans Candida species in all patients, with a trend toward higher mortality in the HTx group. In conclusion, the incidence and attributable mortality of IC in thoracic organ transplant recipients has significantly declined over the past 25 years.The use of newer antifungal agents for prophylaxis and treatment, the decrease in the incidence of cytomegalovirus disease, and the use of more selective immunosuppression, among other factors, may have been responsible for this change.

    View details for DOI 10.1111/j.1399-3062.2009.00364.x

    View details for Web of Science ID 000265015600004

    View details for PubMedID 19254327

  • Twenty-year survivors of heart transplantation at Stanford University AMERICAN JOURNAL OF TRANSPLANTATION Deuse, T., Haddad, F., Pham, M., Hunt, S., Valantine, H., BATES, M. J., Mallidi, H. R., Oyer, P. E., Robbins, R. C., Reitz, B. A. 2008; 8 (9): 1769-1774

    Abstract

    Human heart transplantation started 40 years ago. Medical records of all cardiac transplants performed at Stanford were reviewed. A total of 1446 heart transplantations have been performed between January 1968 and December 2007 with an increase of 1-year survival from 43.1% to 90.2%. Sixty patients who were transplanted between 1968 and 1987 were identified who survived at least 20 years. Twenty-year survivors had a mean age at transplant of 29.4 +/- 13.6 years. Rejection-free and infection-free 1-year survivals were 14.3% and 18.8%, respectively. At their last follow-up, 86.7% of long-term survivors were treated for hypertension, 28.3% showed chronic renal dysfunction, 6.7% required hemodialysis, 10% were status postkidney transplantation, 13.3% were treated for diabetes mellitus, 36.7% had a history of malignancy and 43.3% had evidence of allograft vasculopathy. The half-life conditional on survival to 20 years was 28.1 years. Eleven patients received a second heart transplant after 11.9 +/- 8.0 years. The most common causes of death were allograft vasculopathy (56.3%) and nonlymphoid malignancy (25.0%). Twenty-year survival was achieved in 12.5% of patients transplanted before 1988. Although still associated with considerable morbidity, long-term survival is expected to occur at much higher rates in the future due to major advances in the field over the past decade.

    View details for DOI 10.1111/j.1600-6143.2008.02310.x

    View details for Web of Science ID 000258401700004

    View details for PubMedID 18557718

  • Wound healing complications with de novo sirolimus versus mycophenolate mofetil-based regimen in cardiac transplant recipients AMERICAN JOURNAL OF TRANSPLANTATION Kuppahally, S., Al-Khaldi, A., Weisshaar, D., Valantine, H. A., Oyer, P., Robbins, R. C., Hunt, S. A. 2006; 6 (5): 986-992

    Abstract

    Sirolimus was introduced in de novo immunosuppression at Stanford University in view of its favorable effects on reduced rejection and cardiac allograft vasculopathy. After an apparent increase in the incidence of post-surgical wound complications as well as symptomatic pleural and pericardial effusions, we reverted to a mycophenolate mofetil (MMF)-based regimen. This retrospective study compared the outcome in heart transplant recipients on sirolimus (48 patients) with those on MMF (46 patients) in de novo immunosuppressive regimen. The incidence of any post-surgical wound complication (52% vs. 28%, p=0.019) and deep surgical wound complication (35% vs. 13%, p=0.012) was significantly higher in patients on sirolimus than on MMF. More patients on sirolimus also had symptomatic pleural (p=0.035) and large pericardial effusions (p=0.033) requiring intervention. Logistic regression analysis showed sirolimus (p=0.027) and longer cardiac bypass time (OR=1.011; p=0.048) as risk factors for any wound complication. Sirolimus in de novo immunosuppression after cardiac transplantation was associated with a significant increase in the incidence of post-surgical wound healing complications as well as symptomatic pleural and pericardial effusions.

    View details for DOI 10.1111/j.1600-6143.2006.01282.x

    View details for Web of Science ID 000236860700015

    View details for PubMedID 16611334

  • Outcome analysis of donor gender in heart transplantation JOURNAL OF HEART AND LUNG TRANSPLANTATION Al-Khaldi, A., Oyer, P. E., Robbins, R. C. 2006; 25 (4): 461-468

    Abstract

    Several studies have shown a detrimental effect of female donor gender on the survival of solid-organ transplant recipients, including heart, kidney and liver. We evaluated our own experience in heart transplantation in the cyclosporine era, since 1980, to determine the effect of donor gender on survival.We retrospectively reviewed 869 consecutive patients who underwent primary heart transplantation at Stanford University Medical Center between December 1980 and March 2004. Actuarial life-table data were calculated for survival and freedom from rejection and compared between groups. Multivariate Cox proportional hazard analysis was used to identify predictors of reduced long-term survival.One-year mortality in male recipients who received a female donor heart (24%) was higher than in male recipients who received male donor heart (13%) (p = 0.009). Actuarial survival rates for male recipients at 1, 5 and 10 years were 86%, 69% and 50% (with male donor), and 76%, 59% and 45% (with female donor) (p = 0.01), respectively. Donor gender had no effect on long-term survival in male recipients < 45 years of age and female recipients. Female donor gender was identified as an independent risk factor for death by multivariate analysis, with an odds ratio of 2.3 (95% confidence interval 1.5 to 3.4, p < 0.001).In heart transplantation the detrimental effect of female donor gender on recipient survival is significant but limited to male recipients > 45 years of age. These findings should be considered in the process of donor-recipient matching.

    View details for DOI 10.1016/j.healun.2005.11.456

    View details for Web of Science ID 000236484600016

    View details for PubMedID 16563978

  • Induction therapy for pediatric and adult heart transplantation: Comparison between OKT3 and daclizumab TRANSPLANTATION Chin, C., Pittson, S., Luikart, H., Bernstein, D., Robbins, R., Reitz, B., Oyer, P., Valantine, H. 2005; 80 (4): 477-481

    Abstract

    Induction therapy can reduce morbidity and early mortality in pediatric and adult heart transplant recipients. Monoclonal and polyclonal agents are most widely used; they nonspecifically deplete the T-cell pool and are thus associated with drug-induced side effects. The cytokine release syndrome is one of the most problematic events associated with induction. Daclizumab, a highly humanized, specific interleukin-2 receptor blocker, may be efficacious to the monoclonal agent, OKT3. Due to its specific action and properties, the safety profile of this agent may be superior to OKT3.Forty subjects received daclizumab and their clinical outcomes were compared against a historical group of 40 subjects who received OKT3. Three- and six-month outcome measures included survival, rejection history, steroid burden, and complications.Mortality was low between the groups with equivalent 6-month survival. No differences in rejection profile or time to the first significant rejection event were detected; no subject had severe acute rejection within the first 180 days. Steroid requirement for maintenance immunosuppression and treatment of rejection was also similar between the groups. Six-month prevalence for complications were significantly different; 55% of OKT3-treated subjects having at least one event compared to 33% of daclizumab-treated subjects (P=0.04). The likelihood of complications occurred within the first month after transplantation.Daclizumab induction therapy is as efficacious as OKT3 in the prevention of early acute rejection after heart transplantation among pediatric and adult subjects. Complications related to the induction agent are significantly lower in the humanized product.

    View details for DOI 10.1097/01.tp.0000168153.50774.30

    View details for Web of Science ID 000231566800008

    View details for PubMedID 16123721

  • Acute type A aortic dissection complicated by aortic regurgitation: Composite valve graft versus separate valve graft versus conservative valve repair JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Lai, D. T., Miller, D. C., Mitchell, R. S., Oyer, P. E., Moore, K. A., Robbins, R. C., Shumway, N. E., Reitz, B. A. 2003; 126 (6): 1978-1986

    Abstract

    To clarify the merits of various surgical approaches, we studied the outcome after composite valve graft versus separate valve and graft replacement versus conservative valve treatment with replacement of the ascending aorta in patients with acute type A aortic dissection complicated by aortic regurgitation.Between 1967 and 1999, 123 patients (mean age 56 +/- 15 years) underwent composite valve graft replacement (n = 21), separate valve and graft replacement (n = 20), or conservative valve treatment (n = 82 [commissural resuspension in 46]); follow-up averaged 6.5 years (95% complete).The 30-day, 1-year, and 6-year survival estimates of 85% +/- 4%, 79% +/- 5%, and 69% +/- 5% (+/-1 standard error of mean), respectively, after conservative valve treatment were similar to 86% +/- 8%, 81% +/- 9%, and 65% +/- 16%, respectively, with composite valve graft replacement and better (but insignificantly so) than 70% +/- 10%, 70% +/- 10%, and 45% +/- 11%, respectively, with separate valve and graft replacement. The 6-year freedom from proximal reoperation was 95% +/- 3%, 89% +/- 10%, and 100% in conservative valve graft, separate valve and graft, and composite valve graft subgroups, respectively (P = not significant). Cox regression multivariable analysis identified that previous sternotomy (hazard ratio [or e(beta)] 95% confidence interval 1.4-10.9, P =.006), hypertension (0.99-2.9, P =.05), cardiac tamponade (1.1-4.0, P =.03), and stroke (1.7-7.0, P =.001) increased the hazard of death. No factors predicting a higher likelihood of late proximal reoperation were identified.In patients with acute type A aortic dissection and aortic regurgitation, there was no significant difference in overall survival or reoperation rates among these surgical approaches. We try to save the valve whenever possible unless the aortic root is pathologically dilated (eg, Marfan syndrome or annuloaortic ectasia) or destroyed by the dissection process, when composite valve graft or valve-sparing aortic root replacement is indicated.

    View details for DOI 10.1016/S0022-5223(03)01279-0

    View details for Web of Science ID 000187560400047

    View details for PubMedID 14688716

  • The impact of brain death on survival after heart transplantation: Time is of the essence TRANSPLANTATION Cantin, B., Kwok, B. W., Chan, M. C., Valantine, H. A., Oyer, P. E., Robbins, R. C., Hunt, S. A. 2003; 76 (9): 1275-1279

    Abstract

    It has been suggested that the modality of brain death and time from brain death until harvest impact survival and rejection after heart transplantation.Donor files from 475 adult heart-transplant recipients were examined. From these files, a total management time (time from incident leading to brain death until aortic cross clamp) was determined, and the cause of brain death was noted. Recipient characteristics, details of postoperative course, as well as survival were obtained from the Stanford University Medical Center Heart Transplantation Database.Two hundred and thirty (48.4%) donors sustained traumatic injuries, 112 (23.6%) suffered a subarachnoid hemorrhage, and 102 (21.4%) died of a gunshot wound to the head. The modality of brain death did not influence medium and long-term survival. A management time longer than 72 hours was associated with poorer outcome of the heart-transplant recipients. There were significantly more treated rejection episodes in recipients whose donor sustained traumatic injuries.Modality of brain death does not impact survival but appears to influence rejection. Increased management time is associated with adverse survival trends in heart-transplant recipients.

    View details for DOI 10.1097/01.TP.0000093445.50624.5A

    View details for Web of Science ID 000186653100001

    View details for PubMedID 14627902

  • Long-term results of heart transplantation in patients older than 60 years JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Demers, P., Moffatt, S., Oyer, P. E., Hunt, S. A., Reitz, B. A., Robbins, R. C. 2003; 126 (1): 224-231

    Abstract

    Advanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years.Between 1986 and 2001, 81 patients aged between 60 and 70 years (mean, 63 +/- 2 years) underwent heart transplantation. These patients were compared with 403 adult recipients younger than 60 years (mean, 47 +/- 11 years) who underwent transplantation during the same period.Thirty-day mortality was 6% (5/81) and 6% (25/403) in the older and younger patients, respectively (P = NS). Actuarial survival at 1, 5, and 10 years was 88% +/- 4% versus 83% +/- 2%, 75% +/- 5% versus 69% +/- 2%, and 50% +/- 9% versus 51% +/- 3% in the older and younger patients, respectively (P = NS). Older patients had significantly fewer rejection episodes (P =.003). Freedom from allograft coronary artery disease at 1, 5, and 10 years was 98% +/- 2% versus 92% +/- 2%, 85% +/- 6% versus 76% +/- 3%, and 81% +/- 7% versus 68% +/- 3% (P =.1). The incidences of infectious complication, cytomegalovirus infection, and posttransplant lymphoproliferative disorder were similar between the 2 groups, but older recipients were more likely to have a nonposttransplant lymphoproliferative disorder cancer (P =.002). Age at transplantation was not identified as an independent risk factor for early and late death.Heart transplantation in selected patients aged 60 years and older results in survival comparable with that of younger patients. Older patients have a lower risk of rejection but an increased risk of development of a nonposttransplant lymphoproliferative disorder cancer. Advanced age per se should not be considered as an exclusion criterion for transplantation.

    View details for DOI 10.1016/S0022-5223(03)00055-2

    View details for Web of Science ID 000184365400028

    View details for PubMedID 12878959

  • Post-transplantation lymphoproliferative disease in heart and heart-lung transplant recipients: 30-year experience at Stanford University JOURNAL OF HEART AND LUNG TRANSPLANTATION Gao, S. Z., Chaparro, S. V., Perlroth, M., Montoya, J. G., Miller, J. L., DiMiceli, S., Hastie, T., Oyer, P. E., Schroeder, J. 2003; 22 (5): 505-514

    Abstract

    Post-transplantation lymphoproliferative disease (PTLD) is an important source of morbidity and mortality in transplant recipients, with a reported incidence of 0.8% to 20%. Risk factors are thought to include immunosuppressive agents and viral infection. This study attempts to evaluate the impact of different immunosuppressive regimens, ganciclovir prophylaxis and other potential risk factors in the development of PTLD.We reviewed the records of 1026 (874 heart, 152 heart-lung) patients who underwent transplantation at Stanford between 1968 and 1997. Of these, 57 heart and 8 heart-lung recipients developed PTLD. During this interval, 4 different immunosuppressive regimens were utilized sequentially. In January 1987, ganciclovir prophylaxis for cytomegalovirus serologic-positive patients was introduced. Other potential risk factors evaluated included age, gender, prior cardiac diagnoses, HLA match, rejection frequency and calcium-channel blockade.No correlation of development of PTLD was found with different immunosuppression regimens consisting of azathioprine, prednisone, cyclosporine, OKT3 induction, tacrolimus and mycophenolate mofetil. A trend suggesting an influence of ganciclovir on the prevention of PTLD was not statistically significant (p = 0.12). Recipient age and rejection frequency, as well as high-dose cyclosporine immunosuppression, were significantly (p < 0.02) associated with PTLD development. The prevalence of PTLD at 13.3 years was 15%.The overall incidence of PTLD was 6.3%. It was not altered by sequential modifications in treatment regimens. Younger recipient age and higher rejection frequency were associated with increased PTLD occurrence. The 15% prevalence of PTLD in 58 long-term survivors was unexpectedly high.

    View details for DOI 10.1016/S1053-2498(02)01229-9

    View details for Web of Science ID 000182805100002

    View details for PubMedID 12742411

  • Coronary atherosclerosis in cardiac transplant patients treated with total lymphoid irradiation JOURNAL OF HEART AND LUNG TRANSPLANTATION Pelletier, M. P., Coady, M. A., Macha, M., Oyer, P. E., Robbins, R. C. 2003; 22 (2): 124-129

    Abstract

    Multiple episodes of rejection following cardiac transplantation have been associated with an increased incidence of coronary atherosclerosis. Total lymphoid irradiation (TLI) has been shown to be a successful treatment for persistent allograft rejection, but its effect on coronary arterial disease has yet to be evaluated.From 1987 to 1999, 40 patients required TLI for persistent or recurrent allograft rejection following heart transplantation. Each patient's (Group 1, n = 31) post-transplant coronary angiograms were examined and compared with those of a control group (Group 2, (n = 32) matched for time of transplantation. Degree of coronary stenosis was assessed on a 6-point scale. All patients received induction therapy (rabbit anti-thymocyte globulin or OKT3) and standard triple immunosuppressive therapy. TLI (80 cGy x 10 fractions) was used for the treatment of recurrent or persistent rejection on the basis of clinical indications. Actuarial survival, number and treatment of rejection episodes, and severity of coronary artery disease were compared in each group.Recipient gender, age, race and cytomegalovirus (CMV) status at time of transplant, along with donor gender, CMV status and graft ischemia time, were similar in both groups. Group 1 donor age was younger than that of Group 2 (22.2 +/- 11.2 vs 31.5 +/- 13.6 years, p = 0.004), and the indication for surgery in Group 1 patients was more likely to be ischemic heart disease (15 of 31 vs 6 of 32, p = 0.02). Mean follow-up was 5.7 +/- 3.5 years in Group 1 vs 6.9 +/- 3.8 in Group 2 (p = NS). Group 1 had more rejection episodes (4.4 +/- 2.2 vs 2.3 +/- 2.0, p = 0.0002) and more steroid treatments (9.78 +/- 4.0 g vs 5.14 +/- 4.7 g, p < 0.0001), but less coronary artery disease compared with Group 2 (p = 0.035).Despite multiple episodes of rejection, patients treated with TLI after cardiac transplant appear to develop less coronary atherosclerosis than appropriately matched controls.

    View details for Web of Science ID 000180886300003

    View details for PubMedID 12581759

  • Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections? JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Umana, J. P., Lai, D. T., Mitchell, R. S., Moore, K. A., Rodriguez, F., Robbins, R. C., Oyer, P. E., Dake, M. D., Shumway, N. E., Reitz, B. A., Miller, D. C. 2002; 124 (5): 896-910

    Abstract

    The optimal treatment of patients with acute type B dissections continues to be debated.A 36-year clinical experience of medical and surgical treatments in 189 patients was retrospectively analyzed (multivariable Cox proportional hazards model) with respect to three outcome end points: all deaths, freedom from reoperation, and freedom from late aortic complications or death. Propensity score analysis identified 2 quintiles (quintiles I and II, consisting of 142 comparable patients) for further comparison of the effects of surgical versus medical treatment.Shock (hazard ratio 14.5, 95% confidence interval 4.7-44.5, P <.001) and visceral ischemia (hazard ratio 10.9, 95% confidence interval 3.9-30.3, P <.001) largely predominated as determinants of death, along with 6 other risk factors (arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease), which roughly doubled the hazard of death. Female sex was a significant but weaker predictor of death. Renal dysfunction, year of presentation, age, and mode of therapy (medical vs surgical) had no important bearing on overall survival. The actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. Reoperation and late aortic complications were predicted by the presence of Marfan syndrome. For the propensity-matched patients in quintiles I and II, survival, freedom from reoperation, and freedom from aortic complications were almost identical in the medically treated and surgical subsets.The prognosis for patients with acute type B aortic dissection is bleak and determined primarily by dissection-related and patient-specific risk factors, which do not appear to be readily modifiable.

    View details for DOI 10.1067/mtc.2002.123131

    View details for Web of Science ID 000179012300006

    View details for PubMedID 12407372

  • Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? CIRCULATION Lai, D. T., Robbins, R. C., Mitchell, R. S., Moore, K. A., Oyer, P. E., Shumway, N. E., Reitz, B. A., Miller, D. C. 2002; 106 (13): I218-I228
  • Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? Circulation Lai, D. T., Robbins, R. C., Mitchell, R. S., Moore, K. A., Oyer, P. E., Shumway, N. E., Reitz, B. A., Miller, D. C. 2002; 106 (12): I218-28

    Abstract

    No evidence exists that profound hypothermic circulatory arrest (PHCA) improves survival or reduces the likelihood of distal aortic reoperation in patients with acute type A aortic dissection.Records of 307 patients with acute type A aortic dissection from 1967 to 1999 were retrospectively reviewed. The influence of repair using PHCA (n=121) versus without PHCA (n=186) on death and freedom from distal aortic reoperation was analyzed using multivariable Cox regression models. Propensity score analysis identified a subset of 152 comparable patients in 3 quintiles (QIII-V) in which the effects of PHCA (n=113) versus no PHCA (n=39) were further compared.For all patients, 30-day, 1-year, and 5-year survival estimates were 81+/-2%, 74+/-3%, and 63+/-3% (+/-1 SE). Survival rates and actual freedom from distal aortic reoperation was not significantly different between treatment methods in the entire patient cohort nor in the matched patients in quintiles III-V. Treatment method was not associated with differences in early major complications, late survival, or distal aortic reoperation rates in the entire patient sample or in quintiles III-V.Aortic repair with or without circulatory arrest was associated with comparable early complications, survival, and distal aortic reoperation rates in patients with acute type A aortic dissection. Despite the lack of concrete evidence favoring the use of PHCA, it does no harm, and most of our group uses PHCA regularly because of its practical technical advantages and theoretical potential merit.

    View details for PubMedID 12354737

  • Impact of cytomegalovirus hyperimmune globulin on outcome after cardiothoracic transplantation - A comparative study of combined prophylaxis with CMV hyperimmune globulin plus ganciclovir versus ganciclovir alone TRANSPLANTATION Valantine, H. A., Luikart, H., Doyle, R., Theodore, J., Hunt, S., Oyer, P., Robbins, R., Berry, G., Reitz, B. 2001; 72 (10): 1647-1652

    Abstract

    Cytomegalovirus (CMV) disease was previously shown to be unaltered by a 28-day course of ganciclovir compared with placebo in seronegative recipients of hearts from seropositive donors (D+/R-). This study tests the hypothesis that a combination of ganciclovir plus CMV hyperimmune globulin (CMVIG) is more effective than ganciclovir alone for preventing acute CMV illness and its long-term sequelae.The study population receiving CMVIG (n=80) included 27 heart transplant recipients (D+/R-) and 53 heart-lung and lung transplant recipients (R+ and/or D+). Each group was matched with historical controls who underwent transplantation within the preceding 2-3 years. Outcome measures compared were as follows: 3-year incidence of CMV disease; fungal infection; acute rejection; survival; rates and severity of transplant coronary artery disease (in heart patients) defined by intimal thickness (ultrasound) and coronary artery stenosis (angiographic); and incidence and death from obliterative bronchiolitis defined by pathological criteria on endobronchial biopsy specimens (in heart-lung/lung patients).Patients treated with CMVIG had a higher disease-free incidence of CMV, lower rejection incidence, and higher survival rate compared with the patients treated with ganciclovir alone. The coronary artery intimal thickness and the prevalence of intimal thickening were lower in the patients receiving CMVIG. Heart-lung and lung transplant patients treated with CMVIG had lower incidences of obliterative bronchiolitis and death from obliterative bronchiolitis and longer survival compared with the patients treated with ganciclovir alone.CMVIG plus ganciclovir seems to be more effective that ganciclovir alone for preventing the sequelae of CMV infection. A prospective randomized study is required to confirm these observations.

    View details for Web of Science ID 000172614200012

    View details for PubMedID 11726825

  • Treatment of endocarditis with valve replacement: The question of tissue versus mechanical prosthesis ANNALS OF THORACIC SURGERY Moon, M. R., Miller, D. C., Moore, K. A., Oyer, P. E., Mitchell, R. S., Robbins, R. C., Stinson, E. B., Shumway, N. E., Reitz, B. A. 2001; 71 (4): 1164-1171

    Abstract

    It remains unknown whether there is any important clinical advantage to the use of either a bioprosthetic or mechanical valve for patients with native or prosthetic valve endocarditis.Between 1964 and 1995, 306 patients underwent valve replacement for left-sided native (209 patients) or prosthetic (97 patients) valve endocarditis. Mechanical valves were implanted in 65 patients, bioprostheses in 221 patients, and homografts in 20 patients.Operative mortality was 18+/-2% and was independent of replacement valve type (p > 0.74). Long-term survival was superior for patients with native valve endocarditis (44+/-5% at 20 years) compared with those with prosthetic valve endocarditis (16+/-7% at 20 years) (p < 0.003). Survival was independent of valve type (p > 0.27). The long-term freedom from reoperation for patients who received a biologic valve who were younger than 60 years of age was low (51+/-5% at 10 years, 19+/-6% at 15 years). For patients older than 60 years, however, freedom from reoperation with a biological valve (84+/-7% at 15 years) was similar to that for all patients with mechanical valves (74+/-9% at 15 years) (p > 0.64).Mechanical valves are most suitable for younger patients with native valve endocarditis; however, tissue valves are acceptable for patients greater than 60 years of age with native or prosthetic valve infections and for selected younger patients with prosthetic valve infections because of their limited life expectancy.

    View details for Web of Science ID 000168590600017

    View details for PubMedID 11308154

  • Posttransplantation lymphoproliferative disease in heart and heart-lung transplant recipients: thirty years experience at our hospital. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Chaparro, S., Gao, S., Perlroth, M., Montoya, J., Hastie, T., Miller, J. L., Oyer, P. E., Schroeder, J. 2001; 20 (2): 258

    View details for PubMedID 11250519

  • The Novacor left ventricular assist system: Clinical experience from the Novacor registry JOURNAL OF CARDIAC SURGERY Dagenais, F., Portner, P. M., Robbins, R. C., Oyer, P. E. 2001; 16 (4): 267-271

    Abstract

    The electrically powered Novacor left ventricular assist (LVAS) system was first used clinically as a bridge to transplant in 1984. The configuration has evolved to the current wearable model used clinically for the first time in 1993. In 1998, the inflow conduit was modified, reducing embolic events by 50%. Over 1100 implants have been performed worldwide with cumulative support greater than 300 patient years, and only 0.7% requiring replacement. The Novacor is a safe and effective device for bridge to transplant, bridge to recovery, or potentially permanent implant with reliable long-term support for periods as long as 4 years.

    View details for Web of Science ID 000186228500001

    View details for PubMedID 11833699

  • Coronary atherosclerosis in cardiac transplant patients treated with total lymphoid irradiation. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Pelletier, M. P., Coady, M., Macha, M., Oyer, P. E., Robbins, R. C. 2001; 20 (2): 152

    View details for PubMedID 11250214

  • Impact of prophylactic immediate posttransplant ganciclovir on development of transplant atherosclerosis - A post hoc analysis of a randomized, placebo-controlled study CIRCULATION Valantine, H. A., Gao, S. Z., Menon, S. G., Renlund, D. G., Hunt, S. A., Oyer, P., Stinson, E. B., Brown, B. W., Merigan, T. C., Schroeder, J. S. 1999; 100 (1): 61-66

    Abstract

    Coronary artery disease occurs in an accelerated fashion in the donor heart after heart transplantation (TxCAD), but the cause is poorly understood. The risk of developing TxCAD is increased by cytomegalovirus (CMV) infection and decreased by use of calcium blockers. Our group observed that prophylactic administration of ganciclovir early after heart transplantation inhibited CMV illness, and we now propose to determine whether this therapy also prevents TxCAD.One hundred forty-nine consecutive patients (131 men and 18 women aged 48+/-13 years) were randomized to receive either ganciclovir or placebo during the initial 28 days after heart transplantation. Immunosuppression consisted of muromonab-CD3 (OKT-3) prophylaxis and maintenance with cyclosporine, prednisone, and azathioprine. Mean follow-up time was 4.7+/-1.3 years. In a post hoc analysis of this trial designed to assess efficacy of ganciclovir for prevention of CMV disease, we compared the actuarial incidence of TxCAD, defined by annual angiography as the presence of any stenosis. Because calcium blockers have been shown to prevent TxCAD, we analyzed the results by stratifying patients according to use of calcium blockers. TxCAD could not be evaluated in 28 patients because of early death or limited follow-up. Among the evaluable patients, actuarial incidence of TxCAD at follow-up (mean, 4.7 years) in ganciclovir-treated patients (n=62) compared with placebo (n=59) was 43+/-8% versus 60+/-10% (P<0.1). By Cox multivariate analysis, independent predictors of TxCAD were donor age >40 years (relative risk, 2.7; CI, 1.3 to 5.5; P<0.01) and no ganciclovir (relative risk, 2.1; CI, 1.1 to 5.3; P=0.04). Stratification on the basis of calcium blocker use revealed differences in TxCAD incidence when ganciclovir and placebo were compared: no calcium blockers (n=53), 32+/-11% (n=28) for ganciclovir versus 62+/-16% (n=25) for placebo (P<0.03); calcium blockers (n=68), 50+/-14% (n=33) for ganciclovir versus 45+/-12% (n=35) for placebo (P=NS).TxCAD incidence appears to be lower in patients treated with ganciclovir who are not treated with calcium blockers. Given the limitations imposed by post hoc analysis, a randomized clinical trial is required to address this issue.

    View details for Web of Science ID 000081279300013

    View details for PubMedID 10393682

  • Composite valve graft versus separate aortic valve and ascending aortic replacement: is there still a role for the separate procedure? Circulation Yun, K. L., Miller, D. C., Fann, J. I., Mitchell, R. S., Robbins, R. C., Moore, K. A., Oyer, P. E., Stinson, E. B., Shumway, N. E., Reitz, B. A. 1997; 96 (9): II-368 75

    Abstract

    To ascertain if operative technique has any bearing on outcome, the surgical results after aortic root replacement using either a composite valve graft (CVG) or a separate graft and valve (GV) were analyzed.Three hundred and ninety consecutive, nonrandomized patients treated for aortic valve disease and ascending aortic aneurysm (n=278) or type A dissection (n=112 [45 acute]) between 1965 and 1995 were analyzed retrospectively. One hundred and thirty-five patients received a CVG, and 255 had separate GV replacement. Mean age was 52+/-16 years (+/-1 SD). Eighty-two patients (44% of the CVG group) had the Marfan syndrome (MFS). Follow-up (96% complete) totaled 2247 patient-years and extended to 27 years. The operative mortality rate was 10+/-3% (+/-70% confidence limits) for patients receiving a CVG and 15+/-2% for GV replacement (P=NS). The 15-year actuarial survival estimate was higher for the CVG group (53+/-14% [+/-SEM] versus 36+/-4%, P=.037). Seven patients in the CVG group required reoperation on the aortic valve or ascending aorta, as did 49 in the GV group. The probabilities of freedom from reoperation on the aortic rootwere 82+/-9% and 75+/-4% at 10 years for the CVG and GV group (P=NS). Thirty variables were analyzed in a multivariate model: pulmonary disease, higher New York Heart Association functional class, and longer cardiopulmonary bypass time were linked with higher operative mortality risk; older age, emergency operation, coronary artery disease, and liver dysfunction were independent determinants of late death. Younger age and use of a bioprosthesis were predictors of late reoperation. Type of procedure (GV versus CVG) was not a significant predictor of any outcome variable.The long-term results after CVG or GV were similar, which reflects proper patient selection. Use of a composite valve graft theoretically confers more protection against recurrent aortic root aneurysm, and, unless one opts for a valve-sparing aortic root replacement procedure, is most appropriate for younger patients, those with the MFS (including acute dissections), and others with marked pathological involvement of the sinuses. On the other hand, use of a separate GV should not be abandoned; in carefully selected patients (and if properly performed, eg, excision of the sinuses), GV also provides satisfactory results.

    View details for PubMedID 9386126

  • Heart-lung transplantation: Cardiac clinicopathological correlations CARDIOVASCULAR PATHOLOGY Joshi, A., Oyer, P. E., Berry, G. J., Billingham, M. E. 1996; 5 (3): 153-158
  • Analysis of deaths in patients awaiting heart transplantation: Impact on patient selection criteria HEART Haywood, G. A., Rickenbacher, P. R., Trindade, P. T., Gullestad, L., Jiang, J. P., Schroeder, J. S., Vagelos, R., Oyer, P., Fowler, M. B. 1996; 75 (5): 455-462

    Abstract

    To analyse the clinical characteristics of patients who died on the Stanford heart transplant waiting list and to develop a method for risk stratifying status 2 patients (outpatients).Data were reviewed from all patients over 18 years, excluding retransplants, who were accepted for heart transplantation over an eight year period from 1986 to 1994.548 patients were accepted for heart transplantation; 53 died on the waiting list, and 52 survived on the waiting list for over one year. On multivariate analysis only peak oxygen consumption (peak VO2: 11.7 (SD 2.7) v 15.1 (5.2) ml/kg/min, P = 0.02) and cardiac output (3.97 (1.03) v 4.79 (1.06) litres/min, P = 0.04) were found to be independent prognostic risk factors. Peak VO2 and cardiac index (CI) were then analysed in the last 141 consecutive patients accepted for cardiac transplantation. All deaths and 88% of the deteriorations to status 1 on the waiting list occurred in patients with either a CI < 2.0 or a VO2 < 12. In those with a CI < 2.0 and a VO2 < 12, 38% died or deteriorated to status 1 in the first year on the waiting list. Patients with CI > or = 2.0 and a VO2 > or = 12 all survived throughout follow up. Using a Cox's proportional hazards model with CI and peak VO2 as covariates, tables were constructed predicting the chance of surviving for (a) 60 days and (b) 1 year on the waiting list.These data provide a basis for risk stratification of status 2 patients on the heart transplant waiting list.

    View details for Web of Science ID A1996UK45400010

    View details for PubMedID 8665337

  • Surgical management of aortic dissection during a 30-year period. Circulation Fann, J. I., Smith, J. A., Miller, D. C., Mitchell, R. S., Moore, K. A., Grunkemeier, G., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1995; 92 (9): II113-21

    Abstract

    Certain recent studies have demonstrated improved surgical outcome in patients with aortic dissection. We analyzed the surgical survival rates of patients with acute aortic dissections and the late prognosis of those with aortic dissection during a 30-year period.Between 1963 and 1992, 360 patients (256 men and 104 women; mean +/- 1 SD age, 57 +/- 14 years) underwent surgery for aortic dissection: 174 patients had an acute type A (AcA), 46 an acute type B (AcB), 106 a chronic type A (ChA), and 34 a chronic type B (ChB) aortic dissection. The overall operative mortality rate was 24 +/- 8% (26 +/- 3% for AcA, 39 +/- 8% for AcB, 17 +/- 4% for ChA, and 15 +/- 6% for ChB, [+/- 70% confidence limit]). The operative mortality rates for patients with acute aortic dissection (AcA or AcB) were assessed for five time "windows": 1963 to 1972 (42 +/- 8%), 1973 to 1977 (37 +/- 8%), 1978 to 1982 (15 +/- 6%), 1983 to 1987 (27 +/- 6%), and 1988 to 1992 (26 +/- 6%). Logistic regression analysis suggested that the low operative mortality rate during the 1978-to-1982 interval occurred by chance. Multivariate analysis showed earlier operative year, hypertension, cardiac tamponade, renal dysfunction, and older age were independent determinants of operative death. Actuarial survival rates (including early deaths) after 5, 10, and 15 years for AcA patients were 55%, 37%, and 24%; for AcB, 48%, 29%, and 11%; for ChA, 65%, 45%, and 27%; and for ChB, 59%, 45%, and 27%. Multivariate analysis revealed that older age and previous operation were significant predictors for late death. Freedom from reoperation for all patients was 84%, 67%, and 57% at 5, 10, and 15 years, respectively.Although the operative mortality rate decreased over time for patients with aortic dissection, the risk for those with acute aortic dissection during the last 10 years (1983 to 1992) is probably more realistic than that observed in the preceding 5-year interval (1978 to 1982). The operative mortality rates for patients with chronic aortic dissection have remained relatively static. Earlier diagnosis of acute aortic dissection before development of cardiac tamponade and renal impairment is critical to improve the operative salvage rate. Long-term outcome still is not optimal, which emphasizes the need for better serial postoperative aortic imaging surveillance and medical follow-up and blood pressure control.

    View details for PubMedID 7586393

  • SURGICAL-MANAGEMENT OF AORTIC DISSECTION DURING A 30-YEAR PERIOD CIRCULATION Fann, J. I., Smith, J. A., Miller, D. C., Mitchell, R. S., Moore, K. A., Grunkemeier, G., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1995; 92 (9): 113-121
  • HEART RETRANSPLANTATION - THE 25-YEAR EXPERIENCE AT A SINGLE INSTITUTION JOURNAL OF HEART AND LUNG TRANSPLANTATION Smith, J. A., Ribakove, G. H., Hunt, S. A., Miller, J., Stinson, E. B., Oyer, P. E., Robbins, R. C., Shumway, N. E., Reitz, B. A. 1995; 14 (5): 832-839

    Abstract

    The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford.There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% +/- 8%, 33% +/- 8%, and 22% +/- 7%, respectively.This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% +/- 2%, 62% +/- 2%, 44% +/- 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% +/- 10% versus 33% +/- 16%), but the 5-year survival was similar in both groups (34% +/- 11% versus 33% +/- 16%). Since 1981, actuarial freedoms from infection and rejection were 22% +/- 8% and 41% +/- 9%, respectively, at 1 year, and 7% +/- 7% and 36% +/- 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I.We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.

    View details for Web of Science ID A1995RY62700004

    View details for PubMedID 8800717

  • CLINICAL OUTCOME OF INTERVAL CADAVERIC RENAL-TRANSPLANTATION IN CARDIAC ALLOGRAFT RECIPIENTS CLINICAL TRANSPLANTATION Kuo, P. C., Luikart, H., BUSSEHENRY, S., Hunt, S. A., Valantine, H. A., Stinson, E. B., Oyer, P. E., Scandling, J. D., Alfrey, E. J., Dafoe, D. C. 1995; 9 (2): 92-97

    Abstract

    The introduction of cyclosporine into widespread clinical use has resulted in improved patient survival following cardiac transplantation. As a result of increased numbers of cardiac transplants, the inherent nephrotoxicity of cyclosporine, and prolonged patient survival, cardiac transplant recipients commonly present with renal dysfunction. In the subgroup who ultimately develop end-stage renal disease (ESRD), therapeutic options include renal transplantation. However, the clinical course associated with this treatment modality is unknown. From 1980 to 1993, 430 cardiac transplants were performed with cyclosporine-based immunosuppression at the Standard University Medical Center. Fourteen (3.3%) patients developed ESRD, requiring chronic dialysis or renal transplantation. The cause of ESRD was cyclosporine nephropathy (13/14; 93%) and glomerulonephritis (1/14; 7%). The average time interval to the development of ESRD was 82 +/- 42 months. Nine patients underwent renal transplantation. During the period of followup (38 +/- 27 months; range 6-89 months) after renal transplantation, cardiac function remained stable. There were no episodes of primary nonfunction of the renal allograft. Patient and renal allograft survival was 89% at both 1 and 3 years after renal transplant. Average serum creatinine was 1.3 +/- 0.6 mg/dl at 1 year and 1.6 +/- 0.8 mg/dl at 3 years post-transplant. The incidence of infectious complications was not statistically different when compared to that of the heart transplant controls and that of a group of cadaveric renal transplant controls (n = 20). Surprisingly, the incidence of renal allograft rejection in the heart transplant patients was 10-fold less than that of the renal transplant controls (0.006 +/- 0.02/patient-year vs. 0.062 +/- 0.05/patient-year; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1995QV67600006

    View details for PubMedID 7599409

  • Evaluation of an implantable ventricular assist system for humans with chronic refractory heart failure. Study overview. LVAS Study Group. Left Ventricular Assist System. ASAIO journal Pennington, D. G., Griffith, B. P., McKinlay, S. M., Oyer, P. E., Domanski, M. J., Portner, P. M., Watson, J. T. 1995; 41 (1): 11-15

    Abstract

    In this summary, the authors provide the background of and proposed protocol for a clinical evaluation of the safety and efficacy of the Novacor N120 Left Ventricular Assist System, sponsored by the National Heart, Lung, and Blood Institute. Although the clinical trial was never carried out, the protocol developed for this trial may be useful to other investigators considering a clinical trial of a circulatory support device. The protocol is summarized here and in five more detailed articles in this issue.

    View details for PubMedID 7727812

  • Pediatric cardiac transplantation. The Stanford experience. Circulation Sarris, G. E., Smith, J. A., Bernstein, D., Griffin, M. L., Pitlick, P. T., Baum, D., Billingham, M. E., Oyer, P. E., Stinson, E. B., Starnes, V. A. 1994; 90 (5): II51-5

    Abstract

    Cardiac transplantation for children with endstage heart disease has become an accepted form of therapy and is being practiced with increasing frequency and improving short-term outcome.To assess the medium-term outcome of pediatric cardiac transplantation, we analyzed our experience with 72 patients under the age of 18 (range, 0.1 to 17.7 years; mean, 9 +/- 6.4 [SD]) who underwent orthotopic cardiac transplantation at Stanford University between 1977 and 1993. There were 38 male and 34 female patients. Preoperative diagnoses included congenital heart disease in 24 (33%), idiopathic cardiomyopathy in 27 (37%), viral cardiomyopathy in 12 (17%), and familial cardiomyopathy in 7 (10%) patients. Immunosuppressive management has evolved over time and has included a tapering schedule of steroids, azathioprine, rabbit antithymocyte globulin, cyclosporine in all patients after 1980, and induction with OKT3 since 1987. Operative mortality rate was 12.5 +/- 4.0% (mean +/- 70% confidence intervals). Actuarial survival estimates at 1, 5, and 10 years are 75 +/- 7.1%, 60 +/- 6.4%, and 50 +/- 8.1% (mean +/- 1 SEM), respectively. Causes of death included infection in 8 (28% of deaths), rejection in 7 (24%), graft coronary disease in 5 (17%), pulmonary hypertension in 4 (14%), and nonspecific graft failure in 2 (7%) patients. Survival rates were similar for patients over and those under age 10 years (including the infant cohort of 18 patients transplanted since 1986). Currently, there are 43 patients alive, all in New York Heart Association functional class I. Only 22 +/- 5.6% of patients were free of rejection at 1 year, but 86 +/- 5.4% were free of rejection-related death at 10 years. At 1 year, only 37 +/- 6% of patients were free from any infection, but 88 +/- 4.2% remained free of infection-related death at 5 years. Actuarial freedom from graft coronary artery disease (angiographic or autopsy proven) was 85 +/- 6.6% at 5 years and from coronary artery disease-related death was 91 +/- 4.7%.These data demonstrate satisfactory medium-term outcome of cardiac transplantation in selected pediatric patients with end-stage heart disease, but further progress is necessary to more effectively control rejection, infection, and graft coronary disease.

    View details for PubMedID 7955282

  • Surgical management of aortic dissection in patients with the Marfan syndrome. Circulation Smith, J. A., Fann, J. I., Miller, D. C., Moore, K. A., DeAnda, A., Mitchell, R. S., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1994; 90 (5): II235-42

    Abstract

    Aortic dissection is one of the most lethal potential complications in patients with the Marfan syndrome.Among 360 patients undergoing operative treatment of aortic dissection between 1963 and 1992, 40 had the Marfan syndrome. There were 24 men and 16 women with a mean age of 35 +/- 9 years (+/- 1 SD; range, 15 to 54 years). These patients included 16 with acute type A, 2 with acute type B, 18 with chronic type A, and 4 with chronic type B aortic dissections. The aortic arch was involved in 29 cases. Preoperative complications included acute aortic valvular insufficiency in 13 patients, rupture into the pericardial space in 3, and loss of peripheral pulses in 9. The site of primary intimal tear was the ascending aorta in 25 patients, the aortic arch in 2, the descending aorta in 7, and not identified in 6. Operations included ascending aortic and aortic valvular replacement (with or without coronary artery reimplantation) in 22 patients, ascending aortic replacement alone in 5, and descending thoracic aortic replacement in 9. Four operative deaths (10 +/- 5% [+/- 70% confidence limits]) occurred in 3 acute patient-years and 1 chronic type A patient-years. Long-term follow-up (216 patient-years; range, 1 month to 22 years; mean, 5.4 years) revealed 15 late deaths, 7 from late aortic sequelae. The overall actuarial survival estimates were 71 +/- 8%, 54 +/- 10%, and 22 +/- 11% at 5, 10, and 15 years, respectively. Twenty late aortic operations were required in 14 patients.Despite satisfactory early results, the long-term survival of patients with the Marfan syndrome was suboptimal (albeit similar to those without the Marfan syndrome). Future progress will pivot on reducing the incidence of aortic dissection in these patients with medical therapy and/or earlier surgical intervention and enhanced postoperative serial imaging surveillance of the entire aorta.

    View details for PubMedID 7955259

  • CHYLOTHORAX COMPLICATING CORONARY-ARTERY BYPASS-GRAFTING JOURNAL OF CARDIOVASCULAR SURGERY Smith, J. A., Goldstein, J., Oyer, P. E. 1994; 35 (4): 307-309

    Abstract

    Chylothorax is a rare complication of coronary artery by-pass grafting. We present two patients who developed a left chylothorax at one week and 14 days post-coronary artery by-pass grafting. In both cases an internal mammary artery graft was harvested. Nonoperative therapy, which included adequate pleural drainage and a low fat diet, lead to successful resolution of the chylous leak in each instance.

    View details for Web of Science ID A1994PG48600005

    View details for PubMedID 7929541

  • CARDIAC TRANSPLANTATION - THE STANFORD EXPERIENCE IN THE CYCLOSPORINE ERA JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Sarris, G. E., Moore, K. A., Schroeder, J. S., Hunt, S. A., Fowler, M. B., VALANTINE, H. B., Vagelos, R. H., Billingham, M. E., Oyer, P. E., Stinson, E. B., Reitz, B. A., Shumway, N. E. 1994; 108 (2): 240-252

    Abstract

    We analyzed our experience with 496 patients who underwent primary cardiac transplantation since the introduction of cyclosporine immunosuppression (Dec. 16, 1980, to Jan. 7, 1993). There were 388 male and 108 female patients. Mean recipient age was 40 +/- 16 years (range 0.1 to 70 years, median 44 years). Recipient diagnoses included coronary disease in 188, idiopathic cardiomyopathy in 196, viral cardiomyopathy in 35, and congenital heart disease in 28 patients. Donor age was 25 +/- 10 years (range 1 to 53 years, median 24 years). Graft ischemic time was 148 +/- 57 minutes (range 38 to 495 minutes, median 149 minutes). Operative mortality (hospital death) rate was 7.9% +/- 1.3% (70% confidence intervals). Multivariate logistic regression analysis revealed that (higher) pulmonary vascular resistance and gender (female) were the only independent predictors of hospital death (p < 0.05). Actuarial survival estimates for all patients at 1, 5, and 10 years are 82% +/- 1.7% (83% +/- 1.8% adult, 77% +/- 5.2% pediatric), 61% +/- 2.5% (65% +/- 2.5% adult, 64% +/- 6.6% pediatric), and 41% +/- 3.7% (40% +/- 4% adult, 54% +/- 8.6% pediatric), respectively. For 232 patients treated with triple-drug immunosuppression and induction with OKT3 since 1987, survival estimates at 1 and 5 years are 82% +/- 2.6% and 67% +/- 3.7%, respectively. Causes of death for the entire group were rejection in 29 (14% of deaths), infection in 69 (34%), graft coronary disease in 36 (18%), nonspecific graft failure in 6 (3%), malignancy in 19 (10%), stroke in 6 (3%), pulmonary hypertension in 6 (3%), and other causes in 30 (15%) patients. Actuarial freedom from rejection at 3 months, 1 year, and 5 years was 21% +/- 1.9%, 14% +/- 1.7%, and 7.2% +/- 1.5%, respectively (+/- 1 standard error of the mean). Estimates of freedom from rejection-related death at 1, 5, and 10 years were 96% +/- 1%, 93% +/- 1.4%, and 93% +/- 1.4%, respectively. Actuarial freedom from any infection at 3 months and at 1 and 5 years was 40% +/- 2.3%, 27% +/- 2.1%, and 15% +/- 2.0% and from infection-related death, 95% +/- 1.0%, 93% +/- 1.2%, and 85% +/- 1.9%, respectively. Actuarial freedom from (angiographic or autopsy proved) graft coronary artery disease at 1, 5, and 10 years was 95% +/- 1.2%, 73% +/- 2.7%, and 65% +/- 3.6% and from coronary disease-related death or retransplantation 98% +/- 0.7%, 84% +/- 2.2%, and 66% +/- 4.3%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

    View details for Web of Science ID A1994PB11400006

    View details for PubMedID 8041172

  • RANDOMIZED, PROSPECTIVE ASSESSMENT OF BIOPROSTHETIC VALVE DURABILITY - HANCOCK VERSUS CARPENTIER-EDWARDS VALVES CIRCULATION Sarris, G. E., Robbins, R. C., Miller, D. C., Mitchell, R. S., Moore, K. A., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1993; 88 (5): 55-64
  • Randomized, prospective assessment of bioprosthetic valve durability. Hancock versus Carpentier-Edwards valves. Circulation Sarris, G. E., Robbins, R. C., Miller, D. C., Mitchell, R. S., Moore, K. A., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1993; 88 (5): II55-64

    Abstract

    Although the major limitation of porcine valves is their finite durability, no controlled clinical data exist regarding the relative durability of the two porcine bioprostheses implanted most commonly today, the Carpentier-Edwards (C-E) and Medtronic Hancock I (H) valves.To assess this question, 174 patients undergoing aortic (AVR) or mitral (MVR) valve replacement with a bioprosthesis between March 1980 and March 1982 were randomized to receive either a C-E or a H valve. There were 102 AVRs (54 C-E and 48 H) and 74 MVRs (39 C-E and 35 H). For both the AVR and MVR cohorts, the average patient age was 58 +/- 14 years (+/- SD). The male/female ratio was 2.2:1 for AVR and 0.57:1 for MVR. Clinical follow-up was undertaken periodically; the most recent follow-up closing interval was July through October 1992, and current follow-up was 96% complete. Cumulative follow-up totaled 1369 patient-years (mean, 7.7 +/- 3.6 years; median, 9.1 years; maximum, 12.0 years). The main focus of this analysis was bioprosthetic durability, using the AATS/STS guidelines defining "Structural Valve Deterioration" (SVD). Multivariate analysis revealed that (younger) age was the only significant (P = .024) independent predictor of SVD. Valve manufacturer (C-E versus H) and valve site (aortic versus mitral) did not emerge as significant independent risk factors for SVD. Actuarial rates (Cutler-Ederer) expressed as percent free of SVD (+/- SEM) at 10 years (n = number of patients remaining at risk) were 71 +/- 7% and 59 +/- 9% for the C-E (n = 26) and H (n = 17) groups, respectively, for the AVR cohort; for the MVR cohort, these estimates were 60 +/- 10% (n = 12) and 72 +/- 10% (n = 11), respectively, but these differences were not statistically significant (P = NS, Lee-Desu).After 10 years, there was no statistically significant difference in durability or other valve-related complications between the H and C-E aortic or mitral valves. Based on current information, the choice of a porcine bioprosthesis should be based on factors other than durability, including ease of implantation, hemodynamic performance, and cost.

    View details for PubMedID 8222197

  • CYSTIC-FIBROSIS - TARGET POPULATION FOR LUNG TRANSPLANTATION IN NORTH-AMERICA IN THE 1990S JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Starnes, V. A., LEWISTON, N., Theodore, J., STOEHR, C., STINSON, E., Shumway, N. E., Oyer, P. E. 1992; 103 (5): 1008-1014

    Abstract

    Cystic fibrosis is the most common lethal genetic disease occurring in the white population. It is estimated that 3.5% of the 20,000 individuals with cystic fibrosis in North America will die each year of end-stage lung disease. Lung transplantation (heart-lung or double lung) is becoming more frequent as more patients are referred for this procedure. Since January 1988, we have evaluated 60 patients with cystic fibrosis for lung transplantation and have accepted 30 (50%). Nine patients (30%) died while awaiting a donor. Fifteen patients underwent transplantation (13 heart-lung and two double lung procedures). Actuarial survival at 1, 2, and 3 years is 76%. All survivors are without physical limitations. Pulmonary function, as determined by forced vital capacity, forced expiratory volume in 1 second, and arterial blood gas determinations, is within the normal range. Comparing these data with those of a group of patients without cystic fibrosis who underwent transplantation during the same period did not reveal any significant differences with respect to infection, rejection, and outcome. Preliminary data suggest that obliterative bronchiolitis is less prevalent at 1 year in patients with cystic fibrosis (19%) than in those without cystic fibrosis (41%). Patients with cystic fibrosis present a number of challenges. The problems of pleural adhesions from repeated infections, pleurodesis, and previous thoracic procedures are now readily approached through the bilateral thoracosternotomy (clam shell) incision. Insulin-dependent diabetes mellitus and low-dose corticosteroid therapy are no longer considered absolute contraindications. Both septic lungs must be removed at operation, either with heart-lung transplantation or with double lung transplantation. These data support the therapeutic efficacy of lung transplantation for patients with cystic fibrosis.

    View details for Web of Science ID A1992HU28500023

    View details for PubMedID 1569753

  • DURABILITY OF PORCINE VALVES AT 15 YEARS IN A REPRESENTATIVE NORTH-AMERICAN PATIENT POPULATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Burdon, T. A., Miller, D. C., Oyer, P. E., Mitchell, R. S., Stinson, E. B., Starnes, V. A., Shumway, N. E. 1992; 103 (2): 238-252

    Abstract

    Isolated aortic (n = 857) or mitral (n = 793) valve replacement with a porcine bioprosthesis was performed in 1650 patients between 1971 and 1980. Follow-up (total = 12,012 patient-years) extended to more than 15 years and was 96% complete. Patient age ranged from 16 to 87 years; mean age was 59 +/- 11 years (+/- 1 standard deviation) for the aortic valve replacement cohort and 56 +/- 12 years for the mitral valve replacement cohort. The operative mortality rates were 5% +/- 1% (+/- 70% confidence limits) and 8% +/- 1%, respectively, for the aortic and mitral subgroups. Estimated freedom from structural valve deterioration (+/- 1 standard error of the mean) after 10 and 15 years was significantly higher for the aortic than for the mitral valve replacement subgroup (85% +/- 0.4% and 63% +/- 3% versus 78% +/- 2% and 45% +/- 3%, respectively, p = 0.001). Reoperation-free actuarial estimates were also significantly greater for the aortic valve replacement cohort: 83% +/- 2% and 57% +/- 3% versus 78% +/- 2% and 43% +/- 3% for mitral valve replacement at 10 and 15 years, respectively. The mortality rate for reoperative aortic valve replacement was 11% +/- 1%; it was 8% +/- 1% for reoperative mitral valve replacement. Importantly, the estimates of freedom from valve-related death (including sudden, unexplained deaths) were relatively high at 10 and 15 years: 78% +/- 2% and 69% +/- 3% in the aortic cohort and 74% +/- 2% and 63% +/- 3% in the mitral cohort (p = not significant). Excluding sudden, unexplained deaths, these estimates were 81% +/- 3% (aortic) and 73% +/- 4% (mitral) at 15 years. Thromboembolism-free rates were 84% +/- 3% (aortic) and 78% +/- 6% (mitral) at 15 years, and freedom from anticoagulant-related hemorrhage was 96% +/- 1% and 89% +/- 2%, respectively. At the time of current follow-up, 13% of patients having aortic valve replacement and 50% of patients having mitral valve replacement were receiving warfarin sodium. The hazard functions for thromboembolism and prosthetic valve endocarditis were constant and remained less than 1%/pt-yr over the entire follow-up period.(ABSTRACT TRUNCATED AT 400 WORDS)

    View details for Web of Science ID A1992HD22500008

    View details for PubMedID 1735989

  • HEART, HEART-LUNG, AND LUNG TRANSPLANTATION IN THE 1ST YEAR OF LIFE ANNALS OF THORACIC SURGERY Starnes, V. A., Oyer, P. E., Bernstein, D., Baum, D., Gamberg, P., Miller, J., Shumway, N. E. 1992; 53 (2): 306-310

    Abstract

    Seventeen infants less than 1 year of age have undergone heart (12), heart-lung (3), and lung (2) transplantation for end-stage cardiopulmonary disease. The infants undergoing heart transplantation had a mean age of 4.5 months (range, 19 days to 12 months) with the diagnosis of cardiomyopathy in 4 and congenital heart disease in 8. Four of the 8 patients (50%) had hypoplastic left heart syndrome. Actuarial survival at 1 and 2 years was 74% and compared favorably with the survival of older children at 1 and 2 years of 82% and 69%. The linearized rejection rate was less in infants as compared with children more than 1 year of age (0.61 versus 1.48 episodes per 100 patient days). In intermediate follow-up, no graft atherosclerosis has been noted. Immunosuppression has included a three-drug protocol of cyclosporine, azathioprine, and prednisone. A steroid taper to alternate day steroids or off completely by 6 months has been the goal and has been accomplished in 6 of 12 infants. Heart-lung and lung transplantation has been performed in 5 infants. One infant in each group died: 1 infant secondary to airway complications and sepsis and another due to pulmonary sepsis. A pulmonary lobe from a larger and older donor was transplanted into a 4-week-old infant as a single-lung transplant with good outcome. The 3 surviving infants are well 24, 18, and 2 months after transplantation. Obliterative bronchiolitis has not been clinically apparent in this group. These data support the clinical efficacy of heart, heart-lung, and lung transplantation in the first year of life.

    View details for Web of Science ID A1992HB90700022

    View details for PubMedID 1731673

  • COST CONTAINMENT - COADMINISTRATION OF DILTIAZEM WITH CYCLOSPORINE AFTER HEART-TRANSPLANTATION JOURNAL OF HEART AND LUNG TRANSPLANTATION Valantine, H., Keogh, A., McIntosh, N., Hunt, S., Oyer, P., Schroeder, J. 1992; 11 (1): 1-8

    Abstract

    Coadministration of diltiazem with cyclosporine (CsA) has been reported to alter the metabolism of CsA, resulting in increased blood concentration with potential nephrotoxicity if dosage is not adjusted. This report analyzes the cost saving resulting from use of diltiazem and CsA together and examines the impact on renal function. Sixty-nine heart transplant recipients (59 men, 10 women) were randomized to diltiazem (n = 32) or to no calcium blocker (n = 37). Age range was 18 to 58 years. All patients received CsA (titrated to a 12-hour trough serum level of 100 to 200 ng/ml), azathioprine, and prednisone. Diltiazem was begun at 30 mg three times daily increasing to 60 mg three times daily at 1 month, as tolerated. Renal function was assessed by serial measurements of serum creatinine. Parameters before and after starting diltiazem were compared by paired t-tests, and differences between group means by analysis of variance. CsA doses and levels were comparable at baseline in both groups. At 12 months, CsA dose requirement was 2.5 +/- 1.0 versus 5.9 +/- 3.2 mg/kg/day (diltiazem group versus no calcium blocker group; p less than or equal to 0.001) to achieve similar serum levels (96 +/- 51 versus 123 +/- 96 ng/ml; p = NS). This represents a 48% reduction in dose cost of CsA. The average cost of CsA for 2 to 4 months of therapy in a patient weighing 70 kg was reduced from $12,122 in the no calcium blocker group to $6,356 in the diltiazem group.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1992HC24900001

    View details for PubMedID 1540597

  • CLINICAL-EXPERIENCE WITH THE NOVACOR VENTRICULAR ASSIST SYSTEM - BRIDGE TO TRANSPLANTATION AND THE TRANSITION TO PERMANENT APPLICATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY McCarthy, P. M., Portner, P. M., Tobler, H. G., Starnes, V. A., Ramasamy, N., Oyer, P. E. 1991; 102 (4): 578-587

    Abstract

    At Stanford University, a Novacor left ventricular assist system (Baxter Healthcare Corporation, Novacor Division, Oakland, Calif.) was placed as a bridge to heart transplantation in 13 patients. During the hospitalization preceding device implantation, all patients were receiving inotropic support for biventricular failure, 11 had pulmonary edema, 6 had life-threatening ventricular arrhythmias, 5 had liver dysfunction with coagulopathy, and 2 had renal failure necessitating artificial support. The mean cardiac index before implantation of the Novacor system was 1.5. All survivors with the Novacor device had a dramatic increase in cardiac output (mean cardiac index = 3.1). One patient with cardiac allograft rejection died during implantation of the left ventricular assist system. Two patients died of pulmonary sepsis and multiorgan failure after the device was implanted. All patients who had the Novacor device implanted for more than 7 days were able to walk and ride stationary bicycles while awaiting transplantation. Ten patients (77%) underwent successful heart transplantation after a mean of 18 days' support with the Novacor device. One patient died of presumed sepsis 2 days after transplantation. Nine patients (90%) are alive 4 months to 6 years after transplantation. In the overall United States experience, 68 patients (as of May 1990) have had a Novacor left ventricular assist device implanted. Five were still being supported, 39 had received a transplant (62%), and 35 patients (90%) survived the transplant hospitalization (1 died later). No instances of device failure have occurred. Overall, the Novacor assist system provided effective bridging to transplantation, with posttransplant survival similar to results after routine transplantation. Modifications and improvements based on this clinical experience have been made in the areas of patient selection, techniques of operative placement, postoperative management, and design of the assist system. Isolated left heart support with a fully implantable left ventricular assist system will be offered as an alternative to heart transplantation for selected patients by 1992.

    View details for Web of Science ID A1991GK13900014

    View details for PubMedID 1921434

  • PEDIATRIC HEART-TRANSPLANTATION AT STANFORD - RESULTS OF A 15-YEAR EXPERIENCE PEDIATRICS Baum, D., Bernstein, D., Starnes, V. A., Oyer, P., PITLICK, P., STINSON, E., Shumway, N. 1991; 88 (2): 203-214

    Abstract

    The long-term results of pediatric heart transplantation were evaluated in 53 patients, aged 0.25 to 18.94 years, who received transplants at Stanford University Medical Center between 1974 and 1989. Indications for transplantation were idiopathic cardiomyopathy (68%), congenital heart disease (21%), endocardial fibroelastosis (8%), and doxorubicin cardiomyopathy (3%). Immunosuppression was achieved with combinations of cyclosporine, prednisone, and azathioprine. Thirty-seven of 42 recipients leaving the hospital after transplantation were alive and in New York Heart Association class I at study's end. Cumulative survival was 79% at 1 year, 76% at 3 years, and 69% at 5 years. Fourteen recipients have survived more than 5 years (5.1 to 12.4 years). Hospital readmission for illness has been infrequent, decreasing from 6.8 days to 0.9 days per year over 5 years. Eleven patients have required no rehospitalization. Posttransplant deaths were due to infection (19%), rejection (4%), pulmonary hypertension (4%), coronary artery disease (2%), and lymphoproliferative disease (2%). Retransplantation was required for intractable rejection in 4 patients and advanced coronary artery disease in 2. Hypertension and elevated blood urea nitrogen and creatinine levels were common in individuals receiving cyclosporine. Growth was often impaired in prepubertal children receiving daily prednisone. Based on this 15-year experience, it is concluded that heart transplantation represents a reasonable alternative for selected young patients with end-stage cardiac disease.

    View details for Web of Science ID A1991GA16400002

    View details for PubMedID 1861916

  • SINGLE LUNG TRANSPLANTATION - A NEW THERAPEUTIC OPTION FOR PATIENTS WITH PULMONARY-HYPERTENSION TRANSPLANTATION PROCEEDINGS Starnes, V. A., Stinson, E. B., Oyer, P. E., Theodore, J., Kramer, M. R., Marshall, S., Shumway, N. E. 1991; 23 (1): 1209-1210

    View details for Web of Science ID A1991EV39100118

    View details for PubMedID 1989188

  • INCREASED REJECTION IN GENDER-MISMATCHED GRAFTS - AMELIORATION BY TRIPLE THERAPY JOURNAL OF HEART AND LUNG TRANSPLANTATION Keogh, A. M., Valantine, H. A., Hunt, S. A., Schroeder, J. S., Oyer, P. E. 1991; 10 (1): 106-110

    Abstract

    Increased rejection incidence in female heart transplant recipients receiving immunosuppressive therapy with cyclosporine and azathioprine has been reported and a possible role for gender-mismatched grafting (male donor into female recipient) has been suggested. To test the hypothesis that rejection is more frequent in female patients receiving male hearts, we analyzed the results of heart transplantation in gender-matched and -mismatched grafts in 313 recipients maintained with either double therapy with cyclosporine and prednisone (group 1, n = 104) or triple therapy with cyclosporine, azathioprine, and prednisone (group 2, n = 209). There were 21 female recipients in group 1 and 41 in group 2. The variables studied were 90-day total methylprednisolone sodium succinate requirements, 90-day linearized rejection rate, 90-day event-free actuarial rejection, 6-month actuarial infection-free survival, overall actuarial survival, and median day to first rejection. Statistical analyses included two-tailed t or Cox-Mantel testing as appropriate. In group 1, transplantation of a male heart into a female recipient (M/F grafting) was associated with a 40% higher 90-day cumulative steroid requirement (5008 +/- 3400 mg for M/F vs 3600 +/- 2977 mg for F/F), reflecting a higher rate of rejection in M/F recipients. Linearized rejection rates (90-day) were higher (1.6 +/- 0.4 vs 1.3 +/- 0.5 episodes per patient), and consequent 6-month event-free infection rates were lowest in these patients, although not significantly so. Actuarial survival did not differ significantly between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1991EZ48400016

    View details for PubMedID 2007161

  • TREATMENT OF PATIENTS WITH AORTIC DISSECTION PRESENTING WITH PERIPHERAL VASCULAR COMPLICATIONS ANNALS OF SURGERY Fann, J. I., Sarris, G. E., Mitchell, R. S., Shumway, N. E., Stinson, E. B., Oyer, P. E., Miller, D. C. 1990; 212 (6): 705-713

    Abstract

    The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

    View details for Web of Science ID A1990EN33200009

    View details for PubMedID 2256762

  • 8-YEAR RESULTS OF CYCLOSPORINE-TREATED PATIENTS WITH CARDIAC TRANSPLANTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY GRATTAN, M. T., MORENOCABRAL, C. E., Starnes, V. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1990; 99 (3): 500-509

    Abstract

    To elucidate the long-term effects of cyclosporine, we retrospectively studied 310 consecutive patients who have undergone cardiac transplantation at our institution since December 1980 and in whom immunosuppression has been maintained with cyclosporine. The ages of recipients ranged from 1 month to 64 years and of donors from 1 month to 48 years. The actuarial survival rates for cyclosporine-treated patients were 80.7% at 1 year and 59.7% at 5 years and were significantly greater than those for previous patients not treated with cyclosporine (p less than 0.005). Their actuarial prevalence of rejection was 60.0% at 1 month and 86.9% at 1 year; 206 patients are living. The actuarial prevalence of lymphoma development was 4.6% at 5 years but has been significantly lower with the current immunosuppression protocol of lower doses of cyclosporine, and OKT3 in place of rabbit anti-thymocyte globulin (p less than 0.005). Infection remains the most common cause of death. Recipients less than 50 years of age had a significantly higher actuarial survival than older recipients (p less than 0.01). Male and female recipients had similar overall prevalence of survival and rejection, but men died of graft atherosclerosis significantly more frequently (p less than 0.005). Rehabilitation has been successful in 85% of patients surviving 1 year after transplantation. Of those surviving 1 year, 96.5% were in New York Heart Association class I. Thus the results of orthotopic cardiac transplantation have improved since the introduction of cyclosporine and have allowed measured liberalization of the criteria for recipient selection.

    View details for Web of Science ID A1990CT22700016

    View details for PubMedID 2308368

  • IMPLANTATION RESPONSE FOLLOWING CLINICAL HEART-LUNG TRANSPLANTATION JOURNAL OF CARDIOVASCULAR SURGERY Harjula, A. L., Baldwin, J. C., Silverman, N. E., Blank, N., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1990; 31 (1): 1-6

    Abstract

    Implantation response has been a critical problem following heart-lung and lung transplantation. While the precise etiology of this problem remains unclear, improvements in organ preservation would be expected to have a beneficial effect on implantation response. The time-related profile of the implantation response was studied in 20 patients who underwent heart-lung transplantation between March 1984-March 1987. In 10 operations the donors had intravenous prostaglandin E-1 pretreatment while 10 had no vasodilatation before explantation of the organs. Otherwise lung preservation and early (2 weeks) immunotherapy were similar in both groups. The implantation response was evaluated by chest films and postoperative lung functions and mechanics. Roentgenographic implantation response was evident from the first postoperative day, was less evident at the seventh postoperative day and then gradually increased during the second postoperative week. There was a tendency towards less implantation response in the PGE-1 group than in the control group, but no statistical difference was observed. Patients with severe operative bleeding problems were excluded from the study. Only peak inspiratory pressures were significantly higher in the control group than in the PGE-1 group (p less than 0.01). Other lung function studies (alveolar-capillary pO2 difference, extubation time) were not different in the groups. This study supported the hypothesis that prostaglandin E-1 may have salutary effects on graft preservation and implantation response in heart-lung transplantation. Since 1986, we have performed 16 heart-lung transplantations using graft preservation with PGE-1 and flush perfusion. Thirty-day mortality is 0% and 13 of 16 patients are surviving.

    View details for Web of Science ID A1990CW52700001

    View details for PubMedID 2324169

  • PULMONARY-INFILTRATES AFTER HEART-LUNG TRANSPLANTATION - EVALUATION BY SERIAL TRANS-BRONCHIAL BIOPSIES JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Starnes, V. A., Theodore, J., Oyer, P. E., Stinson, E. B., MORENOCABRAL, C. E., Sibley, R., Barry, G., Shumway, N. E. 1989; 98 (5): 945-950

    Abstract

    Since January 1988, prospective serial transbronchial lung biopsies have been performed as a diagnostic procedure to facilitate the care of recipients of heart-lung transplants. Eighty-five cardiac and 70 transbronchial lung biopsies have been prospectively performed in 10 patients beginning within the first week of transplantation. Forty-eight percent (34/70) of the transbronchial lung biopsies and 16.5% (14/85) of the heart biopsies were positive for either rejection or infection. Pulmonary rejection was evident by a perivascular lymphocytic infiltrate that cleared with pulse steroid therapy. Pulmonary and cardiac rejection were present synchronously on six occasions and asynchronously on 16 occasions (nine pulmonary and seven cardiac). Four patients had early cytomegalovirus pneumonitis on biopsy specimen and were successfully treated with ganciclovir. Of the 40 clinically indicated biopsies, 29 (72.5%) were positive for rejection or infection and guided subsequent therapy. In summary, transbronchial lung biopsies have provided prompt (within 24 hours) serial diagnostic information that has guided successful treatment of infection (cytomegalovirus, aspergillosis, and Pneumocystis) and rejection. Asynchronous rejection of the heart and lungs has been conclusively demonstrated. With the early detection of rejection and infection, we are optimistic that chronic airway disease in patients with a heart-lung transplant may be reduced.

    View details for Web of Science ID A1989CB65200022

    View details for PubMedID 2554070

  • EVALUATION OF HEART-LUNG TRANSPLANT RECIPIENTS WITH PROSPECTIVE, SERIAL TRANS-BRONCHIAL BIOPSIES AND PULMONARY-FUNCTION STUDIES JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Starnes, V. A., Theodore, J., Oyer, P. E., Billingham, M. E., Sibley, R. K., Berry, G., Shumway, N. E., Stinson, E. B. 1989; 98 (5): 683-690

    Abstract

    The insidious development of obliterative bronchiolitis after heart-lung transplantation is thought to be due to rejection and possibly infection (cytomegalovirus). To evaluate further, we prospectively managed the last 16 consecutive heart-lung transplant recipients with serial transbronchial biopsies with lavage and pulmonary function studies as part of a surveillance protocol or as dictated by clinical presentation. A total of 123 transbronchial biopsies with lavage were performed, 77 for clinical indications (group I) and 46 for routine surveillance (group II). Results of 64 (83.1%) group I biopsies were positive for rejection or infection. Thirty-one of these biopsy specimens showed signs of rejection (29 in group I and two in group II), characterized by a perivascular mononuclear infiltrate, lymphocytic bronchiolitis, and occasionally alveolar septal mononuclear infiltrate. Forty-six serial pulmonary function tests were performed. The forced expiratory volume in 1 second (percent predicted), forced expiratory flow rate between 25% and 75% of the forced vital capacity (percent predicted), and arterial oxygen tension (millimeters of mercury) were significantly reduced from baseline values during rejection episodes: forced expiratory volume in 1 second, 75.7% +/- 20.1% versus 52.7% +/- 18.3% (p less than or equal to 0.05); forced expiratory flow rate between 25% and 75% of the forced vital capacity, 97.6% +/- 30.5% versus 49.8% +/- 22.3% (p less than or equal to 0.05); and arterial oxygen tension, 92.1 +/- 8.8 mm Hg versus 71.4 +/- 18.8 mm Hg (p less than or equal to 0.05). The fall in pulmonary function was reversible with pulse methylprednisolone. Asynchronous heart and lung rejection was documented. Of the 29 episodes of pulmonary rejection, 18 (62%) occurred asynchronously. Ten of the 16 (62%) heart-lung recipients had at least one episode of cardiac rejection. Thirteen of 16 (81%) had at least one episode of lung rejection. Serial transbronchial biopsies with lavage, as dictated by pulmonary function tests and clinical status, have guided early and more specific therapy directed against rejection and infection. With early detection, small airway dysfunction has been reversible.

    View details for Web of Science ID A1989AZ79100004

    View details for PubMedID 2554067

  • PROPHYLACTIC OKT3 USED AS INDUCTION THERAPY FOR HEART-TRANSPLANTATION CIRCULATION Starnes, V. A., Oyer, P. E., Stinson, E. B., DEIN, J. R., Shumway, N. E. 1989; 80 (5): 79-83
  • Prophylactic OKT3 used as induction therapy for heart transplantation. Circulation Starnes, V. A., Oyer, P. E., Stinson, E. B., DEIN, J. R., Shumway, N. E. 1989; 80 (5): III79-83

    Abstract

    The benefit of an immunosuppressive agent should be demonstrated by less rejection, less toxicity, decreased hospital stay, and equal or superior patient survival. Since June 1987, a total of 61 patients have received prophylactic OKT3 for 14 days, beginning on postoperative day 1, in addition to cyclosporine, azathioprine, and prednisone (group 1). Group 1 was compared with our conventional-therapy group (group 2, n = 116) treated with cyclosporine, azathioprine, prednisone, and antithymocyte globulin. The hospital stay was reduced from 36 to 22 days (p less than 0.0001). The linearized rejection rate was reduced with OKT3 from 2.82 to 1.09 (p less than 0.0002), from 1.82 to 1.45 (p less than 0.02), and from 1.22 to 0.56 (p less than 0.04) during the first 3 months, respectively. Actuarial freedom from rejection at 12 months was 32% versus 12% (p less than 0.005). Antimurine antibodies developed in 12.7% of OKT3-treated patients.

    View details for PubMedID 2509108

  • SURGICAL-MANAGEMENT OF ACUTE AORTIC DISSECTION COMPLICATED BY STROKE CIRCULATION Fann, J. I., Sarris, G. E., Miller, D. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1989; 80 (3): 257-263
  • CARDIAC RETRANSPLANTATION IN THE CYCLOSPORINE ERA ANNALS OF THORACIC SURGERY DEIN, J. R., Oyer, P. E., Stinson, E. B., Starnes, V. A., Shumway, N. E. 1989; 48 (3): 350-355

    Abstract

    Between December 1980, when immunosuppression with cyclosporine was introduced, and May 1988, 288 patients underwent primary transplantation for end-stage cardiac disease (group TX). Fourteen patients underwent retransplantation for accelerated graft atherosclerosis (group RTXAGA), and 9 underwent retransplantation for intractable acute allograft rejection (group RTXREJ). Cumulative patient follow-up was 724 patient-years (range, 1 month to 7.5 years; mean, 2.3 years). Within the first 3 postoperative months, no differences were noted between groups for linearized rates of infection or rejection except between the rate of rejection for group TX (1.69 +/- 0.09 events/100 patient-days) and group RTXAGA (0.94 +/- 0.3 events/100 patient-days) (p less than 0.02). No significant differences existed between groups for actuarial rates of remaining rejection-free or infection-free for more than 7.5 years. No significant differences in actuarial survival existed except between group TX (81% +/- 2% at 1 year and 58% +/- 4% at 5 years) and group RTXREJ (44% +/- 17% at 1 year and 44% +/- 0% at 5 years) (p less than 0.05). We conclude that patients who undergo retransplantation for accelerated graft atherosclerosis experience a lower rate of early rejection and similar rates of infection and survival compared with patients who receive primary transplants. Cardiac retransplantation for rejection incurs rejection and infection at rates similar to those of primary procedures. However, patients who undergo retransplantation for rejection survive these complications significantly less often than do patients who receive primary transplants. This information should be considered when scarce donor hearts become available and retransplantation is contemplated.

    View details for Web of Science ID A1989AN24400008

    View details for PubMedID 2673087

  • Surgical management of acute aortic dissection complicated by stroke. Circulation Fann, J. I., Sarris, G. E., Miller, D. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1989; 80 (3): I257-63

    Abstract

    Although patients with acute type A aortic dissection are best managed by emergency surgical intervention, preoperative stroke is known to be an independent predictor of late mortality and is considered by some to be a contraindication to operation because of the risk of precipitating hemorrhagic cerebral infarction and poor long-term outcome. In a series of 272 consecutive, unselected patients with aortic dissection undergoing surgical treatment during a 25-year span (1963-1987), 128 (47 +/- 3% [+/- 70% confidence level (CL)]) had an acute type A dissection. A total of seven patients with acute type A dissection (2.6 +/- 1% of all patients, 5.5 +/- 2% of the acute type A cohort) developed a new stroke preoperatively. Thirteen (4.8 +/- 1%) patients had a diminished or absent carotid pulse, only four (31 +/- 13%) of whom sustained a stroke. One patient died in the immediate postoperative period due to severe brain injury, yielding an operative mortality rate of 14 +/- 14%. Two patients had persistent neurological deficits and died within 4 months of operation; the actuarial survival estimate at 1 year was 57 +/- 19% (mean +/- SEM). One patient recovered function of one upper extremity (preoperative left hemiparesis compounded by paraplegia) but died 6 years later. The remaining three long-term survivors (43 +/- 19%) had major resolution of their neurological deficits and are clinically well 2-8 years postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for PubMedID 2766534

  • Chronic ovine evaluation of a totally implantable electrical left ventricular assist system. ASAIO transactions / American Society for Artificial Internal Organs Ramasamy, N., Chen, H., Miller, P. J., Jassawalla, J. S., Greene, B. A., Ocampo, A., Siegel, L. C., Oyer, P. E., Portner, P. M. 1989; 35 (3): 402-404

    Abstract

    The totally implantable Novacor left ventricular assist system (LVAS) comprises a pump/drive unit (VAD), electronic control and power subsystem (ECP), variable volume compensator (VVC), and belt skin transformer (BST). The system is now undergoing chronic in vivo evaluation. Cumulative animal testing of VAD, VVC, and BST subsystems are 12.1, 4.9, and 43 years, respectively. The longest implants were 279 days for the VAD, 767 days for the VVC, and 1,148 days for the BST. A chronic implant of the total system was electively terminated at 260 days. The LVAS was powered via the BST. Continuously monitored hemodynamic and pump parameters have demonstrated normal hemodynamics and LVAS operation. Periodic VVC determinations suggest a 0.8 ml/day diffusive gas loss. Tether-free operation has been demonstrated with an Ag-Zn battery backpack. The animal was healthy and free of infection as indicated by routine hematologic, biochemical and serum enzyme determinations. Hemolysis is minimal (plasma free hemoglobin less than 5 mg%). Pump output ranged from 7 to 8 L/min. Severe valve calcification was the reason for elective termination at 260 days. This preclinical in vivo experience, and in vitro reliability studies, demonstrate efficacy of the total system.

    View details for PubMedID 2597489

  • CYTOMEGALO-VIRUS INFECTION IS ASSOCIATED WITH CARDIAC ALLOGRAFT-REJECTION AND ATHEROSCLEROSIS JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION GRATTAN, M. T., MORENOCABRAL, C. E., Starnes, V. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1989; 261 (24): 3561-3566

    Abstract

    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.

    View details for Web of Science ID A1989AA76400023

    View details for PubMedID 2542633

  • HEART-TRANSPLANTATION IN CHILDREN JOURNAL OF HEART TRANSPLANTATION Starnes, V. A., Bernstein, D., Oyer, P. E., GAMBERG, P. L., Miller, J. L., Baum, D., Shumway, N. E. 1989; 8 (1): 20-26

    Abstract

    Heart transplantation in children is being performed with increasing frequency. As experience has accrued, problems of rejection, graft atherosclerosis, and growth have been noted. Seventeen children (seven boys and 10 girls) between the ages of 5 months and 14 years have undergone heart transplantation since 1981. The preoperative diagnosis was cardiomyopathy in 13 children, congenital heart disease in two, and endocardial fibroelastosis in two. Immunosuppressive therapy has included a tapering schedule of cyclosporine, azathioprine, and prednisone. There are 13 children alive, with four hospital deaths (two of infection, one of rejection, and one of graft failure). Rejection occurs as frequently in children as in adults. Two children have undergone retransplantation for rejection. Long-term hemodynamics are normal. Growth has been delayed in two of five children who are younger than age 10 years. Kidney function remains stable. Rehabilitation is 100% among the discharged patients. Heart transplantation in children represents an effective therapeutic modality. Heart transplantation in the young has emphasized morbidity caused by current immunosuppressive agents.

    View details for Web of Science ID A1989T169600004

    View details for PubMedID 2647927

  • IMPLANTABLE ELECTRICAL LEFT-VENTRICULAR ASSIST SYSTEM - BRIDGE TO TRANSPLANTATION AND THE FUTURE ANNALS OF THORACIC SURGERY Portner, P. M., Oyer, P. E., Pennington, D. G., Baumgartner, W. A., Griffith, B. P., FRIST, W. R., MAGILLIGAN, D. J., Noon, G. P., Ramasamy, N., Miller, P. J., Jassawalla, J. S. 1989; 47 (1): 142-150

    Abstract

    An implantable left ventricular assist system (LVAS) utilizing an electromechanically driven dual pusher-plate blood pump has been employed in a multiinstitutional trial as a bridge to cardiac transplantation. Under development for permanent circulatory support in patients with end-stage heart disease, the LVAS, in this application, derives power and control from an external console via a percutaneous lead. The LVAS was implanted in 20 patients (16 men, 4 women) who were hemodynamically unstable or in refractory cardiogenic shock. The mean age was 44.9 years (range, 25 to 63 years). Preoperative diagnosis was evenly divided between end-stage ischemic disease, cardiomyopathy, and acute myocardial infarction. Implanted in the left upper quadrant within the anterior abdominal wall, the blood pump was connected between the left ventricular apex and ascending aorta. Total support of the systemic circulation and substantial left ventricular unloading were achieved with synchronous counterpulsation for periods up to 90 days (mean, 22.7 days). All patients were stabilized hemodynamically. The mean preoperative cardiac index of 1.5 L/min/m2 increased by a factor of 2. Pulmonary arterial pressures decreased substantially. Serious complications occurred in 16 patients, precluding cardiac transplantation in 10. Most complications (greater than 70%) were in patients who did not receive transplants; the most common complication was bleeding. Twelve of 13 patients with LVAS implants for more than seven days were mobilized, and 4 were fully ambulatory and completely rehabilitated. Orthotopic cardiac transplantation was performed in 10 patients after implants ranging from two to 90 days (mean, 30.3 days).(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1989R771200027

    View details for PubMedID 2643401

  • Bioprosthetic valve calcification and pseudoneointimal proliferation in bovine and ovine models. ASAIO transactions / American Society for Artificial Internal Organs Ramasamy, N., Chen, H., Miller, P. J., Jassawalla, J. S., Oyer, P. E., Portner, P. M. 1988; 34 (3): 696-702

    Abstract

    Both porcine (PX) and bovine pericardial (BP) valves have been used in the implantable Novacor left ventricular assist system (LVAS). Results from 58 chronic LVAS implants of greater than 7 days in calves and adult sheep are presented: the PX valve was used in 41 and the BP in 17. With PX valves, the maximum and mean assist durations were 161 and 54 days, respectively, in the calf and 279 and 129 days, respectively, in the sheep. The maximum and mean durations for BP valves were 93 and 38 days (calf) and 153 and 69 days (sheep). In bovine studies with PX valves, severe obstructive pseudoneointimal (PNI) proliferation in the Dacron inflow conduit was the primary cause for termination; valves exhibited moderate calcification. With BP valves, both PNI proliferation and severe valve calcification contributed to a declining pump output, leading to termination. In contrast to the bovine experience, PNI proliferation was not observed in ovine implants. BP valves still became calcified, as evidenced by a progressive decline in pump output (from about twelve weeks) and confirmed at termination. Valve calcification was minimal with the PX valves, even at 236 days. These results favor the adult ovine animal model for extended implants.

    View details for PubMedID 3196586

  • ISOLATED LEFT-VENTRICULAR ASSIST AS BRIDGE TO CARDIAC TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Starnes, V. A., Oyer, P. E., Portner, P. M., Ramasamy, N., Miller, P. J., Stinson, E. B., Baldwin, J. C., REAM, A. K., Wyner, J., Shumway, N. E. 1988; 96 (1): 62-71

    Abstract

    The electrically driven Novacor implantable left ventricular assist device has been implanted in six patients (four men and two women) since Sept. 7, 1984. In four of the six patients (67%) the device was a successful bridge to cardiac transplantation. One patient died of multiple organ failure and Candida sepsis after 16 days of support with the device. One patient died in the operating room of uncontrollable hemorrhage and biventricular failure caused by severe cardiac rejection. Three patients are alive with cardiac transplants 38, 17, and 10 months after transplantation. One patient died after cardiac transplantation of presumed sepsis. The Novacor left ventricular assist device performed in all cases without mechanical or electrical failure. Excluding the intraoperative death, assist duration ranged from 2 to 16 days. The cardiac index (synonymous with device output) ranged from 2.4 to 3.4 L/min/m2. No embolic events (cerebrovascular or systemic) occurred during assistance with the device. Minimal red cell hemolysis was documented during the period of support. The Novacor left ventricular assist device is a safe and effective bridge to cardiac transplantation in patients with refractory cardiogenic shock.

    View details for Web of Science ID A1988P219900009

    View details for PubMedID 3290589

  • In vitro and in vivo testing of a totally implantable left ventricular assist system. ASAIO transactions / American Society for Artificial Internal Organs Jassawalla, J. S., Daniel, M. A., Chen, H., Lee, J., LaForge, D., BILLICH, J., Ramasamy, N., Miller, P. J., Oyer, P. E., Portner, P. M. 1988; 34 (3): 470-475

    Abstract

    The totally implantable Novacor LVAS is being tested under NIH auspices to demonstrate safety and efficacy before clinical trials. Twelve complete systems (submerged in saline at 37 degrees C) are being tested, with an NIH goal of demonstrating 80% reliability for 2 year operation with a 60% confidence level. The systems, which are continuously monitored, are diurnally cycled between two output levels by automatically varying preload and afterload. Currently, 14.3 years of failure-free operation have been accumulated, with a mean duration of 14 months. Using an exponential failure distribution model, the mean time to failure (MTTF) is greater than 8.8 years, corresponding to a demonstrated reliability (for a 2 year mission time) of 80% (80% confidence level). Recent ovine experiments with VAS subsystems include a 767 day volume compensator implant, a 279 day pump/drive unit implant and a 1,448 day BST implant. The last 12 chronic pump/drive unit experiments had a mean duration of 153 days (excluding early postoperative complications). This compares favorably with the NIH goals for complete systems (5 month mean duration). Complete system experiments are currently underway.

    View details for PubMedID 3196548

  • RECIPIENT SELECTION FOR HEART-LUNG TRANSPLANTATION SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Harjula, A. L., Baldwin, J. C., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1988; 22 (3): 193-196

    Abstract

    Cardiac transplantation has emerged as a standard mode of clinical therapy for end-stage heart failure, while heart-lung transplantation is still an experimental rather than a standard mode of clinical therapy for end-stage heart and lung disease. Since clinical application of heart-lung transplantation began in March 1981, there has been continual improvement in donor care, surgery, post-operative management, and the diagnosis and treatment of lung and heart rejection. According to our 6-year clinical experience, both patients with Eisenmenger's physiology and patients with primary pulmonary hypertension are considered suitable candidates for heart-lung transplantation. In the future, our recipient population will include small children and patients with cystic fibrosis. Suitable candidates must have good liver and kidney function, and freedom from previous major pulmonary emboli, systemic diseases, and previous thoracic surgery. Patients must maintain their functional and emotional status to pass successfully the difficult postoperative period. Proper donor and recipient selection in connection with improved heart-lung preservation has resulted in excellent operative survival (100%) following the last ten operations, and only the lack of suitable donors can limit the number of heart-lung transplantations in the future.

    View details for Web of Science ID A1988Q411100001

    View details for PubMedID 3147509

  • ORTHOTOPIC CARDIAC TRANSPLANTATION FOR UNIVENTRICULAR HEART ANNALS OF THORACIC SURGERY Macoviak, J. A., Baldwin, J. C., Ginsburg, R., Fowler, M., Valentine, H., Oyer, P. E., Stinson, E. B. 1988; 45 (1): 85-86

    Abstract

    The technical aspects of orthotopic cardiac transplantation for univentricular heart in a 22-year-old man are discussed. Abnormal pulmonary artery anatomy resulted in right ventricular failure, which was successfully treated.

    View details for Web of Science ID A1988M025100020

    View details for PubMedID 3337582

  • NONINVASIVE ASSESSMENT OF DONOR AND NATIVE HEART FUNCTION AFTER HETEROTOPIC HEART-TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Allen, M. D., NAASZ, C. A., Popp, R. L., Hunt, S. A., Goris, M. L., Oyer, P. E., Stinson, E. B. 1988; 95 (1): 75-81

    Abstract

    The contribution of the donor heart to total circulatory performance after heterotopic heart transplantation has been difficult to assess. First-pass nuclear angiocardiography and directional Doppler echocardiography were used to examine separately left and right ventricular function of the donor heart after heterotopic transplantation. A comparison was made between two patients, one with a low initial pulmonary vascular resistance and one with a high, relatively fixed pulmonary vascular resistance. In both cases, currently available noninvasive techniques allowed confirmation of the expectation that the donor left ventricle can function effectively as a left ventricular bypass. In neither case was recovery of the native heart demonstrated. The contribution of the donor right ventricle to total right ventricular output appeared to be dependent on the condition of the donor heart and on the pulmonary vascular resistance. In situations with a high pulmonary vascular resistance and end-stage right ventricular failure, it was concluded that the donor heart may not at first constitute an effective assist for the native right ventricle. Native right ventricular failure may then become a major factor influencing survival after heterotopic heart transplantation.

    View details for Web of Science ID A1988L686700010

    View details for PubMedID 3275840

  • PROPER DONOR SELECTION FOR HEART-LUNG TRANSPLANTATION - THE STANFORD EXPERIENCE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Harjula, A., Baldwin, J. C., Starnes, V. A., Stinson, E. B., Oyer, P. E., Jamieson, S. W., Shumway, N. E. 1987; 94 (6): 874-880

    Abstract

    Clinical cardiopulmonary transplantation is currently limited by the availability of suitable heart-lung donors. Distant graft procurement, with pretreatment, of the donor by intravenous prostaglandin E1 and cooling of the graft with pulmonary artery perfusion, is now clinically established and should increase the number of available donors. Between March 1981 and September 1986, 40 heart-lung transplantations were performed. The characteristics of the donor pool were analyzed. Gram stain of the donor tracheal aspirate revealed gram-positive bacteria in 80% and gram-negative organisms in 35%. Yeast was present on stain in 25% of the patients. Donor arterial oxygen tension was less than 100 torr inspired oxygen concentration 40%) repeatedly in one patient; this recipient died of lung failure at operation. Severe deterioration of allograft lung function was seen in 11 (27.5%) recipients. The causes of deterioration were substantial postoperative bleeding in six patients, sepsis in two, and acute rejection, poor lung function, and allograft heart failure in one patient each. HLA-A locus mismatch, poor donor alveolar-capillary gas exchange, tracheal colonization with heavy polymorphonuclear cells, and heavy bacteria and fungus resulted in increased operative mortality. Donor pretreatment with prostaglandin E1 was associated with improved survival. Recipient selection, emphasizing adequate liver function and absence of previous thoracic operation, careful surgical technique with minimal bleeding, and brief perfusion time were factors associated with improved survival. Early morbidity and mortality were principally related to recipient risk factors, and the strict criteria observed for selection of heart-lung donors were valid. The importance of appropriate recipient selection is underscored.

    View details for Web of Science ID A1987L177300009

    View details for PubMedID 3119947

  • Noninvasive detection of human cardiac transplant rejection with indium-111 antimyosin (Fab) imaging. Circulation FRIST, W., Yasuda, T., Segall, G., Khaw, B. A., Strauss, H. W., Gold, H., STINSON, E., Oyer, P., Baldwin, J., Billingham, M. 1987; 76 (5): V81-5

    Abstract

    Diagnosis of rejection after cardiac transplantation is currently made by right ventricular endomyocardial biopsy. To evaluate antimyosin imaging as a noninvasive means of detecting human cardiac rejection, the Fab fragment of murine monoclonal antimyosin antibodies was labeled with indium-111 and given intravenously to 18 patients (age 45 +/- 12 years) in 20 studies 7 days to 9 years after transplantation. Endomyocardial biopsy specimens were obtained at the time of each imaging study. Eight patients had positive scans confirmed by biopsy as rejection, and eight patients had negative scans and no evidence of rejection on biopsy. Discordance was observed in four studies, two with positive scans and no rejection on biopsy and two with negative scans and positive biopsy. The sensitivity, specificity, and overall accuracy of the technique were each 80%. Imaging with radiolabeled antimyosin antibody Fab fragments may be of value in the noninvasive identification of rejection in the cardiac transplant recipient.

    View details for PubMedID 3311460

  • Cardiac transplantation in children and adolescents. Circulation Starnes, V. A., Stinson, E. B., Oyer, P. E., Valantine, H., Baldwin, J. C., Hunt, S. A., Shumway, N. E. 1987; 76 (5): V43-7

    Abstract

    Cardiac transplantation represents an expanding therapeutic modality for end-stage heart disease in children and adolescents. During the past 5 years, 27 patients (15 boys; 12 girls) between the ages of 2 and 18 have undergone cardiac transplantation. The preoperative diagnosis was cardiomyopathy in 24 (six familial), congenital heart disease in two, and endocardial fibroelastosis in one. Immunosuppression included cyclosporine, azathioprine, and prednisone. There were 22 survivors, with four hospital deaths (three infection, one pulmonary hypertension), and one death at 4.5 years from graft atherosclerosis. The actuarial survival at 4 years was 83 +/- 7.4% and that at 5 years was 69 +/- 14.2%. Renal function was stable at 4 years, with an average creatinine clearance of 69.75 +/- 27.0 ml/min/m2. Hypertension was present in 21 of 22 patients, who require multiple drug therapy. Rehabilitation is 100% among discharged patients, with 14 in school, six employed, and two toddlers.

    View details for PubMedID 3311454

  • CARDIAC TRANSPLANTATION IN CHILDREN AND ADOLESCENTS CIRCULATION Starnes, V. A., Stinson, E. B., Oyer, P. E., Valantine, H., Baldwin, J. C., Hunt, S. A., Shumway, N. E. 1987; 76 (5): 43-49
  • LONG-TERM HEMODYNAMIC-RESULTS AFTER CARDIAC TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Frist, W. H., Stinson, E. B., Oyer, P. E., Baldwin, J. C., Shumway, N. E. 1987; 94 (5): 685-693

    Abstract

    Although survival after cardiac transplantation has improved since the introduction of cyclosporine to clinical practice in 1980, the long-term hemodynamic results of transplantation in cyclosporine-treated recipients has not been reported. Annual cardiac catheterization data for 109 cyclosporine-treated recipients were analyzed and compared to those of a nonconcurrent group of 65 recipients treated with azathioprine and corticosteroids. Recipient age, donor age, sex, and human leukocyte antigen mismatch were comparable for the two groups. Satisfactory left ventricular function of the cyclosporine-treated heart was characterized on the first annual study by a normal ejection fraction (60% +/- 10%), cardiac index (3.0 +/- 0.8 L/min/m2) and stroke work index (53 +/- 15 gm-m/m2) associated with moderately increased left ventricular end-diastolic pressures (12 +/- 6 mm Hg) and significantly increased mean aortic pressures (116 +/- 8 mm Hg). With the exception of aortic diastolic pressure, which tended to increase with time, the mean values of each variable analyzed did not change significantly over the period of study. In comparison to the azathioprine group, the cyclosporine cohort displayed higher aortic, left ventricular end-diastolic, and pulmonary artery pressures and produced more stroke work at each annual study. Analysis of the azathioprine group over extended (8 year) follow-up suggested excellent preservation of graft function. In summary, the long-term hemodynamic function of the transplanted heart treated with cyclosporine was satisfactory, demonstrated no deterioration over 5 year follow-up, but manifested substantially greater hypertension than hearts from the pre-cyclosporine era.

    View details for Web of Science ID A1987K815000006

    View details for PubMedID 3312822

  • COMPARISON OF CARDIAC REJECTION IN HEART AND HEART-LUNG TRANSPLANTATION JOURNAL OF HEART TRANSPLANTATION Baldwin, J. C., Oyer, P. E., Stinson, E. B., Starnes, V. A., Billingham, M. E., Shumway, N. E. 1987; 6 (6): 352-356

    Abstract

    Cardiac biopsy remains the principal tool for diagnosis of rejection in heart and heart-lung transplantation. In rare instances pulmonary rejection may occur without cardiac rejection, but the overall incidence of cardiac rejection may be less with heart-lung transplantation than with heart transplantation. During the 6 months from March to September 1986, 40 heart transplantations and nine heart-lung transplantations were performed. Heart transplant patients received cyclosporine (8 to 10 mg/kg/day), azathioprine (1 to 2 mg/kg/day), and prednisone (0.8 mg/kg/day, with tapering). Heart-lung transplant patients received cyclosporine and azathioprine in the same dosages, but steroids were withheld for 3 weeks. Heart-lung transplant patients received three postoperative dosages of rabbit antithymocyte globulin (200 mg intramuscularly). There were five early deaths in the heart transplant group, four from infection and one from cerebrovascular accident. Since the initial rejection analysis presented here, one additional heart transplant patient died from rejection (241 days), and one heart-lung transplant patient died from infection (99 days). Cyclosporine levels were determined by radioimmunoassay, and cardiac rejection was diagnosed by serial endomyocardial biopsy. Early cardiac rejection is notably less common after heart-lung transplantation than after heart transplantation. Although the prophylactic antithymocyte globulin given in heart-lung transplantation may be important in this regard, rejection is probably inherently less common after heart-lung transplantation.

    View details for Web of Science ID A1987L259000007

    View details for PubMedID 3121819

  • NONINVASIVE DETECTION OF HUMAN CARDIAC TRANSPLANT REJECTION WITH IN-111 ANTIMYOSIN (FAB) IMAGING CIRCULATION FRIST, W., Yasuda, T., Segall, G., Khaw, B. A., Strauss, H. W., Gold, H., STINSON, E., Oyer, P., Baldwin, J., Billingham, M., McDougall, I. R., Haber, E. 1987; 76 (5): 81-85
  • CLINICAL HEART-LUNG PRESERVATION WITH PROSTAGLANDIN-E-1 TRANSPLANTATION PROCEEDINGS Harjula, A. L., Baldwin, J. C., Stinson, E. B., Oyer, P. E., Shumway, N. E. 1987; 19 (5): 4101-4102

    View details for Web of Science ID A1987K855800197

    View details for PubMedID 3118534

  • HLA COMPATIBILITY AND CARDIAC TRANSPLANT RECIPIENT SURVIVAL ANNALS OF THORACIC SURGERY Frist, W. H., Oyer, P. E., Baldwin, J. C., Stinson, E. B., Shumway, N. E. 1987; 44 (3): 242-246

    Abstract

    Although the major histocompatibility complex has been linked with the control and expression of immune response in mammalian species, its importance for heart transplantation has not been demonstrated. The relationship of patient survival to human lymphocyte antigen (HLA) (A and B loci) compatibility was studied in 164 consecutive cyclosporine-treated patients who underwent orthotopic heart transplantation between 1980 and 1986 at Stanford University Medical Center. All patients receiving a transplant within this time frame were included except those for whom HLA typing was unavailable. A mismatched antigen was defined as an antigen present in the donor but not in the recipient. The actuarial four-year survival (Cutler-Ederer) for the 19 patients with 0 or 1 mismatch was 88 +/- 8%; for the 39 patients with 2 mismatches, 70 +/- 12%; for the 73 patients with 3 mismatches, 59 +/- 7%; and for the 33 patients with 4 mismatches, 54 +/- 14%. Both actuarial and linear rate analyses revealed no significant correlation between HLA mismatching and rejection rate, likelihood of death from rejection, or length of time to first episode of rejection. Patients with 3 or 4 mismatches had significantly (p less than 0.05) more infections than those with fewer mismatches. By actuarial analysis, a trend toward a higher number of deaths from rejection and infection was observed in the groups with 3 and 4 mismatches, but it did not achieve statistical significance. The data demonstrate that well-matched HLA grafts are associated with better long-term survival and fewer infections in cardiac transplant patients.

    View details for Web of Science ID A1987K153900005

    View details for PubMedID 3307658

  • DISTANT GRAFT PROCUREMENT FOR COMBINED HEART AND LUNG TRANSPLANTATION USING PULMONARY-ARTERY FLUSH AND SIMPLE TOPICAL HYPOTHERMIA FOR GRAFT PRESERVATION ANNALS OF THORACIC SURGERY Baldwin, J. C., Frist, W. H., Starkey, T. D., Harjula, A., Starnes, V. A., Stinson, E. B., Oyer, P. E., Shumway, N. E. 1987; 43 (6): 670-673

    Abstract

    Although combined heart and lung transplantation has great potential for improving survival and rehabilitation in selected patients with pulmonary vascular disease, the lack of suitable donor organs has restricted the number of operations performed. We report a heart and lung transplantation operation for Eisenmenger's syndrome in which distant donor graft procurement was used with a simple system for preservation.

    View details for Web of Science ID A1987H808500020

    View details for PubMedID 3109339

  • Human leukocyte antigen compatibility in heart-lung transplantation. journal of heart transplantation Harjula, A. L., Baldwin, J. C., Glanville, A. R., Tazelaar, H., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1987; 6 (3): 162-166

    Abstract

    The relationship of heart-lung allograft-related death and obliterative bronchiolitis (OB) to human leukocyte antigen (HLA) matching was studied in 40 consecutive heart-lung transplant patients operated on between March 1981 and September 1986. Mismatch was defined as an antigen present in the donor but not in the recipient. Patients with only one antigen identified at a given locus were presumed to be homozygous for that antigen. The results were obtained from the patients who survived more than 3 months after surgery. The patients with zero to one mismatches in the HLA locus A (10 patients) had a tendency toward less OB, less severe OB, and fewer deaths from OB than the patients (15) with two mismatches in HLA locus A. However, only graded OB (1, mild; 2, moderate; 3, severe) was significantly different (p = 0.05) in these groups. There was one patient with no A locus mismatches; she survived 62 months, and no OB was found at her autopsy. This limited experience suggests that HLA-A locus match may have a salutary effect on long-term results and that OB may be at least partly a result of chronic rejection.

    View details for PubMedID 3116183

  • PRIMARY CARDIAC NEOPLASMS - EARLY AND LATE RESULTS OF SURGICAL-TREATMENT IN 42 PATIENTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY DEIN, J. R., Frist, W. H., Stinson, E. B., Miller, C., Baldwin, J. C., Oyer, P. E., Jamieson, S., Mitchell, R. S., Shumway, N. E. 1987; 93 (4): 502-511

    Abstract

    Forty-two patients underwent resection of primary cardiac neoplasms at Stanford University Medical Center and the Palo Alto Veterans Administration Medical Center between 1961 and 1986. A total of 27 atrial myxomas, seven benign nonmyxomatous tumors, and eight malignant tumors were resected. The mean age was 47 years (range 8 to 79) in 27 female and 15 male patients. The clinical presentations included congestive heart failure in 24 patients, palpitations in nine, neurologic symptoms in six, recurrent cardiac tamponade in three, vasculitis in two, and chest pain in two. Thirty-one of 34 benign lesions were completely resected, although one patient required cardiac transplantation to resect completely an "inoperable" benign tumor. All gross tumor was resected in four of eight patients with malignant lesions. All patients survived operation, but three with malignant disease died within 30 days. Late outcome was known for 41 of 42 (98%) patients. Total follow-up for the series was 200.1 patient-years, for an average of 4.7 years (range 1 month to 18 years). Excellent early and late results were obtained in patients with benign lesions, as there was no known tumor recurrence even if resection was incomplete. Effective palliation and local control of disease is possible with extensive resection of malignant primary tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

    View details for Web of Science ID A1987G751000003

    View details for PubMedID 3560997

  • RESULTS OF IMMUNOCONVERSION FROM CYCLOSPORINE TO AZATHIOPRINE IN HEART-TRANSPLANT RECIPIENTS WITH PROGRESSIVE NEPHROTOXICITY TRANSPLANTATION PROCEEDINGS Hunt, S. A., Stinson, E. B., Oyer, P. E., Billingham, M. E., Gamberg, P., Miller, J., Schroeder, J. S., Baldwin, J. C., Shumway, N. E. 1987; 19 (1): 2522-2524

    View details for Web of Science ID A1987G101500252

    View details for PubMedID 3274554

  • A RECONSIDERATION OF CEREBRAL PERFUSION IN AORTIC-ARCH REPLACEMENT ANNALS OF THORACIC SURGERY Frist, W. H., Baldwin, J. C., Starnes, V. A., Stinson, E. B., Oyer, P. E., Miller, D. C., Jamieson, S. W., Mitchell, R. S., Shumway, N. E. 1986; 42 (3): 273-281

    Abstract

    Ten patients underwent aortic arch replacement for aneurysmal disease from 1970 to 1985 using a simplified cardiopulmonary bypass (CPB) technique with partial brachiocephalic perfusion, low CPB flow (30 to 50 ml/kg/min), moderate systemic cooling (26 degrees to 28 degrees C), and topical hypothermic myocardial protection. The arterial line from a single pump head has a Y shape to perfuse the femoral artery (20F cannula) and either the innominate or left carotid artery (14F). Of the 10 patients (mean age, 58 years) with arch aneurysm (6 atherosclerotic, 2 dissections, and 2 degenerative), 3 had previously undergone major cardiovascular operations. Concomitant procedures included aortic valve replacement in 4 and coronary artery bypass grafting in 3. Eight patients survived the procedure, and 1 died three weeks after operation of a ruptured abdominal aneurysm. Among the survivors, CPB time was 119 +/- 36 minutes (+/- standard deviation), myocardial ischemia time was 79 +/- 32 minutes, and intraoperative blood requirement was 5.9 +/- 3.4 units. There were no postoperative strokes. Neurological complications were only minor and included an asymptomatic miosis and ulnar nerve paresthesias in 1 patient and transient vocal cord palsy in another. Applicable in most patients undergoing elective resection of degenerative and atherosclerotic arch aneurysms and in selected patients with arch dissections, this simplified technique of brachiocephalic perfusion without circulatory arrest provides an attractive and safe alternative; the potential advantages are technical simplicity, reduced CPB and operating times, and satisfactory cerebral protection.

    View details for Web of Science ID A1986E046200010

    View details for PubMedID 3489444

  • SEPTAL ORIGIN OF SUSTAINED VENTRICULAR-TACHYCARDIA IN A PATIENT WITH RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION AFTER CORRECTION OF TETRALOGY OF FALLOT PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY Swerdlow, C. D., Oyer, P. E., Pitlick, P. T. 1986; 9 (4): 584-588

    Abstract

    Right ventricular hypertension and ventricular arrhythmias are risk factors for sudden death after correction of tetralogy of Fallot, but sustained ventricular tachycardia has been reported only in patients without residual hemodynamic abnormalities. A patient with right ventricular hypertension and hypotensive ventricular tachycardia tolerated the arrhythmia better after relief of right ventricular outflow tract obstruction. This case provides insight into the relationship between hemodynamic abnormalities and the clinical consequences of arrhythmias. To our knowledge, it is the first report of ventricular tachycardia originating in scar adjacent to the ventricular septal defect patch after correction of tetralogy of Fallot.

    View details for Web of Science ID A1986D099600016

    View details for PubMedID 2426677

  • RESULTS OF OPERATIONS FOR VENTRICULAR-TACHYCARDIA IN 105 PATIENTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Swerdlow, C. D., Mason, J. W., Stinson, E. B., Oyer, P. E., WINKLE, R. A., Derby, G. C. 1986; 92 (1): 105-113

    Abstract

    Operations to treat ventricular tachycardia refractory to antiarrhythmic drugs were performed in 105 patients. Intraoperative epicardial activation sequence maps were completed in 83% and endocardial maps in 57%. Mapping could be used to guide 79% of operations. When no useful mapping data were obtained, patients had visually guided antiarrhythmic operations (17%) or conventional cardiac operations (4%). The most frequently performed antiarrhythmic procedures, alone or in combination, were endomyocardial resection (45%), cryothermal destruction (44%), and encircling procedures (20%). Operative mortality was 16%, including 6% from heart failure and 4% from ventricular tachycardia. Emergency operation (p = 0.002) and New York Heart Association heart failure class (p = 0.01) were independent preoperative risk factors for cardiac operative mortality in the 98 patients with coronary artery disease. At postoperative electrophysiologic study performed in 79 patients, ventricular tachycardia could not be induced in 75% of patients who had map-guided operations and 36% who had visually guided ones (p = 0.001). During follow-up of 23 +/- 21 months, results of postoperative electrophysiologic study predicted ventricular tachycardia recurrence. At 2 years the actuarial incidence of freedom from arrhythmia recurrence was 50% +/- 10% in patients with and 78% +/- 6% in patients without inducible ventricular tachycardia (p = 0.001); it was 71% +/- 5% in patients who had map-guided operations and 37% +/- 12% in patients who had visually guided ones (p = 0.004). Ventricular tachycardia recurrence was infrequent in survivors of map-guided operations; benefits of surgical treatment for ventricular tachycardia were limited by high operative mortality and frequent arrhythmia recurrence when no useful mapping data were obtained.

    View details for Web of Science ID A1986D068800015

    View details for PubMedID 3724212

  • SIGNIFICANT PATIENT-RELATED DETERMINANTS OF PROSTHETIC VALVE PERFORMANCE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Mitchell, R. S., Miller, D. C., Stinson, E. B., Oyer, P. E., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1986; 91 (6): 807-817

    Abstract

    With rare exception, the bulk of out knowledge concerning the performance of any particular valve substitute originates from one institution; thus, if valve-related complications are more a function of the patient substrate undergoing operation than the prosthesis per se, the usefulness of inter-institutional comparisons would be severely limited. To address this question, the outcome of 2,719 patients after mitral or aortic valve replacement over 12,955 patient-years of follow-up was analyzed by time-dependent multivariate statistical methods with respect to thromboembolic events, anticoagulant-related hemorrhage, valve failure, fatal valve failure, all valve-related morbidity and mortality, necessity for reoperation, and late survival. Many patient-related factors were significant predictors of the probability of certain patient groups for sustaining these valve-related complications. Hence, comparisons of results of valve performance from different institutions may be misleading unless patient populations are comparable.

    View details for Web of Science ID A1986C716600001

    View details for PubMedID 3713234

  • THE ROLE OF CYCLOSPORINS IN HEART-TRANSPLANTATION HELVETICA CHIRURGICA ACTA Walpoth, B., Oyer, P., Jamieson, S., STINSON, E., Shumway, N. 1986; 53 (1-2): 123-126
  • COMBINED HEART-LUNG TRANSPLANTATION FOR END-STAGE EISENMENGERS SYNDROME JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY McGregor, C. G., Jamieson, S. W., Baldwin, J. C., Burke, C. M., Dawkins, K. D., Stinson, E. B., Oyer, P. E., Billingham, M. E., Zusman, D. R., Reitz, B. A., Yousem, S., Hunt, S. A., Shumway, N. E. 1986; 91 (3): 443-450

    Abstract

    Between May, 1981, and December, 1984, thirteen combined heart-lung transplants were performed in 12 patients for the treatment of Eisenmenger's syndrome. The age range of the recipients was 22 to 42 years. Two patients had undergone previous open cardiac operations; in addition, one had had closure of a persistent ductus arteriosus, one an open lung biopsy, one a pulmonary artery banding, and one patient received a second heart-lung transplant after 3 years. Four recipients died before hospital discharge, one at operation and three at 4, 10, and 33 days after operation. Early symptomatic results and cardiopulmonary function were excellent in all of the survivors. Two patients died 14 and 15 months after transplantation of accelerated graft arteriosclerosis and respiratory failure, respectively, and six remain alive 7 to 44 months after transplantation. Four of these surviving patients and the two patients who died late subsequently had major pulmonary complications. Symptoms included progressive breathlessness, cough (often productive), and fever with physical signs of diffuse crepitations and expiratory rhonchi. Serial pulmonary function tests showed progressive obstructive physiology in all six patients with superimposed restrictive defects in four. Histologic examination of tissue from open lung biopsy or autopsy displayed bronchiolitis obliterans in five of these patients, one of whom required retransplantation. It is possible that these late changes are the result of rejection, since similar changes in one other patient have now been reversed with augmented immunosuppression. Further understanding of the causes and manifestations of late pulmonary deterioration should improve the late functional results of this operation for Eisenmenger's syndrome.

    View details for Web of Science ID A1986A435500016

    View details for PubMedID 3081765

  • HEART AND HEART-LUNG TRANSPLANTATION PROGRESS IN ALLERGY McGregor, C. G., Oyer, P. E., Shumway, N. E. 1986; 38: 346-365

    View details for Web of Science ID A1986D111900020

    View details for PubMedID 3088581

  • Acute and chronic aortic dissections--determinants of long-term outcome for operative survivors. Circulation Haverich, A., Miller, D. C., Scott, W. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 72 (3): II22-34

    Abstract

    A total of 135 survivors of surgical treatment of aortic dissection was followed for up to 15 years after surgery. Actuarial survival rates were 82 +/- 4% at 5 years and 64 +/- 6% at 10 years. There were no significant differences in long-term survival rates of patients in four subsets based on type and acuity of dissections. The incidence of late reoperation (dissection-related) was 13 +/- 4% at 5 years and 23 +/- 6% at 10 years; again, there was no significant difference among patients with different types or acuity of dissection. Multiple variables were investigated by multivariate discriminant analysis. Significant independent risk factors for late death included stroke, chronic renal dysfunction, remote myocardial infarction, and operation in the early years of this study. Younger age, site of intimal tear (arch), and cardiac tamponade portended a significantly higher likelihood of late reoperation. Except for stroke, no complication of the dissection or intraoperative factor significantly influenced late survival. Patients in whom the intimal tear was located in the aortic arch had the highest probability of late reoperation. Thus, dissection type, acuity, and distal extent, whether or not the tear was resected or concomitant aortic valve replacement performed, and a host of patient-related characteristics had no significant influence on the generally excellent long-term prognosis after surgical treatment. Indefinite surveillance of the remaining natural aorta is imperative (with reoperation when indicated) to attain such results.

    View details for PubMedID 3928189

  • Operative risk of mitral valve replacement: discriminant analysis of 1329 procedures. Circulation Scott, W. C., Miller, D. C., Haverich, A., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1985; 72 (3): II108-19

    Abstract

    The influence of 34 variables on the operative mortality rate for isolated mitral valve replacement (MVR) was assessed by univariate and multivariate logistic regression analysis. The physiologic lesions were classified as stenosis (20%, operative mortality rate 8 +/- 1%), regurgitation (44%, operative mortality rate 13 +/- 2%), and mixed (34%, operative mortality rate 8 +/- 1%). Functional class (NYHA), previous myocardial infarction, and hepatic dysfunction were powerful independent clinical determinants of operative mortality (p less than .001), along with age at operation and emergency operation (p = .001, p = .04). Concomitant coronary artery bypass grafting or tricuspid annuloplasty, angina, ischemic etiology, and physiologic lesion were not significant independent determinants of operative risk. Interestingly, year of operation, prosthetic valve dysfunction, and previous cardiac surgery had no important effect on operative mortality. Early operative risk for MVR was related to preoperative cardiac and hepatic function. Prior myocardial infarction substantially increased the risk even if the mitral valve disease was not ischemic in origin. Increased operative mortality rate in the subgroup with mitral regurgitation was related to advanced left ventricular failure and myocardial infarction rather than the etiology of the mitral regurgitation. These clinical factors coupled with more refined measurements of left ventricular systolic pump function (independent of loading conditions) should permit more intelligent decision making regarding the optimal timing of MVR, at least in terms of early operative risk.

    View details for PubMedID 4028353

  • Surgical treatment of constrictive pericarditis: analysis of outcome and diagnostic error. Circulation Seifert, F. C., Miller, D. C., Oesterle, S. N., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 72 (3): II264-73

    Abstract

    The records of 81 patients with a diagnosis of constrictive pericarditis who underwent surgical treatment were examined to assess the effectiveness of diagnosis and therapy. A false-positive diagnosis occurred in 10 patients (12%); seven had restrictive cardiomyopathy. Of 51 variables examined, only a low right ventricular end-diastolic pressure (RVEDP) significantly and independently predicted diagnostic error. Seventy-one patients with constrictive pericarditis underwent pericardiectomy. Mean follow-up was 4.7 years (maximum 12), and only two patients were untraceable. The study population was notable: 42 patients had visceral as well as parietal pericardial involvement; 32 had idiopathic disease and 25 had pericarditis related to radiation therapy. Results were favorable in 83% of the population. There were seven in-hospital deaths (10%). Actuarial survival estimates were 74% and 64% at 5 and 10 years, respectively. Compared with a normal population, the survival rate of patients with postradiation constrictive pericarditis was significantly inferior, whereas the survival rate of the remaining patients was not significantly different. Patients with constrictive pericarditis and restrictive cardiomyopathy did no better than those with restrictive cardiomyopathy alone. Additionally, patients in NYHA functional class IV had a significantly worse prognosis. Multivariate analysis of 38 preoperative variables identified high RVEDP as a significant independent predictor of in-hospital death, and renal dysfunction and diuretic use were significant independent predictors of overall poor outcome. Differentiation between the diagnosis of constrictive pericarditis and restrictive cardiomyopathy remains a problem. Radiation therapy, pericarditis with restrictive cardiomyopathy, high RVEDP, NYHA class IV status, renal dysfunction, and diuretic use adversely influenced outcome in patients undergoing pericardiectomy.

    View details for PubMedID 4028364

  • Late airflow obstruction in heart-lung transplantation recipients. journal of heart transplantation Burke, C. M., Morris, A. J., Dawkins, K. D., McGregor, C. G., Yousem, S. A., Allen, M., Theodore, J., Harvey, J., Billingham, M. E., Oyer, P. E. 1985; 4 (4): 437-440

    View details for PubMedID 3939654

  • Quantitative analysis of immunosuppression in cyclosporine-treated heart transplant patients with lymphoma. journal of heart transplantation Brumbaugh, J., Baldwin, J. C., Stinson, E. B., Oyer, P. E., Jamieson, S. W., BIEBER, C. P., Henle, W., Shumway, N. E. 1985; 4 (3): 307-311

    Abstract

    Lymphoma remains an important complication after heart transplantation in the era of cyclosporine immunosuppression. It has been generally assumed that the occurrence of lymphoma related to quantitative degree of immunosuppression, and this assumption is exemplified in the treatment of some such lymphomas with reduction of immunosuppression. Seventy-five consecutive survivors of heart and heart-lung transplantation between December 1980 and July 1983 were treated with cyclosporine and steroids; some received rabbit anti-thymocyte globulin for prophylaxis or treatment of rejection. Measured quantitative parameters of immunosuppression during the first three months after transplantation included mean cyclosporine level, total rabbit anti-thymocyte globulin dosage, number of days of T-cell suppression, and mean cyclosporine level during T-cell suppression. Serial Epstein-Barr virus antibody titers were measured. Lymphoma was diagnosed in six patients. The mean number of episodes of rejection did not differ between the lymphoma and the non-lymphoma groups. All quantitative measures of immunosuppression were higher in the lymphoma group, but this difference achieved statistical significance only in the case of total dosage of rabbit anti-thymocyte globulin (p less than 0.02). Four of the six lymphoma patients received some or all of their rabbit anti-thymocyte globulin dosage as prophylaxis against rejection; one received rabbit anti-thymocyte globulin solely for rejection; and the sixth received no rabbit anti-thymocyte globulin. Ebstein-Barr virus titer conversion (four-fold rise in titer) alone was not significantly associated with occurrence of lymphoma. However, logistic regression analysis suggested that Epstein-Barr virus conversion in concurrence with high mean cyclosporine levels predicted a higher risk of lymphoma.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for PubMedID 3039097

  • 4-YEAR EXPERIENCE WITH CYCLOSPORINE FOR HEART AND HEART LUNG TRANSPLANTATION TRANSPLANTATION PROCEEDINGS Macoviak, J. A., Oyer, P. E., Stinson, E. B., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1985; 17: 97-101
  • HEART-LUNG TRANSPLANTATION - THE POSTOPERATIVE CHEST RADIOGRAPH RADIOLOGY Chiles, C., GUTHANER, D. F., Jamieson, S. W., Stinson, E. B., Oyer, P. E., Silverman, J. F. 1985; 154 (2): 299-304

    Abstract

    The postoperative chest radiographs of 10 patients who had undergone heart-lung transplantation at Stanford University Medical Center were evaluated and compared with those of 10 consecutive cardiac transplantation patients and 10 consecutive coronary artery bypass graft patients. In the second week after surgery, we observed an interstitial radiographic pattern in the heart-lung transplantation patients but not in the other two patient populations. This pattern, which did not correspond with any clinical evidence of infection, rejection, fluid overload, or oxygen toxicity, may represent the reimplantation response described in dogs and primates following transplantation of a single lung. This response may be related to the interruption of bronchial circulation, the denervation of both lungs, and the lymphatic interruption that occur during transplantation. It may also be related to the obligatory period of ischemia that is incurred during implantation.

    View details for Web of Science ID A1985AAA8600003

    View details for PubMedID 3917571

  • PANCREATITIS AFTER CARDIAC AND CARDIOPULMONARY TRANSPLANTATION SURGERY Aziz, S., Bergdahl, L., Baldwin, J. C., Weiss, L. M., Jamieson, S. W., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 97 (6): 653-661

    Abstract

    In a review of 176 patients who died after either cardiac or cardiopulmonary transplantation, 15 cases of pancreatitis were identified. The diagnosis was clinically inapparent in 11 of the 15 cases of pancreatitis. A high index of suspicion should therefore be maintained when these patients are cared for. A variety of factors may have contributed to the occurrence of pancreatitis in these patients. These include infection, steroids, azathioprine, low-flow states, extracorporeal circulation, vasopressors, renal failure, and rejection.

    View details for Web of Science ID A1985AJN0900004

    View details for PubMedID 3890242

  • 10 YEAR DURABILITY AND PERFORMANCE OF PORCINE BIOPROSTHESES ZEITSCHRIFT FUR KARDIOLOGIE Miller, D. C., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 74: 15-18

    Abstract

    The results presented herein describe the prognosis over the first 10 postoperative years for patients operated upon at Stanford University Medical Center who received a first generation, commercially-manufactured porcine bioprosthetic valve. Extrapolation of these results to 15 and 20 years cannot be justified at this time. Conversely, newer tissue valves are believed to be superior, in terms of both hemodynamic performance and long-term durability. Indeed, the newer pericardial valves (Hancock Laboratories and American-Edwards Laboratories) have hemodynamic characteristics that do not differ markedly from those of the tilting disk and bi-leaflet mechanical valves. This promise of potential superior durability in terms of resistance to fibrocalcification will only be able to be determined after patients with these second and third generation tissue valves have been followed for 10 to 15 years postoperatively. Speculation regarding the comparative performance between a durable mechanical valve and a bioprosthesis in the 10 to 15 year time frame is also probably not prudent at this time. We continue to submit, however, that the balance between lower cumulative complication and death rates and finite durability--which currently favors the tissue valve at 10 years--will continue to predominate beyond ten years. This is due for the most part to the constant rate of serious (and frequently fatal) valve-related complications which occur in patients with mechanical valves over the years; having 20 to 40% of patients with mechanical valves succumb within 10 to 15 years due to the complications of TE, ACH, and valve thrombosis is not acceptable, in our opinion, as the magnitude of the risk associated with porcine valve PTF and resultant REOP is lower.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1985AXE7200004

    View details for PubMedID 4096073

  • CYCLOSPORINE IN HEART AND HEART-LUNG TRANSPLANTATION CANADIAN JOURNAL OF SURGERY Modry, D. L., Oyer, P. E., Jamieson, S. W., Stinson, E. B., Baldwin, J. C., Reitz, B. A., Dawkins, K. D., McGregor, C. G., Hunt, S. A., Moran, M., Myers, B., Shumway, N. E. 1985; 28 (3): 274-?

    Abstract

    At Stanford University Medical Center from January 1968 until January 1984, 288 patients received 313 heart transplants. The immunosuppressive regimen before December 1980 consisted of azathioprine and prednisone, with or without rabbit antithymocyte globulin. After that time cyclosporine replaced azathioprine. In 92 recipients of 95 heart allografts, the 1- and 3-year survival rates were 82% and 65% to 70% respectively. In the 3 years from March 1981 to March 1984, successful heart-lung transplantation was accomplished in 13 of 19 recipients, using cyclosporine-based immunosuppression. Survival ranged from 1 to 38 months. While it is true that cyclosporine has improved survival in heart transplant recipients, has allowed successful heart-lung transplantation to be performed, has shortened intensive care unit and total hospital stays and therefore hospital costs, and has allowed easier management of rejection and infection, several disconcerting problems have not yet been resolved. These include hypertension that is difficult to control and renal dysfunction in all patients, and the fact that cellular and humoral rejection still occurs, as manifested by graft atherosclerosis, bronchiolitis obliterans and classic acute rejection. Better understanding and application of cyclosporine immunosuppression will undoubtedly minimize both cyclosporine- and non-cyclosporine-related postoperative complications and will improve survival even further.

    View details for Web of Science ID A1985AHW9000026

    View details for PubMedID 3922606

  • HEART AND HEART-LUNG TRANSPLANTATION SCHWEIZERISCHE MEDIZINISCHE WOCHENSCHRIFT Shumway, N. E., Stinson, E. B., Oyer, P. E., Jamieson, S. W., Baldwin, J. C. 1985; 115 (45): 1571-1574

    Abstract

    Twenty-seven years of laboratory experience in cardiac transplantation at Stanford have provided the necessary background for a moderately successful clinical program which now extends over a period of 17 years. Heart-lung transplantation, again entirely a product of intensive laboratory research, is now ready for clinical use. Certainly much work remains to be done in the area of donor tissue preservation, particularly with respect to the lungs. It appears that new and more specific immunosuppressing drugs are on the horizon, so tissue transplantation in general will be increasingly safer. Heart transplantation has come of age, and combined heart-lung transplantation is well under way.

    View details for Web of Science ID A1985ATT2600001

    View details for PubMedID 3936171

  • BRONCHOSCOPY AFTER CARDIOPULMONARY TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Baldwin, J. C., Jamieson, S. W., Oyer, P. E., Stinson, E. B., Billingham, M. E., Shumway, N. E., Mark, J. B. 1985; 89 (1): 1-7

    Abstract

    Eighteen combined heart and lung transplant operations were performed between March, 1981, and March, 1984. Six of these patients have undergone bronchoscopy, at varying intervals after transplantation. Five of these procedures were done for specific clinical indications; one was done incidentally, during another surgical procedure requiring general anesthesia. All patients had intact, healing tracheal anastomotic suture lines; there were no instances of tracheal stenosis. The distal tracheobronchial tree appeared endoscopically normal in the transplanted lungs, except in areas of known infiltrates. Four of the patients had endobronchial biopsies, and alveolar eosinophilic proteinaceous exudate and submucosal mononuclear infiltrate were consistent features. Two of the later biopsies suggest that squamous metaplasia of the respiratory epithelium may occur with long-term follow-up. Controversy exists as to the optimal technique for tracheal anastomosis, but in the case of the steroid-treated, immunosuppressed transplant patient, continuous anastomosis with polypropylene has yielded satisfactory results.

    View details for Web of Science ID A1985AAG3900001

    View details for PubMedID 3880845

  • LONG-TERM RESULTS, HEMODYNAMICS, AND COMPLICATIONS AFTER COMBINED HEART AND LUNG TRANSPLANTATION CIRCULATION Dawkins, K. D., Jamieson, S. W., Hunt, S. A., Baldwin, J. C., Burke, C. M., Morris, A., Billingham, M. E., Theodore, J., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 71 (5): 919-926

    Abstract

    During the first 31/2 years of the Stanford heart-lung transplant program, 23 transplants have been carried out in 22 patients with severe pulmonary vascular disease. Actuarial survival curves predict 1 and 2 year survival rates of 71% and 57%, respectively, for all patients. As a result of increasing experience, the early mortality of 26% has been reduced, with only one early death occurring in the last eight patients; prior cardiac surgery was a contributing factor in three of the six patients suffering early deaths. Two late deaths occurred in the series 14 and 15 months after operation. One patient died suddenly as a result of an acute myocardial infarct and the other patient died because of respiratory failure. At autopsy, both patients had severe proliferative coronary atherosclerosis with obliterative bronchiolitis affecting the lungs. An additional patient required a retransplant for obliterative bronchiolitis 37 months after the initial procedure, and he too was found to have severe coronary artery disease. Hemodynamics and left ventricular function were normal in patients studied 1 and 2 years after undergoing the transplantation procedure. Thus, the early mortality and morbidity of combined heart and lung transplantation has been significantly reduced, but the long-term complications, particularly graft atherosclerosis and obliterative bronchiolitis, are yet to be fully controlled.

    View details for Web of Science ID A1985AGC5100012

    View details for PubMedID 3921277

  • SURGICAL-TREATMENT OF CONSTRICTIVE PERICARDITIS - ANALYSIS OF OUTCOME AND DIAGNOSTIC ERROR CIRCULATION Seifert, F. C., Miller, D. C., Oesterle, S. N., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 72 (3): 264-273
  • NONINVASIVE ASSESSMENT OF CARDIAC ALLOGRAFT-REJECTION TRANSPLANTATION PROCEEDINGS Dawkins, K. D., Oldershaw, P. J., Billingham, M. E., Hunt, S. A., Jamieson, S. W., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 17 (1): 215-217
  • LATE RESULTS OF COMBINED HEART LUNG TRANSPLANTATION TRANSPLANTATION PROCEEDINGS Jamieson, S. W., Dawkins, K. D., Burke, C., Baldwin, J. W., YOUSEUR, S., Billingham, M. E., Hunt, S. A., Reitz, B. A., Theodore, J., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 17 (1): 212-214
  • VALVE-REPLACEMENT IN PATIENTS WITH NATIVE VALVE ENDOCARDITIS - WHAT REALLY DETERMINES OPERATIVE OUTCOME ANNALS OF THORACIC SURGERY DAGOSTINO, R. S., Miller, D. C., Stinson, E. B., Mitchell, R. S., Oyer, P. E., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1985; 40 (5): 429-438

    Abstract

    The influence of 27 variables on operative mortality and late complications (defined as residual or recurrent endocarditis or late bland periprosthetic leak) was determined using discriminant analysis for 108 patients undergoing valve replacement for native valve endocarditis at Stanford University Medical Center from March, 1964, to January, 1983. Congestive heart failure was the indication for valve replacement in 86% of patients. Aortic valve replacement was required in 68% and mitral valve replacement, in 26%. Patients were arbitrarily defined as having active (58%) or healed (42%) endocarditis. Follow-up included 515 patient-years and extended to a maximum of 19 years. Operative mortality was 15 +/- 4%, and 17 patients had late complications (linearized rate, 3.3% per patient-year). Seven variables were significantly related to operative mortality in the univariate analysis, but only organism (Staphylococcus aureus versus all others, p = 0.0302) was a significant independent predictor of operative mortality. For late complications, only 2 of 7 significant univariate covariates proved to be significant independent determinants: organisms on valve culture or gram stain and the presence of annular abscess. Patients with S. aureus endocarditis not showing prompt response to antibiotic treatment must be considered for early operation. Similarly, timely operative intervention for patients with annular abscess will be essential in decreasing late valve infections and perivalvular leaks.

    View details for Web of Science ID A1985AUP5300004

    View details for PubMedID 4062397

  • DETERMINANTS OF OPERATIVE MORTALITY FOR PATIENTS UNDERGOING AORTIC-VALVE REPLACEMENT - DISCRIMINANT-ANALYSIS OF 1,479 OPERATIONS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Scott, W. C., Miller, D. C., Haverich, A., Dawkins, K., Mitchell, R. S., Jamieson, S. W., Oyer, P. E., Stinson, E. B., Baldwin, J. C., Shumway, N. E. 1985; 89 (3): 400-413

    Abstract

    The influence of 35 preoperative and intraoperative characteristics on operative mortality risk after 1,479 isolated aortic valve replacement procedures (1967 to 1981) was investigated utilizing univariate and multivariate logistic regression analyses. Mean age at operation was 58 +/- 13 years; 72% of patients were men. Physiology was classified as aortic stenosis (58%), regurgitation (30%), or both (9%). The overall operative mortality rate was 7% +/- 1%, but there were substantial differences in operative mortality rates among physiological subgroups (aortic regurgitation, 10% +/- 2%; aortic stenosis, 6% +/- 1%; stenosis/regurgitation, 5% +/- 2%). Independent determinants of operative mortality rate in the entire group were advanced New York Heart Association functional class, renal dysfunction, physiological subgroup, atrial fibrillation, and older age. In the aortic regurgitation subgroup, functional class, atrial fibrillation, and operative year were independent predictors. In the aortic stenosis subgroup, the significant determinants were functional class, renal dysfunction, age, prosthetic valve dysfunction, and absence of angina. Concomitant coronary bypass grafting, previous operation, endocarditis, and ascending aortic replacement had no independent predictive effect on operative mortality rate. Thus, the early results of aortic valve replacement can be related to several specific variables describing the functional and physiological status of the patient. Operative mortality rate is not independently related to previous operation or concomitant operative procedures. Specific differences in risk factors exist among the various physiological subgroups, probably reflecting the pathophysiology of the different hemodynamic lesions. This information should provide for a more rational approach to aortic valve replacement, at least in terms of early risk/benefit deliberations.

    View details for Web of Science ID A1985ADH6100009

    View details for PubMedID 3974275

  • OPERATIVE RISK OF MITRAL-VALVE REPLACEMENT - DISCRIMINANT-ANALYSIS OF 1329 PROCEDURES CIRCULATION Scott, W. C., Miller, D. C., Haverich, A., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1985; 72 (3): 108-119
  • ACUTE AND CHRONIC AORTIC DISSECTIONS - DETERMINANTS OF LONG-TERM OUTCOME FOR OPERATIVE SURVIVORS CIRCULATION Haverich, A., Miller, D. C., Scott, W. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1985; 72 (3): 22-34
  • Independent determinants of operative mortality for patients with aortic dissections. Circulation Miller, D. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Jamieson, S. W., Shumway, N. E. 1984; 70 (3): I153-64

    Abstract

    A 20 year (1963 to 1982) surgical experience including 175 consecutive patients with aortic dissections was analyzed by logistic discriminant analyses to identify predictors of high operative risk. The patient population had characteristics similar to those in large autopsy series. Sixty-nine percent had type A and 58% had acute dissections. The intimal tear was located in the ascending aorta in 60% of the patients, the descending aorta in 27%, and the transverse arch in 13%. The overall operative mortality rate was 23 +/- 3%. The operative mortality rates were substantially lower between 1977 and 1982: mortality in patients with acute type A dissections, 7 +/- 5%; in those with chronic type A, 11 +/- 7%; in those with acute type B, 13 +/- 12%; and in those with chronic type B, 11 +/- 11%. After preliminary univariate screening, the following factors were determined to be significant independent predictors of operative mortality (in rank order of declining predictive power): type A patients (n = 121), renal dysfunction, tamponade, renal/visceral ischemia, and operative date; type B patients (n = 54), rupture, renal/visceral ischemia, and age; all patients (n = 175), renal dysfunction, renal/visceral ischemia, site of tear (ascending less than descending less than arch), tamponade, operative date, and pulmonary disease. Interestingly, several variables had no important bearing on operative mortality, including type (acute vs chronic) of dissection, age, previous operation, rupture, stroke, paraplegia, Marfan's syndrome, concomitant aortic valve replacement and/or coronary artery bypass grafting, site of tear, and whether or not the tear was resected in type A patients; emergency operation, hypertension, previous cardiac symptoms, paraplegia, site of tear, and resection of tear in type B patients; and, when all patients were considered together, age, sex, cardiac symptoms, prior operation, stroke, paraplegia, acute myocardial infarction, acute aortic regurgitation, Marfan's syndrome, and tear resection. These data allow calculation of any individual patient's operative risk and document that the operative mortality rate today is relatively low for all patients with aortic dissections, irrespective of type or acuity. Earlier surgical referral of patients with acute type A or acute type B dissection before irreversible major end-organ ischemia and/or infarction is probably in part responsible for the substantially improved results since 1977.

    View details for PubMedID 6235061

  • INDEPENDENT DETERMINANTS OF OPERATIVE MORTALITY FOR PATIENTS WITH AORTIC DISSECTIONS CIRCULATION Miller, D. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Jamieson, S. W., Shumway, N. E. 1984; 70 (3): 153-164
  • HEART AND LUNG TRANSPLANTATION FOR PULMONARY-HYPERTENSION AMERICAN JOURNAL OF SURGERY Jamieson, S. W., Stinson, E. B., Oyer, P. E., Theodore, J., Hunt, S., Dawkins, K., Billingham, M., Shumway, N. E. 1984; 147 (6): 740-742

    Abstract

    Seventeen patients received combined heart and lung transplants at Stanford University between March 1981 and December 1983. All recipients were suffering from end-stage pulmonary hypertension. Five patients died within the first few postoperative weeks, but the remainder were well between 2 and 35 months after operation. Immunosuppression consisted of cyclosporine with an initial course of rabbit antithymocyte globulin, and azathioprine was given for the first 2 postoperative weeks. Maintenance immunosuppression was achieved with cyclosporine and prednisone. Rejection, as diagnosed by cardiac biopsy, was treated with intravenous methylprednisolone. The functional status of the survivors has been good, and upon discharge from the hospital, all returned to normal activity. Our preliminary experience indicates that cardiopulmonary transplantation represents a realistic therapeutic approach for patients with end-stage pulmonary disease.

    View details for Web of Science ID A1984SX48800007

    View details for PubMedID 6428246

  • HEART-LUNG TRANSPLANTATION FOR IRREVERSIBLE PULMONARY-HYPERTENSION ANNALS OF THORACIC SURGERY Jamieson, S. W., Stinson, E. B., Oyer, P. E., Reitz, B. A., Baldwin, J., Modry, D., Dawkins, K., Theodore, J., Hunt, S., Shumway, N. E. 1984; 38 (6): 554-562

    Abstract

    Combined heart and lung transplantation was carried out in 17 patients at Stanford University between March, 1981, and December, 1983. The recipients were between 22 and 45 years old. All patients had end-stage pulmonary hypertension; 10 had Eisenmenger's syndrome and the remaining 7, primary pulmonary hypertension. Five patients died within the first few postoperative weeks. The remainder are well between four weeks and 33 months from operation. The immunosuppressive protocol has consisted of cyclosporine with an initial course of rabbit antithymocyte globulin. Azathioprine also was given for the first two weeks and then was replaced with prednisone. Rejection, as diagnosed by cardiac biopsy, was treated with high doses of methylprednisolone. Modifications of technique that have developed include the removal of the recipient heart and lungs separately, and preservation of the lungs with a modified Collins' solution instead of a cardioplegic solution. Rejection occurred in 6 of the 12 survivors. Infections developed in 9 patients, but only one resulted in a fatal outcome (Legionella). Thus, the results of clinical heart-lung transplantation have been considerably superior to clinical efforts in lung transplantation. It is suggested that the combined operation is preferable for the following reasons: (1) all diseased tissue is removed, thus eliminating recurrent infection and ventilation/perfusion disparity; (2) transplantation of the entire heart-lung block preserves coronary-bronchial vascular anastomoses and makes airway dehiscence less likely; and (3) to date, diagnosis of rejection by cardiac biopsy has appeared to be a satisfactory method of diagnosing and treating pulmonary rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1984TW37500004

    View details for PubMedID 6439134

  • POST-TRANSPLANT OBLITERATIVE BRONCHIOLITIS AND OTHER LATE LUNG SEQUELAE IN HUMAN HEART-LUNG TRANSPLANTATION CHEST Burke, C. M., Theodore, J., Dawkins, K. D., Yousem, S. A., Blank, N., Billingham, M. E., VANKESSEL, A., Jamieson, S. W., Oyer, P. E., Baldwin, J. C., Stinson, E. B., Shumway, N. E., Robin, E. D. 1984; 86 (6): 824-829

    Abstract

    Since March 1981, 19 patients have undergone heart-lung transplantation for end-stage pulmonary vascular disease, with 14 long-term survivors. In five of the survivors, obstructive airway disease has developed with the superimposition of a progressive restrictive ventilatory defect in three of them. None of these five patients showed a tendency for spontaneous improvement of flow rates. Biopsy and postmortem material was available in four of the five patients and showed obliterative bronchiolitis (OB) in three. A fourth patient showed clinical and physiologic data consistent with obliterative bronchitis, but histologic material was not available. Obstructive lung disease without restrictive features developed in a fifth patient, but no histologic evidence of OB was found at transbronchial biopsy. In addition to OB, recurrent lung infections were found in all patients, significant pleural fibrosis in two patients, and bronchiectasis in one patient. Despite these long-term sequelae of human heart-lung transplantation, ten of the 14 surviving patients are leading relatively normal lives.

    View details for Web of Science ID A1984TV20500008

    View details for PubMedID 6437751

  • PHYSIOLOGIC ASPECTS OF HUMAN HEART-LUNG TRANSPLANTATION - PULMONARY-FUNCTION STATUS OF THE POST-TRANSPLANTED LUNG CHEST Theodore, J., Jamieson, S. W., Burke, C. M., Reitz, B. A., Stinson, E. B., VANKESSEL, A., Dawkins, K. D., Herran, J. J., Oyer, P. E., Hunt, S. A., Shumway, N. E., Robin, E. D. 1984; 86 (3): 349-357

    Abstract

    Pulmonary function measurements were performed before and after heart-lung transplantation in nine patients who had undergone surgery for end-stage pulmonary hypertension. In seven of them, sequential follow-up studies were performed at variable times postoperatively with the longest period 27 months. Pre-transplant studies showed a mild restrictive defect in 33 percent and obstructive disease in 50 percent of the patients, respectively. Arterial hypoxemia was present in all patients. The degree of mechanical changes found did not appear severe enough to account for the marked dyspnea and disability characterizing this group of patients with pulmonary hypertension. Following transplantation, all patients showed striking improvement of symptoms and general physical status. In the early post-transplant period, there was a marked decrease in most lung volumes resulting in a moderately severe restrictive ventilatory defect. Flow parameters that were reduced could be related to decreased volumes and not to intrinsic airway obstruction. Arterial O2 tensions improved dramatically and gas exchange was maintained at essentially normal levels. Lung function tended to improve progressively following transplantation with the passage of time. Heart-lung transplant is consistent with an adequate long-term pulmonary functional state which has the capacity to sustain the normal activities of daily living. From the standpoint of lung function, heart-lung transplantation appears to be acceptable as a form of therapy in selected patients.

    View details for Web of Science ID A1984TG73000007

    View details for PubMedID 6432455

  • OPERATIVE TECHNIQUE FOR HEART-LUNG TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Jamieson, S. W., Stinson, E. B., Oyer, P. E., Baldwin, J. C., Shumway, N. E. 1984; 87 (6): 930-935

    Abstract

    Combined heart and lung transplantation has now been carried out in 17 patients at Stanford University Hospital. The emphasis on the management of donors is upon thorough tracheobronchial toilet and ensuring an absence of significant cardiopulmonary disease. The most important aspects of the recipient operation are to remove the heart and lungs without injury to the phrenic, vagus, or recurrent laryngeal nerves and to ensure hemostasis. This is best effected if the heart and lungs are removed separately. The operative technique for both the donor and recipient is described.

    View details for Web of Science ID A1984SV98600018

    View details for PubMedID 6427532

  • CLINICAL HEART-LUNG TRANSPLANTATION TRANSPLANTATION Jamieson, S. W., Baldwin, J., Stinson, E. B., Reitz, B. A., Oyer, P. E., Hunt, S., Billingham, M., Theodore, J., Modry, D., BIEBER, C. P., Shumway, N. E. 1984; 37 (1): 81-84

    Abstract

    Combined heart and lung transplantation was carried out in thirteen patients at Stanford University between March 1981 and May 1983. The recipients were between 22 and 45 years old. All patients were suffering from end-stage pulmonary hypertension; nine patients had Eisenmenger's syndrome; the remaining four were transplanted for primary pulmonary hypertension. Three patients died within one month of surgery. The remainder are well at between 22 months and three weeks from operation. The duration of stay in the hospital for the surviving patients ranged from 38 to 85 days. The immunosuppressive protocol has been essentially the same for all recipients, and has consisted of cyclosporine with an initial course of rabbit antithymocyte globulin (RATG) with azathioprine given for the first two weeks, and then replaced with prednisone. Rejection, as diagnosed by cardiac biopsy, was treated with pulses of methylprednisolone. Early complications included bleeding that necessitated reexploration (five patients); damage to the vagus, recurrent laryngeal, or phrenic nerves (three patients); and failure of the donor lungs (one patient). Modifications of technique that have developed include removal of the recipient heart and lungs separately, and preservation of the lungs with a modified Collins' solution instead of a cardioplegic solution. The results of this operation are considerably superior to clinical efforts in lung transplantation. The combined operation may be preferable for the following reasons: All diseased tissue is removed, thus eliminating recurrent infection, and also perfusion/ventilation disparity. Transplantation of the entire heart and lung block preserves coronary-tracheal vascular anastomoses and makes airway dehiscence less likely. Diagnosis of rejection by cardiac biopsy seems to be a satisfactory method of diagnosis and treatment of pulmonary rejection.

    View details for Web of Science ID A1984RZ82600022

    View details for PubMedID 6420957

  • COMBINED AZYGOUS VEIN AND SUBCLAVIAN ARTERY INJURY IN BLUNT CHEST TRAUMA JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Baldwin, J. C., Oyer, P. E., GUTHANER, D. F., Stinson, E. B. 1984; 24 (2): 170-171

    Abstract

    Blunt chest trauma resulting in azygous vein injury with associated mediastinal widening is described. Emergency operative intervention was required, and subsequent arteriography revealed initial transection of the subclavian artery requiring repair. The potential significance of mediastinal venous bleeding and the importance of arteriography in diagnosing occult arterial injury in this setting are emphasized.

    View details for Web of Science ID A1984SF01700018

    View details for PubMedID 6694246

  • THROMBOEMBOLIC RISK AND DURABILITY OF THE HANCOCK BIOPROSTHETIC CARDIAC-VALVE EUROPEAN HEART JOURNAL Oyer, P. E., Stinson, E. B., Miller, D. C., Jamieson, S. W., Mitchell, R. S., Shumway, N. E. 1984; 5: 81-85

    View details for Web of Science ID A1984ACF9100015

    View details for PubMedID 6519106

  • DEGENERATIVE AND ATHEROSCLEROTIC ANEURYSMS OF THE THORACIC AORTA - DETERMINANTS OF EARLY AND LATE SURGICAL OUTCOME JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY MORENOCABRAL, C. E., Miller, D. C., Mitchell, R. S., Stinson, E. B., Oyer, P. E., Jamieson, S. W., Shumway, N. E. 1984; 88 (6): 1020-1032

    Abstract

    To identify significant predictors of early and late mortality, multivariate discriminant analyses were applied to the clinical outcome of 175 consecutive patients with thoracic aortic aneurysms operated upon over a 20 year span. Only atherosclerotic and degenerative aneurysms were included; the patients were segregated into two groups according to location of the aneurysm. The ascending aortic aneurysm group consisted of 124 patients, 85% of whom required concomitant aortic valve replacement. There were 51 patients in the descending aortic aneurysm group. Mean follow-up was 4.9 years (maximum of 19 years), with a total of 860 patient-years of follow-up. Multivariate analyses revealed that surgical priority and advanced age were independent determinants of hospital mortality in the ascending group; for the descending group, surgical priority and the presence of congestive heart failure were the strongest predictors of hospital mortality. Late mortality in the ascending group correlated with advanced age. Hypertension and the presence of preoperative congestive heart failure were independent determinants of late mortality in the descending group. Several variables did not have any independent bearing on hospital or late mortality, including etiology and location of the aneurysm, previous myocardial infarction, chronic lung disease, and concomitant aortic valve replacement. High-risk subgroups of patients with thoracic aortic aneurysms can be identified by these variables. Aggressive medical plus surgical management and operation prior to aneurysm rupture is necessary to improve both early and long-term survival rates.

    View details for Web of Science ID A1984TV42000015

    View details for PubMedID 6503314

  • PERFORMANCE-CHARACTERISTICS OF THE STARR-EDWARDS MODEL 1260 AORTIC-VALVE PROSTHESIS BEYOND 10 YEARS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Oyer, P. E., Mitchell, R. S., Stinson, E. B., Jamieson, S. W., Baldwin, J. C., Shumway, N. E. 1984; 88 (2): 193-207

    Abstract

    The Starr-Edwards non-cloth-covered silicone ball (Model 1260) aortic valve prosthesis has been widely used for over 15 years and remains a standard against which newer values are compared. To define more completely the performance characteristics of this prosthesis, this study (including 449 patients) analyzed the long-term function of this specific valve over a cumulative total of 2,896 patient-years (pt-yrs) of follow-up which extended beyond 13 years. Expressed in both actuarial (% [+/- standard error of the mean] free at 10 years) and linearized (%/pt-yr) terms, respectively, valve-related complications occurred at the following rates: thromboembolism, 76 +/- 3 and 2.7; anticoagulant-related hemorrhage, 74 +/- 3 and 3.1; prosthetic valve endocarditis, 92 +/- 2 and 0.9; reoperation, 90 +/- 2 and 1.1; valve failure, 82 +/- 2 and 2.2; all valve-related morbidity and mortality, 51 +/- 3 and 6.0; and valve-related death, 88 +/- 2 and 1.3. Thirteen percent of hospital and 18% of late deaths were due to valve-related causes. No case of structural failure was documented. This prosthesis has an admirable structural durability record out to 13 years, and its long-term performance is satisfactory, albeit not optimal. Despite the indestructable design and construction of this mechanical valve substitute, 12% +/- 2% of patients had died of valve-related complications by 10 years, and fully 49% +/- 3% had had some form of serious valve-related complication. The long-term data reported herein can be used for analytical comparison when follow-up of patients with newer mechanical prostheses and tissue bioprostheses reaches 10 years to elucidate whether or not these newer valves truly represent improvements and which type of valve substitute proffers the most possible net benefit to the patient.

    View details for Web of Science ID A1984TE45900006

    View details for PubMedID 6748713

  • 10 TO 15 YEAR REASSESSMENT OF THE PERFORMANCE-CHARACTERISTICS OF THE STARR-EDWARDS MODEL 6120 MITRAL-VALVE PROSTHESIS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Oyer, P. E., Stinson, E. B., Reitz, B. A., Jamieson, S. W., Baumgartner, W. A., Mitchell, R. S., Shumway, N. E. 1983; 85 (1): 1-20
  • CYCLOSPORINE IN CARDIAC TRANSPLANTATION - A 2-1/2 YEAR FOLLOW-UP TRANSPLANTATION PROCEEDINGS Oyer, P. E., Stinson, E. B., Jamieson, S. W., Hunt, S. A., Perlroth, M., Billingham, M., Shumway, N. E. 1983; 15 (4): 2546-2552
  • SIMPLE ADJUNCTS WHICH MAINTAIN SEPTAL TEMPERATURE BELOW 20-DEGREES-C DURING ISCHEMIC ARREST FOR CORONARY-ARTERY BYPASS-GRAFTING AMERICAN HEART JOURNAL Baumgartner, W. A., Miller, D. C., Stinson, E. B., Reitz, B. A., Oyer, P. E., Jamieson, S. W. 1983; 105 (3): 440-444

    View details for Web of Science ID A1983QF05800013

    View details for PubMedID 6338684

  • DIAGNOSIS AND TREATMENT OF ALLOGRAFT-REJECTION IN HEART-LUNG TRANSPLANT RECIPIENTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Reitz, B. A., Gaudiani, V. A., Hunt, S. A., Wallwork, J., Billingham, M. E., Oyer, P. E., Baumgartner, W. A., Jamieson, S. W., Stinson, E. B., Shumway, N. E. 1983; 85 (3): 354-361

    Abstract

    Six patients received heart-lung transplants between March, 1981, and January, 1982. There were four women and two men between 26 and 45 years of age, three with primary pulmonary hypertension and three with congenital heart disease and pulmonary hypertension (Eisenmenger's syndrome). Immunosuppression was primarily with cyclosporin-A, with additional corticosteroid, azathioprine, and rabbit antihuman thymocyte globulin. Six episodes of allograft rejection in four patients (10, 11, 21, 24, 53, and 86 days after transplantation) were detected by means of transvenous endomyocardial biopsy. All patients experienced pulmonary edema early after transplantation (reimplantation response), and two patients required mechanical ventilatory support for allograft rejection at 10 and 11 days. Treatment of rejection consisted of intravenous methylprednisolone (four episodes) or augmented oral prednisone (two episodes), with resolution. No episode thought to be pulmonary rejection has occurred in the absence of cardiac findings. Four patients are alive from 6 to 15 months after transplantation and are functionally normal. Early experience with heart-lung transplantation suggests (1) that allograft rejection can be detected by cardiac findings and successfully treated by augmented corticosteroids, (2) that lung rejection does not occur in the absence of cardiac findings, (3) that the frequency and severity of rejection episodes are not greater than with standard cardiac transplantation, and (4) that the frequency of rejection episodes is highest within the first 60 days after transplantation.

    View details for Web of Science ID A1983QG01700005

    View details for PubMedID 6402622

  • Ten to fifteen year reassessment of the performance characteristics of the Starr-Edwards Model 6120 mitral valve prosthesis. journal of thoracic and cardiovascular surgery Miller, D. C., Oyer, P. E., Stinson, E. B., Reitz, B. A., Jamieson, S. W., Baumgartner, W. A., Mitchell, R. S., Shumway, N. E. 1983; 85 (1): 1-20

    View details for PubMedID 6848878

  • SURGICAL-TREATMENT OF PROSTHETIC VALVE ENDOCARDITIS ANNALS OF THORACIC SURGERY Baumgartner, W. A., Miller, D. C., Reitz, B. A., Oyer, P. E., Jamieson, S. W., Stinson, E. B., Shumway, N. E. 1983; 35 (1): 87-104

    View details for Web of Science ID A1983PX59600012

    View details for PubMedID 6849584

  • INVIVO EVALUATION OF A COMPACT, IMPLANTABLE LEFT-VENTRICULAR ASSIST SYSTEM (LVAS) TRANSACTIONS AMERICAN SOCIETY FOR ARTIFICIAL INTERNAL ORGANS Miller, P. J., Green, G. F., Chen, H., Ramasamy, N., LaForge, D. H., Jassawalla, J. S., REAM, A. K., Oyer, P. E., Portner, P. M. 1983; 29: 551-555

    View details for Web of Science ID A1983SF77400108

    View details for PubMedID 6673285

  • COMBINED HEART AND LUNG TRANSPLANTATION LANCET Jamieson, S. W., Baldwin, J., Reitz, B. A., Stinson, E. B., Oyer, P. E., Hunt, S., Billingham, M., Theodore, J., Modry, D., BIEBER, C. P., Shumway, N. E. 1983; 1 (8334): 1130-1132

    Abstract

    Combined heart and lung transplantation was carried out in ten patients at Stanford University Medical Center between March, 1981, and December, 1982. All patients had end-stage pulmonary hypertension. 7 of them had Eisenmenger's syndrome and 3 primary pulmonary hypertension. 3 patients died within a month of operation, but the remaining recipients are well 2 months to 2 years after transplantation. The hospital stay of the survivors ranged from 38 to 85 days. All survivors have returned to normal activity. The results of heart and lung transplantation have thus been considerably superior to those reported previously for lung transplantation. It is suggested that cardiopulmonary replacement is suitable treatment for end-stage pulmonary hypertension with or without associated congenital heart disease and that its application to other forms of advanced pulmonary failure may be warranted.

    View details for Web of Science ID A1983QQ80700005

    View details for PubMedID 6133156

  • CARDIAC ALLOGRAFT SURVIVAL FOLLOWING PRETREATMENT WITH DONOR SPLEEN-CELLS AND CYCLOSPORIN-A TRANSPLANTATION PROCEEDINGS Aziz, S., Oyer, P., Reitz, B., Jamieson, S. W., Bieber, C., Stinson, E. B., Shumway, N. E. 1983; 15 (1): 809-813
  • CLINICAL HEART-LUNG TRANSPLANTATION TRANSPLANTATION PROCEEDINGS Reitz, B. A., Hunt, S. A., GAUDIANI, V., Wallwork, J., Oyer, P. E., Baumgartner, W. A., Jamieson, S. W., Stinson, E. B., Shumway, N. E. 1983; 15 (1): 1256-1259
  • DISCRIMINANT-ANALYSIS OF THE CHANGING RISKS OF CORONARY-ARTERY OPERATIONS - 1971-1979 JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Stinson, E. B., Oyer, P. E., Jamieson, S. W., Mitchell, R. S., Reitz, B. A., Baumgartner, W. A., Shumway, N. E. 1983; 85 (2): 197-213

    Abstract

    The risk of perioperative myocardial infarction (PMI) and operative mortality (OM) associated with coronary artery bypass grafting (CABG) has declined since the introduction of this procedure 15 years ago. Rigorous scientific investigation of the reasons for this trend has been hindered by the complex interactions between changing indications for operation, criteria for patient selection, and management methods. Using univariate and multivariate logistic regression analyses, we investigated the effects of 42 variables on PMI and OM for two cohorts undergoing CABG between 1971 and 1975 (Group A) and 1977 and 1979 (Group B). According to previously identified risk factors, Group B patients were at higher potential risk than those in Group A. Nevertheless, the PMI and OM rates declined from 8.7% +/- 0.9% to 4.6% +/- 0.7% (p = 0.005) and from 2.4% +/- 0.5% to 1.2% +/- 0.4% (p = 0.07), respectively. In calendar year 1979 (N = 438), the PMI and OM rates were 2.8% +/- 0.8% and 0.7% +/- 0.4%. More importantly, the independent determinants of PMI and OM for the two time intervals were distinctly different. Factors which affected the PMI rate in Group A were no longer determinants of PMI in Group B; with the exception of emergency operation and, to a modest extent, congestive heart failure (CHF), predictors of OM in Group A were not determinants of OM in Group B. Thus the adverse impact of multiple patient-related and disease-related determinants of PMI and OM has been neutralized over this decade by the real improvements in patient management. The specific factors and management concepts responsible for these superior results in sicker patients remain uncharacterized; however, in general terms, more sophisticated medical, anesthetic, and nursing management and more refined surgical expertise have essentially nullified the concept of high-risk candidates. Furthermore, the more propitious early results being attained currently may translate directly into parallel long-term improvements in functional benefit and survival.

    View details for Web of Science ID A1983QC22500005

    View details for PubMedID 6600507

  • CYCLOSPORIN-A IN CARDIAC ALLOGRAFTING - A PRELIMINARY EXPERIENCE TRANSPLANTATION PROCEEDINGS Oyer, P. E., Stinson, E. B., Jamieson, S. W., Hunt, S. A., Billingham, M., Scott, W., BIEBER, C. P., Reitz, B. A., Shumway, N. E. 1983; 15 (1): 1247-1252
  • The durability of porcine xenograft valves and conduits in children. Circulation Miller, D. C., Stinson, E. B., Oyer, P. E., Billingham, M. E., Pitlick, P. T., Reitz, B. A., Jamieson, S. W., Baumgartner, W. A., Shumway, N. E. 1982; 66 (2): I172-85

    Abstract

    One hundred four patients younger than 20 years of age underwent intracardiac xenograft valve replacement (n = 41) or extracardiac conduit implantation (n = 63). Long-term follow-up averaged 4.5 and 4.3 years, respectively, and cumulative follow-up totaled 344 patient-years (pt-yr). Thirty patients were followed more than 5 years. Functional results and survival were satisfactory, but valve failure and conduit failure prompted 23 reoperations at linearized rates of 10.1 +/- 2.6% and 4.1 +/- 1.5%/pt-yr, respectively. The rate of valve failure due to leaflet fibrocalcification (primary tissue failure [PTF] was 8.1 +/- 2.4%/pt-yr. Among patients who underwent valve replacement, 52 +/- 13% were free of reoperation at 5 years (59 +/- 13% for PTF only), as were 80 +/- 9% of patients who received an extracardiac conduit. There were no deaths associated with the 22 late reoperations or with the 21 reoperations for PTF. Valve failure was due to PTF in 80% of cases; conversely, isolated valvular PTF was the cause of conduit failure in only one of eight patients. The most common cause of conduit failure was exuberant pseudointimal proliferation in the proximal conduit, which was seen in six of eight patients (75%) with or without other sites of obstruction and responsible for nine of the 15 obstructions (60%). These results underscore the palliative nature of these procedures, militate against indiscriminant use of conduits, prompt consideration of alternative nonconduit techniques where possible, and reemphasize the clinical need for superior valve substitutes and biomaterials for use in the pediatric age group.

    View details for PubMedID 7083540

  • HEART-LUNG TRANSPLANTATION - SUCCESSFUL THERAPY FOR PATIENTS WITH PULMONARY VASCULAR-DISEASE NEW ENGLAND JOURNAL OF MEDICINE Reitz, B. A., WALLWORK, J. L., Hunt, S. A., Pennock, J. L., Billingham, M. E., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1982; 306 (10): 557-564

    Abstract

    We report our initial experience with three patients who received heart-lung transplants. The primary immunosuppressive agent used was cyclosporin A, although conventional drugs were also administered. In the first patient, a 45-year-old woman with primary pulmonary hypertension, acute rejection of the transplant was diagnosed 10 and 25 days after surgery but was treated successfully; this patient still had normal exercise tolerance 10 months late. The second patient, a 30-year-old man, underwent transplantation for Eisenmenger's syndrome due to atrial and ventricular septal defects. His graft was not rejected, and his condition was markedly improved eight months after surgery. The third patient, a 29-year-old woman with transposition of the great vessels and associated defects, died four days postoperatively of renal, hepatic, and pulmonary complications. We attribute our success to experience with heart-lung transplantation in primates, to the use of cyclosporin A, and to the anatomic and physiologic advantages of combined heart-lung replacement. We hope that such transplants may ultimately provide an improved outlook for selected terminally ill patients with pulmonary vascular disease and certain other intractable cardiopulmonary disorders.

    View details for Web of Science ID A1982ND99400001

    View details for PubMedID 6799824

  • [Heart transplantation. Experience at Stanford University: 221 cases]. Annales de médecine interne Perlroth, M. G., Oyer, P. E. 1982; 133 (4): 238-244

    View details for PubMedID 7051920

  • THE DURABILITY OF PORCINE XENOGRAFT VALVES AND CONDUITS IN CHILDREN CIRCULATION Miller, D. C., Stinson, E. B., Oyer, P. E., Billingham, M. E., Pitlick, P. T., Reitz, B. A., Jamieson, S. W., Baumgartner, W. A., Shumway, N. E. 1982; 66 (2): 172-185
  • CARDIAC TRANSPLANTATION - THE STANFORD EXPERIENCE - 221 CASES ANNALES DE MEDECINE INTERNE Perlroth, M. G., Oyer, P. E. 1982; 133 (4): 238-244
  • CALCIFICATION OF PORCINE PROSTHETIC HEART-VALVES - A RADIOGRAPHIC AND LIGHT MICROSCOPIC STUDY CIRCULATION Cipriano, P. R., Billingham, M. E., Oyer, P. E., KUTSCHE, L. M., Stinson, E. B. 1982; 66 (5): 1100-1104

    Abstract

    To determine the incidence and extent of calcification of implanted glutaraldehyde-treated porcine prosthetic heart valves, 82 valves explanted from 73 patients were examined for calcium by radiography and light microscopy. At the time of valve implantation, the patients were 2 1/4-76 years old. The included 15 children (patients younger than 15 years of age, mean age at time of valve implantation 8.7 +/- 4.1 years) and 58 adults (patients older than 15 years, mean age at time of valve implantation 53.5 +/- 15.1 years). Valves explanted from children (average time implanted 4.6 +/- 1.7 years) included four aortic, five mitral, as well as six right ventricle-pulmonary artery conduits and one left ventricle-abdominal aorta conduit. Valves explanted from adults (average time implanted 3.2 +/- 2.5 years) included 32 aortic and 32 mitral, as well as one tricuspid valve and one valve from a right ventricle-pulmonary artery conduit. Calcification of explanted valves was graded from 0 to 4+ based on radiographs. All 16 valves from children were calcified, with grade 3+ or 4+ calcification in each of the aortic and mitral valves. In adult patients, calcification was present in 10 of 33 valves (30%) implanted for less than 3 years (average time implanted 1.0 year), in nine of 11 valves (82%) implanted for 3-5 years (average time implanted 3.7 years) and in 21 of 22 valves (96%) implanted for 5 years or longer (average time implanted 6.2 years). Analysis of variance demonstrated that calcification was strongly related to the duration that valves were implanted (p less than 0.001). Age at the time of valve implantation also had a strong effect (p less than 0.001) on the amount of valvular calcium. Valves from children showed the most calcification, and the amount did not change when valves were implanted in patients 30 years of age or older. Patient sex and valve position had no effect on the amount of calcification. Calcification occurred at each right- and left-heart valve position, most frequently at sites of commissural attachments.

    View details for Web of Science ID A1982PM98800028

    View details for PubMedID 7127695

  • CARDIOVASCULAR PHYSIOLOGY IN A CASE OF HETEROTOPIC CARDIAC TRANSPLANTATION AMERICAN JOURNAL OF CARDIOLOGY MELVIN, K. R., Pollick, C., Hunt, S. A., McDougall, R., Goris, M. L., Oyer, P., Popp, R. L., Stinson, E. B. 1982; 49 (5): 1301-1307

    Abstract

    Successful heterotopic cardiac transplantation in a 24 year old man with end stage cardiomyopathy provided an opportunity to study cardiovascular physiology. The donor and native hearts, functioning independently in parallel, were studied by serial physical examination, electrocardiography, echocardiography, nuclear angiography and cardiac catheterization. Results indicated that the donor left heart assumed the predominant role in supplying systemic output, possibly contributing to decreasing function of the patient's own (native) heart. Analysis of serial nuclear angiograms revealed an initial postoperative ejection fraction of 52 and 21 percent in the donor and the native left ventricle, respectively; repeat studies 3 months postoperatively showed values of 50 and 9 percent, respectively, indicating significant deterioration in native left ventricular cardiac function. Observation of valve motion of the native heart showed major irregularities of the aortic valve in contrast to seemingly normal, regular mitral valve motion. These data rise interesting questions regarding interpretation of valve motion as an indicator of ventricular function.

    View details for Web of Science ID A1982NH12800029

    View details for PubMedID 7039290

  • METHOD FOR CARDIAC TRANSPLANTATION IN CORRECTED TRANSPOSITION OF THE GREAT-ARTERIES JOURNAL OF CARDIOVASCULAR SURGERY Reitz, B. A., Jamieson, S. W., Gaudiani, V. A., Oyer, P. E., Stinson, E. B. 1982; 23 (4): 293-296

    Abstract

    A patient with corrected transposition of the great vessels (L-transposition) required cardiac transplantation because of severe myopathy of th systemic ventricle of right ventricular morphology. Because of the L-transposition of the great vessels, a modification of the transplantation procedure was necessary in order to make the great vessel anastomoses. This was accomplished without the need for prosthetic material primarily by extensive removal of donor pulmonary artery and aorta together with the heart. Anastomosis of the recipient ascending aorta was accomplished to the superior aspect of the transverse aortic arch of the donor, and the recipient pulmonary artery to the superior portion of the right pulmonary artery of the donor. The postoperative hemodynamics were normal and a thoracic aortogram one year post-transplant demonstrated the unusual anatomy.

    View details for Web of Science ID A1982PH44200004

    View details for PubMedID 7050128

  • CARDIAC TRANSPLANTATION IN PERSPECTIVE FOR THE FUTURE - SURVIVAL, COMPLICATIONS, REHABILITATION, AND COST JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Pennock, J. L., Oyer, P. E., Reitz, B. A., Jamieson, S. W., BIEBER, C. P., Wallwork, J., Stinson, E. B., Shumway, N. E. 1982; 83 (2): 168-177

    Abstract

    Two hundred twenty-seven cardiac transplant procedures have been performed in 206 patients from January, 1968, to April, 1981. Postoperative survival rates, calculated by the actuarial method for program years 1968 to 1973 (66 patients), are 44%, 33%, 27%, 21%, and 18% at 1, 2, 3, 4, and 5 years after transplantation, respectively. Postoperative survival rates for program years 1974 to 1981 (140 patients) are 63%, 55%, 51, 44%, and 39% at 1, 2, 3, 4, and 5 years after transplantation, respectively. This increase results primarily from improvement in survival achieved in the first 3 postoperative months (59% +/- 7%, 1968 to 1973, versus 80% +/- 40%, 1974 to 1980), reflecting improved patient management. Infection remains the primary cause of death following transplantation (76/131 patients, 58%), followed by acute rejection (24/181, 18.3%), graft arteriosclerosis (14/131, 10.7%), and malignancy (6/131, 4.6%). The development of graft arteriosclerosis has been examined in 85 one-year survivors studied by annual coronary arteriograms. Coronary lesions of varying severity have developed in 21 patients. HLA-A2 incompatibility was associated with a higher incidence of graft arteriosclerosis than was apparent for all other A locus incompatibilities (p less than 0.0003). Lymphoma has been shown to be associated with younger recipient age, a primary disease diagnosis of idiopathic cardiomyopathy, and retransplantation. One hundred six patients have survived at least 1 year after transplantation; 97% were in NYHA Class 1 at that time interval and 82% returned to employment or activity of choice. The longest survival time is new 11 years, 3 months. Cardiac transplantation can be considered "reasonable and therapeutic treatment to extend life" in selected individuals.

    View details for Web of Science ID A1982NC06600002

    View details for PubMedID 7035753

  • Therapeutic efficacy of intraaortic balloon pump counterpulsation. Analysis with concurrent "control" subjects. Circulation DOWNING, T. P., Miller, D. C., Stinson, E. B., Burton, N. A., Oyer, P. E., Reitz, B. A., Jamieson, S. W., Shumway, N. E. 1981; 64 (2): II108-13

    Abstract

    During a 7-year period, intraaortic balloon pumping (IABP) was attempted in 319 cardiac surgical patients. The indications for IABP were stringent and consisted of unsuccessful discontinuation of cardiopulmonary bypass (39%), anticipated failure (40%) to wean from cardiopulmonary bypass, postoperative low cardiac output, or intractable ventricular tachyarrhythmias (15%). IABP support was successfully instituted in 280 patients and was unsuccessful in 39 patients ("controls"). These two groups were comparable except for an older mean age and a higher ejection fraction in controls. Operative mortality rates were 45% and 62% for IABP and control groups, respectively (p = 0.077). This difference was most evident in coronary artery bypass patients, in whom the decision to institute IABP counterpulsation was made intraoperatively before attempted discontinuation of cardiopulmonary bypass. Two years postoperatively the actuarial survival rate was 45 +/- 3% for the IABP group and 23 +/- 9% for the control group (p = 0.006). After exclusion of operative deaths, however, these survival rates were 81 +/- 3% and 60 +/- 20%, respectively (p = NS). The average hospital charge incurred by IABP patients was threefold greater than that of uncomplicated cardiac surgical procedures. We conclude that IABP counterpulsation is therapeutic for some cardiac surgical patients, but its benefits cannot be defined easily. The long-term survival rates for patients with advanced disease requiring IABP support perioperatively are poor and warrant continued development of more effective methods of mechanical circulatory assistance and heart replacement.

    View details for PubMedID 6788404

  • THERAPEUTIC EFFICACY OF INTRA-AORTIC BALLOON PUMP COUNTERPULSATION - ANALYSIS WITH CONCURRENT CONTROL SUBJECTS CIRCULATION DOWNING, T. P., Miller, D. C., Stinson, E. B., Burton, N. A., Oyer, P. E., Reitz, B. A., Jamieson, S. W., Shumway, N. E. 1981; 64 (2): 108-113
  • PREPARATION AND EFFICACY OF CYCLOSPORIN-A LIPOSOMES FOR PROLONGATION OF CARDIAC ALLOGRAFT SURVIVAL TRANSPLANTATION PROCEEDINGS Aziz, S., BIEBER, C. P., Reitz, B. A., Bieber, M. M., Oyer, P. E., Hoyt, G., Stinson, E. B. 1981; 13 (1): 410-411

    View details for Web of Science ID A1981LF81600092

    View details for PubMedID 7022863

  • THE USE OF ECHOCARDIOGRAPHY IN DIAGNOSING CULTURE-NEGATIVE ENDOCARDITIS CIRCULATION Rubenson, D. S., Tucker, C. R., Stinson, E. B., LONDON, E. J., Oyer, P., MORENOCABRAL, R., Popp, R. L. 1981; 64 (3): 641-646

    Abstract

    We reviewed M-mode and two-dimensional echocardiographic findings in 11 patients with abacteremic endocarditis to study the application of echocardiography in this setting. All patients had negative blood cultures but underwent surgery that confirmed the presence of active infective endocarditis. The infection involved native valves in five patients and prosthetic valves in six patients. Valvular masses were identified in eight patients. The other three patients, who had prosthetic aortic valves, had diastolic mitral valve vibration characteristic of aortic regurgitation. One of these also showed dehiscence of the prosthesis. Three patients had poorly defined clinical illnesses and echocardiography was a prime element in the diagnosis because valvular masses were identified. The operation was facilitated by knowledge of the mass indicated by echocardiography in these eight cases. Also, the surgical approach was affected by knowledge of dehiscence and perivalvular abscess formation in two cases each.

    View details for Web of Science ID A1981MB94200028

    View details for PubMedID 7020979

  • NOREPINEPHRINE-STIMULATED LIPOLYSIS IN ACUTE AND CHRONIC HYPOXEMIA AMERICAN JOURNAL OF PHYSIOLOGY Baum, D., Oyer, P. 1981; 241 (1): E28-E34

    Abstract

    The effects of acute and chronic hypoxemia on norepinephrine-stimulated lipolysis were studied in dogs. Right-to-left shunts were created in experimental dogs to render them chronically hypoxemic (PaO2 37-55 torr). Control animals received sham operations (PaO2 greater than 70 torr). During air ventilation, there was no significant difference in norepinephrine-induced glycerol and free fatty acid (FFA) rises in the control and experimental groups. In control dogs, glycerol and FFA responses to norepinephrine were unaffected by acutely lowering oxygen tensions (PaO2 46-48 torr) to levels found in air-breathing experimental dogs. However, greater acute reductions in oxygen tensions (PaO2 less than 30 torr) in both control and experimental animals resulted in pronounced glycerol and FFA falls from the elevated levels produced by norepinephrine infusions during air ventilation. PaO2 levels less than 30 torr similarly decreased the glycerol and FFA elevations in control animals given phenoxybenzamine and norepinephrine. As with severe hypoxemia, propranolol suppressed glycerol and FFA increases stimulated by norepinephrine. Theophylline did not influence the hypoxemic-induced glycerol and FFA falls. These observations suggest that severity was important in the hypoxemic inhibition of norepinephrine-stimulated lipolysis; the effects of low oxygen breathing were not ameliorated by chronic hypoxemia. A beta-adrenergic receptor abnormality appears to contribute to this inhibition.

    View details for Web of Science ID A1981LY93800017

    View details for PubMedID 7246766

  • ORTHOTOPIC HEART AND COMBINED HEART AND LUNG TRANSPLANTATION WITH CYCLOSPORIN-A IMMUNE SUPPRESSION TRANSPLANTATION PROCEEDINGS Reitz, B. A., BIEBER, C. P., Raney, A. A., Pennock, J. L., Jamieson, S. W., Oyer, P. E., Stinson, E. B. 1981; 13 (1): 393-396

    View details for Web of Science ID A1981LF81600088

    View details for PubMedID 6791329

  • CARDIAC ALLOGRAFT SURVIVAL IN CYNOMOLGUS MONKEYS TREATED WITH CYCLOSPORIN-A IN COMBINATION WITH CONVENTIONAL IMMUNE SUPPRESSION TRANSPLANTATION PROCEEDINGS Pennock, J. L., Reitz, B. A., BIEBER, C. P., Jamieson, S. W., Raney, A. A., Oyer, P. E., Stinson, E. B. 1981; 13 (1): 390-392

    View details for Web of Science ID A1981LF81600087

    View details for PubMedID 7022859

  • COMPLICATIONS IN LONG-TERM SURVIVORS OF CARDIAC TRANSPLANTATION TRANSPLANTATION PROCEEDINGS BIEBER, C. P., Hunt, S. A., Schwinn, D. A., Jamieson, S. A., Reitz, B. A., Oyer, P. E., Shumway, N. E., Stinson, E. B. 1981; 13 (1): 207-211

    View details for Web of Science ID A1981LF81600046

    View details for PubMedID 7022823

  • LONG-TERM CLINICAL-ASSESSMENT OF THE EFFICACY OF ADJUNCTIVE CORONARY ENDARTERECTOMY JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Stinson, E. B., Oyer, P. E., Reitz, B. A., Jamieson, S. W., MORENOCABRAL, R. J., Shumway, N. E. 1981; 81 (1): 21-29

    View details for Web of Science ID A1981KY44100003

    View details for PubMedID 6969824

  • SURVIVAL OF PRIMATES FOLLOWING ORTHOTOPIC CARDIAC TRANSPLANTATION TREATED WITH TOTAL LYMPHOID IRRADIATION AND CHEMICAL IMMUNE SUPPRESSION TRANSPLANTATION Pennock, J. L., Reitz, B. A., BIEBER, C. P., Aziz, S., Oyer, P. E., Strober, S., Hoppe, R., KAPLAN, H. S., Stinson, E. B., Shumway, N. E. 1981; 32 (6): 467-473

    Abstract

    Fractionated total lymphoid irradiation (TLI) has been used for attempts at induction of a donor-specific tolerant-like state in allograft recipients and for immunosuppressive effects. Cyclosporin A (Cy A) has been shown to suppress rejection of organ grafts in many species including man. The present study was designed to test the effectiveness of TLI in combination with either CY A or rabbit anticynomolgus thymocyte globulin (ATG) and azathioprine. Thirty-one orthotopic cardiac allografts were performed using surface cooling and total circulatory arrest in outbred cynomolgus monkeys. TLI was administered preoperatively in fractions of 100 rad until a total of 600 or 1800 rad was achieved. Cy A was administered 17 mg/kg/day. All treatment groups demonstrated extended survival. Myocardial biopsies as early as 4 weeks were consistent with mild rejection in all treatment groups. No significant synergistic effect upon survival could be demonstrated utilizing TLI plus Cy A when compared with using Cy A alone. TLI (1800 rad) plus ATG and azathioprine was associated with a high incidence of early death attributable to leukopenia and infection. Cy A alone or in combination with TLI was associated with the development of lymphoid malignancy.

    View details for Web of Science ID A1981MU64300003

    View details for PubMedID 7041345

  • POST-INFARCTION VENTRICULAR SEPTAL-DEFECT - AN ARGUMENT FOR EARLY OPERATION SURGERY Gaudiani, V. A., Miller, D. C., Stinson, E. B., Oyer, P. E., Reitz, B. A., MORENOCABRAL, R. J., Shumway, N. E. 1981; 89 (1): 48-55

    Abstract

    We reviewed our experience with 43 consecutive patients who underwent operations for postinfarction ventricular septal defect to determine optimal time for operative intervention, to identify factors responsible for failure of operative treatment, and to determine long-term survival rates. Patients were referred for operation after expectant medical management had failed or after 6 weeks electively. The operative mortality rate was 42% and ranged from 90% for those who required operation within 1 day of 11% for those underwent surgery after 1 month. In a multivariate discriminant analysis of preoperative variables, we found that inferior infarction with perforation (P less than 0.02) and preoperative multisystem failure (evidenced by abnormal mental status, P less than 0.02) were the major factors correlating with high operative risk. Early operation per se did not affect operative mortality rates. Technical problems with early operation were not a source of major morbidity and mortality. Actuarial long-term survival was good, and 88.5% of survivors were alive 5 years after surgery. Because preoperative multisystem failure is often progressive, we recommend immediate operation for all patients with postinfarction ventricular septal defect unless no deterioration is present. Moreover, because of the high risk of those patients with inferior infarction and perforation, we recommended immediate surgery for this group regardless of symptomatic status.

    View details for Web of Science ID A1981KY49800008

    View details for PubMedID 7466611

  • PRESENT AND FUTURE OF CARDIAC TRANSPLANTATION ANNALS OF CLINICAL RESEARCH Oyer, P. E., Stinson, E. B., Shumway, N. E. 1981; 13 (4-5): 318-326

    View details for Web of Science ID A1981MY21100011

    View details for PubMedID 7039484

  • CARDIAC TRANSPLANTATION - 1980 TRANSPLANTATION PROCEEDINGS Oyer, P. E., Stinson, E. B., Reitz, B. A., BIEBER, C. P., Jamieson, S. W., Shumway, N. E. 1981; 13 (1): 199-206

    View details for Web of Science ID A1981LF81600045

    View details for PubMedID 7022822

  • OPERATIVE TREATMENT OF AN UNRESECTABLE TUMOR OF THE LEFT-VENTRICLE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Jamieson, S. W., Gaudiani, V. A., Reitz, B. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1981; 81 (5): 797-799

    Abstract

    A 17-year-old girl presented with an enlarged cardiac silhouette on routine chest roentgenogram. After clinical evaluation, echocardiography, and pericardiocentesis failed to provide a diagnosis, exploratory thoracotomy and biopsy revealed an unresectable left ventricular fibroma. The tumor continued to enlarge and began causing ventricular arrhythmia. Therefore, she underwent cardiac transplantation 2 years after the initial diagnosis was made. She is now alive nd well 18 months following transplantation.

    View details for Web of Science ID A1981LQ24300023

    View details for PubMedID 6261046

  • LONG-TERM SURVIVAL AND FUNCTION AFTER CARDIAC TRANSPLANTATION ANNALS OF SURGERY Gaudiani, V. A., Stinson, E. B., Alderman, E., Hunt, S. A., Schroeder, J. S., Perlroth, M. G., BIEBER, C. P., Oyer, P. E., Reitz, B. A., Jamieson, S. W., CHRISTOPHERSON, L., Shumway, N. E. 1981; 194 (4): 381-385

    Abstract

    Cardiac transplantation now permits prolonged survival for some patients with otherwise fatal heart disease. This report summarizes the hemodynamic and clinical characteristics of 25 patients who have survived five or more years after cardiac replacement. The average age of the patients at the time of operation was 40 +/- 10 (SD) years; 23 were men. The average duration of survival is 6.7 years, and ranges from five to 10.5 years. Annual cardiac catheterization and clinical follow-up were performed to assess systolic cardiac function, coronary anatomy, and quality of extended rehabilitation. We found that among these long-term survivors, the left ventricular ejection fraction remained constant (0.59 +/- 0.08 one year postoperatively, 0.57 +/- 0.09 at most recent study, p = ns). Segmental wall motion measured by fluoroscopic examination of midwall intramyocardial markers also remained normal. Four of 21 (19%) patients with complete longitudinal studies developed significant graft coronary artery disease. Clinical evaluation revealed that the long-term survivors required fewer than one unscheduled admission to the hospital per year. Sixteen of 25 patients (64%) were gainfully employed, and 22 of 25 (88%) enjoyed substantial benefit in terms of extended rehabilitation. These 25 long-term survivors represent 27% of 92 patients transplanted between 1968 and 1975. The actuarial survival rate at five years, of patients transplanted since 1975, is 40 +/- 5%. This increase in survival rate reflects improved techniques of early postoperative management. Cardiac transplantation now offers prolonged survival with good quality of life for selected patients with terminal heart disease.

    View details for Web of Science ID A1981ML08000002

    View details for PubMedID 7025768

  • Distant heart procurement for human transplantation. Ultrastructural studies. Circulation Billingham, M. E., Baumgartner, W. A., Watson, D. C., Reitz, B. A., Masek, M. A., Raney, A. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1980; 62 (2): I11-9

    Abstract

    The paucity of donor hearts for human transplantation can be remedied by distant heart procurement. In the present study, 12 donor hearts obtained at distant locatins were preserved by infusion with 500 ml of cardioplegic solution at 4 degrees C at 150 mm Hg and immersion in 4 degrees C saline for rapid transmural cooling. They were transported in ice-cold saline. Maximal ischemic times were 110-182 minutes. Septal biopsies before coronary reperfusion showed normal mitochondria (11 and 12), normal nuclei (seven of 12), myofibrillar I-bands (six of 12), and capillary endothelial swelling (12 of 12). Septal biopsies 30 minutes after reperfusion showed mitochondrial swelling (six of 10), nuclear damage (10 of 10), myofibrillar contraction (10 of 10), and endothelial swelling (eight of 10). All grafts functioned satisfactorily. Eight of the 12 patients were alive 6-15 months later; four patients died (one of pulmonary hypertension and three of infection). We concluded that (1) human hearts show significant ultrastructural changes after 3 hours of ischemia, but (2) these worsen after reperfusion, and (3) distant heart procurement is feasible for human transplantation.

    View details for PubMedID 6994923

  • DISTANT HEART PROCUREMENT FOR HUMAN TRANSPLANTATION - ULTRASTRUCTURAL STUDIES CIRCULATION Billingham, M. E., Baumgartner, W. A., Watson, D. C., Reitz, B. A., Masek, M. A., Raney, A. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1980; 62 (2): 11-19
  • DEVELOPMENT OF A TOTALLY IMPLANTABLE, ELECTRICALLY ACTUATED LEFT-VENTRICULAR ASSIST SYSTEM AMERICAN JOURNAL OF SURGERY Oyer, P. E., Stinson, E. B., Portner, P. M., REAM, A. K., Shumway, N. E. 1980; 140 (1): 17-25

    View details for Web of Science ID A1980JZ81100003

    View details for PubMedID 7396081

  • THE USE OF COMPUTED-TOMOGRAPHY IN THE DIAGNOSIS OF CORONARY-ARTERY BYPASS GRAFT PATENCY CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY GUTHANER, D. F., Brody, W. R., RICCI, M., Oyer, P. E., Wexler, L. 1980; 3 (1): 3-8

    Abstract

    In a preliminary evaluation of the use of dynamic computed tomography (CT) for the detection of patent aortocoronary bypass grafts, 30 patients were scanned either during the early postoperative period or after graft patency was determined by angiography. To visualize the proximal grafts, CT scans were taken through the aortic root following an intravenous bolus injection of contrast medium. Patent bypass grafts to the left anterior descending and right coronary arteries were demonstrated in 77.5%, while posterior grafts to the circumflex and obtuse marginal coronary arteries were detected in 40%. With its potential for extracting dynamic events, CT scanning provides a new, noninvasive modality for the diagnosis of patent bypass grafts, which heretofore have only been visualized by selective angiography.

    View details for Web of Science ID A1980JW69900001

    View details for PubMedID 6966186

  • HEMODYNAMIC AND CLINICAL COMPARISON OF THE HANCOCK MODIFIED ORIFICE AND STANDARD ORIFICE BIOPROSTHESES IN THE AORTIC POSITION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Rossiter, S. J., Miller, D. C., Stinson, E. B., Oyer, P. E., Reitz, B. A., MORENOCABRAL, R. J., MACE, J. G., ROBERT, E. W., TSAGARIS, T. J., Sutton, R. B., Alderman, E. L., Shumway, N. E. 1980; 80 (1): 54-60

    Abstract

    Bioprosthetic aortic valve replacement in patients with a small aortic root has been associated with postoperative transvalvular gradients. A modified orifice Hancock xenograft bioprosthesis has been developed and is purported to increase significantly the effective orifice area (as evaluated by in vitro testing) compared to the standard orifice Hancock bioprosthesis. To assess the in vivo differences, we compared 481 patients with standard orifice prostheses with 156 patients with modified orifice prostheses. Postoperative catheterization was performed in 24 patients with modified orifice (valve diameters 19 to 25 mm) with 14 with standard orifice valves (valve diameters 21 to 25 mm). Actuarial rates of survival, valve failure, endocarditis, and thromboembolism did not differ significantly between the two subgroups. Peak aortic valve gradients on the whole were less in the modified orifice subgroup than in the standard origice subgroup (12 +/- 1 torr versus 20 +/- 6 torr [mean +/- SEM]), but the difference was not statistically significant (p greather than 0.05). The calculated in vivo aortic valve areas were slightly, but insignificantly, greater in the modified orifice subgroup than in the standard orifice subgroup (p greater than 0.05). These in vivo data partially corroborate the in vitro findings of increased effective orifice area and internal-to-external diameter ratio for the modified orifice bioprosthesis. The hemodynamic differences between the two valve types are small, however, and the putative clinical advantages inherent in the use of the modified orifice bioprosthesis remain to be completely defined.

    View details for Web of Science ID A1980JZ53400012

    View details for PubMedID 7382536

  • SURGICAL APPROACH FOR S,L,L SINGLE VENTRICLE INCORPORATING TOTAL RIGHT ATRIUM-PULMONARY ARTERY DIVERSION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY MORENOCABRAL, R. J., Miller, D. C., Oyer, P. E., Stinson, E. B., Reitz, B. A., Shumway, N. E. 1980; 79 (2): 202-210

    Abstract

    Patients with single ventricle and unfavorable anatomy for partitioning procedures have been considered inoperable. Such was the case in two patients with single ventricle and subaortic inverted (hypoplastic) infundibulum associated with subaortic obstruction and levo-transposition of the great vessels (S,L,L). Both had undergone pulmonary artery banding in infancy and presented 11 and 14 years later, cyanotic and severely incapacitated. Both patients were treated surgically by resection of the subaortic obstruction, patch closure of the right artrioventricular valve, closure of the proximal pulmonary artery, and diversion of systemic venous flow through a xenograft valved conduit from the right atrium to the distal pulmonary artery. Early postoperative complications included atrial dysrhythmias and right-sided congestion. The first patient, who had massive cardiomegaly and complete heart block preoperatively, developed congestive failure 20 months postoperatively. The second patient has an excellent functional result and is leading a normal life 1 years after operation. This procedure may be of value for patients with single ventricle in whom corrective ventricular septation is considered too risky or technically unfeasible.

    View details for Web of Science ID A1980JE62300008

    View details for PubMedID 7188708

  • CLINICAL DURABILITY OF THE HANCOCK PORCINE BIOPROSTHETIC VALVE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Oyer, P. E., Miller, D. C., Stinson, E. B., Reitz, B. A., MORENOCABRAL, R. J., Shumway, N. E. 1980; 80 (6): 824-833

    Abstract

    The principal feature of the Hancock xenograft bioprosthesis which remains to be completely defined is long-term durability. This report provides extended data regarding valve durability derived from a data base of 1,407 patients (707 aortic [AVR] and 700 mitral [MVR] replacements) who received Hancock bioprostheses between 1971 and 1979; cumulative duration of follow-up was 1,732 patient-years for AVR and 1,843 for MVR patients, with a maximum follow-up duration of 8.4 years. One hundred seventy-nine patients were followed for more than 5 years and 67 for more than 6 years. Valve failure was defined on the basis of one or more of the following criteria: (1) postoperative development of a new regurgitant murmur, (2) thrombotic valvular occlusion, (3) infective endocarditis resulting in reoperation or death, and (4) hemodynamic valvular dysfunction confirmed by catheterization and resulting in reoperation or death. Twenty-one such failures occurred among all AVR patients and 23 among all MVR patients. The actuarial probability of freedom from valve failure (all causes) was 95.4% +/- 1.2% (+/- SEM) for adult AVR patients 5 years postoperatively and 90.9% +/- 2.6% for adult MVR patients 6 years postoperatively. The probability of freedom from primary tissue failure in adults was 99% +/- 1% in AVR patients at 5 years and 94.3% +/- 2.4% in MVR patients at 6 years. The linearized incidence of primary tissue failure in children (< 15 years old) was 9.8% per patient-year (combined AVR and MVR patients), compared to 0.2% per patient-year among all adult patients in the analysis. The combined actuarial incidence of primary tissue failure among adults with AVR and MVR was 98.6% +/- 0.7% at 5 years and 94.2% +/- 2.3% at 6 years; thus there appears to be a slight acceleration in the rate of valve tissue failure between 5 and 6 years after operation. The incidence of failure, however, remains acceptably low through 6 years of follow-up, and continued clinical use of the xenograft bioprosthesis seems warranted.

    View details for Web of Science ID A1980KT96500002

    View details for PubMedID 7431981

  • POSTOPERATIVE ENHANCEMENT OF LEFT-VENTRICULAR PERFORMANCE BY COMBINED INOTROPIC-VASODILATOR THERAPY WITH PRELOAD CONTROL SURGERY Miller, D. C., Stinson, E. B., Oyer, P. E., Derby, G. C., Reitz, B. A., Shumway, N. E. 1980; 88 (1): 108-117

    View details for Web of Science ID A1980JZ48400014

    View details for PubMedID 7385014

  • CONCOMITANT RESECTION OF ASCENDING AORTIC-ANEURYSM AND REPLACEMENT OF THE AORTIC-VALVE - OPERATIVE AND LONG-TERM RESULTS WITH CONVENTIONAL TECHNIQUES IN 90 PATIENTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Stinson, E. B., Oyer, P. E., MORENOCABRAL, R. J., Reitz, B. A., Rossiter, S. J., Shumway, N. E. 1980; 79 (3): 388-401

    Abstract

    We reviewed a consecutive series of 90 patients undergoing concomitant resection of ascending aortic anerysm and aortic valve replacement (AVR) utilizing noncomposite "conventional" techniques in order to assess the early and late results, to define limitations of this operative approach, and thereby to clarify the indications for composite reconstruction of the aortic root. Mean age was 55 years. Twenty percent had Marfan's syndrome, and 13% had aortic dissections. The cause of the aneurysm was dissection in 13% of cases, syphilis in 11%, atherosclerosis in 9%, and degeneration (with or without cystic medionecrosis) in 67%. Follow-up averaged 3.8 years and extended to 11.5 years maximum. AVR and complete excision of the aneurysm (preserving small tongues of aortic wall circumscribing the coronary artery ostia) coupled with tubular graft replacement of the ascending aorta were performed. Nineteen percent of patients required individual technical modifications relating to the coronary arteries. Operative mortality rate was 13%, with the majority of deaths being due to cardiac causes. Contemporary (1975 to 1978) operative mortality rate was 4.3%. Seven percent required re-exploration for hemorrhage and 2.4% had perioperative myocardial infarctions. Late functional results were generally good (average N.Y.H.A. Class 1.4). Late thromboembolism, angina, myocardial infarction, and congestive heart failure occurred at linearized rates of 3.4% per patient-year, 4.9% per patient-year, 1.1% per patient-year, and 5.2% per patient-year, respectively. No prosthetic valve endocarditis, graft infection, or recurrent aneurysms of the aortic root were observed. Late reoperation was necessary in eight patients (3% per patient-year), but reoperation for disease confined to the ascending aorta accounted for only three of these cases (1.1% per patient-year). Overall actuarial survival rates were 67% +/- 5% at 5 years and 50% +/- 9% at 10 years; survival rates for the 78 operative survivors were 77% +/- 5% and 57% +/- 10% at the same time intervals, respectively. Only one late death could be attributed to complications arising in the reconstructed aortic root. These results confirm that such simple, noncomposite techniques are safe, portend minimal risk of late complications and the attendant necessity for reoperation, and provide satisfactory long-term survival. We believe that composite techniques should be primarily reserved for selected cases of advanced necrotizing prosthetic or natural endocarditis.

    View details for Web of Science ID A1980JJ18300009

    View details for PubMedID 6986512

  • SEQUENTIAL ORTHOTOPIC HEART-TRANSPLANTATION IN MAN TRANSPLANTATION Watson, D. C., Reitz, B. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1980; 30 (6): 401-403

    Abstract

    Between January 1968 and March 1980, 202 hearts had been transplanted into 185 patients at Stanford University Medical Center. Occasionally, patients after transplantation develop myocardial failure which is amenable only to retransplantation. Sixteen patients underwent initial orthotopic allograft using standard techniques. Eight patients developed accelerated arteriosclerotic coronary disease, six had unrelenting rejection, and two had donor heart dysrrhythmia or right ventricular failure requiring retransplantation. One patient required a third transplant because of donor left ventricular ischemia. All sequential transplants were managed similarly to the primary transplant. Of the initial transplant hearts at risk, 60% survived for more than 1 year, and 57% survived for more than 2 years. These results are similar to those of patients not requiring retransplantation. Of the secondary transplant hearts at risk, 31% survived for more than 1 year and 29% survived for more than 2 years. The severity of infection and/or rejection contributed most significantly to secondary heart transplant mortality. Sequential orthotopic cardiac transplantation offers an acceptable alternative to patients with allograft failure. Survival is not as favorable as with initial transplantation because of the prolonged immunosuppression during sequential transplantation.

    View details for Web of Science ID A1980KV49400002

    View details for PubMedID 7008286

  • LETHAL COMPLICATIONS DUE TO CYCLOSPORIN A IMMUNE SUPPRESSION WITH COMBINATION-DRUG THERAPY IN MONKEY HEART AND COMBINED HEART AND LUNG TRANSPLANTATION SURGICAL FORUM Pennock, J. L., Reitz, B. A., BIEBER, C. P., Jamieson, S. W., Burton, N. A., Raney, A. A., Oyer, P. E., Stinson, E. B. 1980; 31: 375-378
  • Cardiac homotransplantation. Current problems in surgery Baumgartner, W. A., Reitz, B. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1979; 16 (9): 1-61

    View details for PubMedID 387341

  • Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. journal of thoracic and cardiovascular surgery Miller, D. C., Stinson, E. B., Oyer, P. E., Rossiter, S. J., Reitz, B. A., Griepp, R. B., Shumway, N. E. 1979; 78 (3): 365-382

    Abstract

    An unselected, consecutive cohort of 125 patients underwent operative repair of acute and chronic aortic dissections with tubular graft interposition over a 16 year span. The absence of remote geographical referral biases and the unselected nature of this series provided a patient population that was representative of the disease process (as assessed heretofore only from autopsy series). Furthermore, this enabled high-risk subsets to be defined by retrospective analysis. Patients were classified according to whether the ascending aorta was involved (type A with involvement, type B without), irrespective of the site of intimal tear, and according to age of the dissection: Fifty-three patients had acute type A (Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the dissections had ruptured. Concomitant aortic valve replacement (AVR) was performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A total of 391 patient-years of follow-up was analyzed; follow-up averaged 4.5 years and extended to 13.7 years. Over-all operative mortality rate was 34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22% (5/23) for Ch-B; during the most recent 5 year interval these figures were lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative variables were found to correlate significantly with both operative death and long-term survival. Operative survivors generally experienced satisfactory functional benefit. Late attrition averaged 8% per year; 61% of all late deaths were related to cardiac or cerebral causes. Over-all actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5 years and 26% +/- 7% at 10 years; for the 89 patients surviving operation, these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant differences in long-term survival were evident between the different subgroups. Whether the primary intimal tear had been resected or concomitant AVR had been performed had no statistically significant bearing on operative mortality, functional result, necessity for late reoperation, or late attrition. The long-term "natural" history of surgically treated patients with aortic dissections, as defined in this study, should facilitate comparison with other treatment modalities. Results of the present analysis support immediate operative intervention for patients with Ac-A dissections and probably for those with Ac-B dissections. Additionally, surgical treatment of patients with symptomatic or enlarging Ch-A and Ch-B dissections provides satisfactory rehabilitation and long-term survival. Finally, we re-emphasize our recommendation for simplified classification of aortic dissections, based solely upon the presence or absence of ascending aortic involvement. Pathophysiology and expected biologic behavior pivot on this feature, and appropriate clinical strategy can thereby be defined.

    View details for PubMedID 470417

  • An important complication of Hancock mitral valve replacement in children. Circulation KUTSCHE, L. M., Oyer, P., Shumway, N., Baum, D. 1979; 60 (2): 98-103

    Abstract

    Nine children ages 2--15 years have undergone mitral valve replacement (MVR) with Hancock porcine heterograft valves for severe mitral insufficiency. The etiology of the mitral valve disease was rheumatic in two patients, and congenital in seven. Porcine valve sizes ranged from 19--31 mm. Follow-up has been from 1.6 to 6.1 years (mean, 4.3 years). All nine children have had marked postoperative improvement, no thromboembolic complications despite no long-term anticoagulations, and no episodes of endocarditis. There have been no early or late deaths. Although six of the nine patients remain asymptomatic, three others developed severe fibrocalcific obstruction of the heterograft, requiring valve re-replacement at 3.5, 3.6, and 4.8 years following the initial valve replacement. This complication has not been previously reported in children. It is a factor that must be considered when deciding on MVR for children and their postoperative management.

    View details for PubMedID 445780

  • IMPORTANT COMPLICATION OF HANCOCK MITRAL-VALVE REPLACEMENT IN CHILDREN CIRCULATION KUTSCHE, L. M., Oyer, P., Shumway, N., Baum, D. 1979; 60 (2): I98-I103
  • LATE RIGHT HEART RECONSTRUCTION FOLLOWING REPAIR OF TETRALOGY OF FALLOT ANNALS OF THORACIC SURGERY Miller, D. C., Rossiter, S. J., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1979; 28 (3): 239-251

    Abstract

    Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.

    View details for Web of Science ID A1979HK73000008

    View details for PubMedID 485625

  • HEPATITIS RISK IN CARDIAC-SURGERY PATIENTS RECEIVING FACTOR-IX CONCENTRATES JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Rossiter, S. J., Miller, D. C., Raney, A. A., Oyer, P. E., Reitz, B. A., Stinson, E. B., Shumway, N. E. 1979; 78 (2): 203-207

    Abstract

    Experience with the clinical use and hepatitis risks of factor IX concentrate (Proplex) in cardiac surgical patients is presented in this report. Seventy-five patients received the concentrate for severe intraoperative or postoperative hemorrhage and 75 patients constituted matched controls. The incidence of probable type B viral hepatitis in patients receiving factor IX concentrate was 13.8 percent (four of 29) versus zero percent (zero of 29) in control patients (difference not significant). However, there was a greater incidence (p less than 0.05) of anti-HBs in patients receiving factor IX concentrate as compared to control subjects. No hepatitis-associated deaths or major morbidity were noted in these patients. It is confirmed that factor IX concentrate carries an associated significant risk of hepatitis. However, its use is justified in certain severe, acquired coagulopathies in which conventional platelet and fresh-frozen plasma therapy is inadequate.

    View details for Web of Science ID A1979HG27100008

    View details for PubMedID 459527

  • SURGICAL TREATMENT OF ANEURYSMS OF THE INFERIOR LEFT-VENTRICULAR WALL JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY BUEHLER, D. L., Stinson, E. B., Oyer, P. E., Shumway, N. E. 1979; 78 (1): 74-78

    Abstract

    Experience with surgical treatment of 10 patients with aneurysms of the inferior wall of the left ventricle is presented. Six of the 10 aneurysms were false (pseudoaneurysms), and four were classified as true aneurysms. All except one resulted from myocardial infarction. Combined procedures, performed at the time of aneurysm resection, included mitral valve replacement (five patients), coronary artery bypass grafting (four patients), and closure of an interventricular septal defect (one patient). Three of four patients with true inferior aneurysms had mitral valve dysfunction, whereas only two of six patients with false aneurysms required mitral valve replacement (one because of infective endocarditis). Nine of the 10 patients survived operation, and all are functionally improved except one. On the basis of this and previously reported experience, it is concluded that a substantial proportion of inferior left ventricular aneurysms exhibit the pathological features of false aneurysms. Because of the associated propensity toward rupture of such lesions, an aggressive surgical approach is recommended.

    View details for Web of Science ID A1979HC45000014

    View details for PubMedID 449388

  • AORTIC AND MITRAL PROSTHETIC VALVE REOPERATIONS - EARLY AND LATE RESULTS ARCHIVES OF SURGERY Rossiter, S. J., Miller, D. C., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1979; 114 (11): 1279-1283

    Abstract

    A total of 232 valvular reoperations (123 mitral valve reoperations [RMVR] and 109 aortic valve reoperations [RAVR] were performed in 194 patients with previously implanted prosthetic valves. Early mortality was 10% (12/123) for the RMVR subgroup and 14% (15/109) for the RAVR subgroup (P = NS). Late mortality was 16% (18/111) for the RMVR subgroup and 25% (23/94) for the RAVR subgroup (P = NS). Patients with prosthetic endocarditis or prosthetic stenosis constituted higher-risk subpopulations. Principal determinants of both operative mortality and late attrition were preoperative cardiac functional status and the nature of the pathology mandating valve replacement. Early prosthetic valve replacement is advocated to correct hemodynamic abnormalities before advanced ventricular decompensation ensues, especially when prosthetic valvular endocarditis or prosthetic stenosis exists.

    View details for Web of Science ID A1979HS43800008

    View details for PubMedID 496629

  • SURGICAL IMPLICATIONS AND RESULTS OF COMBINED AORTIC-VALVE REPLACEMENT AND MYOCARDIAL REVASCULARIZATION AMERICAN JOURNAL OF CARDIOLOGY Miller, D. C., Stinson, E. B., Oyer, P. E., Rossiter, S. J., Reitz, B. A., Shumway, N. E. 1979; 43 (3): 494-501

    View details for Web of Science ID A1979GL34000005

    View details for PubMedID 420100

  • LONG-TERM EVALUATION OF THE PORCINE XENOGRAFT BIOPROSTHESIS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Oyer, P. E., Stinson, E. B., Reitz, B. A., Miller, D. C., Rossiter, S. J., Shumway, N. E. 1979; 78 (3): 343-350

    View details for Web of Science ID A1979HL52600003

    View details for PubMedID 470415

  • DISTANT HEART PROCUREMENT FOR TRANSPLANTATION SURGERY Watson, D. C., Reitz, B. A., Baumgartner, W. A., Raney, A. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1979; 86 (1): 56-59

    Abstract

    Between January 1, 1977, and September 15, 1978, 39 cardiac transplants were performed on 38 patients. Twenty donor hearts were removed at Stanford University Hospital, and 19 donor hearts were removed at distant hospitals. The characteristics of recipients and donors in both groups were similar. The only significant difference between donor hearts was the mean ischemia time (154 +/- 30 minutes in distant hearts and 52 +/- 12 minutes in local hearts, P less than 0.001). As of February 1, 1979, the total mortality rate was 32% for the distant heart donors and 40% for the local heart donors. No difference between the two groups was present in immediate myocardial function, the need for postoperative inotropic support, the mortality rate within the first 90 days after operation, the mean maximum serum enzyme levels, the occurrence of rejection or infection, and the histological appearance of the hearts, both early and late. The results of cardiac transplantation when hearts are removed at distant hospitals are entirely comparable to the results with hearts removed on site with a minimum ishchemic time. Distant heart procurement provides an expanded donor pool for potential cardiac recipients.

    View details for Web of Science ID A1979HC69500009

    View details for PubMedID 377542

  • DIAGNOSIS AND TREATMENT OF ACUTE CARDIAC ALLOGRAFT-REJECTION TRANSPLANTATION PROCEEDINGS Oyer, P. E., Stinson, E. B., BIEBER, C. P., Reitz, B. A., Raney, A. A., Baumgartner, W. A., Shumway, N. E. 1979; 11 (1): 296-303

    Abstract

    Integration of data derived from immunologic monitoring techniques and endomyocardial biopsy currently permits more precise administration of immunosuppressive medications for the treatment of acute cardiac allograft rejection than was formerly possible, resulting in a substantially improved outlook for long-term survival. Indeed, the probability of survival for 5 years postoperatively of 50% exceeds that for several categories of cardiac patients currently undergoing other more common forms of heart surgery. The continuing demonstration of the potential for cardiac transplantation clearly warrants further application of this procedure for the treatment of appropriate patients with end-stage cardiac disease.

    View details for Web of Science ID A1979GQ02500066

    View details for PubMedID 377648

  • LEFT-VENTRICULAR ANEURYSM - PREOPERATIVE RISK-FACTORS AND LONG-TERM POST-OPERATIVE RESULTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Burton, N. A., Stinson, E. B., Oyer, P. E., Shumway, N. E. 1979; 77 (1): 65-75

    Abstract

    The results of operative treatment of postinfarction left ventricular aneurysm in 169 patients undergoing operation since 1970 are analyzed in this report. Maximum follow-up extended to 7 year (average 2.9 years). Average patient age was 56 years (range 34 to 82 years). Nearly all patients (94%) had left anterior descending coronary artery disease with anterior aneurysm formation and 73% had multivessel disease. Sixty-eight percent of patients underwent aorta-coronary bypass grafting (ACBG) and/or mitral valve replacement (MVR) concomitantly with aneurysmectomy. The over-all operative mortality rate was 17.8%. Preoperative factors that correlated significantly (p less than 0.05) with increased operative risk reflected primarily the quality of left ventricular function, and included functional classification, cardiac index, contractile function of residual myocardium not involved by aneurysm, and mitral regurgitation. Patients whose primary preoperative disability consisted of angina pectoris (42 patients) exhibited significantly higher over-all survival rates (actuarial 5 year survival 75%) than those undergoing operation because of congestive heart failure (86 patients) or ventricular tachyarrhythmias (38 patients), whose 5 year survival rates were 52 and 57%, respectively. Concomitant ACBG (+/- MVR) was associated with a higher operative mortality rate than aneurysmectomy alone (21.1 versus 10.9%), but late postoperative attrition was similar. The over-all 5 year survival rate, including operative death, was 60%, and 90% of surviving patients were in Functional Class I or II at follow-up evaluation. We conclude from this analysis that the long-term prognosis of patients with symptomatic postinfection left ventricular aneurysms, although determined importantly by preoperative left ventricular function, is enhanced by surgical treatment.

    View details for Web of Science ID A1979GE10600008

    View details for PubMedID 309979

  • SURVIVAL OF CARDIAC ALLOGRAFTS IN RATS TREATED WITH CYCLOSPORIN-A SURGICAL FORUM Jamieson, S. W., Burton, N. A., BIEBER, C. P., Reitz, B. A., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1979; 30: 289-291

    View details for Web of Science ID A1979JB37300127

    View details for PubMedID 395684

  • CURRENT MANAGEMENT OF CARDIAC TRANSPLANT RECIPIENTS BRITISH HEART JOURNAL Jamieson, S. W., Reitz, B. A., Oyer, P. E., BIEBER, C. P., Stinson, E. B., Shumway, N. E. 1979; 42 (6): 703-708

    Abstract

    Changes in the management of cardiac transplant recipients over the past 10 years have resulted in a substantial improvement in the outlook for survival. Imuran and prednisone remain the primary immunosuppressive agents, but rabbit antihuman thymocyte globulin is used initially and reinstituted during rejection. Endomyocardial biopsy has allowed more precise diagnosis and management of rejection, and more recently immunological monitoring has been introduced to provide more frequent assessment of the host immune response. Infection is the major cause of death, and its diagnosis and treatment is managed aggressively. Current survival figures justify the use of cardiac transplantation, by an experienced team, when other measures have been exhausted.

    View details for Web of Science ID A1979HZ98900010

    View details for PubMedID 394751

  • OPERATIVE TREATMENT OF AORTIC DISSECTIONS - EXPERIENCE WITH 125 PATIENTS OVER A 16-YEAR PERIOD JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Miller, D. C., Stinson, E. B., Oyer, P. E., Rossiter, S. J., Reitz, B. A., Griepp, R. B., Shumway, N. E., WHEAT, M. W., Cohn, L. H. 1979; 78 (3): 365-382
  • PREDICTIVE VARIABLES IN REOPERATION FOR CORONARY-ARTERY DISEASE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Allen, R. H., Stinson, E. B., Oyer, P. E., Shumway, N. E. 1978; 75 (2): 186-192

    View details for Web of Science ID A1978EM10800005

    View details for PubMedID 304945

  • LOCALIZED TAMPONADE OF RIGHT ATRIUM AND RIGHT VENTRICLE - INDUCTION OF INTRA-CARDIAC RIGHT-TO-LEFT SHUNTING AFTER USE OF A GOTT SHUNT ARCHIVES OF SURGERY Miller, D. C., Oyer, P. E., RICKS, W., Cipriano, P. R., Shumway, N. E. 1978; 113 (6): 764-766

    Abstract

    After repair of a traumatic tear of the descending aorta, using a Gott shunt between the left ventricle and the distal descending aorta, a patient was readmitted with profound postural cyanosis and dyspnea. Catheterization showed right-to-left shunting at the atrial level caused by extrinsic deformation of the right atrium and right ventricle. Sternotomy showed selective pericardial tamponade on the right side of the heart caused by a localized collection of organizing thrombus and old blood. The previously unsuspected large patent foramen ovale was closed. This complication represents a form of iatrogenic cyanosis tardice and is thought to be attributable to the method of shunting used during the first operation. Moreover, this complication should be easily preventable if the pooled blood and clot in the most dependent portion of the pericardial cavity is adequately evacuated.

    View details for Web of Science ID A1978FB53200021

    View details for PubMedID 655856

  • PROSTHETIC VALVE ENDOCARDITIS - COMPARISON OF HETEROGRAFT TISSUE VALVES AND MECHANICAL VALVES JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Rossiter, S. J., Stinson, E. B., Oyer, P. E., Miller, D. C., SCHAPIRA, J. N., Martin, R. P., Shumway, N. E. 1978; 76 (6): 795-803

    View details for Web of Science ID A1978GA20800007

    View details for PubMedID 713586

  • An implantable permanent left ventricular assist system for man. Transactions - American Society for Artificial Internal Organs Portner, P. M., Oyer, P. E., Jassawalla, J. S., Miller, P. J., Chen, H., LaForge, D. H., SKYTTE, K. W. 1978; 24: 99-103

    Abstract

    A new implantable, electrically powered LV AS suitable for long-term use in man has been designed and is under development. The system is based on the well developed high-efficiency pulsed solenoid technology and a careful a priori systems approach to integration of the energy converter with a suitable blood pump. A novel dual pusher-plate sac-type blood pump with significant advantages in hemodynamics, antithrombogenicity and durability has been designed. The complementary energy converter, a pivoted-armature dual-gap solenoid, addresses weaknesses in previous designs while retaining all the good features of its forerunners and provides for the first time a truly integrated implantable circulatory assist system for man.

    View details for PubMedID 716101

  • OPERATIVE TREATMENT OF CONGENITAL AORTIC-STENOSIS ANNALS OF THORACIC SURGERY Salomon, N. W., Stinson, E. B., Oyer, P., Copeland, J. G., Shumway, N. E. 1978; 26 (5): 452-460

    Abstract

    The operative treatment of 131 patients with congenital aortic stenosis is reviewed. Of the 131 patients, 77% had left ventricular outflow tract (LVOT) obstruction at a single level and 23%, major obstruction at more than one level. There were 3 operative deaths (2.3%) and 10 late deaths (7.8%). Twenty of the 128 discharged patients have undergone a second procedure and 6 a third procedure for recurrent or residual LVOT obstruction. The 26 reoperations included 7 aortic valve replacements, 4 left ventricular apical-abdominal aortic (LV-AA) valved conduits, and 15 extensive aortic valvotomies with or without supravalvular aortoplasty. Five of the 20 patients undergoing reoperation died; 4 of these deaths occurred in patients who had valve replacement at reoperation. The 4 who received LV-AA conduits have sustained excellent hemodynamic and clinical results with no complications. Highly satisfactory clinical results can be obtained with minimal operative risk, regardless of the level of LVOT obstruction. Reoperation for recurrent or residual LVOT obstruction, however, is comparatively more hazardous, and alternative surgical approaches (LV-AA conduits) should be considered.

    View details for Web of Science ID A1978FV91700010

    View details for PubMedID 753159

  • IMPACT OF SIMULTANEOUS MYOCARDIAL REVASCULARIZATION ON OPERATIVE RISK, FUNCTIONAL RESULT, AND SURVIVAL FOLLOWING MITRAL-VALVE REPLACEMENT SURGERY Miller, D. C., Stinson, E. B., Rossiter, S. J., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1978; 84 (6): 848-857

    Abstract

    A cohort of 282 patients who underwent mitral valve replacement with a xenograft bioprosthesis was strictly segregated according to etiology of mitral dysfunction and analyzed regarding the impact of arteriographic coronary artery disease (CAD) and concomitant coronary artery bypass grafting (CABG) on operative risk, functional result, and survival. CAD was present in 21% of the 122 patients with predominant mitral stenosis (MS) and 59% of the 155 patients with mitral regurgitation (MR); moreover, discordance between the presence of angina and anatomic CAD was found in 27% (33 of 122) of the MS subgroup and 36% (56 of 155) of the MR subgroup. Etiology of the valvular dysfunction was rheumatic in 148 patients, myxomatous degeneration in 83, and ischemic in 32. Within these subgroups, 41 patients (27%), 40 patients (48%), and 32 patients (100%), respectively, had CAD. Of those patients with CAD, 85% of the rheumatic subgroup, 90% of the degenerative subgroup, and 81% of the ischemic subgroup underwent concomitant CABG at the time of valve replacement. Within each subgroup no statistically significant (P greater than 0.05) differences in operative mortality rate, perioperative myocardial infarction rate, incidence of late angina or late infarction, or late actuarial survival were evident when compared on the basis of CAD, and/or CABG, with one exception. The exception was the 10% incidence of perioperative myocardial infarction in the rheumatic subgrohp with coronary disease versus 2% in the rheumatic subgroup without coronary disease (P = 0.05). Within the time constraints of this study (mean follow-up = 2.3 years; maximum follow-up = 5.9 years), these results support simultaneous MVR and CABG when hemodynamically appreciable CAD is found. Moreover, the overall 43% incidence of arteriographic CAD warrants routine coronary angiography in most adults undergoing preoperative catheterization for mitral valvular disease.

    View details for Web of Science ID A1978FY91700014

    View details for PubMedID 568831

  • CURRENT EXPECTATIONS IN CARDIAC TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Baumgartner, W. A., Reitz, B. A., BIEBER, C. P., Oyer, P. E., Shumway, N. E., Stinson, E. B. 1978; 75 (4): 525-530

    Abstract

    Survival after cardiac transplantation has improved significantly over the past 3 1/2 years at our Center as compared to previous experience (Fig. 5). Currently, survival rates for 60 patients who have had heart transplantation since late in 1973 (program year mean survival +/- S.E.) are 66 percent (+/- 6.6 S.E.), 63 percent (+/- 7.0) and 58 percent (+/- 8.2) 1, 2, and 3 years after operation, respectively. In this report the major reasons for this successful trend have been summarized. These consist of transvenous endomyocardial biopsy for diagnosis and management of graft rejection, use of RATG, immunologic monitoring for early detection of impending rejection, and cardiac retransplantation in selected cases. The present expectations for survival and rehabilitation after heart transplantation are fully comparable to the current results of renal transplantation from unrelated donors. These considerations support the inclusion of cardiac transplantation as a realistic therapeutic alternative in the management of patients with advanced heart disease irremediable by standard forms of treatment.

    View details for Web of Science ID A1978EV09600006

    View details for PubMedID 347177

  • EVOLUTION OF SOLENOID-ACTUATED LEFT-VENTRICULAR ASSIST SYSTEM - INTEGRATION WITH A PUSHER-PLATE PUMP FOR INTRA-ABDOMINAL IMPLANTATION IN CALF ARTIFICIAL ORGANS Portner, P. M., Oyer, P. E., Miller, P. J., Jassawalla, J. S., REAM, A. K., CORBIN, S. D., SKYTTE, K. W. 1978; 2 (4): 402-412

    Abstract

    The performance of an implantable left ventricular assist system (LVAS) utilizing a pulsed solenoid energy converter and a pusher-plate blood pump has been characterized in vitro and in vivo. A microprocessor-based electronic control system makes the LVAS completely self-regulating over the range of operating conditions and provides considerable flexibility in various assist modalities. Over forty thousand hours of in vitro and in vivo operating experience has been accumulated with current systems, and significant progress has been acheived in system durability and reliability. A new toggle latch has provided nearly a year of failure-free operation on the bench, without measurable wear. Energy converter efficiencies of 50% have been demonstrated. In vivo evaluation has been highlighted by an animal experiment still in progress after nearly four months of fault-free, continuous synchronous pumping.

    View details for Web of Science ID A1978GA30000019

    View details for PubMedID 743015

  • IMPLANTABLE PERMANENT LEFT-VENTRICULAR ASSIST SYSTEM FOR MAN TRANSACTIONS AMERICAN SOCIETY FOR ARTIFICIAL INTERNAL ORGANS Portner, P. M., Oyer, P. E., Jassawalla, J. S., Miller, P. J., Chen, H., LaForge, D. H., SKYTTE, K. W. 1978; 24: 98-103
  • Heart and other organs. Increasing patient survival following heart transplantation. Transplantation proceedings Griepp, R. B., Stinson, E. B., BIEBER, C. P., Oyer, P. E., Reitz, B. A., Copeland, J. G., Shumway, N. E. 1977; 9 (1): 197-201

    View details for PubMedID 325759

  • INCREASING PATIENT SURVIVAL FOLLOWING HEART-TRANSPLANTATION TRANSPLANTATION PROCEEDINGS Griepp, R. B., Stinson, E. B., BIEBER, C. P., Oyer, P. E., Reitz, B. A., Copeland, J. G., Shumway, N. E. 1977; 9 (1): 197-201
  • RELATIONSHIP OF RABBIT ATG SERUM CLEARANCE RATE TO CIRCULATING T-CELL LEVEL, REJECTION ONSET, AND SURVIVAL IN CARDIAC TRANSPLANTATION TRANSPLANTATION PROCEEDINGS BIEBER, C. P., Griepp, R. B., Oyer, P. E., David, L. A., Stinson, E. B. 1977; 9 (1): 1031-1036

    View details for Web of Science ID A1977DA33000211

    View details for PubMedID 325730

  • CONTROL OF MYOCARDIAL PERFORMANCE EARLY AFTER OPEN-HEART OPERATIONS BY VASODILATOR TREATMENT JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Stinson, E. B., HOLLOWAY, E. L., Derby, G. C., Copeland, J. G., Oyer, P. E., BEUHLER, D. L., Griepp, R. B. 1977; 73 (4): 523-530

    Abstract

    The hemodynamic effects of vasodilator treatment (afterload reduction) with nitroprusside at a constant heart rate were studied in 24 patients early after aorta-coronary bypass grafting. In 12 patients, dose-response relationships were determined. Graded incremental infusions of nitroprusside produced progressive decreases in mean arterial pressure (MAP), right and left atrial pressures, and stroke work index. Stroke volume index and cardiac index rose significantly until MAP was reduced below the range of 80 to 90 mm. Hg, and then they fell to base-line levels owing to insufficient preload. In an additional 12 patients, MAP was reduced with nitroprusside to the range of 80 to 90 mm. Hg, and left atrial pressure was then restored to base-line levels during continued vasodilator administration. This sequence resulted in further augmentation of stroke volume index to a level higher than that produced by nitroprusside alone. We conclude from this investigation that nitroprusside is a clinically useful agent for primary or adjunctive therapy of mild-to-moderate low cardiac output states immediate postoperatively and that simultaneous regulation of left ventricular preload and after load during its administration is necessary in order to achieve maximal hemodynamic benefit.

    View details for Web of Science ID A1977DB80700005

    View details for PubMedID 300133

  • CONTROL OF GRAFT ARTERIOSCLEROSIS IN HUMAN HEART-TRANSPLANT RECIPIENTS SURGERY Griepp, R. B., Stinson, E. B., BIEBER, C. P., Reitz, B. A., Copeland, J. G., Oyer, P. E., Shumway, N. E. 1977; 81 (3): 262-269

    View details for Web of Science ID A1977CX71700004

    View details for PubMedID 320695

  • LONG-TERM EXPERIENCE WITH PORCINE AORTIC-VALVE XENOGRAFTS JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Stinson, E. B., Griepp, R. B., Oyer, P. E., Shumway, N. E. 1977; 73 (1): 54-63

    Abstract

    Between 1971 and 1975, glutaraldehyde-preserved porcine aortic valve xenografts were employed for isolated replacement of the mitral valve (MVR) in 243 patients, replacement of the aortic valve (AVR) in 167 patients, and double valve replacement (AVR and MVR) in 51 patients. Postoperatively, long-term anticoagulation was not routinely given. Operative mortality rates for AVR, MVR, and double valve groups were 7.8, 6.0, and 11.8 per cent, respectively; the majority of early postoperative deaths were associated with concomitant coronary artery disease. No death was attributable to xenograft dysfunction. Follow-up of all patients was obtained. The total duration of follow-up for the MVR group was 347 patient-years, for the AVR GROUP 148 148 patient-years, and for double valve replacement 37 patient-years; maximum follow-up for these three groups was 4.4, 4.0, and 2.4 years, respectively. Actuarial analysis of postoperative survival rates at a common interval of 3 years showed 78 per cent for MVR patients, 91 per cent for AVR patients, and 80 per cent (projected) for patients with double valve replacement (85, 96, and 91 per cent for operative survivors, respectively. At this same interval 92 per cent of MVR patients, 99 per cent of AVR patients, and 93 per cent (projected) of patients with double valve replacement were free of thromboembolic episodes. Altogether, 12 of the total 512 valves implanted exhibited some evidence of dysfunction during the entire period of follow-up evaluation, but in only 2 instances (both mitral) was intrinsic pathological involvement of the xenograft tissue documented. Actuarial analysis of xenograft dysfunction at a common interval of 3 years after operation showed 95 per cent of MVR patients, 98 per cent of AVR patients, and 97 per cent (projected) of patients with double valve replacement to be free of this complication. These data support the use of glutaraldehyde-preserved porcine xenografts as superior bioprostheses that pose a low risk of thromboembolism without anticoagulation. The over-all durability of such valves, within the restriction of a maximum current follow-up interval of 4.4 years, appears comparable to that of currently available mechanical prostheses and justifies continued clinical use.

    View details for Web of Science ID A1977CS69200006

    View details for PubMedID 556634

  • VALVE-REPLACEMENT WITH STARR-EDWARDS AND HANCOCK PROSTHESES - COMPARATIVE ANALYSIS OF LATE MORBIDITY AND MORTALITY ANNALS OF SURGERY Oyer, P. E., Stinson, E. B., Griepp, R. B., Shumway, N. E. 1977; 186 (3): 301-309

    Abstract

    Although the Starr-Edwards caged-ball valve remains a standard of comparison for more recently introduced prostheses, a substantial incidence of thromboembolic and hemorrhagic complications prompted our evaluation of the Hancock glutaraldehyde-fixed porcine xenograft. We have compared the results of 435 aortic valve replacements using the Starr- Edwards valve (SE-AVR), 515 mitral valve replacements (SE-MVR), and 121 double-valve replacements (SE-AVRMVR) with 251 aortic valve replacements using the xenograft aortic valve (X-AVR), 338 mitral valve replacements (X-MVR), and 88 double-valve replacements (X-AVR-MVR). The Starr- Edwards valves were used during the period 1963 through 1973 and the xenograft valves between 1971 and 1976. No significant differences in patient age, sex, or preoperative hemodynamic data were noted between comparable groups. All patients with Starr-Edwards valves received long-term anticoagulation while anticoagulants were used only for specific indications in patients with xenograft valves. Total follow up was 3944 patient years for the Starr-Edwards patients and 947 patient years for the xenograft patients. Hospital mortality was not significantly different for comparable groups: SE-AVR 6.9% vs. X-AVR 6.4%, SE-MVR 9.7% vs X-MVR 8.6%, and SE-AVR-MVR 7.5% vs. X-AVR-MVR 10.2%. Linearized mortality and morbidity data expressed as percent per patient- year are tabulated below. Pairs which differ significantly (p < .05) are italicized.

    View details for Web of Science ID A1977DS66600008

    View details for PubMedID 560824

  • ABDOMINAL AORTIC ANEURYSMECTOMY IN LONG-TERM CARDIAC TRANSPLANT SURVIVORS ARCHIVES OF SURGERY Reitz, B. A., Baumgartner, W. A., Oyer, P. E., Stinson, E. B. 1977; 112 (9): 1057-1059

    Abstract

    Two thirds of the 114 patients undergoing heart transplantation at Stanford (Calif) Medical Center have had atherosclerotic cardiac disease. Two of these patients have been found in the late posttransplant period to have symptomatic abdominal aortic aneurysms requiring resection. We present the clinical course and successful operative treatment of these two patients, with emphasis on the prophylaxis of infection and maintenance of hemodynamic, metabolic, and immune stability. Close surveillance of the long-term cardiac transplant survivor should be directed towards other manifestations of atheroscleortic disease.

    View details for Web of Science ID A1977DT66300007

    View details for PubMedID 332113

  • HUMAN HEART-TRANSPLANTATION - CURRENT STATUS ANNALS OF THORACIC SURGERY Griepp, R. B., Stinson, E. B., BIEBER, C. P., Reitz, B. A., Copeland, J. G., Oyer, P. E., Shumway, N. E. 1976; 22 (2): 171-175

    Abstract

    The overall survival rate for 97 heart transplant recipients operated on from 1968 to 1975 has been 49% at one year and 23% at five years. Progressive improvement in one-year survival has been achieved, from 22% in 1968 to 62% in 1974. The major factors responsible for increasing survival are better understanding and management of acute and chronic rejection. Current results suggest that heart transplantation deserves wider application in the treatment of selected patients with end-stage myocardial insufficiency.

    View details for Web of Science ID A1976CB63500011

    View details for PubMedID 788661

  • USE OF RABBIT ANTITHYMOCYTE GLOBULIN IN CARDIAC TRANSPLANTATION - RELATIONSHIP OF SERUM CLEARANCE RATES TO CLINICAL OUTCOME TRANSPLANTATION BIEBER, C. P., Griepp, R. B., Oyer, P. E., Wong, J., Stinson, E. B. 1976; 22 (5): 478-488

    Abstract

    Serum rabbit globulin (RG) clearance rates were determined in 30 consecutive cardiac transplant recipients by radioimmune assay of serum RG levels after completion of an initial postoperative course of rabbit anti-human antithymocyte globulin (RATG). Twenty patients, who exhibited rapid RG elimination rates (average half-life, 1.6 days), had a rejection onset time of 16.2 days rejection frequency of 3.9 episodes/100 patient days, and a 1-year survival rate of 59%, respectively, as compared with 28.3 days, 1.9 episodes/100 patient days, and 80%, respectively, for the 10 patients with more prolonged initial RG elimination rates (average half-life, 11.4 days); Nineteen patients received one or more repeat courses of RATG. In 16 of these a progressive increase in RG half-life during subsequent RATG administration could be demonstrated. A close correlation was observed between total RATG doses given in the initial course and peak serum levels of RG obtained (r = 0.82) and between onset of rejection and initial t1/2 RG (r = 0.69). This latter correlation was improved by the elimination of one of the 30 patients (r = 0.81) or by considering only those patients treated from a single RATG batch (r = 0.85; n = 15). No significant relationship was detected between any of the parameters assayed and (1) total RATG dose, or (2) rosette inhibition titers of RATG administered. Survival and rejection parameters of the first 30 patients receiving RATG were compared with the previous 20 receiving equine antithymocyte globulin; these 50 comprising the entire population in which rejection was confirmed by cardiac biopsy. Rejection onset was 20 versus 12 days, rejection frequency was 3.1 versus 5.0 episodes/100 patient days, and graft survival at 1 year was 66 versus 41% for the RATG-equine antithymocyte globulin-treated patients, respectively. From these data it was concluded that (1) RATG administration favorably affects transplantation outcome; (2) RATG half-life, as reflected by RG clearance rates, was the most important variable governing RATG effectiveness, (3) variation in rosette inhibition titers within RATG batches made in the same fashion from large rabbit pools were of minimal clinical importance; and (4) monitoring of serum RG levels provided a necessary and rational basis for effective modulation of immunosuppressive therapy.

    View details for Web of Science ID A1976CM04300011

    View details for PubMedID 793103

  • Postoperative hemodynamics following aortic cross-clamping during aortocoronary bypass surgery. Circulation Griepp, R. B., Stinson, E. B., Oyer, P., Copeland, J., Shumway, N. E. 1975; 52 (2): I93-7

    Abstract

    Forty-one patients undergoing aortocoronary bypass surgery were divided into two groups: an "unclamped" group (17 patients) in whom the aorta was not cross-clamped during operation and a "clamped" group (24 patients) in whom the ascending aorta was cross-clamped during performance of distal anastomoses. Myocardial protection was provided during aortic clamping by cooling the anoxic heart with cold saline immersion. Immediate postoperative hemodynamic function was assayed in both groups, as was cardiopulmonary bypass time and cardiopulmonary bypass time/graft. Cardiopulmonary bypass time was 107 minutes in the unclamped group and 87 minutes in the clamped group (P less than 0.05). Cardiopulmonary bypass time/graft was 48 minutes in the unclamped group and 40 minutes in the clamped group (P less than 0.01). Results of hemodynamic studies with values for the unclamped group listed first were as follows: cardiac index (L/min/m2) 2.3 and 2.5 (NS), stroke index (ml/beat/m2) 23 and 25 (NS), left ventricular minute work index (kg-m/min/m2) 3.03 and 2.81 (NS), and stroke work index (g-m/min/m2) 31 and 30 (NS). These data indicate that aortic cross-clamping during performance of distal anastomoses expedites the performance of aortocoronary bypass surgery and does not adversely affect postoperative hemodynamics.

    View details for PubMedID 1098807

  • Comparative hemodynamic responses to chlorpromazine, nitroprusside, nitroglycerin, and trimethaphan immediately after open-heart operations. Circulation Stinson, E. B., HOLLOWAY, E. L., Derby, G., Oyer, P. E., Hollingsworth, J., Griepp, R. B., HARRISON, D. C. 1975; 52 (2): I26-33

    Abstract

    The hemodynamic effects of intravenous chlorpormazine, nitroprusside, nitroglycerin, and trimethaphan camsylate were studied in 51 patients with high mean arterial pressures immediately after open-heart operations. Chlorpromazine was given by bolus intravenous injection to 24 patients (average dose 10.3 mg); nitroprusside (17 patients), nitroglycerin (8 patients), and trimethaphan (12 patients) were administered by constant intravenous infusion at average doses of 77 mug/min, 59 mug/min, and .097 mg/min, respectively. Measured or derived variables included right atrial pressure, pulmonary artery pressure, left atrial pressure, systemic arterial pressure, heart rate (HR), cardiac index (CI), stroke index (SI), stroke work index (SWI), and systemic vascular resistance index (SVRI). All four vasodilators significantly reduced systemic and intracardiac pressures and SWI (P less than 0.01). Associated changes in left ventricular pumping performance, however, differed importantly between groups. Chlorpromazine caused a significant rise (+19%) in HR with preservation of SI; thus, CI rose significantly (P less than 0.01). Only nitroprusside, however, resulted in enhancement of SI (P less than 0.05) at the lowered left atrial pressure; CI increased by 19% (P less than 0.01), HR rose minimally (6.5%), and calculated SVRI diminished 33% (P less than 0.01). Both nitroglycerin and trimethaphan caused decreases in SI and CI. These results indicate that in general, among the vasodilators studied, nitroprusside is associated with the most favorable hemodynamic responses in early postoperative cardiac surgical patients.

    View details for PubMedID 808358

  • POSTOPERATIVE HEMODYNAMICS FOLLOWING AORTIC CROSS-CLAMPING DURING AORTOCORONARY BYPASS SURGERY CIRCULATION Griepp, R. B., Stinson, E. B., Oyer, P., Copeland, J., Shumway, N. E. 1975; 52 (2): 93-97
  • COMPARATIVE HEMODYNAMIC RESPONSES TO CHLORPROMAZINE, NITROPRUSSIDE, NITROGLYCERIN, AND TRIMETHAPHAN IMMEDIATELY AFTER OPEN-HEART OPERATIONS CIRCULATION Stinson, E. B., HOLLOWAY, E. L., Derby, G., Oyer, P. E., Hollingsworth, J., Griepp, R. B., HARRISON, D. C. 1975; 52 (2): 26-33
  • RADIOIMMUNE ASSAY OF HETEROLOGOUS SERUM GAMMA-GLOBULIN IN PATIENTS RECEIVING RABBIT ANTIHUMAN THYMOCYTE GLOBULIN TRANSPLANTATION BIEBER, C. P., Lydick, E., Griepp, R. B., David, L. A., Oyer, P. E., Stinson, E. B. 1975; 20 (5): 393-398

    Abstract

    A radioimmune assay (RIA) method for detecting heterologous serum rabbit gamma-globulin (RG) and antibody to this protein is described. The methodology is used for monitoring serum levels of rabbit globulin in patients receiving rabbit ATG (RATG). In 7 cardiac recipients receiving RATG, maximum serum levels of RG were achieved 1-3 days after administration of final dose. RG half-life subsequent to peak serum levels was rapid (X = 36 hr) in 4 patients and prolonged (X = 18 days) in 3 patients. Patient antibody to rabbit gamma-globulin was detectable only in those patients with short RG half-life. Antirabbit antibody titers in these patients were extremely low and barely detectable by RIA.

    View details for Web of Science ID A1975AW24400006

    View details for PubMedID 54964

  • HEMODYNAMIC OBSERVATIONS IN EARLY PERIOD AFTER HUMAN HEART-TRANSPLANTATION JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Stinson, E. B., CAVES, P. K., Griepp, R. B., Oyer, P. E., RIDER, A. K., Shumway, N. E. 1975; 69 (2): 264-270

    Abstract

    Serial hemodynamic measurements, including determination of cardiac output by the Fick technique, were obtained in 10 human cardiac recipients for intervals up to 38 days after transplantation. Immediately postoperatively, donor cardiac output was severely depressed because of limitation of stroke volume. Spontaneous recovery of cardiac output and stroke volume then occurred gradually over the first 4 postoperative days to normal or nearly normal levels. Rate augmentation by arterial and/or ventricular pacing early after transplantation had little effect on donor heart performance, but isoproterenol caused significant enhancement of graft function and is now used routinely in postoperative management. Serial hemodynamic monitoring proved to be of little use in the prediction or confirmation of acute graft rejection episodes.

    View details for Web of Science ID A1975V563500016

    View details for PubMedID 1089847

  • SUPERIORITY OF AORTIC CROSS-CLAMPING WITH PROFOUND LOCAL HYPOTHERMIA FOR MYOCARDIAL PROTECTION DURING AORTA-CORONARY BYPASS GRAFTING JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Griepp, R. B., Stinson, E. B., Oyer, P. E., Copeland, J. G., Shumway, N. E. 1975; 70 (6): 995-1009

    Abstract

    Two different operative techniques for aorta-coronary bypass grafting were utilized in two comparable groups of patients. In one group (155 patients) distal anastomoses were carried out with the aorta cross-clamped and myocardial protection provided by profound local hypothermia (clamped group). In a second group (149 patients) distal anastomoses were carried out with the aorta unclamped and the left ventricle fibrillating and vented (unclamped group). Mortality rates were similar in the two groups (0.6 per cent in clamped group versus 1.3 per cent in unclamped group). The incidence of perioperative infarction was 15 per cent in the unclamped group and 8 per cent in the clamped group (p less than 0.05). Postoperative serum glutamic oxaloacetic transaminase (SGOT) and lactic dehydrogenase (LDH) levels were significantly higher for the first 4 postoperative days in the unclamped group than in the clamped group. Hemodynamic studies in a subset of each group revealed no important differences in left ventricular function in the immediate postoperative period. The data demonstrate that in patients undergoing aorta coronary bypass grafting, performance of distal anastomoses with aortic cross-clamping and profound local hypothermia results in less intraoperative myocardial injury than performance of distal anastomoses in the perfused, fibrillating, and vented left ventricle.

    View details for Web of Science ID A1975AZ33500006

    View details for PubMedID 1081170

  • Editorial: Again, via the median sternotomy. Archives of surgery Oyer, P. E., Shumway, N. E. 1974; 109 (5): 604-?

    View details for PubMedID 4429444

  • Serum antithymocyte globulin (ATG) and anti-ATG levels in cardiac recipients. Surgical forum BIEBER, C. P., Oyer, P. E., David, L., Griepp, R. B., Stinson, E. B. 1974; 25 (0): 285-287

    View details for PubMedID 4612778

Conference Proceedings


  • Severe tricuspid regurgitation after heart transplantation Chan, M. C., Giannetti, N., Kato, T., Kornbluth, M., Oyer, P., Valantine, H. A., Robbins, R. C., Hunt, S. A. ELSEVIER SCIENCE INC. 2001: 709-717

    Abstract

    Tricuspid regurgitation (TR) is common after heart transplantation. However, the incidence of severe TR and the incidence of symptoms after echocardiographic diagnosis of severe TR have not been documented. The purpose of this study is to determine the incidence of severe TR and its clinical significance in the heart transplant population.We reviewed echocardiograms (echo) of all heart transplant patients coming for regular echocardiographic follow-up between 1990 and 1995. We reviewed the charts of all patients who had echo diagnosis of severe TR.A total of 336 patients had echo follow-up during this time period. The number of months post-heart transplant to last echo was 54 +/- 50 (range, 1 to 265 months). Ninety patients had moderate TR and 23 patients had severe TR. Mean time from heart transplantation to diagnosis of severe TR was 43 +/- 38 months (range, 1 to 132). Using Cutler-Ederer analysis, at 5 years, 92.2% of surviving patients were free from severe TR. At 10 years, 85.8% of surviving patients were free from severe TR. Of the 23 patients with severe TR, 17 had charts available for review. The mean number of prior endomyocardial biopsies was 28 +/- 21 (range, 3 to 88). These patients were followed for 35 +/- 18 months after diagnosis. During this period, they developed significant heart failure and peripheral edema. Six patients eventually underwent tricuspid valve replacement.Moderate to severe TR commonly occurs following heart transplantation. Severe TR is associated with significant morbidity.

    View details for Web of Science ID 000169835400002

    View details for PubMedID 11448795

  • The totally implantable Novacor Left Ventricular Assist System Robbins, R. C., Kown, M. H., Portner, P. M., Oyer, P. E. ELSEVIER SCIENCE INC. 2001: S162-S165

    Abstract

    The Novacor Left Ventricular Assist System (LVAS) (Novacor Corp, Oakland, CA) was initially console-based and has been available since 1993 in a wearable configuration. It has been successfully used for the past 16 years as a bridge to cardiac transplantation in patients with end-stage congestive heart failure. The Stanford experience represents 53 patients (48 male, 5 female) with a mean age of 44 +/- 13 years (16 to 62) and a mean support time of 56 +/- 76 days (1 to 374). Complications with LVAS use consisted predominantly of bleeding (43%), infection, (30%), and embolic cerebrovascular events (24.5%). Sixty-six percent of the supported patients were successfully bridged to cardiac transplantation. In animal studies, 4 sheep had the totally implantable configuration in place for a cumulative duration of 1 year with 1 animal supported for 260 days. The next generation Novacor LVAS will be small, quiet, and fully implantable without the need for volume compensation. It will also provide physiologic pulsatile flow and will be fail-safe.

    View details for Web of Science ID 000167554400023

    View details for PubMedID 11265853

  • Improved outcomes with an implantable left ventricular assist system: A multicenter study Portner, P. M., Jansen, P. G., Oyer, P. E., Wheeldon, D. R., Ramasamy, N. ELSEVIER SCIENCE INC. 2001: 205-209

    Abstract

    Cumulative experience with the Novacor wearable electric left ventricular assist system (LVAS) now exceeds 850 recipients. The pump inflow conduit (IFC) has been implicated in embolic complications.Clinical outcomes were compared for two IFC designs in a retrospective, nonrandomized, multicenter study. The original IFC (woven, unsupported, crimped polyester: control group) and an alternative IFC (knitted, gelatin-sealed, integrally supported, uncrimped polyester: test group) were utilized upon availability in North American and European centers. Differences in cerebral embolism to 180 days postimplant were analyzed.Four hundred ninety patients implanted between August 1996 and August 1999, were studied. Two hundred eighty-eight received the control IFC and 202 received the test IFC. The groups (control, test) were well matched for age (48, 49 years), etiology (idiopathic 53%[152 of 288], 55% [112 of 202]; ischemic 34% [97 of 288], 33% [66 of 202]) and mean observation time (97, 91 days). The incidence of embolic cerebrovascular accidents (CVA) was 21% (60 of 288) in the control and 12% (24 of 202) in the test group (p = 0.010). Independent risk factors for embolic CVA were found to be preimplant acute myocardial infarction (odds ratio 4.3), age above 50 years (odds ratio 2.1), and ischemic etiology (odds ratio 1.7). There was no difference in survival between the groups (71% [205 of 288], 68% [137 of 202]).The alternative (test) IFC has significantly reduced the incidence of embolic CVA. This improvement is likely due to increased resistance to deformation at implant, improved neointimal adhesion, and more favorable blood flow characteristics within the conduit.

    View details for Web of Science ID 000166457600050

    View details for PubMedID 11216747

  • Bridge to transplant with the Novacor left ventricular assist system Robbins, R. C., Oyer, P. E. ELSEVIER SCIENCE INC. 1999: 695-697

    Abstract

    The Novacor left ventricular assist system is an implantable, electrically powered, wearable system that has been successfully used as a bridge to transplant since 1984. The pump is placed anterior to the left posterior rectus sheath with the percutaneous drive line positioned in the right lower abdominal wall. The seamless polyurethane blood sac is compressed by two solenoid-driven pusher plates. The inflow and outflow valves are porcine prostheses. The use of wearable external power packs facilitate patient mobility and rehabilitation before transplantation and may provide long-term support to selected patients as an alternative to transplantation.

    View details for Web of Science ID 000082253200107

    View details for PubMedID 10475473

  • Thirty years of cardiac transplantation at Stanford University Robbins, R. C., Barlow, C. W., Oyer, P. E., Hunt, S. A., Miller, J. L., Reitz, B. A., Stinson, E. B., Shumway, N. E. MOSBY-ELSEVIER. 1999: 939-949

    Abstract

    The experience with 30 years of cardiac transplantation at Stanford University Medical Center was reviewed. A total of 954 transplants were performed in 885 patients. Patients were divided into 3 groups based on immunosuppression received: group I, no cyclosporine (INN: ciclosporin) (n = 201) (January 1968-November 1980); group II, cyclosporine (n = 248) (December 1980-June 1987); and group III, cyclosporine + OKT3 (n = 436) (July 1987-March 1998).The 1-, 5-, and 10-year actuarial survivals were 68%, 41%, and 24% (group I); 80%, 57%, and 37% (group II); and 85%, 68%, and 46% (group III) (I vs II, P <.01; I vs III, P <.005; and II vs III, P <.005). The 1-, 5-, and 10-year actuarial death rates from rejection were 8%, 12%, and 14% (group I); 5%, 7%, and 7% (group II); and 2%, 5%, and 5% (group III) (I vs II, P = not significant; I vs III, P <.005; and II vs III, P <.005). The 1-, 5-, and 10-year actuarial death rates from infection were 25%, 43%, and 50% (group I); 8%, 17%, and 29% (group II); and 6%, 11%, and 16% (group III) (I vs II, P <.005; I vs III, P <.005; and II vs III, P <.05). The 1-, 5-, and 10-year actuarial death rates from graft coronary artery disease were 0%, 5%, and 13% (group I); 0%, 12%, and 19% (group II); and 1%, 6%, and 9% (group III) (I vs II, P <.01; I vs III, P <.005; and II vs III, P = not significant). There have been 69 retransplants in 67 patients with 1-, 5-, and 10-year actuarial survivals of 49%, 27%, and 15%, respectively.The evolution of 3 decades of experience with cardiac transplantation has resulted in improved overall survival. The incidence of rejection and of death from infection and graft coronary artery disease have decreased over time, primarily as a result of improvements in immunosuppression and in the prevention and treatment of infection. Continued advances in perioperative management and the development of more specific, less toxic immunosuppressive agents could further refine this initial experience and improve the survival and quality of life of patients after cardiac transplantation.

    View details for Web of Science ID 000080116000015

    View details for PubMedID 10220689

  • Significant reduction in the number of fungal infections after lung-, heart-lung, and heart transplantation using aerosolized amphotericin B prophylaxis Reichenspurner, H., Gamberg, P., Nitschke, M., Valantine, H., Hunt, S., Oyer, P. E., Reitz, B. A. ELSEVIER SCIENCE INC. 1997: 627-628

    View details for Web of Science ID A1997WM12700260

    View details for PubMedID 9123449

  • Twenty-year clinical experience with porcine bioprostheses Fann, J. I., Miller, D. C., Moore, K. A., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Robbins, R. C., Reitz, B. A., Shumway, N. E. ELSEVIER SCIENCE INC. 1996: 1301-1311

    Abstract

    For the past 25 years, porcine valves have been the most widely implanted bioprosthesis, thereby becoming the standard for comparison with newer bioprosthetic valves.We retrospectively analyzed 2,879 patients who underwent aortic (AVR; n = 1,594) or mitral (MVR; n = 1,285) valve replacement between 1971 and 1990. Follow-up was 97% complete and extended to 20 years (total, 17,976 patient-years). Patient age ranged from 16 to 94 years; mean age in patients who underwent AVR was 60 +/- 15 (+/- standard deviation) years; that for patients who underwent MVR was 58 +/- 13 years.The operative mortality rates were 7% +/- 1% (70% confidence limits) for AVR and 10% +/- 1% for MVR. Actuarial estimates of freedom from structural valve deterioration at 10 and 15 years were 78% +/- 2% (SE) and 49% +/- 4%, respectively, for the AVR subgroup; and 69% +/- 2% and 32% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from reoperation at 10 and 15 years were 76% +/- 2% and 53% +/- 4%, respectively, for the AVR subgroup and 70% +/- 2% and 33% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from thromboembolism at 10 and 15 years were 92% +/- 1% and 87% +/- 2%, respectively, for the AVR subgroup and 86% +/- 1% and 77% +/- 3%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from anticoagulant-related hemorrhage at 10 and 15 years were both 96% +/- 1% for the AVR subgroup and 93% +/- 1% and 90% +/- 2%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from valve-related mortality at 10 and 15 years were 86% +/- 1% and 78% +/- 3%, respectively, for the AVR subgroup and 84% +/- 2% and 70% +/- 4%, respectively, for the MVR subgroup (p = not significant). Multivariate analysis (Cox model) showed younger age, later year of operation, and valve site (MVR > AVR) to be significant risk factors for structural valve deterioration. Younger age, later year of operation, valve site (MVR > AVR), and renal insufficiency were the significant, independent risk factors for reoperation. Multivariate analysis revealed that higher New York Heart Association functional class, longer cardiopulmonary bypass time, congestive heart failure, renal insufficiency, and longer cross-clamp time were significant risk factors for valve-related mortality. Valve manufacturer did not emerge as a factor in any analysis.These long-term results with porcine bioprostheses were satisfactory, particularly in older patients and those undergoing AVR. As expected, younger age was a significant risk factor for structural valve deterioration and reoperation in both groups. Surprisingly, the durability of porcine bioprosthetic valves has not improved over time, which possibly can be attributed to more enhanced postoperative surveillance and earlier reintervention. These first-generation Hancock and Carpentier-Edwards porcine bioprostheses achieved similar long-term performance.

    View details for Web of Science ID A1996VQ16700014

    View details for PubMedID 8893561

  • DURABILITY OF THE HANCOCK-MO BIOPROSTHESIS COMPARED WITH STANDARD AORTIC-VALVE BIOPROSTHESES Yun, K. L., Miller, D. C., Moore, K. A., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Robbins, R. C., Reitz, B. A., Shumway, N. E. ELSEVIER SCIENCE INC. 1995: S221-S228

    Abstract

    To compare the durability of the Hancock modified orifice (Hancock MO, model 250 [H-MO]) valve with two other commonly used standard aortic valve bioprostheses, a cohort of 1,602 patients undergoing aortic valve replacement using porcine valves between 1971 and 1990 (excluding simultaneous mitral valve replacement) was analyzed retrospectively using Cox model multivariate techniques. Five hundred sixty-one patients received a composite H-MO valve, 652 received a standard Hancock model 242 (H) valve, and 389 received a Carpentier-Edwards model 2625 (C-E) valve. Mean age was 60 +/- 15 years (+/- 1 standard deviation) (71% male). Follow-up (10,247 patient-years) extended to 15 years and was 97% complete. The main focus of this study was bioprosthetic durability, using The American Association for Thoracic Surgery/The Society of Thoracic Surgeons guidelines to define structural valve deterioration (SVD). Multivariate analysis revealed that (younger) age (p < 10(-5), liver disease (p = 0.02), and 1981 to 1985 operative period (p = 0.012) were the only significant, independent predictors of SVD. In concordance with previous reports, the SVD freedom estimate was greater than 90% at 15 years for patients older than 70 years of age. Hepatic dysfunction had an adverse effect on SVD (estimated freedom from event at 10 years was 34 +/- 17% [standard error of mean] versus 78 +/- 2% for those without liver disease), but this affected only 3% of patients. Interestingly, one operative period (1981 to 1985) was associated with a slightly higher risk of SVD compared to the three other 5-year time windows. Valve type did not emerge as a significant risk factor for SVD.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1995RT15700035

    View details for PubMedID 7646163

  • LONG-TERM RESULTS OF COMBINED HEART-LUNG TRANSPLANTATION - THE STANFORD EXPERIENCE Sarris, G. E., Smith, J. A., Shumway, N. E., Stinson, E. B., Oyer, P. E., Robbins, R. C., Billingham, M. E., Theodore, J., Moore, K. A., Reitz, B. A. ELSEVIER SCIENCE INC. 1994: 940-949

    Abstract

    We assessed the long-term results of our experience with 109 patients with end-stage cardiopulmonary disease who underwent primary combined heart-lung transplantation at Stanford University Medical Center between March 1981 and January 1994. Average recipient age was 31 +/- 10 years (mean +/- standard deviation) median, 31 years; range, 1 month to 52 years. Recipient diagnoses included primary pulmonary hypertension (31%), Eisenmenger's syndrome (39%), complex congenital heart disease (8%), cystic fibrosis (14%), bronchiectasis (2%), and emphysema (3%). Immunosuppression was with cyclosporine and a tapering regimen of corticosteroids. In 1986 azathioprine was added, and since 1987 induction therapy with OKT3 has been employed. Actuarial survival rates at 1, 5, and 10 years were 68% +/- 4.6%, 43% +/- 5.4%, and 23% +/- 8.1%, respectively (mean +/- 1 standard error of the mean). Fourteen deaths occurred in the hospital for an operative mortality rate of 12.8% +/- 3.3%, and 61 deaths occurred overall. Causes of death included hemorrhage (five patients), infection (21), rejection (one), nonspecific pulmonary failure (four), graft coronary artery disease (six), and obliterative bronchiolitis (eight). Infection, rejection, and obliterative bronchiolitis were the major complications. Only 20% +/- 3.9% of patients were free from any infection 3 months after transplantation. Heart and lung rejection commonly occurred asynchronously; actuarial estimates of freedom from isolated lung rejection at 1 and 5 years were 47% +/- 5.2% and 40% +/- 5.6%, respectively. For simultaneous heart and lung rejection these estimates were 87% +/- 3.5% and 86% +/- 3.8%, and for isolated heart rejection 63% +/- 5.1% and 51% +/- 6.4%, respectively. Although graft coronary artery disease developed less frequently than in patients after isolated heart transplantation (90% +/- 4.6% of patients were free of graft coronary artery disease at 5 years), obliterative bronchiolitis remains a major long-term complication and cause of morbidity and mortality. Actuarial estimates of freedom from obliterative bronchiolitis at 1, 5, and 10 years were 71% +/- 5.1%, 51% +/- 6.1%, and 42% +/- 7.8%, respectively. These results show satisfactory early and medium-term outcome after combined heart-lung transplantation but also underscore that much progress is needed in controlling infection, rejection, and obliterative bronchiolitis, all of which remain as major impediments to long-term survival.

    View details for Web of Science ID A1994PV61100002

    View details for PubMedID 7865527

  • IMPACT OF PROXIMAL OR MIDVESSEL DISCRETE CORONARY-ARTERY STENOSES ON SURVIVAL AFTER HEART-TRANSPLANTATION Keogh, A. M., Valantine, H. A., Hunt, S. A., Schroeder, J. S., McIntosh, N., Oyer, P. E., Stinson, E. B. MOSBY-YEAR BOOK INC. 1992: 892-901

    Abstract

    To assess survival after the development of transplant coronary artery disease, annual angiography reports from 353 heart transplant recipients were reviewed. Fifty-four patients who survived beyond 1 year and in whom moderate-to-severe proximal or midvessel coronary artery disease developed were identified. Moderate-to-severe proximal or midvessel coronary disease was defined for this study as a 40% or more stenosis in 1 or more primary or secondary epicardial arteries. Actuarial survival (Kaplan-Meier) from the time of disease detection in those 54 patients was 67% at 1 year, 44% at 2 years, and 17% at 5 years. Actuarial survival was reduced proportionate to disease severity. Survival for single-vessel disease (> or = 40% stenosis) was 64% at 1 year, 36% at 2 years, and 22% at 5 years. Survival was significantly worse with triple-vessel disease (13% at 2 years; p = 0.01) and intermediate for double-vessel disease (41% at 2 years; p = 0.01). Of 19 patients who underwent retransplantation for coronary artery disease, 13 patients (68%) died at a mean of 24 +/- 20 months (range, 1 to 59), and of 15 patients from whom postmortem or angiographic data were available, 11 patients (73%) showed recurrence of significant coronary artery disease in the new graft. Identification of moderate or severe proximal or midvessel coronary disease at angiography predicts an overall mortality rate of more than 50% at 2 years. The poor survival rate in those who underwent retransplantation (around 50% at 4 years) and the high rate of redevelopment of coronary disease suggest that retransplantation should be reserved for selected candidates with angiographically severe disease, if used at all.

    View details for Web of Science ID A1992JR77000007

    View details for PubMedID 1420237

  • THE CASE AGAINST THE INDEFINITE USE OF CYCLOSPORINE Myers, B. D., Newton, L., Oyer, P. ELSEVIER SCIENCE INC. 1991: 41-42

    View details for Web of Science ID A1991EV39000015

    View details for PubMedID 1990570

  • NONTUBERCULOUS MYCOBACTERIAL INFECTIONS IN HEART-TRANSPLANT RECIPIENTS - A 17-YEAR EXPERIENCE Novick, R. J., MORENOCABRAL, C. E., Stinson, E. B., Oyer, P. E., Starnes, V. A., Hunt, S. A., Shumway, N. E. MOSBY-YEAR BOOK INC. 1990: 357-363

    Abstract

    A retrospective review was undertaken to determine the clinical features, outcome, and impact on survival of nontuberculous mycobacterial infections in 14 (of 502) heart transplant recipients. The prevalence of these infections was significantly higher (p less than 0.05) during the precyclosporine than during the cyclosporine era. The mean interval from transplantation to diagnosis was 3.5 +/- 0.7 years (+/- SEM). The 14 patients had a higher (p less than 0.05) linearized rejection rate than did other transplant patients during postoperative years 1, 2, and 4 to 6, and had received 7.3 +/- 2 gm of methylprednisolone as bolus treatment of rejection before diagnosis. Eight patients were initially seen with disseminated disease, four had localized pulmonary infection, one had subcutaneous infection in the previous site of a left ventricular assist device, and in one the organism was cultured from a fluid collection adjacent to a hip prosthesis. Twelve patients were first given 3 +/- 1 antimycobacterial drugs; the infections were usually controlled, but in 75% of patients the therapeutic regimen was prematurely stopped or altered because of drug toxicity. Mycobacterial infection was a contributory cause of death in only one patient. Actuarial survival in the 14 patients was not significantly different from the entire transplant population at 4 to 7 years. We conclude that nontuberculous mycobacterial infections occur late after heart transplantation, that drug treatment is usually successful (although difficult), and that long-term survival is not adversely affected if the infection is successfully controlled.

    View details for Web of Science ID A1990DT02600006

    View details for PubMedID 2398429

  • THE STANFORD EXPERIENCE - SURVIVAL AND RENAL-FUNCTION IN THE PRESANDIMMUNE ERA COMPARED TO THE SANDIMMUNE ERA Hunt, S. A., Gamberg, P., Stinson, E. B., Oyer, P. E., Shumway, N. E. APPLETON & LANGE. 1990: 1-5

    View details for Web of Science ID A1990DM53300002

    View details for PubMedID 2349732

  • IMPROVED SURVIVAL AFTER HEART-LUNG TRANSPLANTATION McCarthy, P. M., Starnes, V. A., Theodore, J., Stinson, E. B., Oyer, P. E., Shumway, N. E. MOSBY-YEAR BOOK INC. 1990: 54-60

    Abstract

    Sixty-two patients underwent 65 heart-lung transplant operations before April 1989. Thirty of these patients (operated on March 1981 to February 1986) were given cyclosporine and prednisone for immunosuppression. These 30 patients (group 1) are compared with the 32 most recent patients (group 2) treated with cyclosporine, prednisone, and azathioprine. Patient characteristics (group 1 versus group 2) were similar including age (mean 32 versus 26 years) and indication for operation (51% versus 38%, primary pulmonary hypertension; 46% versus 45%, Eisenmenger complex; 3% versus 17%, other). The perioperative (in-hospital) mortality rate was 35% in group 1 versus 16% in group 2. Obliterative bronchiolitis developed in 12 (63%) of 19 hospital survivors in group 1 from 2 months to 49 months postoperatively (mean 12 months). This complication has developed in five (20%) of the 25 hospital survivors in group 2 from 3 to 13 months postoperatively (mean 8 months). Overall, 24 of the 30 patients in group 1 died (infection in eight, obliterative bronchiolitis in five, graft coronary artery disease in two, other causes in nine). Eight of the 32 patients in group 2 died (infection in six, other cases in two). Survival rates for group 1 patients were 60% at 1 year, 50% at 2 years, 43% at 3 years, and 25% at 5 years. Survival rates for group 2 patients were 73% at 1 year, 73% at 2 years, and 65% at 3 years (p less than 0.05). When group 2 patients were compared with 134 patients undergoing heart transplantation during the same time period, there was no difference in survival. Routine bronchoscopic surveillance in the more recent group of patients has led to the earlier detection of rejection and infection. In combination with decreased perioperative mortality and augmented immunosuppression, this had led to improved survival in our more recent heart-lung transplant recipients. In addition, the earlier recognition of infection and rejection has led to a decrease in severity of obliterative bronchiolitis.

    View details for Web of Science ID A1990CH73800009

    View details for PubMedID 2294365

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