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- Kjellman, Ulf, 1952
(author)
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Metabolic intervention during blood cardioplegia. Clinical studies in coronary surgery and heart transplantation
- 2000
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Doctoral thesis (other academic/artistic)abstract
- Myocardial ischemia and injury (infarction) during open heart surgery and heart transplantation is a problem in spite of the fact that it is a safe procedure today. The myocardial substrate metabolism is well investigated before and after the cardioplegic period but little knowledge exists about the myocardial metabolic changes during cardioplegia. We hypothesized that the myocardial metabolic abnormalities and decreased oxygen extraction during cardioplegia may depend on restricted access of the intermediate a - ketoglutarate (a-KG) in the citrate cycle (Krebs). We also hypothesized that the during ischemic conditions persisting insulin resistance, could be bridged by addition of supra physiological doses of insulin. During heart transplantation the heart is exposed for greater trauma than under conventional heart surgery. Early graft failure and allograft injury is an obvious problem and potentially aggravating factors has been sparsely evaluated. The aim of this study was to investigate the effects of adding a-KG and insulin to blood cardioplegia on the myocardial extraction and substrate metabolism and to identify predictors in development of ischemic injury in heart transplantation.Seventy-four patients, 49 submitted for elective first-time coronary artery bypass grafting and 25 for heart transplantation, were included in three prospective, randomized and controlled studies. Two studies were performed during coronary artery bypass grafting and one during heart transplantation. In paper I and II we evaluated the effect on myocardial oxygen extraction and substrate metabolism after addition of a-KG to blood cardioplegia. GIK (glucose-insulin-potassium) was administrated in combination with a-KG in paper III. During heart transplantation GIK was administrated in similar way as in paper III and variables were detective in order to identify predictors causing ischemic injury on the allograft.Addition of a-KG to blood cardioplegia significant increased the myocardial oxygen extraction and significant reduced the release of the ischemic markers creatine kinase MB and troponin T compared to the control group. a-KG alone had no effect of myocardial substrate metabolism. Insulin (GIK) showed improvement on the myocardial substrate metabolism during cardioplegia compared to the control group. On the contrary addition of insulin had no effect on allograft substrate metabolism during implantation. The age of donor and the implantation time seemed to be predictors responsible for development of ischemic injury on the allograft.
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- Lidén, Hans, 1971, et al.
(author)
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Does pretransplant left ventricular assist device therapy improve results after heart transplantation in patients with elevated pulmonary vascular resistance?
- 2009
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In: European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. - : Oxford University Press (OUP). - 1873-734X. ; 35:6
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Journal article (peer-reviewed)abstract
- OBJECTIVE: Pulmonary hypertension (PH), defined as a pulmonary vascular resistance (PVR) >2.5 Wood units (WU) and (or) a transpulmonary gradient (TPG) >12 mmHg, is an established risk factor for mortality in heart transplantation. Elevated PVR in heart transplant candidates can be reduced using a left ventricular assist device (LVAD), and LVAD is proposed to be the treatment of choice for candidates with PH. We analyzed the effect on PVR of pretransplant LVAD therapy in patients with PH and compared posttransplant outcome with matched controls. Long-term survival was compared between heart transplant recipients with mild, moderate or severe PH and patients with no PH. METHODS: Heart transplant recipients 1988-2007 (n=405) were reviewed and divided into two groups with respect to pretransplant PVR: <2.5 WU (n=148) and >2.5 WU (n=158). From the group with PH, patients subjected to pretransplant LVAD therapy (n=11) were analyzed with respect to PVR at implant and at transplant and, with respect to outcome, compared to matched historical controls (n=22). Patients with PH without LVAD treatment (n=147) were stratified into three subgroups: mild, moderate and severe PH and survival according to Kaplan-Meier was analyzed and compared to patients with no PH. RESULTS: LVAD therapy reduced PVR from 4.3+/-1.6 to 2.0+/-0.6 WU, p<0.05. Three cases of perioperative heart failure required mechanical support whereas one control patient developed perioperative right heart failure requiring mechanical support. The incidence of other perioperative complications was comparable between groups. There was no difference in survival between LVAD patients and controls, 30-day survival was 82% and 91%, respectively and 4-year survival was 64% and 82%, respectively. CONCLUSIONS: Pretransplant LVAD therapy reduces an elevated PVR in heart transplant recipients, but there was no statistically significant difference in posttransplant survival in patients with PH with, or without LVAD therapy. The study revealed no differences in survival in patients regardless of the severity of the PH.
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- Scherstén, Henrik, 1956, et al.
(author)
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ECMO kan vara brygga till lungtransplantation : Ny metod räddar liv vid akut lungsvikt, visar retrospektiv studie.
- 2011
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In: Läkartidningen. - 0023-7205. ; 108:32-33, s. 1493-7
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Journal article (peer-reviewed)abstract
- Lungtransplantation har utförts i Sverige sedan 20 år. Patienter som snabbt försämras i akut lungsvikt och inte återhämtar sig med konservativ behandling har tidigare bedömts som inte transplantabla och därför avlidit. Sedan några år använder vi i utvalda fall extrakorporeal membranoxygenering (ECMO) som brygga till lungtransplantation hos annars döende patienter. Överlevnaden för patienter som behandlats med ECMO syftande till lungtransplantation var 73 procent (8/11). Överlevnaden för dem som sedan genomgick lungtransplantation var 89 procent (8/9). Ingreppen genererade en hel del morbiditet, dock mest av övergående natur. Vi anser att ECMO-behandling i selekterade fall kan erbjudas yngre och medelålders patienter, trots att behandlingen i sig väcker frågor om morbiditet, kostnader och resursförbrukning. Det återstår att utvärdera långtidsresultaten hos patienter som genomgått ECMO-behandling som brygga till lungtransplantation.
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- Wiklund, Lars, 1954, et al.
(author)
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Extracorporeal membrane oxygenation as a bridge to lung transplantation in a patient with persistent severe porto-pulmonary arterial hypertension following liver transplantation.
- 2011
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In: European journal of cardio-thoracic surgery. - : Oxford University Press (OUP). - 1873-734X .- 1010-7940. ; 39:5, s. 777-778
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Journal article (peer-reviewed)abstract
- Idiopathic pulmonary artery hypertension (IPAH) is a progressive disease with a dismal prognosis and lung transplantation is often the only option for patients, who do not respond to pharmacological therapy. We report the use of an extracorporeal membrane oxygenation (ECMO) system in a 49-year-old woman with primary pulmonary hypertension, previously liver transplanted. The patient, listed for lung transplantation, developed respiratory and circulatory failure despite maximal pharmacological therapy and was successfully bridged to emergent bilateral lung transplantation with veno-arterial ECMO. Emergent veno-arterial ECMO was able to rescue the patient and bridge her to bilateral lung transplantation and should therefore be an option for patients with PAH and circulatory collapse.
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