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Management of biliary tract stones in heart transplant patients
IN
CONSULTATION
tion. Methods: A chart review was conducted for 211 patients who had heart transplants between January 1988 and September 1994 to determine prevalence of biliary tract stones, management strategies used, and outcome. Results: Of 175 long-term heart transplant survivors, 52 (29.7%) had stones detected: 32.8% of adults (47/143) and 15.6% of children (5/32). The majority of patients (31) were diagnosed 4 months (mean) after transplantation; cholelithiasis developed in 10 of these patients (32%) within 11 months (median) after a negative ultrasound. Symptoms developed in 45% of patients. All patients underwent either elective (36) or urgent (6) cholecystectomy via an open (32) or laparoscopic (10) approach, or endoscopy for common bile duct stones (2). There were no deaths or complications during a follow-up period of up to 7 years. Conclusion: Heart transplant patients have a high prevalence of symptomatic biliary tract stone disease. They can be treated safely via an open or laparoscopic approach after transplantation. The authors recommend routine gallbladder ultrasound screening and elective cholecystectomy in the posttransplant period if stones are detected.
Atherosclerotic Renal Artery Stenosis: Ostial or Truncal? I~ Kaatee,F.JJEBeek, E.J.Verschuyt,P.J.G.V.Ven,J.J. Beuder,].P.]. Van SchaiL W.P.T.M. Hali. Departmentof Radiology,UniversityHospitalUtrecht,Utrecht,The Nethedands.Radiology1996;199:637-40. Purpose: To evaluate a discrepancy between the location of renal artery stenoses on intraarterial digital subtraction angiographic (DSA) images and that on spiral computed tomographic (CT) angiograms. Materials and Methods: The spiral CT angiograms and intraarterial DSA images of 40 consecutive patients with atherosclerotic renal artery stenoses were examined retrospectively. Stenoses were classified as truncal or ostial. The atherosclerotic changes in the abdominal aorta were graded. Results: Fifty-eight stenoses were demonstrated. In 48 ostial stenoses, there was no discrepancy in the location of the stenoses on spiral CT angiograms and DSA images. In 10 patients, spiral CT angiography showed an ostial lesion, whereas DSA demonstrated an apparent truncal lesion. Most of these stenoses ("pseudotruncal" ostial stenoses) were in patients with severe aortic atherosclerotic disease. Conclusion: A renal artery stenosis at or within 10 mm of an atherosclerotic aorta at DSA may be diagnosed as an ostial stenosis.
Appetite-Suppressant Drugs and the Risk of Primary Pulmonary Hypertension L Abenhaim,Y. Horide, F. Brenot, S. Rich,J, Benichou,X. Ilm, T. Higenbottam, C Oakley,E. Wouters, H. Aubier,G. Simonneau,B. gegaud.CCECS,SItBD-]ewish General Hospital,HcGillUniversity,Montreal,Que~ Canada. N EngtJ Ned 1996;335: 609-16. Background: Recently in France, primary pulmonary hyper-
ACE Inhibitors and Unilateral Renal Artery Stenosis--What Price? S.S. Kothari.CardiothoracicCentre,All India Inst. of MedicalSciences,New Delhi, India. Int J Cardiol 1996;53:199-201. The effects of ACE inhibitors on the stenosed kidney in patients with unilateral arterial stenosis are not well characterised. While there are conflicting reports, some experimental and clinical evidence suggest that the stenosed kidney may undergo atrophy secondary to effective blood pressure lowering and decreased perfusion pressure distally, or due to other mechanism(s). Such a loss of renal function may go unrecognised. In view of the widespread use of ACE inhibitors, the fate of the stenosed kidney needs to be more accurately known.
tension developed in a cluster of patients exposed to derivatives of fenfluramine in appetite suppressants (anorexic agents), which are used for weight control. We investigated the potential role of anorexic agents and other suspected risk factors for primary pulmonary hypertension. Methods: In a case-control study, we assessed 95 patients with primary pulmonary hypertension from 35 centers in France, Belgium, the United Kingdom, and the Netherlands and 355 controls recruited from general practices and matched to the patients' sex and age. Results: The use of anorexic drugs (mainly derivatives of fenfluramine) was associated with an increased risk of primary pulmonary hypertension (odds ratio with any anorexic drug use, 6.3; 95 percent confidence interval, 3.0 to 13.2). For the use of anorexic agents in the preceding year, the odds ratio was 10.1 (95 percent confidence interval, 3.4 to 29.9). When anorexic drugs were used for a total of more than three months, the odds ratio was 23.1 (95 percent confidence interval, 6.9 to 77.7). We also confirmed an association with several previously identified risk factors: a family history of pulmonary hypertension, infection with the human immunodeficiency virus, cirrhosis, and use of cocaine or intravenous drugs. Conclusions: The use of anorexic drugs was associated with the devel-
Management of Biliary Tract Stones in Heart Transplant Patients H. Milas, IEIk Ricketts,J.lE Amerson,IC Kanter,J3. Aldrete,T.N. Pappas,H.J. Sugerman,LIE Bendey,H. Milas. Emo~ Clinic,Manta, Gk Ann Surg 1996;223: 747-56. Objective: The authors report their experience with biliary tract stones in adult and pediatric heart transplant patients, and review the current literature relative to this problem. Summary Background Data: Prior studies in adults have noted that heart transplant patients frequently have cholelithiasis, but offer no consensus about treatment strategy. Few studies exist for pediatric heart transplant patients. A higher rate of hemolysis and cyclosporine-induced changes in bile metabolism may contribute to lithogenesis in this popula-
ACC CURRENTJOURNAL REVIEW May/June 1997
81
CONSULTATION
tion. Methods: A chart review was conducted for 211 patients who had heart transplants between January 1988 and September 1994 to determine prevalence of biliary tract stones, management strategies used, and outcome. Results: Of 175 long-term heart transplant survivors, 52 (29.7%) had stones detected: 32.8% of adults (47/143) and 15.6% of children (5/32). The majority of patients (31) were diagnosed 4 months (mean) after transplantation; cholelithiasis developed in 10 of these patients (32%) within 11 months (median) after a negative ultrasound. Symptoms developed in 45% of patients. All patients underwent either elective (36) or urgent (6) cholecystectomy via an open (32) or laparoscopic (10) approach, or endoscopy for common bile duct stones (2). There were no deaths or complications during a follow-up period of up to 7 years. Conclusion: Heart transplant patients have a high prevalence of symptomatic biliary tract stone disease. They can be treated safely via an open or laparoscopic approach after transplantation. The authors recommend routine gallbladder ultrasound screening and elective cholecystectomy in the posttransplant period if stones are detected.
Atherosclerotic Renal Artery Stenosis: Ostial or Truncal? I~ Kaatee,F.JJEBeek, E.J.Verschuyt,P.J.G.V.Ven,J.J. Beuder,].P.]. Van SchaiL W.P.T.M. Hali. Departmentof Radiology,UniversityHospitalUtrecht,Utrecht,The Nethedands.Radiology1996;199:637-40. Purpose: To evaluate a discrepancy between the location of renal artery stenoses on intraarterial digital subtraction angiographic (DSA) images and that on spiral computed tomographic (CT) angiograms. Materials and Methods: The spiral CT angiograms and intraarterial DSA images of 40 consecutive patients with atherosclerotic renal artery stenoses were examined retrospectively. Stenoses were classified as truncal or ostial. The atherosclerotic changes in the abdominal aorta were graded. Results: Fifty-eight stenoses were demonstrated. In 48 ostial stenoses, there was no discrepancy in the location of the stenoses on spiral CT angiograms and DSA images. In 10 patients, spiral CT angiography showed an ostial lesion, whereas DSA demonstrated an apparent truncal lesion. Most of these stenoses ("pseudotruncal" ostial stenoses) were in patients with severe aortic atherosclerotic disease. Conclusion: A renal artery stenosis at or within 10 mm of an atherosclerotic aorta at DSA may be diagnosed as an ostial stenosis.
Appetite-Suppressant Drugs and the Risk of Primary Pulmonary Hypertension L Abenhaim,Y. Horide, F. Brenot, S. Rich,J, Benichou,X. Ilm, T. Higenbottam, C Oakley,E. Wouters, H. Aubier,G. Simonneau,B. gegaud.CCECS,SItBD-]ewish General Hospital,HcGillUniversity,Montreal,Que~ Canada. N EngtJ Ned 1996;335: 609-16. Background: Recently in France, primary pulmonary hyper-
ACE Inhibitors and Unilateral Renal Artery Stenosis--What Price? S.S. Kothari.CardiothoracicCentre,All India Inst. of MedicalSciences,New Delhi, India. Int J Cardiol 1996;53:199-201. The effects of ACE inhibitors on the stenosed kidney in patients with unilateral arterial stenosis are not well characterised. While there are conflicting reports, some experimental and clinical evidence suggest that the stenosed kidney may undergo atrophy secondary to effective blood pressure lowering and decreased perfusion pressure distally, or due to other mechanism(s). Such a loss of renal function may go unrecognised. In view of the widespread use of ACE inhibitors, the fate of the stenosed kidney needs to be more accurately known.
tension developed in a cluster of patients exposed to derivatives of fenfluramine in appetite suppressants (anorexic agents), which are used for weight control. We investigated the potential role of anorexic agents and other suspected risk factors for primary pulmonary hypertension. Methods: In a case-control study, we assessed 95 patients with primary pulmonary hypertension from 35 centers in France, Belgium, the United Kingdom, and the Netherlands and 355 controls recruited from general practices and matched to the patients' sex and age. Results: The use of anorexic drugs (mainly derivatives of fenfluramine) was associated with an increased risk of primary pulmonary hypertension (odds ratio with any anorexic drug use, 6.3; 95 percent confidence interval, 3.0 to 13.2). For the use of anorexic agents in the preceding year, the odds ratio was 10.1 (95 percent confidence interval, 3.4 to 29.9). When anorexic drugs were used for a total of more than three months, the odds ratio was 23.1 (95 percent confidence interval, 6.9 to 77.7). We also confirmed an association with several previously identified risk factors: a family history of pulmonary hypertension, infection with the human immunodeficiency virus, cirrhosis, and use of cocaine or intravenous drugs. Conclusions: The use of anorexic drugs was associated with the devel-
Management of Biliary Tract Stones in Heart Transplant Patients H. Milas, IEIk Ricketts,J.lE Amerson,IC Kanter,J3. Aldrete,T.N. Pappas,H.J. Sugerman,LIE Bendey,H. Milas. Emo~ Clinic,Manta, Gk Ann Surg 1996;223: 747-56. Objective: The authors report their experience with biliary tract stones in adult and pediatric heart transplant patients, and review the current literature relative to this problem. Summary Background Data: Prior studies in adults have noted that heart transplant patients frequently have cholelithiasis, but offer no consensus about treatment strategy. Few studies exist for pediatric heart transplant patients. A higher rate of hemolysis and cyclosporine-induced changes in bile metabolism may contribute to lithogenesis in this popula-
ACC CURRENTJOURNAL REVIEW May/June 1997
81