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HD, PD, and RT can be useful for the treatment of ESRF after heart transplantation. After initiating HD, patient survival is nearly the same as that reported in patients in Europe undergoing HD for other causes. But ESRF seems to reduce life expectancy in heart-transplant recipients.

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Purpose: To report the case of a patient with HIT that received a prolonged infusion of r-hirudin (lepirudin; Refludan®; Hoechst, France) before, during and after cardiopulmonary bypass (CPB) for aortic surgery. Although administration of r-hirudin for CPB anticoagulation has previously been reported, many questions persist concerning the best therapeutic regimen for CPB anticoagulation as well as the time of onset and the doses for postoperative anticoagulation.Clinical Features: A 65-yr-old man was admitted for surgery of aortic stenosis after an episode of acute pulmonary edema complicated by deep venous thrombosis in the context of documented HIT. The patient received r-hirudin for 13 dy before surgery at doses (0.4 mg·kg -1 bolus followed by 0.15 mg·kg -1 ·hr -1 continuous infusion) that maintained activated partial thromboplastin time (aPTT) ratios between 2 and 2.5. Anticoagulation for CPB was performed with r-hirudin given as 0.1 mg·kg -1 iv bolus and 0.2 mg·kg -1 in the CPB priming volume. Anticoagulation during CPB was monitored with the whole blood activated coagulation time and ecarin clotting time (ECT) performed in the operating room with values corresponding to r-hirudin concentrations > 5 µg·ml -1 during CPB. Anticoagulation during CPB was uneventful. Two bleeding episodes, related to the r-hirudin regimen and necessitating allogeneic blood transfusion, occurred after surgery. Conclusion:This case report confirms previous experience of the use of r-hirudin for anticoagulation during CPB and provides additional information in the context of prolonged r-hirudin infusion before and after CPB.Objectif : Rendre compte du cas d'un patient qui présentait une TIH et qui a reçu une perfusion prolongée de r-hirudine (lépirudine; Refludan®; Hoechst, France) avant, pendant et après la circulation extracorporelle (CEC) lors d'une intervention chirurgicale aortique. L'administration de l'anticoagulant r-hirudine pour la CEC est un fait connu, mais de nombreuses questions persistent sur le meilleur schéma thérapeutique à utiliser pendant la CEC et, sur le délai d'installation de l'anticoagulation et sur les doses à respecter après l'opération.Éléments cliniques : Un homme de 65 ans a été admis pour l'opération d'une sténose aortique survenue après un épisode d'oedème pulmonaire aigu compliqué d'une thrombose veineuse profonde dans le contexte d'une TIH connue. Le patient a reçu de la r-hirudine pendant 13 jrs avant l'intervention (bolus de 0,4 mg·kg -1 suivi d'une perfusion continue à 0,15 mg·kg -1 ·hr -1 ) pour maintenir les ratios de temps de céphaline activé entre 2 et 2,5 (aPTT). Pendant la CEC, l'anticoagulation a été réalisée avec de la r-hirudine administrée en bolus de 0,1 mg·kg -1 iv et 0,2 mg·kg -1 dans le volume d'amorçage de la CEC. Elle a été contrôlée avec les test du temps de coagulation activé du sang complet et du temps de coagulation de l'écarine (TCE) réalisés dans la salle d'opération selon des valeurs qui correspondent à des concentrations de r-hirudine > 5 µg·ml -1 . Aucun incident n'a mar...

Ofloxacin penetration into heart tissue (valve and myocardium), mediastinal fat, and sternal bone marrow was the object of a prospective nonrandomized study. Thirty-six patients undergoing mitral and/or aortic valve replacement were included. Patients were divided into two groups of 18 patients each. Group 1 patients were administered a single 400-mg intravenous dose of ofloxacin over a 30-min period upon anesthesia (n = 6) or at 1 h (n = 6) or 6 h (na-6) prior to surgery. Group 2 patients received a 200-mg oral dose of ofloxacin every 12 h during the 48 h preceding surgery. In this group, the final dose of ofloxacin was administered 3 h (n = 9) or 8 h (n = 9) before anesthesia. Plasma and tissue ofloxacin concentrations were assayed by high-pressure liquid chromatography. In group 1 patients, the peak level in plasma was 15.9 2.5 pg/ml. Peak ofloxacin levels in tissue were reached by hour 1 and were 8.89 2.16 pg/g in myocardium and 5 0.75 pg/g in heart valves. A significant decrease in ofloxacin levels in heart valve tissue and sternal bone marrow was observed after hour 3. Nevertheless, ofloxacin myocardial, heart valve, and sternal bone marrow levels remained higher than the MICs for the usually susceptible pathogens for at least 3 h. In group 2 patients, myocardial levels were long lasting (