Clin. exp. Immunol. (1979) 38, 189-197.
Clinical significance of immunopathological findings in patients with post-pericardiotomy syndrome I. RELEVANCE OF ANTIBODY PATTERN B. MAI S CH, P. A. BERG & K. KOCH S IEK Medizinische Universitatsklinik, Otfried-Muller-Str., 7400 Tubingen, Abt. III + I, West Germany
(Acceptedfor publication 12 February 1979) SUMMARY
Sera from sixty-five patients were collected before and after cardiac surgery to determine striated muscle antibodies (anti-heart and anti-skeletal), non-organ-specific antibodies, immunoglobulin and complement levels. According to the clinical features of pericarditis, fever and leucocytosis, patients were divided into three groups: (1) complete post-pericardotomy syndrome (PPS) (n = 19) with all three symptoms; (2) incomplete PPS with two symptoms (n = 18); and (3) no PPS with one or no symtpoms (n = 28). Almost all the patients with complete PPS, two thirds of the patients with incomplete PPS and one third of the patients with no PPS showed striated muscle antibodies. Anti-sarcolemmal antibodies predominated. In patients with complete PPS, antibodies persisted beyond the fourth post-operative week and correlated well with symptoms. An even better correlation with the syndrome could be obtained by including the post-operative occurrence of anti-endothelial (AEA), smooth muscle (SMA), the pre- and post-operative frequency of antinuclear antibodies (ANA) and the increase in immunoglobulin concentrations after surgery in an immunological grading system. These criteria permitted a redistribution of the nineteen patients with an incomplete PPS: fourteen were immunologically positive for a PPS. Although autoantibodies are predominantly associated with PPS, their role in the pathogenesis of the syndrome is not clear. The complementary influence of surgical and non-surgical factors, such as the degree of myocardial damage, the time of ischemia during the operation and a possible viral infection by blood transfusion, is analysed.
INTRODUCTION The post-pericardiotomy syndrome (PPS) is a complication which occurs after cardiac surgery (Bercu, 1953; Dressler, 1955; McCabeetal., 1972; 1973; Engleetal., 1974; 1975a). The clinical features of this syndrome are fever, leucocytosis and pericarditis with or without pericardial effusion after the first post-operative week. A left-sided pleurisy with effusion may be found. Although these features are characteristic, it is still sometimes difficult to distinguish this syndrome from other post-operative complications (Kloster, 1975) such as bacterial endocarditis and the posttransfusion syndrome (Bergstrom & Dahlstrom, 1957; Kaariainen, Klewola & Paloheimo, 1966; Handrick et al., 1975). The clinical observation that this syndrome appears after the first post-operative week and is sensitive to corticosteroid therapy suggests that immunological factors may play a role in its pathogenesis (Robinson & Bridgen, 1965; Drusin et al., 1965; McCabe et al., 1972; 1973; Engle et al., 1974; 1975a,b; Manabe, Shirakura & Moro, 1975). The finding of anti-heart antibodies (AHA) in the sera of most of the patients supports this view. AHA occur quite frequently in different kinds of cardiac diseases and may be induced transiently by the release of hidden Correspondence: Dr B. Maisch, Medizinische Universitatsklinik, Otfried-Muller-Str., 7400 Tubingen, West Germany. 0099-9104/79/1100-0189$02.00 (0 1979 Blackwell Scientific Publications
189
190
B. Maisch, P. A. Berg
&
K. Rochsiek
antigens, indicating a temporary loss of tolerance in respect to heart autoantigens (Das, Cassidy & Petty, 1972; Davies & Gery, 1960; Fowler, 1971). We were therefore interested to study the frequency of autoantibodies in patients with PPS and to see whether immunological parameters correlated with the intensity of the clinical features.
PATIENTS AND METHODS Patients. The study was undertaken over a period of 24 months and included sixty-five patients (thirty-two female, thirty-three male). Twenty-six patients (40%) underwent aortic valve and thirteen (20%) mitral valve replacement, ten patients (15%) had mitral valve commissurotomy, five (8%) underwent aorta-coronary bypass procedures, one (1-5%) the closure of a VSD, and five (8%) the closure of an atrial septum. In two patients (3%) an atrial myxoma was removed, one patient was operated on for a Fallot Pentalogy, and two patients had coarctation ofthe aorta. Serum samples were collected prior to surgery on day 1 or day 2 after the operation and thereafter at weekly intervals. Sera from nineteen patients who had undergone non-cardiac surgery and from nine patients before and after blood transfusion were used as controls. According to their clinical features we divided the sixty-five patients into three groups. Group 1: nineteen patients who had all three classical features after the first post-operative week: pericarditis, fever and leucocytosis. Group 2: eighteen patients who had one or two ofthe main features (incomplete PPS). Group 3: twenty-eight who did not have a PPS. Blood transfusion. Patients with PPS received 6-3±2-3 units of transfused blood compared to 5-2+2-4 units given to patients with incomplete PPS, 4-2+2-1 units to patients with no PPS and 0-7+0-6 to the control group. In all three groups of patients there was a remarkable predominance of blood group A (57-63%) over group 0 (21-26%) compared to the regional distribution of 42-9% for A and 41-5% for 0 in 39,031 blood donors (Schneider & Dick, 1962). Clinical findings. The clinical findings of all groups are given in Table 1. It is evident that pericarditis and fever were always found in group 1, whereas only 33% ofthe patients in group 2 had pericardial rubs. TABLE 1. Clinical findings in sixty-five patients after cardiotomy
Group 1 Complete PPS
Symptoms: No. of patients No. of patients with leucocytosis after 7th post-operative day Mean highest leucocyte count after 7th post-operative day Pericardial rubs Pericardial effusion
Fever>37-50Cafter 7th post-operative day Pleural rubs Pleural effusion (left side) Precordial pain Tachycardia Low voltage (ECG) Post-operative hepatomegaly LDH increase Mean number of interventions at operation (valves, aorto-coronary bypasses) Total cardioplegy time (min) Total extracorporal circulation time (min) Mean no. of days in hospital Mortality (no of patients) after 7th post-operative day
19 19 (95)
Group 2 Incomplete PPS
Group 3 No PPS 28 7 (25)
18 15 (83)
6230+3150*
Control Non-cardiac surgery 19
2(11) 6510+2710*
11,480+4640*
9470+2450*
19 (100) 11 (58) 18 (95)
6 (33) 0 14 (78)
0 0 6 (21)
0 0 2 (11)
7 (37) 7 (37) 19 (100) 13 (68) 4 (21) 8 (42) 10 (53)
3 (17) 1 (6) 15 (83) 11 (61) 0 6 (33) 6 (33)
1 (4) 1 (4) 14 (50) 12 (43) 0 3 (11) 4 (14) 1-09+0-30*
0 0
1.47+0-65*
1-56+0-62*
60-4±41-3*
48 1± 7-7*
74.2+58.8*
64-0± 12-2* 49-7±61-6*
50.9+44.6* 1 (5%)
0
41-4+14-8* 65-1+23-2* 35 1+14.7* 1 (4%)
* Mean+ s.d. Figures in parentheses are the percentage of patients with the particular feature.
0
0 0 0 0
-
11P2 0
Immunology in post-pericardiotomy syndrome. I
191
The mean pre-operative severity of heart disease was classified according to the criteria of the New York Heart Association (1973). It was greatest in group 1 with 3-21 points and differed significantly (2P< 0 05) from group 2 (2-70 points) and group 3 (2-90 points). The mean number of valves replaced and the number of bypass-grafts used were both significantly higher in patients with complete and incomplete PPS as compared to those without symptoms (2P < 0 05). The mean total cardioplegy time and extracorporal circulation time were therefore higher in groups 1 and 2, but not significantly, when compared to group 3 (0-15< 2P< 0-2). Hospitalization was significantly longer (2P< 0-05) in groups with PPS and incomplete PPS as compared to controls. Age distribution (44-47 years), however, did not differ. Complement fixation tests (CFT) were done in all patients with PPS and in twenty without PPS, pre- and post-operatively, against influenza A and B, mumps, cytomegalovirus, Cocksackie B1, B2, B3 and B4. Six patients with PPS were treated with steroids. CFT titres against mumps and Cocksackie B1 viruses were elevated above normal pre-operative values (1 : 10) up to 1 : 40 after surgery in five of the patients with complete PPS. Viral antibodies were negative in all patients with no PPS. Immunological studies. All immunological studies were performed on sera stored at - 250C for 2 years. Immunofluorescence. The indirect technique of Coons & Kaplan (1950) was used. Isopentane-fixed (4 gm) cryostat sections of human operatively resected myocardium from patients with congenital heart disease of the skeletal muscle, kidney, homologous thyroid gland, uterus and skin, heterologous (rat) liver, oesophagus and stomach were used, mounted on pre-treated slides and incubated for 20 min with 1: 10 diluted serum. To determine the immunoglobulin class specificity, the sections were tested with monospecific labelled antisera and anti-Clq antiserum (Hyland). We used the Orthoplan microscope (Leitz) and the filter combinations S 525, KP 500, BG 36, UG, or K 460). The intensity of fluorescence staining was graded from +1 to +4. Sera were also tested for cytoplasmic complement-fixing antibodies using the CFT with homogenate from rat kidney according to Berg, Doniach & Roitt (1967). Sera with fluorescence patterns suggestive of mitochondrial antibodies were tested in subfractions as described by Berg et al. (1967; 1969). Anti-DNA antibodies were tested radioimmunologically (Abbot). Other serological tests. Quantitative immunoglobulin concentrations for IgG, IgGm, IgA, C, and C2 concentrations were determined by the Mancini technique on immunodiffusion plates (Behring Tri-Partigen).
RESULTS
Frequency ofantibodies Striated muscle antibodies were detected by immunofluorescence using homologous and heterologous cardiac and skeletal tissue. In the post-operative period, 95% of the patients in group 1 (complete PPS) showed antibodies against myocardium and skeletal muscle. Fifty per cent of the patients in group 2 (incomplete PPS) had anti-heart antibodies (AHA) and 72% had antibodies against skeletal muscle. In group 3 (no PPS) 29% of the patients reacted with both types of striated muscle tisuse. In a fourth group (non-cardiac surgery as controls) only 5% had antibodies against heart and 22% against skeletal muscle. In the pre-operative period only 5-11% of all patients tested had striated muscle antibodies (Table 2). These results demonstrate the close association between the myocardial and skeletal ASA. Three different types of striated muscle antibodies were found: anti-sarcolemmal antibodies (ASA), antifibrillary antibodies (AFA) and anti-intercalated disc antibodies (AIDA). ASA predominated in group 1 (complete PPS) with 84-90% of patients having this antibody. AFA against heart and skeletal muscle were found most frequently in patients with complete PPS. Sera of two patients showed, in addition to myocardial AFA, the preferential staining of one type of muscle fibre (red zebra). AIDA were found in three instances in only one patient in each group. In the preoperative period only 5-1 1% ofall patients tested had striated muscle antibodies (Table 2). Smooth muscle antibodies (SMA) and antibodies against the endothelium of small vessels (AEA) predominated in group 1 and group 2 (Table 2). Since it has been previously demonstrated that AEA can react with blood group substances (Berg, Brandt & Maerker, 1973), the association ofAEA with the different blood groups was analysed (Table 3). The frequency of AEA was almost identical in patients with blood groups A, B and 0, ranging from 53-75%. This indicates that AEA after cardiac surgery is associated with blood groups A, B and 0, but not with blood group AB. Antinuclear antibodies had a high incidence in patients with PPS (47%) and in patients with incomplete PPS (42%), as compared to 25% positive in group 3 and none in group 4. Pre-operatively, ANA occurred more frequently in patients of group 1 (21%) and group 2 (16%) (Table 2). No anti-DNA antibodies were found.
192
B. Maisch, P. A. Berg & K. Kochsiek 00
t00__obbn
!lt_ tt00000
E~~~~~L
II',
I-
0$-
- n\ L00t
t
°N
o
C-i
Xb
tn
l_ _n
0
mgN~~~~~~~0
_ n>
Ln
0
co
U)
.
bo
4
.9
co
¢
CD
e~~~s eD _ ur N %o
tO
ner
# r.
O 3~~~~L #
Ln
o
I
m
tn o: oo
o
n+N~~~~~t
|*_ 2 = z En E
00¢O
W_
_
6
0
Immunology in post-pericardiotomy syndrome. I
193
TABLE 3. Association of anti-endothelial antibodies after cardiac surgery with the A, B and 0 blood groups (n = 34 AEA-positive patients)
Heterologous AEA
Homologous AEA Blood group
Homo- or heterologous AEA
No. of patients
(%)*
No. of patients
(%)*
No. of patients
(%)*
17 3 0 8
40 9 0 24
11 1 0 5
31 3 0 15
21 3 0 10
62 8 0 30
A B AB 0
*
Percentage of the AEA-positive patients (n - 34).
There was a close relationship between anti-sarcolemmal antibodies (ASA) and antibodies to endothelium (AEA). Eighty-eight per cent of patients with ASA had also AEA; 71% of patients with ASA had SMA. Twelve of the ASA-positive patients also had antinuclear factors (ANA). A heterologous renal tubular immunofluorescent pattern associated with a positive anti-sarcolemmal reaction was observed in three patients ('heterophile antibodies') (Hawkins, McDonald & Dawkins, 1977). Antibodies against mitochondria were not detected by the complement fixation test using purified mitochondrial fractions obtained by differential centrifugation.
Follow-up ofstriated and non-striated muscle antibodies after cardiac surgery The results of this follow-up study in patients with complete PPS are illustrated in Fig. 1. The number of ASA- and AEA-positive patients increased almost proportionally during the first 3 weeks and at the end of the third week 80% of the patients were ASA-positive. Similarly, most of the AFA-positive patients were found in the third post-operative week, whereas patients with SMA and ANA had already developed these antibodies by the second week. Forty per cent of ASA- and AEA-positive patients were still positive 6 weeks after operation; only 22% were still AFA-positive. In patients with incomplete PPS, the incidence of ASA and AEA reached a maximum after the second week and became negative in most patients after the third week, thus demonstrating a different time course between these two groups. AFA in most patients in groups 1 and 2 had disappeared by 4 weeks after surgery.
80-
-
60-
;i
4020
-7
~
OP
~
7
U
14
21 Doys
28
35
42
75
FIG. 1. Appearance and frequency of antibodies after cardiac surgery in patients with complete post-peri-
cardiotomy syndrome (follow-up study in nineteen patients). Antibodies against: (0 o) heart fibrils (AFA); A) endothelium AEA; (z ) sarcolemma (ASA); (a (I zi) smooth muscle SMA; and (-El) nuclei ANA. Arrow indicates day of operation.
194
B. Maisch, P. A. Berg 3 K. Kochsiek
Immunoglobulin classes ofthe autoantibodies The distribution of the immunoglobulin classes of the striated muscle antibodies tested 3 weeks after surgery were as follows: 41% of the twenty-nine ASA (heart) positive patients had IgG, 38% IgM and 24% IgA specificity. Only one patient had ASA of both IgG and IgM specificity. In contrast, 58% of myocardial AFA were of IgM specificity. ASA and AFA of skeletal muscle showed a similar distribution. ASA fixed complement in 82% of positive patients as compared to AFA which gave a complement fixation to heart tissue in 8% and to skeletal muscle in 29% of patients. AIDA were only of IgG specificity. A similar distribution of immunoglobulin classes of non-organspecific antibodies were found when tested 3 weeks after surgery: AEA were mostly of IgG specificity (65%), ANA of IgM specificity (79%); 48% of SMA belonged to the IgG class, 35% had IgM specificity and 55% fixed complement. About 20% of ASA, AEA, AFA and SMA belonged to more than one immunoglobulin class.
Relationship between presence ofautoantibodies and duration ofhospitalization Patients with positive pre-operative ANA and a more complicated clinical course had to be treated considerably longer (61±66 days) than those without ANA (50± 47 days; 0 05 < 2P < 0.1). There was no correlation between the frequency of the various other antibodies after surgery and the clinical course or the duration of hospitalization. AHA-positive patients were hospitalized on average only 4 days longer than those without AHA (AHA-positive 50±58 days, AHA-negative 46±35 days). Globulin and immunoglobulin concentration The serum protein concentrations (7.31+0-58 g/100 ml) of all patients were not altered significantly after operation (7-02±0-91 g/100 ml). a,-globulin increased from 3 45 to 4-61% (P
Clinical significance of immunopathological findings in patients with post-pericardiotomy syndrome I. RELEVANCE OF ANTIBODY PATTERN B. MAI S CH, P. A. BERG & K. KOCH S IEK Medizinische Universitatsklinik, Otfried-Muller-Str., 7400 Tubingen, Abt. III + I, West Germany
(Acceptedfor publication 12 February 1979) SUMMARY
Sera from sixty-five patients were collected before and after cardiac surgery to determine striated muscle antibodies (anti-heart and anti-skeletal), non-organ-specific antibodies, immunoglobulin and complement levels. According to the clinical features of pericarditis, fever and leucocytosis, patients were divided into three groups: (1) complete post-pericardotomy syndrome (PPS) (n = 19) with all three symptoms; (2) incomplete PPS with two symptoms (n = 18); and (3) no PPS with one or no symtpoms (n = 28). Almost all the patients with complete PPS, two thirds of the patients with incomplete PPS and one third of the patients with no PPS showed striated muscle antibodies. Anti-sarcolemmal antibodies predominated. In patients with complete PPS, antibodies persisted beyond the fourth post-operative week and correlated well with symptoms. An even better correlation with the syndrome could be obtained by including the post-operative occurrence of anti-endothelial (AEA), smooth muscle (SMA), the pre- and post-operative frequency of antinuclear antibodies (ANA) and the increase in immunoglobulin concentrations after surgery in an immunological grading system. These criteria permitted a redistribution of the nineteen patients with an incomplete PPS: fourteen were immunologically positive for a PPS. Although autoantibodies are predominantly associated with PPS, their role in the pathogenesis of the syndrome is not clear. The complementary influence of surgical and non-surgical factors, such as the degree of myocardial damage, the time of ischemia during the operation and a possible viral infection by blood transfusion, is analysed.
INTRODUCTION The post-pericardiotomy syndrome (PPS) is a complication which occurs after cardiac surgery (Bercu, 1953; Dressler, 1955; McCabeetal., 1972; 1973; Engleetal., 1974; 1975a). The clinical features of this syndrome are fever, leucocytosis and pericarditis with or without pericardial effusion after the first post-operative week. A left-sided pleurisy with effusion may be found. Although these features are characteristic, it is still sometimes difficult to distinguish this syndrome from other post-operative complications (Kloster, 1975) such as bacterial endocarditis and the posttransfusion syndrome (Bergstrom & Dahlstrom, 1957; Kaariainen, Klewola & Paloheimo, 1966; Handrick et al., 1975). The clinical observation that this syndrome appears after the first post-operative week and is sensitive to corticosteroid therapy suggests that immunological factors may play a role in its pathogenesis (Robinson & Bridgen, 1965; Drusin et al., 1965; McCabe et al., 1972; 1973; Engle et al., 1974; 1975a,b; Manabe, Shirakura & Moro, 1975). The finding of anti-heart antibodies (AHA) in the sera of most of the patients supports this view. AHA occur quite frequently in different kinds of cardiac diseases and may be induced transiently by the release of hidden Correspondence: Dr B. Maisch, Medizinische Universitatsklinik, Otfried-Muller-Str., 7400 Tubingen, West Germany. 0099-9104/79/1100-0189$02.00 (0 1979 Blackwell Scientific Publications
189
190
B. Maisch, P. A. Berg
&
K. Rochsiek
antigens, indicating a temporary loss of tolerance in respect to heart autoantigens (Das, Cassidy & Petty, 1972; Davies & Gery, 1960; Fowler, 1971). We were therefore interested to study the frequency of autoantibodies in patients with PPS and to see whether immunological parameters correlated with the intensity of the clinical features.
PATIENTS AND METHODS Patients. The study was undertaken over a period of 24 months and included sixty-five patients (thirty-two female, thirty-three male). Twenty-six patients (40%) underwent aortic valve and thirteen (20%) mitral valve replacement, ten patients (15%) had mitral valve commissurotomy, five (8%) underwent aorta-coronary bypass procedures, one (1-5%) the closure of a VSD, and five (8%) the closure of an atrial septum. In two patients (3%) an atrial myxoma was removed, one patient was operated on for a Fallot Pentalogy, and two patients had coarctation ofthe aorta. Serum samples were collected prior to surgery on day 1 or day 2 after the operation and thereafter at weekly intervals. Sera from nineteen patients who had undergone non-cardiac surgery and from nine patients before and after blood transfusion were used as controls. According to their clinical features we divided the sixty-five patients into three groups. Group 1: nineteen patients who had all three classical features after the first post-operative week: pericarditis, fever and leucocytosis. Group 2: eighteen patients who had one or two ofthe main features (incomplete PPS). Group 3: twenty-eight who did not have a PPS. Blood transfusion. Patients with PPS received 6-3±2-3 units of transfused blood compared to 5-2+2-4 units given to patients with incomplete PPS, 4-2+2-1 units to patients with no PPS and 0-7+0-6 to the control group. In all three groups of patients there was a remarkable predominance of blood group A (57-63%) over group 0 (21-26%) compared to the regional distribution of 42-9% for A and 41-5% for 0 in 39,031 blood donors (Schneider & Dick, 1962). Clinical findings. The clinical findings of all groups are given in Table 1. It is evident that pericarditis and fever were always found in group 1, whereas only 33% ofthe patients in group 2 had pericardial rubs. TABLE 1. Clinical findings in sixty-five patients after cardiotomy
Group 1 Complete PPS
Symptoms: No. of patients No. of patients with leucocytosis after 7th post-operative day Mean highest leucocyte count after 7th post-operative day Pericardial rubs Pericardial effusion
Fever>37-50Cafter 7th post-operative day Pleural rubs Pleural effusion (left side) Precordial pain Tachycardia Low voltage (ECG) Post-operative hepatomegaly LDH increase Mean number of interventions at operation (valves, aorto-coronary bypasses) Total cardioplegy time (min) Total extracorporal circulation time (min) Mean no. of days in hospital Mortality (no of patients) after 7th post-operative day
19 19 (95)
Group 2 Incomplete PPS
Group 3 No PPS 28 7 (25)
18 15 (83)
6230+3150*
Control Non-cardiac surgery 19
2(11) 6510+2710*
11,480+4640*
9470+2450*
19 (100) 11 (58) 18 (95)
6 (33) 0 14 (78)
0 0 6 (21)
0 0 2 (11)
7 (37) 7 (37) 19 (100) 13 (68) 4 (21) 8 (42) 10 (53)
3 (17) 1 (6) 15 (83) 11 (61) 0 6 (33) 6 (33)
1 (4) 1 (4) 14 (50) 12 (43) 0 3 (11) 4 (14) 1-09+0-30*
0 0
1.47+0-65*
1-56+0-62*
60-4±41-3*
48 1± 7-7*
74.2+58.8*
64-0± 12-2* 49-7±61-6*
50.9+44.6* 1 (5%)
0
41-4+14-8* 65-1+23-2* 35 1+14.7* 1 (4%)
* Mean+ s.d. Figures in parentheses are the percentage of patients with the particular feature.
0
0 0 0 0
-
11P2 0
Immunology in post-pericardiotomy syndrome. I
191
The mean pre-operative severity of heart disease was classified according to the criteria of the New York Heart Association (1973). It was greatest in group 1 with 3-21 points and differed significantly (2P< 0 05) from group 2 (2-70 points) and group 3 (2-90 points). The mean number of valves replaced and the number of bypass-grafts used were both significantly higher in patients with complete and incomplete PPS as compared to those without symptoms (2P < 0 05). The mean total cardioplegy time and extracorporal circulation time were therefore higher in groups 1 and 2, but not significantly, when compared to group 3 (0-15< 2P< 0-2). Hospitalization was significantly longer (2P< 0-05) in groups with PPS and incomplete PPS as compared to controls. Age distribution (44-47 years), however, did not differ. Complement fixation tests (CFT) were done in all patients with PPS and in twenty without PPS, pre- and post-operatively, against influenza A and B, mumps, cytomegalovirus, Cocksackie B1, B2, B3 and B4. Six patients with PPS were treated with steroids. CFT titres against mumps and Cocksackie B1 viruses were elevated above normal pre-operative values (1 : 10) up to 1 : 40 after surgery in five of the patients with complete PPS. Viral antibodies were negative in all patients with no PPS. Immunological studies. All immunological studies were performed on sera stored at - 250C for 2 years. Immunofluorescence. The indirect technique of Coons & Kaplan (1950) was used. Isopentane-fixed (4 gm) cryostat sections of human operatively resected myocardium from patients with congenital heart disease of the skeletal muscle, kidney, homologous thyroid gland, uterus and skin, heterologous (rat) liver, oesophagus and stomach were used, mounted on pre-treated slides and incubated for 20 min with 1: 10 diluted serum. To determine the immunoglobulin class specificity, the sections were tested with monospecific labelled antisera and anti-Clq antiserum (Hyland). We used the Orthoplan microscope (Leitz) and the filter combinations S 525, KP 500, BG 36, UG, or K 460). The intensity of fluorescence staining was graded from +1 to +4. Sera were also tested for cytoplasmic complement-fixing antibodies using the CFT with homogenate from rat kidney according to Berg, Doniach & Roitt (1967). Sera with fluorescence patterns suggestive of mitochondrial antibodies were tested in subfractions as described by Berg et al. (1967; 1969). Anti-DNA antibodies were tested radioimmunologically (Abbot). Other serological tests. Quantitative immunoglobulin concentrations for IgG, IgGm, IgA, C, and C2 concentrations were determined by the Mancini technique on immunodiffusion plates (Behring Tri-Partigen).
RESULTS
Frequency ofantibodies Striated muscle antibodies were detected by immunofluorescence using homologous and heterologous cardiac and skeletal tissue. In the post-operative period, 95% of the patients in group 1 (complete PPS) showed antibodies against myocardium and skeletal muscle. Fifty per cent of the patients in group 2 (incomplete PPS) had anti-heart antibodies (AHA) and 72% had antibodies against skeletal muscle. In group 3 (no PPS) 29% of the patients reacted with both types of striated muscle tisuse. In a fourth group (non-cardiac surgery as controls) only 5% had antibodies against heart and 22% against skeletal muscle. In the pre-operative period only 5-11% of all patients tested had striated muscle antibodies (Table 2). These results demonstrate the close association between the myocardial and skeletal ASA. Three different types of striated muscle antibodies were found: anti-sarcolemmal antibodies (ASA), antifibrillary antibodies (AFA) and anti-intercalated disc antibodies (AIDA). ASA predominated in group 1 (complete PPS) with 84-90% of patients having this antibody. AFA against heart and skeletal muscle were found most frequently in patients with complete PPS. Sera of two patients showed, in addition to myocardial AFA, the preferential staining of one type of muscle fibre (red zebra). AIDA were found in three instances in only one patient in each group. In the preoperative period only 5-1 1% ofall patients tested had striated muscle antibodies (Table 2). Smooth muscle antibodies (SMA) and antibodies against the endothelium of small vessels (AEA) predominated in group 1 and group 2 (Table 2). Since it has been previously demonstrated that AEA can react with blood group substances (Berg, Brandt & Maerker, 1973), the association ofAEA with the different blood groups was analysed (Table 3). The frequency of AEA was almost identical in patients with blood groups A, B and 0, ranging from 53-75%. This indicates that AEA after cardiac surgery is associated with blood groups A, B and 0, but not with blood group AB. Antinuclear antibodies had a high incidence in patients with PPS (47%) and in patients with incomplete PPS (42%), as compared to 25% positive in group 3 and none in group 4. Pre-operatively, ANA occurred more frequently in patients of group 1 (21%) and group 2 (16%) (Table 2). No anti-DNA antibodies were found.
192
B. Maisch, P. A. Berg & K. Kochsiek 00
t00__obbn
!lt_ tt00000
E~~~~~L
II',
I-
0$-
- n\ L00t
t
°N
o
C-i
Xb
tn
l_ _n
0
mgN~~~~~~~0
_ n>
Ln
0
co
U)
.
bo
4
.9
co
¢
CD
e~~~s eD _ ur N %o
tO
ner
# r.
O 3~~~~L #
Ln
o
I
m
tn o: oo
o
n+N~~~~~t
|*_ 2 = z En E
00¢O
W_
_
6
0
Immunology in post-pericardiotomy syndrome. I
193
TABLE 3. Association of anti-endothelial antibodies after cardiac surgery with the A, B and 0 blood groups (n = 34 AEA-positive patients)
Heterologous AEA
Homologous AEA Blood group
Homo- or heterologous AEA
No. of patients
(%)*
No. of patients
(%)*
No. of patients
(%)*
17 3 0 8
40 9 0 24
11 1 0 5
31 3 0 15
21 3 0 10
62 8 0 30
A B AB 0
*
Percentage of the AEA-positive patients (n - 34).
There was a close relationship between anti-sarcolemmal antibodies (ASA) and antibodies to endothelium (AEA). Eighty-eight per cent of patients with ASA had also AEA; 71% of patients with ASA had SMA. Twelve of the ASA-positive patients also had antinuclear factors (ANA). A heterologous renal tubular immunofluorescent pattern associated with a positive anti-sarcolemmal reaction was observed in three patients ('heterophile antibodies') (Hawkins, McDonald & Dawkins, 1977). Antibodies against mitochondria were not detected by the complement fixation test using purified mitochondrial fractions obtained by differential centrifugation.
Follow-up ofstriated and non-striated muscle antibodies after cardiac surgery The results of this follow-up study in patients with complete PPS are illustrated in Fig. 1. The number of ASA- and AEA-positive patients increased almost proportionally during the first 3 weeks and at the end of the third week 80% of the patients were ASA-positive. Similarly, most of the AFA-positive patients were found in the third post-operative week, whereas patients with SMA and ANA had already developed these antibodies by the second week. Forty per cent of ASA- and AEA-positive patients were still positive 6 weeks after operation; only 22% were still AFA-positive. In patients with incomplete PPS, the incidence of ASA and AEA reached a maximum after the second week and became negative in most patients after the third week, thus demonstrating a different time course between these two groups. AFA in most patients in groups 1 and 2 had disappeared by 4 weeks after surgery.
80-
-
60-
;i
4020
-7
~
OP
~
7
U
14
21 Doys
28
35
42
75
FIG. 1. Appearance and frequency of antibodies after cardiac surgery in patients with complete post-peri-
cardiotomy syndrome (follow-up study in nineteen patients). Antibodies against: (0 o) heart fibrils (AFA); A) endothelium AEA; (z ) sarcolemma (ASA); (a (I zi) smooth muscle SMA; and (-El) nuclei ANA. Arrow indicates day of operation.
194
B. Maisch, P. A. Berg 3 K. Kochsiek
Immunoglobulin classes ofthe autoantibodies The distribution of the immunoglobulin classes of the striated muscle antibodies tested 3 weeks after surgery were as follows: 41% of the twenty-nine ASA (heart) positive patients had IgG, 38% IgM and 24% IgA specificity. Only one patient had ASA of both IgG and IgM specificity. In contrast, 58% of myocardial AFA were of IgM specificity. ASA and AFA of skeletal muscle showed a similar distribution. ASA fixed complement in 82% of positive patients as compared to AFA which gave a complement fixation to heart tissue in 8% and to skeletal muscle in 29% of patients. AIDA were only of IgG specificity. A similar distribution of immunoglobulin classes of non-organspecific antibodies were found when tested 3 weeks after surgery: AEA were mostly of IgG specificity (65%), ANA of IgM specificity (79%); 48% of SMA belonged to the IgG class, 35% had IgM specificity and 55% fixed complement. About 20% of ASA, AEA, AFA and SMA belonged to more than one immunoglobulin class.
Relationship between presence ofautoantibodies and duration ofhospitalization Patients with positive pre-operative ANA and a more complicated clinical course had to be treated considerably longer (61±66 days) than those without ANA (50± 47 days; 0 05 < 2P < 0.1). There was no correlation between the frequency of the various other antibodies after surgery and the clinical course or the duration of hospitalization. AHA-positive patients were hospitalized on average only 4 days longer than those without AHA (AHA-positive 50±58 days, AHA-negative 46±35 days). Globulin and immunoglobulin concentration The serum protein concentrations (7.31+0-58 g/100 ml) of all patients were not altered significantly after operation (7-02±0-91 g/100 ml). a,-globulin increased from 3 45 to 4-61% (P
