Insuficiencia cardiaca secundaria a amiloidosis AL: diagnóstico y tratamiento / Heart failure secondary to amyloidosis AL: diagnosis and treatment

Resumen La amiloidosis por depósito de cadenas livianas de inmunoglobulinas (AL) es una enfermedad poco frecuen te y subdiagnosticada. El mejor tratamiento disponible al momento es el trasplante autólogo de médula ósea (TMO). El compromiso cardíaco es el principal determi nante pronóstico en esta patología y en ocasiones un impedimento para recibir el TMO. Se presenta el caso de un varón de 44 años que consultó por signos y síntomas de insuficiencia cardiaca (IC) con biomarcadores cardia cos elevados. Se realizó un ecocardiograma transtorácico donde se objetivó aumento de espesores parietales con hipoquinesia global y fracción de eyección deteriorada en grado leve (50%). El paciente se internó en unidad coronaria para balance negativo y para estudio etiológico del cuadro. Ante la sospecha de enfermedad infiltrativa, se solicitaron un centellograma óseo con pirofosfato y cadenas livianas libres en suero. El centellograma óseo resultó no sugestivo para amiloidosis por transtiretina y las cadenas livianas libres mostraron una relación me nor a 0.26 con predominio lambda. Se realizó una biopsia de encía que confirmó el diagnóstico de amiloidosis AL. Posterior al diagnóstico comenzó tratamiento qui mioterápico específico con Ciclofosfamida, Bortezomib y Dexametasona (esquema CYBORD) y Daratumumab. Evolucionó con IC refractaria por lo que ingresó a lista de trasplante cardiaco, recibiendo el mismo al poco tiempo con buena evolución. Esto permitió reiniciar el esquema quimioterápico y en segundo término finalmente recibir el TMO, con buena evolución.

Abstract Light chain amyloidosis (AL) is a rare and underdi agnosed disease. The best treatment available is au tologous bone marrow transplantation (BMT). Cardiac involvement is the main prognostic determinant in this pathology and sometimes an impediment to re ceive BMT. We present a clinical case of a 44-year-old who consulted for signs and symptoms of heart failure (HF) with elevated cardiac biomarkers. A transthoracic echocardiogram showed increased wall thickness with global hypokinesia and mildly impaired ejection fraction (50%). The patient was admitted to the coronary unit for treatment with diuretics and for etiological study of the condition. In view of the suspicion of infiltrative disease, a bone scintigraphy with pyrophosphate and free light chains in serum were requested. The bone scintigraphy was not suggestive of transthyretin amyloidosis and the free light chains showed a ratio of less than 0.26 with lambda predominance. A gum biopsy was per formed and confirmed the diagnosis of AL amyloidosis. After diagnosis, specific chemotherapy treatment with Cyclophosphamide, Bortezomib and Dexamethasone (CYBORD scheme) and Daratumumab was started. He evolved with refractory HF so it was decided to admit him to the cardiac transplantation list, receiving the same soon after, with good evolution. This allowed the patient to restart the chemotherapy regimen and finally receive BMT, with good evolution.

Trasplante cardíaco por hemocromatosis. Caso pediátrico / Cardiac transplantation due to hemochromatosis. A pediatric case report

La hemocromatosis es una enfermedad caracterizada por el excesivo depósito de hierro en múltiples órganos, entre ellos hígado, páncreas, piel y corazón. La infiltración de este último es un importante factor en morbilidad y mortalidad. Presentamos un caso de un paciente pediátrico con insuficiencia cardíaca terminal que ameritó trasplante cardíaco, que resultó sin complicaciones. Posterior a la cirugía, mostró mejoría bioquímica y clínica, lo que influyó positivamente en su calidad de vida y prolongó su supervivencia.

Hemochromatosis is a disease characterized by excess iron stores in multiple organs, including the liver, pancreas, skin, and heart. The infiltration of the heart is an important factor in morbidity and mortality. Here we describe the case of a pediatric patient with end-stage heart failure who required a heart transplantation, with no complications. After the surgery, she showed biochemical and clinical improvement, with a positive impact on her quality of life and a prolonged survival.

Pediatric Ventricular Assist Device

There have been great advances in ventricular assist device (VAD) treatment for pediatric patients with advanced heart failure. VAD support provides more time for the patient in the heart transplant waiting list. Augmented cardiac output improves heart failure symptoms, end-organ function, and general condition, and consequently provides beneficial effects on post-transplant outcomes. Miniaturized continuous flow devices are more widely adopted for pediatric patient with promising results. For infants and small children, still paracorporeal pulsatile device is the only option for long-term support. Younger age, congenital heart disease, biventricular support, patient's status and end-organ dysfunction at the time of implantation are risks for poor outcomes. Patient selection, timing of implantation, and selection of device for each patient are critical for optimal clinical outcomes.

Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications

Congestive heart failure is a major cause of morbidity and mortality as well as a major health care cost in the developed world. Despite the introduction of highly effective heart failure medical therapies and simple devices such as cardiac resynchronization therapy that reduce mortality, improve cardiac function and quality of life, there remains a large number of patients who do not respond to these therapies or whose heart failure progresses despite optimal therapy. For these patients, cardiac transplantation is an option but is limited by donor availability as well as co-morbidities which may limit survival post-transplant. For these patients, left ventricular assist devices (LVADs) offer an alternative that can improve survival as well as exercise tolerance and quality of life. These devices have continued to improve as technology has improved with substantially improved durability of the devices and fewer post-implant complications. Pump thrombosis, stroke, gastrointestinal bleeding and arrhythmias post-implant have become less common with the newest devices, making destination therapy where ventricular assist device are implanted permanently in patients with advanced heart failure, a reality and an appropriate option for many patients. This may offer an opportunity for long term survival in many patients. As the first of the totally implantable devices are introduced and go to clinical trials, LVADs may be introduced that may truly be alternatives to cardiac transplantation in selected patients. Post-implant right ventricular failure remains a significant complication and better ways to identify patients at risk as well as to manage this complication must be developed.

Reversal of neuromuscular block with sugammadex in five heart transplant pediatric recipients / Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco

Abstract Heart transplantation is a frequent procedure in the treatment of end-stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose-dependent life-threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequale and discuss the reversal of neuromuscular block in this patient population.

Resumo O transplante cardíaco é um procedimento frequente no tratamento da disfunção cardíaca em estágio final. Portanto, essa população de pacientes também será exposta com mais frequência a outros procedimentos cirúrgicos mais comuns após o transplante. Em sua avaliação, o anestesiologista deve ter em mente algumas questões específicas relacionadas à história de transplante cardíaco desses pacientes, tais como a reversão do bloqueio neuromuscular. Vários estudos relataram que os inibidores da colinesterase, como a neostigmina, podem produzir uma bradicardia dose-dependente que ameaça a vida em receptores de transplante cardíaco, enquanto um estudo relatou o uso seguro de neostigmina. A reversão do bloqueio neuromuscular com sugamadex é outra possibilidade, mas os dados na literatura são escassos. Descrevemos cinco casos nos quais a reversão bem-sucedida do bloqueio neuromuscular foi realizada com sugamadex em receptores pediátricos de transplante cardíaco sem deixar sequelas e discutimos a reversão do bloqueio neuromuscular nessa população de pacientes.

Fatal case of donor-derived colistin-resistant carbapenemase-producing Klebsiella pneumoniae transmission in cardiac transplantation

ABSTRACT Herein we report a fatal case of donor-derived transmission of XDR-resistant carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) in cardiac transplantation. A 59-year-old male patient with non-obstructive hypertrophic cardiomyopathy underwent heart transplantation. On day 5 post-operation, blood cultures from the donor were positive for colistin-resistant carbapenemase-producing K. pneumoniae (ColR KPC-Kp) susceptible only to amikacin. Recipient blood cultures were also positive for ColR KPC-Kp with the same sensitivity profile as the donor isolate with an identical PFGE pattern. The patient was treated with double-carbapenems and amikacin. The patient evolved to pericarditis, osteomyelitis, and pulmonary necrosis, all fragment cultures positive for the same agent. The patient developed septic shock, multiple organ failure and died on day 50 post-transplantation. Based on current microbiological scenario worldwide the possibility of transmitting multidrug resistant (MDR) organisms should be considered.

Establishment and improvement of abdominal heterotopic heart transplantation model in mice / 第二军医大学学报

Objective To establish and improve the abdominal heterotopic heart transplantation model in mice, so as to provide references for the research on organ transplantation immunology. Methods C57BL/6 mice were selected as donors and recipients for syngeneic cardiac transplantation and recipients for allogeneic cardiac transplantation; BALB/c mice were selected as donors for allogeneic cardiac transplantation. The ascending aorta and pulmonary artery of the heart of the donors were end-to-side anastomosed with the abdominal aorta and inferior vena cava of the recipients, respectively, to establish abdominal heterotopic heart transplantation models in mice. Furthermore, the techniques of preparing recipient heart before implantation, extracting and preparing donor heart, and vascular anastomosis were improved, and the surgical results and advantages were observed and analyzed. Results Preliminary experiments were performed on 50 pairs of mice. For formal experiments, syngeneic cardiac transplantation was performed on 20 pairs and the success rate was 85.0% (17/20); allogeneic cardiac transplantation was performed on 15 pairs and the success rate was 86.7% (13/15). The total success rate of abdominal heterotopic heart transplantation was 85.7% (30/35). The average time for preparing recipient before vascular anastomosis was (11.2±2.5) min, the average time for extracting and preparing donor heart was (13.6±3.3) min, and the average time for vascular anastomosis was (21.7±3.5) min. Conclusion The improved abdominal heterotopic heart transplantation model in mouse has the advantages of easy-to-perform and high success rate, which lays a foundation for the further study of transplantation immunology.

The use of meld score (model for end-stage liver disease) and derivatives in cardiac transplantation / A utilização do escore meld (model for end-stage liver disease) e derivados no transplante cardíaco

ABSTRACT Introduction: Heart transplantation is still the best therapeutic alternative for the treatment of end-stage heart failure. The use of criteria that consider the complications associated with this procedure can guarantee a better evaluation of the recipient and prepare the team for possible unsatisfactory post-transplant results. The use of the MELD score has been expanded to evaluate cirrhotic patients undergoing various procedures, including cardiac transplantation. Objective: To analyze the knowledge on MELD score and its derivatives to the prognosis of patients with end-stage heart failure considered for heart transplantation. Method: Was carried out an integrative review of the publications of the last ten years in Pubmed and Lilacs databases, using the descriptors "heart transplantation", "liver disease" and "prognosis". From the total of 111 articles found, six were selected and composed the sample. Results: The MELD-XI score (eXcluding INR) was the most analyzed in the studies due to the exclusion of INR, since many patients with heart failure use anticoagulants, which may alter their value. MELD and derivatives were associated with unsatisfactory results in cardiac transplantation. Conclusion: The MELD score can be considered as a good predictor for heart transplantation; however, there are still few studies that make this correlation.

RESUMO Introdução : O transplante de coração ainda é a melhor alternativa terapêutica para o tratamento da insuficiência cardíaca terminal. A utilização de critérios que considerem as complicações associadas a esse procedimento pode garantir melhor avaliação do receptor e preparar a equipe para possíveis resultados insatisfatórios no pós-transplante. O uso do escore MELD vem sendo expandido para avaliar pacientes cirróticos submetidos a diversos procedimentos, incluindo o transplante cardíaco. Objetivo : Analisar o conhecimento produzido relacionando o escore MELD e os seus derivados com o prognóstico dos pacientes com insuficiência cardíaca terminal considerados para o transplante cardíaco. Método : Foi realizada revisão integrativa das publicações dos últimos dez anos nas bases de dados Pubmed e Lilacs, utilizando os descritores "transplante cardíaco", "doença hepática" e "prognóstico". Do total de 111 artigos encontrados, seis foram selecionados e compuseram a amostra. Resultados : O escore MELD-XI (eXcluding INR) foi o mais analisado nos estudos devido à exclusão do INR, já que boa parte dos pacientes com insuficiência cardíaca fazem uso de anticoagulantes, podendo alterar o seu valor. O MELD e derivados esteve associado aos resultados insatisfatórios no transplante cardíaco. Conclusão : O escore MELD pode ser considerado como bom preditor para o transplante cardíaco; porém, ainda são poucos os estudos que fazem essa correlação.

<b>A Japanese Herbal Medicine, Shigyakusan, Induces Prolonged Survival of Fully MHC-Mismatched Murine Cardiac A</b><b>llografts</b> / 日本東洋医学雑誌

<p><b>Background </b>: Shigyakusan, a 4-component Japanese herbal medicine (Paeoniae radix, Aurantii fructus immaturus, Glycyrrhizae radix and Bupleuri radix), is used not only for cholecystitis and gastritis as an antiinflammatory agent, but also for anxiety neurosis and insomnia as an anti-anxiety agent.<br><b>Methods </b>: We investigated the effects of shigyakusan on alloimmune responses in fully MHC-mismatched murine cardiac allograft transplantation. CBA mice underwent transplantation of a C57BL/6 heart and received shigyakusan or one component of shigyakusan administered orally from the day of transplantation until 7 days afterward. Histologic studies, cytokine measurements, and flow cytometry assessments were performed.<br><b>Results </b>: Untreated CBA recipients acutely rejected C57BL/6 cardiac grafts (median survival times [MST], 7 days). On the other hand, CBA transplant recipients given shigyakusan had significantly prolonged C57BL/6 allograft survival (MST, 22.5 days). MSTs for C57BL/6 transplant recipients given Paeoniae radix, Aurantii fructus immaturus, Glycyrrhizae radix and Bupleuri radix were 11, 9.5, 18.5 and 8 days, respectively. Additionally, flow cytometry studies showed that the percentage of CD25+Foxp3+ cell populations in CD4+ cells was increased in transplant recipients given shigyakusan.<br><b>Conclusion </b>: Shigyakusan induced hyporesponsiveness to fully MHC-mismatched allogeneic cardiac allografts and may generate CD4+CD25+Foxp3+ cells in our model.</p>

Síndrome de encefalopatía posterior reversible secundaria a tacrolimus / Tacrolimus-associated posterior reversible encephalopathy syndrome

Los inhibidores de la calcineurina, la ciclosporina y el tacrolimus han jugado un papel preponderante en la prevención de los episodios de rechazo y de la enfermedad de injerto contra el huésped en pacientes tratados mediante el trasplante de órgano sólido y de la médula ósea. No obstante, el tacrolimus presenta efectos adversos relacionados con la neurotoxicidad, siendo el síndrome de encefalopatía posterior reversible la consecuencia más severa de dicha neurotoxicidad. El reporte de nuestro caso es de una mujer de 30 años de edad, con 2 días de evolución de cefalea intensa en la frente, náuseas, emesis, hiporexia y epigastralgia, afebril. Antecedente de un trasplante cardiaco 45 días antes, en tratamiento inmunosupresor con tacrolimus y micofenolato mofetilo. Se documentan niveles de tacrolimus adecuados (12,1 ng/ml), los estudios imagenológicos normales y los resultados de laboratorio negativos para infección, lo que permite descartar las causas vasculares e infecciosas y la neurotoxicidad por el tacrolimus. Sin embargo, ante el desarrollo de alteraciones neuropsiquiátricas, y a pesar de niveles de tacrolimus < 5,5 ng/ml, se realiza nueva resonancia nuclear magnética cerebral con hallazgos que indican síndrome de leucoencefalopatía posterior reversible. Se suspende el tacrolimus y se inicia tratamiento con everolimus, lográndose remisión total. Este sería el primer caso reportado en el cual las alteraciones imagenológicas asociadas al síndrome de encefalopatía posterior reversible se desarrollaron en una paciente intervenida de trasplante cardiaco con niveles de tacrolimus < 10 ng/ml. El reporte de este caso permitirá a los grupos médicos tratantes considerar este diagnóstico a pesar de niveles de tacrolimus en rango terapéutico, de manera que se realice un reconocimiento y tratamiento oportuno, evitando así el desarrollo de complicaciones o secuelas neurológicas.

Calcineurin inhibitors, cyclosporine and tacrolimus, have played a major role in preventing graft rejection and graft-versus-host disease in patients undergoing bone marrow and solid organ transplantation. However, tacrolimus has adverse effects related with neurotoxicity, being the posterior reversible encephalopathy syndrome the most severe consequence of this neurotoxicity. We report the case of a 30 year-old woman with 2-day history of severe frontal headache, náusea, emesis, hiporexia and epigastric pain, without fever. History of heart transplant 45 days ago, immunosuppressive therapy with tacrolimus and mycophenolatemofetil. Appropriate levels of tacrolimus (12.1 ng/ml), normal imaging and lab results were documented, excluding vascular and infectious causes as well as tacrolimus neurotoxicity. Nevertheless, due to the development of neuropsychiatric disorders and despite tacrolimus levels being < 5.5 ng/ml, a new brain MRI was performed showing a reversible posterior leukoencephalopathy syndrome. Tacrolimus was switched to everolimus achieving complete remission. This is the first reported case in which the imaging alterations associated with posterior reversible encephalopathy syndrome were developed in a patient undergoing heart transplantation with tacrolimus levels < 10 ng/ml. The report of this case will allow the treating physician groups to consider this diagnosis regardless oftacrolimus levels within therapeutic range, allowing therefore an early recognition and treatment, thus avoiding the development of complications and/or neurological sequels.

A Tale of Two Surgeons.

Cardiac transplantation is one of the greatest medical marvels of the twentieth century. Performing this miraculous operation on 3rd December 1967, Dr. Christiaan Barnard, an unknown surgeon from the then apartheid state of South Africa suddenly became an international celebrity. Probably no single procedure in the history of medicine had attracted so much media and public attention. But there were many who thought that he didn’t deserve much of this glory. A lion share of this should have gone to somebody else. Although Barnard completed the final step in the road to transplant, it was the end product of serious research work carried out in many centers around the World. Most important was Stanford University Medical Center, Palo Alto, California USA, where Dr. Norman Edward Shumway was engaged in transplantation related research work along with his junior colleague Dr. Richard Lower. The most of the techniques used in cardiac transplantation today were actually developed by Dr. Shumway and his team. Barnard worked in the same unit with Shumway at University of Minnesota when he came to USA. He visited USA again in 1966 when he observed the works of Shumway’s research partner Dr. Richard Lower. During both of his visits he had adopted many techniques from the research work of his American counterparts and later used in his unique accomplishment. Barnard succeeded utilizing techniques developed through Shumway’s painstaking work over the years depriving Shumway much of the glory he deserved. Both later on continued in the development of transplantation when most others left because of poor outcome. Shumway excelled the technical details and Barnard drew media and public attention to the importance of this procedure. After almost five decades the name of Barnard is still well known by the common people around the World; whereas Shumway remains unknown even to most of the cardiac surgeons as well. This was the destiny of the two main heroes credited behind this exciting medical accomplishment. Here lies a very interesting story, the tale of two surgeons.

Pediatric Mechanical Circulatory Support

Mechanical circulatory support (MCS) in the pediatric heart failure population has a limited history especially for infants, and neonates. It has been increasingly recognized that there is a rapidly expanding population of children diagnosed and living with heart failure. This expanding population has resulted in increasing numbers of children with medically resistant end-stage heart failure. The traditional therapy for these children has been heart transplantation. However, children with heart failure unlike adults do not have symptoms until they present with end-stage heart failure and therefore, cannot safely wait for transplantation. Many of these children were bridged to heart transplantation utilizing extracorporeal membranous oxygenation as a bridge to transplant which has yielded poor results. As such, industry, clinicians, and the government have refocused interest in developing increasing numbers of MCS options for children living with heart failure as a bridge to transplantation and as a chronic therapy. In this review, we discuss MCS options for short and long-term support that are currently available for infants and children with end-stage heart failure.

Individualized mycophenolate mofetil therapy based on monitoring of mycophenolic acid trough level in cardiac transplant recipients / 中华器官移植杂志

Objective To compare clinical outcomes in cardiac transplant recipients treated with individualized dosing (ID) and fixed dosing (FD) of mycophenolate mofetil (MMF).Methods Fortyeight de novo cardiac transplant patients in ID group received MMF (2.0 g/day) in combination with calcineurin inhibitors and prednisone.The MMF dosages were adjusted individually based on clinical events and MPA trough levels (MPA-C0).The target range of C0 was maintained within 2.0-4.0rng/L.The FD group included 55 recipients retrospectively from the transplant database who were also treated with MMF (2.0 g/day).In this group,the MMF dose adjustment was performed empirically according to clinical events only.All of the follow-up data were collected up to 12 months post-transplantation.Results The follow-up rate was 95.8％ and the mean MPA-AUC0-12 was (54.37± 17.03) rng h-1 L-1 in the ID group.The mean MPA-C0 on the day 7 post-transplantation was significantly higher in the ID group than that at 12th month [(3.44 ± 0.58) mg/L vs.(2.79 ± 0.54)mg/L] (P＜0.05).The dose of MMF was significantly lower in the ID group at 4th week posttransplantation than in control group [(1.49± 0.48) g/day vs.(1.96 ± 0.39) g/d] (P＜0.05),while there was no significant difference at 12 th month post-transplantation [(1.61 ± 0.77) g/day vs.(1.68 ± 0.84) g/day] (P＞ 0.05).No significant difference was found in the incidence of acute rejection episode between two groups (8.7％ vs.9.1％,P＞0.05).57.6％ of overall side effects were observed within one month postoperatively,and the incidence of MPA-related side effects was significantly lower in the ID group than in the control group (47.8％ vs.67.3％,P＜0.05).Conclusion It was demonstrated that individualized use of MMF based on therapeutic drug monitoring may prevent MMF-related side effect and appears to be valuable to optimize the treatment of cardiac transplantation.

Transplante cardíaco: perfil demográfico e epidemiológico de pacientes em um hospital de grande porte em Belo Horizonte / Transplante de corazón: perfil demografico y epidemiologico de los pacientes de um gran hospital de Belo Horizonte / Cardiac transplantion: demographic and epidemiological patients’ profile at a large hospital in Belo Horizonte

O transplante cardíaco entre humanos passou a ser considerado opção para o tratamento de doenças antes consideradas fora de possibilidade terapêutica, e a enfermagem tem acompanhado os avanços nessa área. Nesse sentido, o processo de enfermagem, fundamentado na “teoria das necessidades humanas básicas ”de Horta, passou a ser o norteador da assistência de enfermagem para pacientes de transplante cardíaco a partir de 2003, na instituição campo da pesquisa. Como objetivo de traçar o perfil demográfico e epidemiológico desses pacientes, foi desenvolvido um estudo descritivo e retrospectivo por meio de avaliação dos registros de enfermagem constantes em 49 prontuários de pacientes submetidos a transplante cardíaco, no período entre 2003 e 2006. Os resultados mostraram que houve predomínio de pacientes do sexo masculino, casados, com ensino fundamental incompleto, aposentados, católicos e de procedênciade Belo Horizonte. A doença de base prevalente foi miocardiopatia chagásica. Conclui-se que os resultados deste estudo podem subsidiar o planejamento de intervenções de enfermagem a serem planejadas nessa população específica e de ações preventivas das doenças de base que levam à insuficiência cardíaca grave.

Human to human cardiac transplantation is an alternative for the treatment of illnesses previously with no cure and Nursing kept up with the developments in the cardiac specialty. The nursing process based on Horta’s “theory of basic human needs provided”, from 2003, the basis for the assistance of heart transplant patients in that hospital’s research unit. This is a descriptive and retrospective study aiming to outline a demographic and epidemiological profile of these patients. 49 nursing reports (included on medical records) of patients submitted to heart transplants between 2003 and 2006 were evaluated. The results showed the majority of patients were married man, catholic, retired, with an incomplete Basic Education, and from the city of Belo Horizonte. The prevailing underlying disease was chagasic cardiomyopathy. The study’s results could be the basis for the planning of nursing strategies and preventive actions to heart failure underlying diseases directed to that specific part of the population.

El trasplante cardiaco entre las personas pasó a ser considerado como una opción para el tratamiento de enfermedad es que antes no tenían cura y Enfermería también ha seguido los avances en este campo. En ese sentido, el proceso de Enfermería, basado en la “teoría de las necesidades humanas básicas” de Horta, a partir de 2003, pasó a orientarla atención de enfermería para pacientes de trasplante cardíaco en la institución campo de la investigación. Con el objetivo de trazar el perfil demográfico y epidemiólogo de los pacientes, se realizó un estudio retrospectivo descriptivo por medio de la evaluación de los registros de enfermería de 49 historias clínicas de pacientes sometidos a trasplante cardiaco entre 2003 y 2006. Los resultados indicaron que predominaban los pacientes del sexo masculino, casados, con educación básica incompleta, jubilados, católicos y oriundos de Belo Horizonte. La enfermedad de base prevalente fue miocardiopatía chagásica Se concluye que los resultados de este estudio podrían ayudar a planificar acciones de enfermería para esta población específica y preventivas de las enfermedades de base que provocaron la insuficiencia cardíaca grave.

Comparación de angiografía coronaria con el ultrasonido intracoronario como patrón de referencia en el diagnóstico de vasculopatía post trasplante cardíaco / Comparison of coronary angiography and intra-coronary ultrasound as gold standard in the diagnosis of post cardiac transplantation vasculopathy

Antecedentes: La Vasculopatía del injerto (VDI) es la principal causa de muerte tardía del trasplante cardiaco (TX). Un diagnóstico precoz de esta complicación tendría un impacto en la terapia y pronóstico de esta afección. El ultrasonido intracoronario (IVUS), permite un diagnóstico precoz y certero de VDI, pero en la mayoría de los centros aún se utiliza la coronariografía. Objetivo: Evaluar la validez de la coronariografía en el diagnostico de VDI en pacientes trasplantados cardiacos, comparado con el IVUS. Metodología: Estudio transversal, en el cual se analizó una muestra de 36 pacientes con un tiempo promedio de trasplante de 3,7 +/- 3,7 años, a quienes se realizó simultáneamente un examen de coronario-grafía y un IVUS. Se evaluó la reproducibilidad contrastando los resultados de la interpretación visual de la coronariografía versus la coronariografía con análisis cuantitativo. Se calculó la Sensibilidad, Especificidad, Valores predictivos (VPP, VPN), Likelihoods y el coeficiente de equivalencia de Spearman-Brown. Resultados: La coronariografía cualitativa mostró ser más exacta que la cuantitativa, con una sensibilidad 30,4 por ciento [95 por ciento IC= 11,6 - 49,2], una especificidad 92,3 por ciento [95 por ciento IC= 77,8 - 106,7], VPP 87,5 por ciento [95 por ciento IC= 64,5 - 110,4], VPN 42,8 por ciento [95 por ciento IC= 24,5 - 61,1], LR (+) 3,9 [95 por ciento IC 0,55 - 28,7] y un LR (-) 0,75 [95 por ciento IC= 0,55 - 1,03]. La coronariografía cualitativa y cuantitativa son moderadamente equivalentes con un coeficiente de equivalencia Spearman Brown de 0,65. Conclusión: La validez y la reproducibilidad de la coronariografía en el paciente con TX es moderada y debería ser complementada con IVUS para el diagnóstico de VDI.

Background: Graft vasculopathy (GV) is the main cause of late death following cardiac transplantation (TX). Early diagnosis of this condition may have an impact upon treatment and prognosis of this complication. Intravascular ultrasound (IVUS) allows an early and accurate diagnosis of GV. However, most centers continue to use coronary angiography for this purpose. Aim: to evaluate coronary angiography for the diagnosis of GV in relation to IVUS in post TX patients. Methods: In a cross-sectional study the results of coronary angiography and IVUS, used as gold standard, were compared in 36 patients with a mean post TX follow up of 3.7 +/- 3.7 years. Results were compared between visual and quantitative coronary angiography. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), likelihood ratios and the equivalence Spearman-Brown coefficient were calculated. Results: Visual evaluation of coronary angiography was more accurate than quantitative coronary angiography. The sensitivity for GV was 30.4 percent (95 percent C.I. 11.6 - 49.2), specificity 92.3 percent (95 percent C.I. 77.8 - 106.7), PPV 87.5 percent (95 percent C.I. 64.5 - 110.4, NPP 42.8 percent (95 percent C.I. 24.5 - 61.1), likelihood ratio (+) 3.9 (95 percent C.I. 0.55 - 28.7), likelihood ratio (-) 0.75 (95 percent C.I. 0.55 -1.03). The Spearman Brown coefficient between visual and quantitative coronary angiography evaluation was 0.65. Conclusion: Accuracy and reproducibility of coronary angiography in the evaluation of GV is limited. IVUS should be used for better identification of GV.

Protocolos de selección y estudio del donante y receptor aplicables a la práctica chilena, en trasplante cardiaco / Donor recipient screening and selection protocols in cardiac trasplantation applied to chilean practice

La terapia actual de la insuficiencia cardiaca (IC) logra disminuir la morbilidad y la mortalidad, ésta persiste siendo elevada en etapas avanzadas, por lo que el trasplante cardiaco (TC) constituye la mejor alternativa terapéutica en la fase terminal de la enfermedad. Como todo procedimiento quirúrgico, una adecuada selección de los candidatos, tanto receptor como donante, es fundamental para el éxito de un programa de trasplante cardíaco, más aún cuando constituye un procedimiento electivo. La indicación de TC está dada por la presencia de una cardiopatía con severa limitación de la capacidad funcional (CF III o IV) sin otra alternativa de terapia médica y/o quirúrgica. La evaluación del receptor se basa en el descarte de enfermedades sistémicas, infecciones o neoplasias activas, así como de hipertensión pulmonar no reversible, y de cualquiera otra condición que comprometa la expectativa de vida del paciente. El estudio del donante se base en descartar una cardiopatía estructural o disfunción sistólica y enfermedades trasmisibles. En suma la morbilidad y mortalidad en un programa de TC depende la adecuada selección de los candidatos a receptor y el donante, así como del delicado equilibrio entre el nivel de la terapia inmunosupresora necesaria para controlar el rechazo y los efectos secundarios de la misma, como el aumento de la susceptibilidad a las infecciones.

Even though the present therapy for heart failure (HF) successfully decreases the morbidity and mortality rates, these are persistently high in advanced stages. Therefore Cardiac Transplantation (CT) constitutes the best therapeutic alternative in terminal stages of the illness. As in every surgical procedure, an adequate selection of the candidates - both transplant patient and donor- are fundamental for the success of the cardiac transplantation, even more when this constitutes an elective procedure. The normal recommendation for CT is given in the presence of cardiopathy with severe limitation of functional capacity (FC) III or IV without other alternative of medical or surgical therapies. The receptor evaluation is based on the absence of systemic diseases –infections, active neoplasia or non reversible pulmonary hypertention as well or any other condition which can compromise the patiente life expectancy. The donors study is based on discard structural cardiophaty, systolic dysfunction and transmissible diseases. In summary in a programme of CT the morbidity and mortality rates dependson an adequate candidates selection to transplant patient and donor, as a delicate equilibium between immunosuppressant therapy needed to control rejection and colateral effects related to this and to the increased sensitivity to infections.

Endocardial Fibroelastosis in a 57-Year-Old Transplant Recipient

Endocardial fibroelastosis (EFE) is characterized by deposition of collagen and elastin leading to ventricular hypertrophy and diffuse endocardial thickening. Here we report (for the first time in Korea) the case of a EFE presenting with heart failure. The patient was a 57-year-old woman who had complained of dyspnea on exertion {New York Heart Association (NYHA) functional class 3} and abdominal distension at the time of hospital admission. Echocardiography showed severe diastolic dysfunction with normal systolic function. On MRI, the contrast-enhanced delayed myocardial image demonstrated hyperenhancement in the endocardium. Owing to progressive heart failure, the patient was transplanted. Histological examination of the explanted heart showed irregularly thickened endocardium with fibrosis and elastosis in the both ventricles, compatible with the diagnosis of EFE.

Cardiac Transplantation for a Patient with Intra-aortic Balloon Pump and Extracorporeal Membrane Oxygenator due to Cardiogenic Shock after Acute Myocardial Infarction: A Case Report / 대한구급학회지

A 66-year-old male patient who suffered from chest pain and dyspnea was admitted to our hospital. He was diagnosed as having an acute myocardial infarction, and recovered from cardiogenic shock after cardiopulmonary-cerebral resuscitation. Under the support of extracorporeal membrane oxygenator (ECMO) he underwent successful percutaneous coronary intervention. After this, an intra-aortic balloon pump (IABP) was inserted to increase coronary perfusion and reduce the impedance to left ventricular ejection. After 6 days, the patient was weaned from ECMO support; however, IABP therapy and infusion of inotropic agents were required to maintain adequate hemodynamic status. One week later, cardiac transplantation was performed successfully without major complications.

Orthotopic Cardiac Transplantation after Inter-caval Anastomosis in a Patient with Hypertrophic Cardiomyopathy and Persistent Left Superior Vena Cava / 대한흉부외과학회지

Cardiac transplantation in a patient with persistent left superior vena cava (SVC) necessitates unifocalization of the caval veins. Here we report a successful case of orthotopic heart transplantation in a patient with hypertrophic cardiomyopathy and persistent left SVC. Cardiac transplantation was done after the left SVC was anastomosed to the right SVC in an end to side fashion. The postoperative course was uneventful, and the patient is currently in an excellent clinical condition.

Early stage mechanism of the specific NF-κB inhibition induced cardiac allograft tolerance / 中华微生物学和免疫学杂志

Objective To investigate whether allocardiac graft acceptance in the specific NF-κB impaired mice is due to regulatory T cell(Tr) and Th17 cells.Methods Mice abdominal heterotopic cardiac transplantation was performed and then divided in to control group(BALB/c→C57BL/6) and experimental group(BALB/c→IκBα/△N-Tg).Pretransplant and at day 7,30,100 posttransplant,spleens were harvested from the IκBα△ N-Tg mice,and then the Tr were detected by the fluorescence activated cell sorter.At day 5 posttransplant,the CD4 + Th17 cells from the spleens of the two groups were examined by the FACS.Additionally,at day 3 and 5 posttransplant,IL-17 expressed in the cardiac allograft was detected by Western blot.Results In the IκBα/ N-Tg mice group,the cardiac allografts were survived more than day 100,and without obviously lymphocytes infiltration.At the day 7 and 30 posttransplant,the Tr was obviously increased(21.23 ± 3.95,23.17 ± 4.11 vs 11.64 ± 1.96,P ＜ 0.05); however,the Tr decreased at the day 100 posttransplant,and had no difference with before transplant(10.79 ±2.48 vs 11.64 ± 1.96,P ＞0.05).Compared with the control group,at day 5 posttransplant,CD4+ Th17 cells in the IκBα/N-Tg mice and IL-17 expression of the cardiac allograft were both decreased.Conclusion In the early stage after transplantation,specific T cell NF-κB impaired could abrogate the balance of the Tr and Th17 cells,and induce the T cells differentiated into Tr and inhibit the Th17 cells differentiation,and then induce tolerance.