The falling incidence of hematologic cancer after heart transplantation.

BACKGROUND: A number of changes in the management of heart transplantation (HT) patients have each tended to reduce the risk of post-HT hematologic cancer, but little information is available concerning the overall effect on incidence in the HT population. METHODS: Comparison of data from the Spanish Post-Heart-Transplantation Tumour Registry for the periods 1991-2000 and 2001-2010. RESULTS: The incidence among patients who underwent HT in the latter period was about half that observed in the former, with a particularly marked improvement in regard to incidence more than five yr post-HT. CONCLUSIONS: Changes in HT patient management have jointly reduced the risk of hematologic cancer in the Spanish HT population. Long-term risk appears to have benefited more than short-term risk.

Influence of steroid dosage, withdrawal, and reinstatement on survival after heart transplantation: results from the RESTCO study.

BACKGROUND: Little information is available regarding the consequences of steroid withdrawal following heart transplantation (HT) in Spain. METHODS: We analyzed the records of 1068 patients (81.6% men) who underwent HT between 2000 and 2005 in 13 Spanish centers who were aged ≥ 18 years and who survived at least 1 year. Death rates and Kaplan-Meier survival curves for 1 to 5 years post-HT were compared among four groups: groups A and B, patients on steroids throughout the first 5 years post-HT at dosages of ≤ 5 mg/d between 1-year and 5-year follow-up (group A; n = 148), or >5 mg/d for some part of this period (group B; n = 578). Groups C and D were patients from whom steroids were at some point withdrawn including group D (n = 73) with and group C (n = 269) without subsequent reintroduction into the maintenance regimen. RESULTS: Steroids were withdrawn at 1.6 ± 0.9 years post-HT in group C, and 1.7 ± 1.2 years post-HT in group D. The death rate between 1- and 5-year follow-up (deaths per 1000 person-years) was 44.3% (95% confidence interval 26.2-62.5) in group A, 42.6% (33.7-51.4) in group B, 30.5% (19.6-41.4) in group C, and 47.8% (21.8-73.7) in group D. There was no significant difference among them or among Kaplan-Meier survival curves of the four groups (P = .34 in both cases). Comparison of combined groups C + D with groups A + B showed no evidence of a greater mortality among combined groups C + D. CONCLUSIONS: The late withdrawal of steroids following HT was not associated with increased mortality.

Lung cancer after heart transplantation: results from a large multicenter registry.

In this study we analyzed Spanish Post-Heart-Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post-HT follow-up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post-HT. Incidence increased with age at HT from 149 per 100 000 person-years among under-45s to 542 among over-64s; was 4.6 times greater among men than women; and was four times greater among pre-HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age-at-diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan-Meier 2-year survival to 70% versus 16% among inoperable patients.

The prognosis of noncutaneous, nonlymphomatous malignancy after heart transplantation: data from the Spanish Post-Heart Transplant Tumour Registry.

INTRODUCTION: Malignancy is a major complication in the management of solid organ transplant patients. Skin cancers show a better prognosis than other neoplasms, but not all others are equal: Ideally, patient management must take into account the natural history of each type of cancer in relation to the transplanted organs. We sought to determine the prognosis of various groups of noncutaneous nonlymphomatous (NCNL) cancers after heart transplantation (HT). METHODS: We retrospectively analyzed the records of the Spanish Post-Heart-Transplant Tumour Registry, which collects data on posttransplant tumors in all patients who have undergone HT in Spain since 1984. Data were included in the study up to December 2008. We considered only the first NCNL post-HT tumors. RESULTS: Of 4359 patients, 375 developed an NCNL cancer. The most frequent were cancers of the lung (n=97; 25.9%); gastrointestinal tract (n=52; 13.9%); prostate gland (n=47; 12.5%; 14.0% of men), bladder (n=32; 8.5%), liver (n=14; 3.7%), and pharynx (n=14; 3.7%), as well as Kaposi's sarcoma (n=11; 2.9%). The corresponding Kaplan-Meier survival curves differed significantly (P<.0001; log-rank test), with respective survival rates of 47%, 72%, 91%, 73%, 36%, 64%, and 73% at 1 year versus 26%, 62%, 89%, 56%, 21%, 64%, and 73% at 2 years; and 15%, 51%, 77%, 42%, 21%, 64%, and 52% at 5 years post-diagnosis, respectively. CONCLUSION: Mortality among HT patients with post-HT NCNL solid organ cancers was highest for cancers of the liver or lung (79%-85% at 5 years), and lowest for prostate cancer (23%).

[Angioplasty for acute coronary syndromes in the era of the stent]. / Papel de la angioplastia en los síndromes coronarios agudos en la era del stent.

Pharmacological treatment frequently stabilizes symptoms of patients with acute myocardial ischemia. However, significant quiescent residual stenosis normally persists and leads to rethrombosis. Since rethrombosis produces reischemia and has a deleterious impact on initial and long-term prognosis in these patients, definitive normalisation of local flow assured through deactivation treatments and complete passivation of quiescent residual stenosis in an inert plaque should be a main priority in modern treatment of acute coronary ischemia. Considering the negative influence of significant stenosis on rethrombosis, and that the normalization has a clear antithrombotic effect of flow, routine elimination of residual stenosis by means of angioplasty should prevent rethrombosis and its side effects. Nevertheless, according to trials carried out previous to the most relevant progresses in the field of interventional cardiology, the advantage of this strategy over the conservative treatment has not been clearly demonstrated. Coronary stenting produces a real normalisation of flow and lumen which prevents local thrombosis. In concordance with these facts, recent evidence indicates a substancial clinical benefit of stenting in very thrombogenic acute settings, such as primary angioplasty or refractory acute coronary angina. Presumably, routine stenting also benefits initial and long-term prognosis of other subsets of unstable patients, especially those with thrombolysed myocardial infarction and stabilized patients with acute ischemia without ST-segment elevation. To demonstrate this new trials are needed to compare the efficacy of conservative and interventional approaches that incorporate the advances of each strategys. Until new data are available on these studies, the treatment of acute coronary ischemia should be tailored to each patient and no out-dated recommendation should be given or accepted.

[Prognostic implications of early discharge from the coronary unit in patients with acute myocardial infarction]. / Implicaciones pronósticas del alta precoz de la unidad coronaria en pacientes con infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: The high demand for health care has obliged Coronary Units to hasten the discharge of patients in less serious condition and this might be an influence on their prognosis. Our objective have been: a) to analyse the characteristics and the evolution (death or readmission) during the first month of patients with myocardial infarction and very early discharge from the Coronary Unit (stay of 2 days or less), and b) to assess the profile of very low risk group patients for complications who could be discharged early from the Coronary Unit. PATIENTS AND METHODS: A study of 978 consecutive patients who had been admitted for acute myocardial, in faration were divided into two groups according to their length of stay in the Coronary Unit (A < or = 2 and B > 2 days). Their baseline characteristics, course of stay and vital status at month, were compared. A subgroup of patients at low risk was studied and complications that might have arisen from their early discharge from the Coronary Unit were assessed. RESULTS: Seventy-three patients (7.5%) died within the first two days. Of the remaining 905, the stay was 2 days or less for 336 patients (group A); and longer than 2 days for 569 (group B). Group A had a higher frequency of dyslipemia, Killip class I on admission, uncomplicated myocardial infarction in the Coronary Unit and the use of beta-blockers and had less frequency of diabetes, Q wave myocardial infarction, anterior infarction or the use of fibrinolytics. In the first month after discharge from the Coronary Unit, 10 patients from group A and 18 patients from group B died, the rate of death or readmission into the Coronary Unit within 30 days was similar between both groups (group A = 13% and group B = 13%). A multiple regression showed that Killip class on admission (p < 0.001) and an uncomplicated course (p < 0.001) were independently related with the length of stay in the coronary unit. A subset of 378 low risk patients (Killip I on admission, uncomplicated course in the ICU and age < 71 years) had no mortality at 30 days and their readmission rate in the first month was 4%. In this subgroup, those patients whose stay was equal to or less than two days were more frequently readmitted in the first week. (group A = 9/197 [5%] and group B = 1/181 ([0.5%]; p = 0.034). CONCLUSION: Selected patients with myocardial infarction can be discharged very early from the Coronary Unit with a low risk of death. A readmission rate following discharge of some 5% must be allowed for these patients.

[Preoperative coronary angiography in valve patients. Criteria for indication in a determined population]. / Coronariografía preoperatoria en pacientes valvulares. Criterios de indicación en una determinada población.

BACKGROUND AND PURPOSE: The indication for preoperative coronary angiography in patients with valvular heart disease depends on the prevalence of coronary disease in these patients, which differs among different geographical areas. Our aim was to determine the indication criteria for preoperative coronary angiography in our population. METHODS: We studied retrospectively the prevalence of significant coronary disease in 511 consecutive patients with valvular disease diagnosed by non-invasive methods, who underwent preoperative coronary angiography from August/1991 to July/1996. We analyzed in each patient: demographic data, symptoms and presence of risk factors for coronary artery disease. We considered that preoperative coronary angiography had to be performed on patients who had a coronary artery disease prevalence > or = 5%. RESULTS: Mean age was 64 +/- 10 years (51% male). There was mitral valvulopathy in 135 patients, aortic in 234 and combined mitro-aortic in 142. Angina was present in 30% of patients, and risk factors for coronary artery disease in 52%. The prevalence of significant coronary disease was 20.3%. It was significantly higher in patients with angina (35.3% versus 13.8% in patients without angina) and in those with risk factors (28% versus 12.2% in patients without risk factors); no differences between valvulopathies were found. Age was significantly higher in patients with coronary disease (69 +/- 8 versus 63 +/- 10 years). Multivariate analysis showed three independent predictors for significant coronary disease: 1) age; 2) previous angina, and 3) risk factors. Regarding the prevalence of significant coronary disease in patients neither angina nor risk factors was < 5% in males who were under 60 years old (1 man; 3.3%) and in females under 65 years old (2 women; 3.5%). CONCLUSIONS: In our reference population and in others with a similar cardiovascular profile, preoperative coronary angiography is indicated in males who are > or = 60 years old and in females who are > or = 65 years old, and in younger patients who present angina or risk factors, regardless of the valvulopathy present.

[Post-implant antithrombotic treatment after intracoronary stents. Thrombotic occlusion]. / Tratamiento antitrombótico postimplante intracoronario de stent. Oclusión trombótica.

The stent has been demonstrated to be a useful device in the treatment of complicated coronary angioplasty and in the prevention of restenosis. However, its efficacy was seen to be initially limited due to a high incidence of thrombotic occlusion of the stent in the first month after implantation and a high rate of hemorrhagic complications when a severe antithrombotic treatment with antiplatelet drugs (aspirin and dypiridomole) was associated with anticoagulation therapy with intravenous sodium heparin and dicumarol. Both phenomena increased morbidity and the post-implantation costs of stenting. The development of new strategies in stent implantation and post-implantation management have significantly reduce these complications. The objective of this study is to review the physiopathology of thrombotic occlusion following intracoronary stent implantation and the efficacy of various antithrombotic pharmacological strategies being used for its prevention. Although certain factors existing prior to implantation (thrombus, severe dissection, and the size of the vessel) augment the probability of occlusion in the stent, the result of the implantations is a good predictor of the development of this complication. Recent studies have shown that when optimal coronary stent implantation (high pressure, strict angiographic or ultrasound criteria) resulting in a minimal or absent residual stenosis and adequate apposition of the stent against the arterial wall is associated with new antithrombotic strategies, the rate of thrombotic occlusion should be less than 1.5% and the rate or hemorrhagic complications should not be greater than what has been described for conventional angioplasty. The most consolidated current antithrombotic therapy is the association of aspirin and ticlopodine which has demonstrated its efficacy in both observational and randomized studies. The combination of antiplatelet drugs and low molecular weight heparin has also demonstrated its efficacy in non-randomized studies and may constitute an alternative in some clinical or angiographic situations. The development of stents with a smaller thrombogenic surface contact with blood (made of materials which are not thrombogenic or are coated) hopefully provides another possibility for the near future. All of these advances have minimized the problem of thrombotic occlusion of the stent and have contributed to the great expansion in the use of this technique in current interventional cardiology.

[Influence of the degree of aortic valve calcification on the estimate of valvular area using planimetry with transesophageal echocardiography]. / Influencia del grado de calcificación de la válvula aórtica en el cálculo del área valvular mediante planimetría con ecocardiografía transesofágica.

BACKGROUND AND PURPOSE: Continuity equation to measure aortic valve area is limited by poor acoustic window or difficulty in obtaining acceptable Doppler signal. Our aim has been to analyze the accuracy of planimetry by transesophageal echocardiography to calculate aortic valve area and the impact of calcification on results. METHODS: Planimetry of aortic valve area by transesophageal echocardiography has been compared to continuity equation by transthoracic approach and the Gorlin formula in 26 consecutive patients with aortic stenosis. Degree of calcification was qualitatively estimated by the 3 methods and 2 groups were distinguished: group A (mild or moderate calcification) and group B (severe calcification). RESULTS: An excellent agreement between continuity equation and the Gorlin formula was found (mean difference: 0.03 +/- 0.15 cm2). Agreement between transesophageal planimetry and the Gorlin formula was poor (mean difference: 0.14 +/- 0.25 cm2). Planimetry and the Gorlin formula demonstrated an excellent agreement in group A (mean difference: -0.03 +/- 0.17 cm2). By contrast, agreement in group B was not acceptable (mean difference: 0.27 +/- 0.22 cm2). CONCLUSIONS: 1) continuity equation by transthoracic echocardiography is useful in calculating aortic valve area. 2) aortic planimetry by transesophageal echocardiography is an excellent method in noncalcified aortic valves, and must not be used on severely calcified valves.