Severe cardiac allograft dysfunction without endomyocardial biopsy signs of cellular rejection: incidence and management.

Acute dysfunction of cardiac allograft without evidence of cellular rejection is a potentially fatal complication of heart transplantation that suggests a humoral origin. In clinical practice, humoral rejection (HR) is suspected when there is evidence of severe allograft dysfunction but endomyocardial biopsy (EMB) shows no evidence of cellular rejection. Between April 1991 and August 2003, 12 patients (2.74%) among 438 heart transplants displayed this condition. Time post-heart transplant (HT) was 21.3 +/- 24.7 months (range 2 to 72 months). Immunofluorescence studies using classic markers were negative. All patients were treated with methylprednisolone "bolus" and plasmapheresis until clinical recovery, after which their immunosuppressive regimens were modified. Eleven of the 12 patients recovered satisfactory allograft function. In this series the incidence of suspected HR was low. Unlike other studies, we observed HR not only soon but also even years after HT. Plasmapheresis seems to be an effective treatment.

Feocromocitoma suprarrenal con extensión endovascular a la cava inferior / Adrenal pheochromocytoma with endovascular extension/invasion of inferior vena cava

Mujer de 26 años con un voluminoso feocromocitoma suprarrenal izquierdo que presentaba invasión endovascular de la vena renal izquierda y cava inferior hasta la aurícula derecha. Fue intervenida en dos tiempos: primero, laparotomía y resección en bloque del tumor, riñón y vena renal izquierda; segundo, endoflebectomía de la vena cava bajo derivación cardiopulmonar. A los 8 años de estas intervenciones, no hay evidencia alguna de recidiva. En la revisión de la bibliografía sólo hemos encontrado otros 3 casos de resección de feocromocitomas con invasión endovascular hasta la aurícula (AU)

Absence of enteroviral RNA in hearts explanted from patients with dilated cardiomyopathy.

BACKGROUND: The role of enterovirus infection in the pathogenesis of dilated cardiomyopathy (DCM) remains unclear. The objective of this study was to determine the prevalence of enterovirus in hearts explanted from patients with DCM and to compare it with enterovirus prevalence in hearts explanted from patients with other etiologies and in healthy donor hearts. METHODS: A total of 138 cardiac samples were analyzed, 70 from heart donors and 68 from transplant recipients (22 with DCM). A highly sensitive enterovirus-specific nested RT-PCR was used to test for enterovirus. RESULTS: All tests were negative except for one positive result that was attributed to carryover because sequencing of the amplification product showed it to be identical to the positive control. CONCLUSIONS: In this study the sample of explanted hearts nested RT-PCR showed no evidence of the presence of enteroviral RNA. This suggests that if enterovirus had a role in the genesis of DCM, it does not require or lead to the persistence of the virus in myocardial tissue.

[The "Heart Area" of Juan Canalejo Hospital Complex. A new approach to clinical management]. / El "área del corazón" del complejo hospitalario Juan Canalejo. Una nueva forma de gestión clínica.

The present work describes the process by which the pilot project of clinical management of the Hospital Complex Juan Canalejo, designated as "Heart Area", was implemented. In the first section, the needs and reasons that led to the undertaking of this project are explained. The project's objectives and operative strategies are listed. In the Material and Methods section, three basic aspects of the "Heart Area" are described: selection criteria of the "Area", its structure and function, and its foundation and development. In the Results section, we compare the activity undertaken in the "Area" to the situation present prior to its implementation, in relation to quality and costs. Finally, in the Conclusions, we comment on the important implications that our project can have within the Hospital Complex Juan Canalejo as well as in the health care field in general.

[Combined valvular and coronary surgery]. / Cirugía valvular y coronaria asociadas.

Combined valvular and coronary surgery is more common every day. Coexistence of valvular and coronary disease makes a complex setting of physiopathological interactions, specially in the ischemic mitral regurgitation. So an ideal surgical strategy, including a thorough knowledge of valvular shape, ventricular function and myocardial reserve, as well as new mitral repair techniques and cardioplegic myocardial protection is essential. Despite these conditions, combined surgical mortality is higher than in isolated valve or coronary surgery. Severe complications in the early postoperative period and long term follow up are also more frequent. In any case, combined valvular and coronary surgery remains a challenge for surgical groups all over the world.

[New frontiers in myocardial preservation]. / Nuevas fronteras en preservación miocárdica.

The high hospital mortality due to primary graft failure, together with the ever more frequent use of "Suboptimum" donors because of the scarcity of organs has, in the recent years, caused renewed interest in perfectioning techniques of cardiac preservation. The numerous studies supporting the benefits of a period of controlled warm reperfusion after global ischemia, and the growth of the continuous warm blood cardioplegia, led us to the evolution of our own technique for myocardial protection during transplantation. Dr John Wallwork introduced the concept of donor "resuscitation" in the attempt to improve the hemodynamic state of the donor, by preload and afterload manipulation and pharmacological treatment of the unstable or "marginal" donor. The Juan Canalejo Hospital introduced the concept "Resuscitation during the implantation" using continuous warm blood cardioplegia. Maintenance of normothermia during heart transplantation produces what is referred to as "cell repair" or "resuscitation during the implantation" and avoid the reperfusion damage. From january 1992 to april 1995, 91 orthotopic heart transplantation were performed at our institution. By harvesting we have employed the conventional preservation technique. We performed a controlled continuous anterograde/retrograde warm blood cardioplegic reperfusion of the graft, before and during the implantation in 53 patients. Since january 1994 we performed in 38 cases the same controlled continuous warm blood reperfusion, but only anterograde. Continuous warm blood cardioplegia in heart transplantation is a safety myocardial protection method. Trasplant programs require the optimal use of the available donors.