Complex Congenital Heart Disease: Is Heart Transplantation an Option?

INTRODUCTION: Within the heart transplant (HT) population, few patients have complex congenital heart disease (CHD) underlying disease. Our objective is to assess the complications and follow-up of patients with CHD transplanted in our center (1991-present). MATERIAL AND METHODS: Retrospective analysis of patients older than 14 years old with CHD and HT. Clinical and surgical variables were analyzed. RESULTS: Ten patients (age 25 ± 7 years old, 60% male) were analyzed, which represents 2.2% of the entire series of HT; 9 of the 10 patients were electively transplanted and 1 was under support with extracorporeal membrane oxygenation. Compared with the rest of the transplanted patients, patients with CHD had a lower median age (25 [25-36] vs 53 [15-69]; P < .009); more cardiac surgeries prior to HT (100% vs 14.4%; P < .001); a lower percentage of cardiovascular risk factors (CVRF; 0% vs 60%; P < .001). The left ventricle ejection fraction also showed statistically significant differences (33.5 [12-67] vs 20 [6-70]). CONCLUSIONS: Our patients with CHD and HT are younger and have less CVRF and more cardiac surgeries, which highlights that it is a subgroup with clear clinical differences in its comorbidity and pretransplantation assessment. They also require longer extracorporeal circulation time, more hours of intubation, and more days in the intensive care unit. Primary graft failure is more common in patients with CHD. Therefore, survival at 1-month follow-up is lower than the rest of the series and equalizes after the year of follow-up. This long-term survival reaffirms the possibility of HT in CHD despite the fact that its postoperative period is more difficult.

Early mortality after cardiac transplantation: comparison of demographic, clinical, biological and surgical variables.

Cardiac transplantation is the last alternative for those patients in terminal heart failure. However, its mortality is high, and approximately 20% of patients die in the first month after cardiac transplantation. We retrospectively reviewed 116 patients transplanted at our center in the last 6 years. Data about clinical, biological and surgical variables were collected. We undertook a multivariate analysis in order to find differences between those patients who died in the first month and those who survived. We found statistically significant differences in total ischemia time (P = .036) and extracorporeal circulation time (P = .001), with those patients that died in the first month having longer times. We also found a statistically significant difference in the weight of the recipient, with those recipients that died in the first month having a higher weight (P = .03). No statistically significant differences were found in the other variables. Of particular interest was the absence of a significant association in both groups (survival <1 month vs survival >1 month) in the variables related to pulmonary hypertension (pulmonary half-time pressure, pulmonary systolic pressure, vascular pulmonary resistances).

Cardiac allograft vasculopathy: coronary computed tomography and virtual histology assessment.

INTRODUCTION: Cardiac allograft vasculopathy remains the leading cause of late morbidity and mortality in heart transplantation. The main diagnostic methods, coronary angiography or intracoronary ultrasound (when angiography is normal), are invasive. Other study methods, such as coronary computed tomography (CT) and virtual histological analysis, have not been widely assessed in this condition. OBJECTIVE: The objective of this study was to assess the correlation between data obtained from analysis of virtual histology compared with those obtained from the performance of coronary CT in cardiac transplant recipients. MATERIALS AND METHODS: During the same admission we performed coronary angiography and intravascular ultrasound with virtual histological analysis (automatic pull-back in anterior descending artery and one additional vessel if the former was normal) as well as coronary CT. RESULTS: The study included 10 patients. Virtual histology was done in segments with intimal thickening>0.5 mm, defining 2 groups of plaque, those with an inflammatory component (necrotic core>30% and calcium) versus those without it defined as the combination of both being <30%. A calcium component of the inflammatory plaque allowed coronary CT detection. CONCLUSIONS: The detection of inflammatory plaque in graft vessel disease can be based on an initial noninvasive method, such as coronary CT, although confirmation requires further study.

Safety and effectiveness of ivabradine after cardiac transplantation.

BACKGROUND: Heart denervation is the primary cause of sinus tachycardia in transplant recipients. Drugs are usually needed to treat associated symptoms. OBJECTIVE: To evaluate the safety and effectiveness of the novel I(f) channel antagonist ivabradine to control heart rate after transplantation. METHODS: Of 316 heart transplant recipients at a single center since 1991, ivabradine was administered in 15 patients, in addition to ß-blockers in 4 patients and contraindication to use of ß-blocker therapy in the others. A prospective follow-up study was conducted to identify possible adverse effects, tolerance, and drug effects on heart rate and control of symptoms. RESULTS: Of the 15 patients, 13 were men; overall mean (SD) patient age was 46 (4.6) years. In all patients, treatment was begun after verification of basal heart rate greater than 100 bpm and after other causes of sinus tachycardia had been ruled out. During follow-up of 1.13 (0.3) years, no substantial adverse effects were observed. It was possible to reach the maximum drug dosage in all patients, achieving a reduction in basal heart rate of 33 (6.2) bpm. All patients reported substantial clinical improvement, and demonstrated an increase in functional class. CONCLUSION: Ivabradine is safe, well tolerated, and effective in heart transplant recipients.

Comparison between two drugs on the hemodynamic evaluation of pulmonary hypertension prior to heart transplantation.

INTRODUCTION: Invasive estimation of pulmonary pressure is part of the usual protocol prior to heart transplantation. The aim of this study was to compare the results of 2 different vasodilators, nitric oxide (NO) and prostacyclin, in an acute vasodilator test (AVT) for patients with pulmonary venous hypertension. MATERIALS AND METHODS: From January 2000 to December 2006, 94 right-sided heart catheterizations were performed in our center within pretransplantation evaluations. AVT was performed if the mean pulmonary artery pressure (mPAP) >35 mm Hg or if the pulmonary vascular resistance (PVR) was >4 Wood units (WU). Epoprostenol was administered to 40 patients, NO to 6 patients, and both agents to 8 patients. RESULTS: A significant decrease in both mPAP and PVR was shown with maximum doses of epoprostenol, with an average variation of 8.96 mm Hg in mPAP (P < .001) and 3.26 WU in PVR (P < .001). An increased cardiac output (CO) was observed with epoprostenol, with a mean difference of 1.9 L/min (P < .001) at maximum compared with baseline doses. A tendency for the mPAP and PVR to decrease was also observed with maximum NO doses, with mean decreases of mPAP and PVR of 5.62 mm Hg and 1.14 WU, respectively. A tendency for CO to decrease was observed with NO (0.75 L/min; P = .039). CONCLUSIONS: In our experience, NO is the best drug for AVT due to its pulmonary tree selectivity. A study with epoprostenol was complementary; both drugs can be used in these patients prior to heart transplantation.

Insuficiencia cardiaca con patrón de pseudoinfarto en el electrocardiograma como forma de presentación de amiloidosis / Heart failure with electrocardiographic pseudo-infarction pattern as presentation form of amyloidosis

La afectación cardiaca por amiloidosis es una entidad infrecuente que implica un sombrío pronóstico, con una mediana de supervivencia de menos de un año. Aunque su diagnóstico es difícil al poder simular otras formas de cardiopatía, su existencia puede ser sospechada en pacientes que se presenten con la conjunción de: 1) insuficiencia cardiaca con datos ecocardiográficos de disfunción diastólica e hipertrofia ventricular; y 2) patrón de pseudoinfarto en el ECG (alteraciones electrocardiográficas que simulan un infarto de miocardio en ausencia de este antecedente). Presentamos el caso de un paciente con amiloidosis cuya enfermedad comenzó de este modo, y posteriormente revisamos la literatura al respecto (AU)

Varón de 46 años con clínica de insuficiencia cardíaca / 46-year old male patient with heart failure symptoms

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[Q fever-induced endocarditis. An analysis of 6 cases]. / Endocarditis por fiebre Q. Análisis de 6 casos.

Endocarditis by Q fever is a diagnostic and therapeutic challenge given the diagnostic delay and elevated morbidity and mortality it carries. Six cases of endocarditis by Q fever attended over the last 7 years were retrospectively studied. Five patients had been previously diagnosed of valvular involvement and three had prosthesis. Five patients presented a febrile syndrome of prolonged duration with negative hemocultures and progressive valvular changes. One patient presented acute valvular failure requiring emergency surgery. The most significant laboratory data were anemia, thrombocytopenia, high ESR and hypergammaglobulinemia. In the echocardiograms valvular vegetations were observed in 4 cases. All the patients received medical treatment with doxicylin, one associated with rifampicin and another cotrimoxazol. In 4 patients valvular reposition was required due to a severe hemodynamic alteration. After a minimum follow up of 2 years all the patients remain asymptomatic. The serologic evolution is described.