Steroid withdrawal during 5 years following heart transplantation, and the relationship between steroid dosage at 1-year follow-up and complications during the next 2 years: results from the RESTCO study.

BACKGROUND: Little information is available regarding the controversial issue of steroid withdrawal following heart transplantation (HT), or instead in the incidence of adverse steroid effects at dosages typically employed in Spain. METHODS: We analyzed the 5-year follow-up records of 1209 patients (82.5% men, aged ≥ 18 years) who underwent HT between 2000 and 2005 and survived at least 1 month in 13 Spanish centers. The incidences of first steroid withdrawal before 1, 3, and 5 years post-HT were expressed as Kaplan-Meier probability estimates. Three patient groups defined in accordance with steroid dosage at 1-year follow-up (0, ≤ 5, and >5 mg/d; groups A, B, and C, respectively) were compared with regard to the incidence of de novo hypertension, diabetes, and bone fractures over the following 2 years. RESULTS: The 5-year incidence of withdrawal was 28%, 21% of whom required reintroduction of steroids. Kaplan-Meier probabilities of withdrawal before 1, 3, and 5 years post-HT were 8.8% (95% confidence interval ([CI] 7.3%-10.7%), 27.8% (CI 25.2%-30.6%), and 30.2% (CI 27.5%-33.2%), respectively. At 1-year follow-up, 9.9% of patients were steroid-free, 28.9% were taking ≤ 5 mg/d, and 61.3% >5 mg/d. The 2-year incidence of de novo hypertension increased significantly (P = .012) from 13.5% to 29.6% to 35.3% in groups A, B, and C respectively. These groups did not differ significantly in regard to the 2-year incidence of diabetes or bone fractures. CONCLUSIONS: Reintroduction of steroids was required by 21% of the 28% of Spanish HT patients who has been weaned from steroids within 5 years of HT. The incidence of de novo hypertension between 1 and 3 years post-HT increased with steroid dosage at 1-year follow-up. De novo diabetes and bone fractures showed no similar significant association.

Incidence and risk factors for nonmelanoma skin cancer after heart transplantation.

INTRODUCTION: The incidence of skin cancer in heart transplant (HT) patients is higher than in the general population, reversing the proportion of cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) with a predominance of the former. The etiologic role of new immunosuppressants is not well known. We sought to ascertain the incidence of SCC and BCC in HT patients and the risk factors for its occurrence. PATIENTS AND METHODS: We report the incidence of all types of post-HT skin cancer, SCC, and BCC among adult HT patients in Spain (4089 subjects) as well as the influence of gender, age at heart transplant, immunosuppression, and sunlight exposure. RESULTS: The incidence rates of SCC and BCC, per 1000 persons/year, were 8.5 and 5.2, respectively. Males had a higher risk of SCC but not BCC. Induction therapy increased the risk of SCC and BCC. The relative risk of mycophenolate mofetil (MMF) was 0.3 (0.2-0.6; P<.0005) and azathioprine (AZA) 1.8 (1.2-2.7; P<.0032) for SCC, whereas tacrolimus and cyclosporine showed no difference. The relative risk of BCC was not affected by any immunosuppressant. CONCLUSION: Age at transplantation>45 years, induction therapy use, and high sunshine zone were risk factors for both SCC and BCC. Different immunosuppressive agents have different risks of nonmelanoma skin cancer, as AZA increases the risk of SCC and MMF is a protective factor. The relative risk of BCC was not affected by any immunosuppressor.

Predictors of mortality following heart transplantation: Spanish Registry of Heart Transplantation 1984-2003.

INTRODUCTION: Because the number of heart transplants performed per center is rather low, multicenter registries and databases are designed to analyze a large number of transplants to draw reliable conclusions. The objective of this study was to determine the factors associated with early and late mortality following heart transplantation. MATERIALS AND METHODS: All heart transplants performed in Spain since the start of activity (May 1984) to December 31, 2001 were analyzed. Using multivariate methods with Cox regression. The variables included donor, recipient, immunosuppression, surgical and follow-up factors (a total of 111 variables). RESULTS: The Total number of transplants was 4386. Early survival (at 30 days posttransplant) was 86%; survivals at 1, 5, and 10 years were 76%, 66%, and 54%, respectively. Variables associated with early mortality were acute graft failure, ventricular assistance, prior surgery, urgent transplant, bypass duration >180 minutes, and combined transplant. Variables associated with late mortality were acute graft failure, renal dysfunction, obesity, CMV+ serology, absence of induction therapy, infection, dialysis, and neurologic complications. CONCLUSIONS: Multicenter records of large databases are essential to draw reliable conclusions. This Registry provided reliable information on heart transplants in our country. The identification of factors associated with mortality provides a good perspective on the problems and a basis for future solutions and prospective studies.

Predictors of mortality following heart transplantation: Spanish Registry of Heart Transplantation 1984-2001.

UNLABELLED: Because the number of heart transplants performed at each center is rather low, multicenter registries are designed to analyze a large number of transplants to draw reliable conclusions. OBJECTIVE: To determine the factors associated with early and late mortality following heart transplantation. MATERIALS AND METHODS: All heart transplants performed in Spain since the start of transplant activity (May 1984) to December 31, 2001 were subjected to multivariate test using Cox regression in blocks of variables grouped into donor, recipient, immunosuppression, surgical and follow-up variables (a total of 111 metrics). RESULTS: Among the 3786 transplants early survival at 30 days after transplant was 86%, while survivals at 1, 5, and 10 years were 76%, 63%, and 50%. Variables associated with early mortality included acute graft failure, pulmonary vascular resistance >2.5 Wood Units (WU), prior thoracic surgery, respiratory obstruction, donor treatment with dobutamine, ventricular assistance, hepatic and/or renal dysfunction, hyperuricemia, mechanical ventilation, prior infection, duration of ischemia and/or extracorporeal circulation >4 hours. Variables associated with late mortality were: acute graft failure, graft vascular disease, tumors, rejection, infection, dialysis, and hypertension. CONCLUSIONS: Multicenter records provide reliable information on heart transplants in our country, revealing factors associated with mortality for future solutions.

Right ventricular infarction mimicking anterior infarction: a case report.

Right ventricular infarction usually occurs in association with inferior infarction, with no remarkable electrocardiographic signs in conventional leads. This report describes a patient with a previous inferior acute myocardial infarction who developed right ventricular infarction with significant anterior lead ST segment elevation (V1-V4) caused by the loss of two large right ventricular branches during a coronary angioplasty of the right coronary artery. The case is discussed and the literature is reviewed.

Left ventricular end-diastolic extrasystole with pseudonormalization of a left bundle branch block unmasking inferior ischemia.

An electrocardiogram tracing of a patient in conducted sinus rhythm with left bundle branch block is shown, in which occasional pseudonormalization of intraventricular conduction is seen. This event is attributed to ventricular fusions with end-diastolic extrasystoles of the left His-Purkinje system distal to the block site. This type of extrasystole is discussed. In this case, normalization of ventricular activation allowed for diagnosis of inferior subepicardial ischemia.